Information and shared decision-making are top patients' priorities

Health-Related Internet Use Among New Urology Clinic Patients

OBJECTIVE

To assess internet usage among new patients seen by urologists and impact on post-consultation understanding for four common conditions: kidney stones, elevated prostate specific antigen, male voiding, and female voiding.

METHODS

We performed a prospective study of new urology patients at our diverse urban, academic urology practice for the above conditions over a 1-year period. A voluntary questionnaire assessed patients' internet use related to referred conditions prior to encounters. Questions evaluated quality of information and patient understanding of symptoms/condition at baseline, after online searches, and after their urology visit. A patient-reported Likert scale of 1 (poor) to 10 (excellent) was used and internet "searchers" were compared to "non-searchers."

RESULTS

215 patients participated. Most respondents were Latino (41%) or Black (35%) and English-speaking (81%). Cohorts comprised 130 searchers (60%) and 85 non-searchers (40%). Searchers were significantly younger (median 53 vs. 63 years, P<0.001), more likely to have home internet access (P<0.001), and more general medical internet use (P<0.001). Overall, patients' understanding of visit diagnoses increased after their encounters (median pre-visit rating 5 vs. post-visit rating 10). Searchers reported a greater post-visit understanding compared to non-searchers (median rating 10 vs. 9, P<0.001), and a greater change in understanding from baseline (median +4 vs. +3, P=0.02).

CONCLUSION

Internet use is common amongst younger patients referred to urologists and may be associated with improved understanding of their condition after urologic consultation. Continued investigation of patient uses of and attitude towards popular online resources can help urologists curate resources to benefit patients and providers alike.

Assessing the Efficacy of an AI-Powered Chatbot (ChatGPT) in Providing Information on Orthopedic Surgeries: A Comparative Study With Expert Opinion

Background The use of artificial intelligence (AI) as a tool for patient care has continued to rapidly expand. The technology has proven its utility in various applications across several specialties in a variety of applications. However, its practicality in orthopedics remains widely unknown. This study seeks to determine if the open-access software Chat Generative Pre-Trained Transformer (ChatGPT) can be a reliable source of data for patients. Questions/purposes This study aims to determine: (1) Is the open-access AI software ChatGPT capable of accurately answering commonly posed patient questions? (2) Will there be a significant difference in agreement among the study experts in the answers generated by ChatGPT? Methods A standard list of questions for six different procedures across six subspecialties is posed to ChatGPT. The procedures chosen were anterior cruciate ligament (ACL) reconstruction, microdiscectomy, total hip arthroplasty (THA), rotator cuff repair, carpal tunnel release, and ankle fracture open reduction and internal fixation. The generated answers are then compared to expert opinion using a Likert scale based on the agreement of the aforementioned experts. Results On a three-point Likert scale with 1 being disagree and 3 being agree, the mean score across all subspecialties is 2.43, indicating at least partial agreement with expert opinion. There was no significant difference in the Likert scale mean across the six subspecialties surveyed (p = 0.177). Conclusions This study shows promise in using ChatGPT as an aid in answering patient questions regarding their surgical procedures. This opens doors for the use of the software by patients for understanding and increased shared decision-making with their surgeons. However, studies with larger participation groups are necessary to ensure accuracy on a larger and broader scale as well as studies involving specific application of AI within surgeon's practice.

"I am not just a place for implementation. I should be a partner": a qualitative study of patient-centered care from the perspective of diabetic patients in Saudi Arabia

INTRODUCTION

Patient involvement in care is a major component of high quality of care and is becoming recognized worldwide with many beneficial for improving patient outcomes. However, a little is known about patient involvement in the Middle East region and Saudi Arabia in particular.

OBJECTIVES

To evaluate patients' perceptions of their involvement during their interactions with healthcare providers in Saudi Arabia.

METHODS

A qualitative exploratory study using semi structured interview was conducted from February 2022 to March 2022. Responses were transcribed and analyzed using a thematic analysis approach.

RESULTS

We conducted seven interviews with patients with diabetes ranging in age from 19 to 69 years old. We identified the following themes:1) patients' perceptions of their involvement in care, 2) barriers to patient involvement, 3) effective communication, 4) empathy, and 5) culture. We found that patients had minimal knowledge of patient involvement in care.

CONCLUSION

There is a clear need to improve education and awareness of patient involvement in Saudi Arabia. By educating patients about the possibilities of patient involvement and explaining their role it will make it easier for patients to understand appropriate levels of involvement. In addition, there is a need to understand the patient-centred care culture in Saudi Arabia through establishing frameworks with the focus on culture and patient-centred healthcare delivery.

Evaluation of psychometric properties of a leaflet developed for schizophrenia

BACKGROUND

Patients with severe mental illnesses like schizophrenia may benefit from a variety of patient education materials. Despite the availability of various resources, it is essential to assess the extent to which patients can comprehend the materials provided.

OBJECTIVE

This study aims to evaluate the reliability and readability of the patient information leaflet (PIL) for schizophrenia.

METHOD

A quasi-experimental study was conducted for a period of 6 months in the departments of psychiatry. Patients with a diagnosis of schizophrenia were recruited for the study. A user-testing questionnaire was developed and validated with the help of an expert committee to assess reliability. Later, translated versions of the questionnaire were then administered to the patients based on their language preference and evaluated by test-retest analysis. The readability was assessed using pre-validated and translated versions of the PIL. Initially, baseline scores of patient knowledge were assessed using a reliable user-testing questionnaire. Later, their responses were reassessed again using the same questionnaire after reading the PIL.

RESULTS

A total of 45 patients participated in the study. From the total sample, 20 participants were randomly selected for reliability assessment. Intraclass-correlation coefficient (ICC), a statistical tool of reliability, give .6 for Kannada, .7 for Malayalam and 1 for the English version of the questionnaire. The overall patient's knowledge was found to be improved from 50.4 to 76.4 after reading the PIL.

CONCLUSION

Patients with schizophrenia were able to comprehend the information available on the PIL. Therefore, further research is needed to determine its efficacy in a larger population.

Patient-centered care in the Middle East and North African region: a systematic literature review

BACKGROUND

The need for patient centered care (PCC) and its subsequent implementation has gained policy maker attention worldwide. Despite the evidence showing the benefits and the challenges associated with practicing PCC in western countries there has been no comprehensive review of the literature on PCC practice in the Middle East and North African (MENA) region, yet there is good reason to think that the practices of PCC in these regions would be different.

OBJECTIVES

This paper summarizes the existing research on the practice of PCC in the MENA region and uses this analysis to consider the key elements of a PCC definition based on MENA cultural contexts.

METHODS

Five electronic databases were searched (EMBASE, Cochrane, Medline, CINAHL and Scopus) using the search terms: patient OR person OR client OR consumer AND centered OR centred AND care. The MENA countries included were Bahrain, Iran, Iraq, Jordan, Kuwait, Lebanon, Oman, Palestine, Israel, Qatar, Saudi Arabia, Syria, United Arab Emirates, Yemen, Algeria, Egypt, Libya, Morocco, Tunisia, Djibouti, Pakistan, Sudan, and Turkey. Identified papers were imported to Covidence where they were independently reviewed against the inclusion criteria by two authors. The following data were extracted for each paper: author, year, location (i.e., country), objectives, methodology, study population, and results as they related to patient centred care.

RESULT

The electronic search identified 3582 potentially relevant studies. Fifty articles met the inclusion criteria. Across all papers five themes were identified: 1) patient centered care principles; 2) patient and physician perceptions of PCC; 3) facilitators of PCC; 4) implementation and impact of PCC; and 5) barriers to PCC.

CONCLUSION

The preliminary findings suggest that the concept of PCC is practiced and supported to a limited extent in the MENA region, and that the implementation of PCC might be impacted by the cultural contexts of the region. Our review therefore highlights the importance of establishing patient-centered care definitions that clearly incorporate cultural practices in the MENA region. The elements and impact of culture in the MENA region should be investigated in future research.

Qualitatively exploring the impact of a relationship-centered communication skills training program in improving patient perceptions of care

Objective

To explore qualitative patient experience comments before and after a relationship-centered communication skills training to understand patient experience, program impact, and opportunities for improvement.

Methods

Qualitative patient experience evaluation data was captured from January 2016 to December 2018 for 483 health care clinicians who participated in the skills training. A random sampling of available open-ended patient comments (N = 33,223) were selected pre-training (n = 668) and post-training (n = 566). Comments were coded for valence (negative/neutral/positive), generality versus specificity, and based on 12 communication behaviors reflective of training objectives.

Results

No significant difference was found in the valence of comments, or generality versus specificity of comments before and after the training. A significant decrease was present in perceived clinician concern. "Confidence in care provider" was the communication skill most frequently identified in comments both pre- and post-training.

Conclusion

Perceptions of interactions largely remained the same following training. Key relationship-centered communication skills require further attention in future training efforts. Measurements of patient satisfaction and engagement may not adequately represent patient experience.

Innovation

This study identified areas for improvement in the training program and offers a model for utilizing patient experience qualitative data in understanding communication training impact.

Pelvic organ prolapse: The lived experience

BACKGROUND

Up to 50% of women will develop pelvic organ prolapse (POP) over their lifetime. Symptoms include pain, bulge, urinary, bowel and sexual symptoms affecting all aspects of a woman's life. This study explores the lived experience of women with POP.

METHODOLOGY

A qualitative study was undertaken. Following institutional ethical approval women from an online peer support group (n = 930 members) were recruited to participate in semi-structured interviews. Inclusion criteria stipulated women (> 18years), pre-menopausal, at least one-year post-partum, diagnosed with POP and aware of their diagnosis. Semi-structured interviews were undertaken with a clinician specialising in pelvic health. A battery of questions was designed to elicit discussion on their experience of being diagnosed with POP and its impact on daily life and relationships. Interviews were carried out via Zoom, recorded and transcribed. Thematic analysis was undertaken.

FINDINGS

Fourteen women (32-41 years), para 1-3 participated. All had at least one vaginal birth; three had vacuum, four had forceps operative births. All had Grade 1-3 POP. Interviews lasted 40-100 minutes. Three core themes with subthemes were identified; biological/physical, psychological and social. Women were particularly affected in terms of sport and exercise participation, their own perceptions of their ability as mothers and fear of their condition worsening. They described societal attitudes, reporting stigma around POP and women's pelvic health in general, expectations placed on women to put up with their symptoms and an idealised perception of new motherhood.

CONCLUSIONS

The impact of POP from a biopsychosocial perspective reflects other chronic conditions. Prevention, early education and supports for developing strong self-management approaches would be beneficial for long term management of this condition.

Drivers of shared decision making in inpatient psychiatry: An exploratory survey of patients' and multi-disciplinary team members' perspectives

OBJECTIVE

To assess the prevalence and predictors of Shared Decision Making (SDM) in an adult, inpatient psychiatric setting.

METHOD

Multi-disciplinary clinician focus groups and patient pre-testing informed the development of a survey on 4 SDM and 11 factors hypothesized to interfere with SDM. The survey was administered to 89 adult inpatients (80% response rate) and their treatment team psychiatrists, nurses, and social workers (n = 338 ratings, 95% response rate). Group differences and predictors were estimated using t and F-tests.

RESULTS

Patients' mean SDM score (n = 64, standardized Cronbach alpha = 0.858) was 3.35 ± 1.13 (5 = highest agreement), and correlated with overall satisfaction with care (n = 61, r = 0.399, p = 0.001). Patients' disagreement with clinician's diagnosis (44% of patients) correlated with lower SDM ratings by patients (t = 2.55, df = 62, p = 0.013) and by clinicians (t = 2.99, df = 69, p = 0.004). Psychotic diagnoses were not a significant determining factor for SDM. Overall, clinicians rated SDM more favorably than patients (t = -5.43, df = 63, p < 0.001), with nurses and social workers rating SDM higher than physicians (p < 0.001).

CONCLUSIONS

Diagnostic agreement / disagreement is a key predictor of SDM for patients and clinicians, while presence of psychosis is not. SDM was rated higher by clinicians than patients. SDM ratings vary significantly between clinical disciplines.

Information sharing across mental health service providers and criminal legal system stakeholders: Perspectives of people with serious mental illnesses and their family members

OBJECTIVE

The overrepresentation of people with serious mental illnesses in the criminal legal system has spurred information-sharing initiatives to transmit information between mental health service providers and criminal legal system stakeholders with the goal of improving resources and streamlining access to care. However, no research to date has examined the perspectives of people with mental illnesses who have their information shared across these systems or the perspectives of their family members. This study examined the perspectives on mental health-criminal legal system information sharing among people with serious mental illnesses and a history of arrest, as well as their family members.

METHODS

Researchers interviewed 24 clients with serious mental illnesses and a history of arrest who are enrolled in a randomized, controlled trial of a police-mental health Linkage System as well as 11 of their family members. Participants were recruited and interviewed between November 2020 and February 2021. A thematic analysis was used to code and analyze all interview transcripts.

RESULTS

Study participants articulated perceived benefits and concerns around cross-system information sharing. There was strong support for information sharing in both directions, with the anticipation that such information sharing can prevent unnecessary arrest and/or incarceration, promote positive and safe interactions with criminal legal system professionals, and foster greater understanding and access to treatment. Concerns were more limited and largely related to perceived stigma around mental illnesses and the potential consequences of such stigma.

CONCLUSIONS

While concerns about information sharing should be considered, study participants overwhelmingly perceived the sharing of information between mental health providers and criminal legal stakeholders as a positive intervention. Such perspectives can be understood as a pragmatic choice in the face of criminal legal system contact and additional research could guide programmatic and policy changes.

Shared Decision Making in the Psychiatric Inpatient Setting: An Ethnographic Study about Interprofessional Psychiatric Consultations

Shared decision making is increasingly receiving attention in health care and might improve both the quality of care and patient outcomes. Nevertheless, due to its complexity, implementation of shared decision making in clinical practice seems challenging. This ethnographic study aimed to gain a better understanding of how psychiatric inpatients and the interprofessional care team interact during regular interprofessional psychiatric consultations. Data were collected through participant observation on two different psychiatric wards in a large psychiatric hospital in Switzerland. The observation focused on the contextual aspects of interprofessional patient consultations, the communication and interaction as well as the extent to which patients were involved in decision making. Participants included patients, psychiatrists, junior physicians, nurses, psychologists, social workers and therapists. We observed 71 interprofessional psychiatric consultations and they differed substantially in both wards in terms of context (place and form) and culture (way of interacting). On the contrary, results showed that the level of patient involvement in decision making was comparable and depended on individual factors, such as the health care professionals’ communication style as well as the patients’ personal initiative to be engaged. The main topics discussed with the patients related to pharmacotherapy and patient reported symptoms. Health care professionals in both wards used a rather unidirectional communication style. Therefore, in order to promote patient involvement in the psychiatric inpatient setting, rather than to focus on contextual factors, consultations should follow a specific agenda and promoting a bidirectional communication style for all parties involved is strongly recommended.

Clinical decision-making style preferences of European psychiatrists: Results from the Ambassadors survey in 38 countries

Background

While shared clinical decision-making (SDM) is the preferred approach to decision-making in mental health care, its implementation in everyday clinical practice is still insufficient. The European Psychiatric Association undertook a study aiming to gather data on the clinical decision-making style preferences of psychiatrists working in Europe.

Methods

We conducted a cross-sectional online survey involving a sample of 751 psychiatrists and psychiatry specialist trainees from 38 European countries in 2021, using the Clinical Decision-Making Style – Staff questionnaire and a set of questions regarding clinicians’ expertise, training, and practice.

Results

SDM was the preferred decision-making style across all European regions ([central and eastern Europe, CEE], northern and western Europe [NWE], and southern Europe [SE]), with an average of 73% of clinical decisions being rated as SDM. However, we found significant differences in non-SDM decision-making styles: participants working in NWE countries more often prefer shared and active decision-making styles rather than passive styles when compared to other European regions, especially to the CEE. Additionally, psychiatry specialist trainees (compared to psychiatrists), those working mainly with outpatients (compared to those working mainly with inpatients) and those working in community mental health services/public services (compared to mixed and private settings) have a significantly lower preference for passive decision-making style.

Conclusions

The preferences for SDM styles among European psychiatrists are generally similar. However, the identified differences in the preferences for non-SDM styles across the regions call for more dialogue and educational efforts to harmonize practice across Europe.

What should people expect from person-centred dental visits? The Montreal-Toulouse Wheel of expectations

There is a dearth of tools designed to inform people about what to expect from person-centred dental encounters and to guide them during the care process. This is why we propose the Montreal-Toulouse Wheel of patients' expectations for dental visits, which describes what people could expect during person-centred clinical encounters. The Wheel comprises four core expectations: 1) be understood; 2) be respected; 3) have power; and 4) be given enough time. It also includes three expectations that are more specific to the process of care: 5) be informed and understand; 6) share decisions with the dentist and even co-construct the treatment plan; and 7) be comfortable during clinical procedures and the whole care process. We also propose a Q-List to help patients reflect on their relationship with dental professionals and engage them in person-centred dental care. This Q-List describes the seven expectations of the Wheel and provides open-ended questions that we invite patients to reflect upon. We also hope that dental professionals and educators will find the Wheel and the Q-List useful to develop person-centredness and promote inclusive and equitable dentistry.

Quality of care for people with multimorbidity: a focus group study with patients and their relatives

BACKGROUND

Prevalence of people with multimorbidity rises. Multimorbidity constitutes a challenge to the healthcare system, and treatment of patients with multimorbidity is prone to high-quality variations. Currently, no set of quality indicators (QIs) exists to assess quality of care, let alone incorporating the patient perspective. We therefore aim to identify aspects of quality of care relevant to the patients' perspective and match them to a literature-based set of QIs.

METHODS

We conducted eight focus groups with patients with multimorbidity and three focus groups with patients' relatives using a semistructured guide. Data were analysed using Kuckartz's qualitative content analysis. We derived deductive categories from the literature, added inductive categories (new quality aspects) and translated them into QI.

RESULTS

We created four new QIs based on the quality aspects relevant to patients/relatives. Two QIs (patient education/self-management, regular updates of medication plans) were consented by an expert panel, while two others were not (periodical check-ups, general practitioner-coordinated care). Half of the literature-based QIs, for example, assessment of biopsychosocial support needs, were supported by participants' accounts, while more technical domains regarding assessment and treatment regimens were not addressed in the focus groups.

CONCLUSION

We show that focus groups with patients and relatives adding relevant aspects in QI development should be incorporated by default in QI development processes and constitute a reasonable addition to traditional QI development. Our QI set constitutes a framework for assessing the quality of care in the German healthcare system. It will facilitate implementation of treatment standards and increase the use of existing guidelines, hereby helping to reduce overuse, underuse and misuse of healthcare resources in the treatment of patients with multimorbidity.

TRIAL REGISTRATION NUMBER

German clinical trials registry (DRKS00015718), Pre-Results.

Using DEMATEL Technique to Identify the Key Success Factors of Shared Decision-Making Based on Influential Network Relationship Perspective

In the field of medicine, shared decision-making (SDM) is an important issue primarily aimed at resolving the problem of information asymmetry between clinicians and patients in the selection of treatment options and follow-up nursing plans. Most previous studies on this topic have focused on key elements and the development and implementation of SDM scales. This study used the decision-making trial and evaluation laboratory (DEMATEL) method to establish a network of influence relationships among factors that are keys to the success of the SDM process. Survey data were obtained from a well-known brain hospital in China. The key factors of success included tailor information, flexibility approach, check understanding patient, document (discussion about) decision, present evidence, make or explicitly defer decision, and patient values and preferences. We determined that clinicians should provide a series of treatment options and follow-up care plans based on a patientʼs conditions and preferences. Clinicians should also actively communicate with patients and their families to ensure a thorough understanding of the entire treatment and nursing process. This study also highlights the academic value of the cross-disciplinary integration of medical decision issues and multiple attribute decision-making methodologies.

Development of Japanese Versions of the Control Preferences Scale and Information Needs Questionnaire: Role of Decision-Making and Information Needs for Japanese Breast Cancer Patients

PURPOSE

The importance of shared decision-making (SDM) between physicians and patients is increasingly recognized. In Japan, patients have shown more willingness to participate in treatment if medical professionals provide sufficient information; however, relationships between physicians and patients have traditionally been asymmetric, with patients accepting information from physicians without discussion. To explore the benefits of SDM in cancer treatment, including confidence in treatment decisions, satisfaction with treatment, and trust in healthcare providers, this study developed Japanese versions of the Control Preference Scale (CPS) and Information Needs Questionnaire (INQ).

PATIENTS AND METHODS

Reliability and validity of the CPS and INQ were tested with 49 breast cancer patients.

RESULTS

The CPS showed good test-retest reliability (kappa coefficient: 0.61, weighted kappa coefficient: 0.61, Kendall's tau coefficient: 0.61) and acceptable criterion validity. The INQ showed adequate consistency; the mean number of circular triads and coefficient of consistency were 3 (range 0-19) and 0.9 (range 0.37-1), respectively. Using the CPS and INQ to identify patients' roles in decision-making and information needs, results further suggested that breast cancer patients in Japan want to participate in SDM. Medical issues, including disease spread and cure, were found to be of high interest, while social and psychological issues, including sexual attractiveness, genetic risk, and family impact, tended to be low.

CONCLUSION

The Japanese CPS and INQ can be used to assess patients' needs to improve care. Further, as patients' information needs change along the care trajectory, these tools should be used throughout treatment.

Patients' perception of user involvement in psychiatric outpatient treatment: Associations with patient characteristics and satisfaction

BACKGROUND

The patient's right to be involved in treatment decisions is anchored in guidelines and legislation in many countries. Previous research suggests challenges in the implementation of user involvement across different areas of health care, including mental health. However, little is known about psychiatric outpatients' experiences of being involved in their treatment.

OBJECTIVE

To investigate how psychiatric outpatients after treatment rate the degree to which they were included in the treatment and explore the associations between perceived user involvement, demographic characteristics of the sample and patient satisfaction.

DESIGN

Cross-sectional.

SETTING AND PARTICIPANTS

The sample consisted of 188 psychiatric outpatients (67% female, mean age 42.2 years) who were discharged in the two years prior to data collection.

MAIN VARIABLES STUDIED

Perceived user involvement in psychiatric outpatient treatment and patient satisfaction as measured by the Psychiatric Out-Patient Experiences Questionnaire.

RESULTS

About half of the participants rated the overall degree of involvement in their treatment as high or very high. The lowest percentage of participants reporting high or very high involvement was found for sufficient information to contribute to treatment decisions (36%). Female gender, higher education and, to a small degree, younger age were associated with more involvement. Perceived user involvement was strongly associated with treatment satisfaction.

DISCUSSION AND CONCLUSION

The findings suggest that user involvement in psychiatric outpatient treatment can be improved. Patient information that facilitates user involvement should be given more attention.

PATIENT OR PUBLIC CONTRIBUTION

The hospital's user panel was involved in the development of items assessing user involvement.

The Limits of Empowerment: How to Reframe the Role of mHealth Tools in the Healthcare Ecosystem

This article highlights the limitations of the tendency to frame health- and wellbeing-related digital tools (mHealth technologies) as empowering devices, especially as they play an increasingly important role in the National Health Service (NHS) in the UK. It argues that mHealth technologies should instead be framed as digital companions. This shift from empowerment to companionship is advocated by showing the conceptual, ethical, and methodological issues challenging the narrative of empowerment, and by arguing that such challenges, as well as the risk of medical paternalism, can be overcome by focusing on the potential for mHealth tools to mediate the relationship between recipients of clinical advice and givers of clinical advice, in ways that allow for contextual flexibility in the balance between patiency and agency. The article concludes by stressing that reframing the narrative cannot be the only means for avoiding harm caused to the NHS as a healthcare system by the introduction of mHealth tools. Future discussion will be needed on the overarching role of responsible design.

Written patient information materials used in general practices fail to meet acceptable quality standards

BACKGROUND

Patient information materials and decision aids are essential tools for helping patients make informed decisions and share in decision-making. The aim of this study was to investigate the quality of the written patient information materials available at general practices in Styria, Austria.

METHODS

We asked general practitioners to send in all patient information materials available in their practices and to answer a short questionnaire. We evaluated the materials using the Ensuring Quality Information for Patients (EQIP-36) instrument.

RESULTS

A total of 387 different patient information materials were available for quality assessment. These materials achieved an average score of 39 out of 100. The score was below 50 for 78% of all materials. There was a significant lack of information on the evidence base of recommendations. Only 9 % of the materials provided full disclosure of their evidence sources. We also found that, despite the poor quality of the materials, 89% of general practitioners regularly make active use of them during consultations with patients.

CONCLUSION

Based on international standards, the quality of patient information materials available at general practices in Styria is poor. The vast majority of the materials are not suitable as a basis for informed decisions by patients. However, most Styrian general practitioners use written patient information materials on a regular basis in their daily clinical practice. Thus, these materials not only fail to help raise the health literacy of the general population, but may actually undermine efforts to enable patients to make shared informed decisions. To increase health literacy, it is necessary to make high quality, evidence-based and easy-to-understand information material available to patients and the public. For this, it may be necessary to set up a centralized and independent clearinghouse.

Patients' Use and Perception of Internet-Based Orthopaedic Sports Medicine Resources

Background:

Current research is sparse regarding how patients with orthopaedic injuries perceive and use internet-based information resources.

Hypothesis:

The majority of patients use the internet to research their orthopaedic condition and are receptive to guidance from their provider.

Study Design:

Cross-sectional study.

Methods:

A total of 213 patients attending a sports medicine clinic on the East Coast of the United States were asked to complete a questionnaire regarding their use of internet-based information. Data from 185 patients were available for analysis. Bivariate and multivariate statistical analyses were used to determine the significance of identified associations.

Results:

Overall, 54% of patients used the internet to find information about their orthopaedic condition prior to their consultation. A higher percentage of internet users were women (P = .01), were white (P = .03), and had internet access at home (P = .02). Multivariable analysis found home internet access to be the only significant independent factor predictive of patients using internet-based information sources (P < .01). The majority of patients (61%) were neutral toward orthopaedic information found online, and only 32% of patients trusted the orthopaedic information they found online. The majority of patients (83%) reported they would be receptive to providers’ guidance on which internet resources to use.

Conclusion:

Only half of patients use the internet to research their orthopaedic condition. Most patients were either neutral toward or did not trust the internet-based information that they found and may forgo internet sources altogether. To help patients avoid misleading information, sports medicine providers should understand how patients are using the internet and guide patients in selecting high-quality, peer-reviewed sources of information. Doing so allows physicians to proactively educate their patients even after the clinic visit.

Evaluation of Information Sources in Plastic Surgery Decision-making

Background

Today, patients can access a myriad of information sources regarding plastic surgery procedures prior to meeting with a surgeon. Despite their widespread use, the role of these sources in a patient’s decision-making remains undefined. We hypothesized that the physician remains the key information source for patients making surgical decisions in plastic surgery, but that other sources may deliver important insights and prove helpful to varying degrees. We also explored motivations for this outside information search and any differences in perceived value among patients.

Methods

We administered a survey regarding various information sources to our breast reconstruction, reduction, and abdominoplasty patients. Responses were compared between surgery groups and demographic groups. Ordinal logistic regression analysis was used to determine the impact of patient characteristics on helpfulness rank of different sources.

Results

Survey results were obtained from 58 patients, of whom 10 (17.2%) had abdominoplasty, 35 (60.3%) breast reconstruction, and 13 (22.4%) breast reduction. The most popular information sources prior to the first surgical appointment were Internet searches (56.9%) and family/friends/other patients (39.7%). After the initial appointment, the most useful sources were plastic surgeons (84.5%), and the Internet (36.2%). Most patients (73.5%) still sought outside information after their appointment.

On a Likert-type scale of helpfulness, plastic surgeons ranked 4.28/5, followed by the web-based patient education platform, 3.73 and the Internet, 3.6. A total of 63% of participants listed plastic surgeons as their single most important source of information.

In ordinal logistic regression analysis, non-white race was significantly associated with higher rank of surgeon helpfulness (p < 0.05). Relative to low-income patients, income $50-100k (p < 0.05) and $100k+ (p < 0.05) were associated with lower rank of surgeon helpfulness.

Conclusions

Most patients seek outside information prior to visiting with a surgeon from the Internet, social media, or family and friends. Patients consider plastic surgeons their most valuable information source overall, though still in need of supplementation for varying reasons. Additionally, certain demographic differences affect patient perception of information sources, and this is an important factor for surgeons to consider as they approach educating patients.

Efficacy of a Procedure-Specific Education Module on Informed Consent in Plastic Surgery

INTRODUCTION

Truly informed consent is an elusive goal, seldom attained in medical or surgical practice. Patients often do not fully understand procedures and therapies they undergo or the associated sequelae. Historically, informed consent and patient education have been limited to physician discussions, sometimes with the addition of simple visual aids. More recently, there is a growing body of decision aids available, including interactive multimedia patient educational modules that review preoperative through postoperative care, risks, benefits, alternatives, different surgical options, as well as commonly asked questions. We hypothesized that the addition of a Web-based educational tool would positively impact attainment of informed consent and satisfaction in plastic surgery patients.

METHODS

We performed a prospective randomized controlled study comparing patients who presented in consultation for breast reconstruction, breast reduction, and abdominoplasty. Patients received standard patient education along with a procedure-specific (study) or general patient safety (control) Web-based educational module. Informed consent was measured using a surgical-focused, modified version of the Shared Decision-making 25 index tool. Patient demographic information as well as surrogate markers of familiarity with technology were recorded preoperatively and postoperatively. Comparisons were made between study and control groups, procedure subgroups, and preoperative and postoperative time points. Demographic factors and consent variables were compared among experimental and procedure groups.

RESULTS

Data were collected from 65 patients preoperatively and 48 patients postoperatively. Thirty patients competed both surveys. Overall, no differences in patient characteristics or familiarity with technology were observed between experimental groups. Demographic characteristics were also similar between groups. No meaningful differences were identified in comparisons between experimental groups on either cross-sectional or longitudinal analyses. Nearly all patient responses were consistent with being well informed and satisfied with the educational process.

CONCLUSIONS

Overall, patients undergoing plastic surgery procedures are adequately informed and have a high degree of satisfaction regarding their patient education. The addition of a Web-based informed consent tool did not make a demonstrable difference in informed consent.

Choosing the appropriate treatment setting: which information and decision-making needs do adult inpatients with mental disorders have? A qualitative interview study

BACKGROUND

Decisions on medical treatment setting are perceived as important but often difficult to make for patients with mental disorders. Shared decision-making as a strategy to decrease decisional conflict has been recommended, but is not yet widely implemented. This study aimed to investigate the information needs and the decision-making preferences of patients with mental disorders prior to the decision for a certain treatment setting. The results will serve as a prerequisite for the development of a high-quality patient decision aid (PtDA) regarding the treatment setting decision.

METHODS

We conducted retrospective individual semi-structured interviews with n=24 patients with mental disorders in three psychotherapeutic inpatient care units. The interviews were audiotaped, transcribed, coded, and content-analyzed.

RESULTS

The majority of the patients wanted to be involved in the decision-making process. They reported high information needs regarding treatment options in order to feel empowered to participate adequately in the decision for a certain treatment setting. However, some patients did not want to participate or receive information, for example, because of their high burden of mental disorder. Whereas the majority were satisfied with the extent they were involved in the decision, few participants felt sufficiently informed about treatment options. Most patients reported that a decision aid regarding an appropriate treatment setting would have been helpful for them. Important information that should be included in a PtDA was general information about mental illness, effective treatment options, specific information about the different treatment settings, and access to treatment.

DISCUSSION

The identified information and decision-making needs provide a valuable basis for the development of a PtDA aiming to support patients and caregivers regarding the decision for an adequate treatment setting. As preferences for participation vary among patients and also depend on the current mental state, a flexible approach is needed to meet patients' individual wishes and needs.

The role of depression pharmacogenetic decision support tools in shared decision making

Patients discontinue antidepressant medications due to lack of knowledge, unrealistic expectations, and/or unacceptable side effects. Shared decision making (SDM) invites patients to play an active role in their treatment and may indirectly improve outcomes through enhanced engagement in care, adherence to treatment, and positive expectancy of medication outcomes. We believe decisional aids, such as pharmacogenetic decision support tools (PDSTs), facilitate SDM in the clinical setting. PDSTs may likewise predict drug tolerance and efficacy, and therefore adherence and effectiveness on an individual-patient level. There are several important ethical considerations to be navigated when integrating PDSTs into clinical practice. The field requires greater empirical research to demonstrate clinical utility, and the mechanisms thereof, as well as exploration of the ethical use of these technologies.

Implementing shared decision making in routine mental health care

Shared decision making (SDM) in mental health care involves clinicians and patients working together to make decisions. The key elements of SDM have been identified, decision support tools have been developed, and SDM has been recommended in mental health at policy level. Yet implementation remains limited. Two justifications are typically advanced in support of SDM. The clinical justification is that SDM leads to improved outcome, yet the available empirical evidence base is inconclusive. The ethical justification is that SDM is a right, but clinicians need to balance the biomedical ethical principles of autonomy and justice with beneficence and non-maleficence. It is argued that SDM is "polyvalent", a sociological concept which describes an idea commanding superficial but not deep agreement between disparate stakeholders. Implementing SDM in routine mental health services is as much a cultural as a technical problem. Three challenges are identified: creating widespread access to high-quality decision support tools; integrating SDM with other recovery-supporting interventions; and responding to cultural changes as patients develop the normal expectations of citizenship. Two approaches which may inform responses in the mental health system to these cultural changes - social marketing and the hospitality industry - are identified.

Autonomy, consent and responsibility. Part II. Informed consent in medical care and in the law

Legal recognition of patient's rights aspired to change clinical relationship and medical lex artis. However, its implementation has been hampered by the scarcity of resources and the abundance of regulations. For several years, autonomy, consent, and responsibility have formed one of the backbones of the medical profession. However, they have sparked controversy and professional discomfort. In the first part of this article, we examine the conceptual and regulatory limitations of the principle of autonomy as the basis of informed consent. We approach the subject from philosophical, historical, legal, bioethical, deontological, and professional standpoints. In the second part, we cover the viability of informed consent in health care and its relationship with legal responsibility.

Patient choice, Internet based information sources, and perceptions of health care: Evidence from Sweden using survey data from 2010 and 2013

BACKGROUND

Several countries have increased patients' abilities to choose their health care providers, frequently under the assumption that patients are themselves the best agents to make such decisions. In parallel, national and regional health authorities have enhanced access to Internet based information sources (IBIS) to assist patients in making an informed choice. Relatively little, however, is known about the effect that the use of such sources has on key outcomes, including patients' perceptions of care. The aim of this study is to analyze the role of the Internet for patients' confidence in the provider and perceived access to care in the context of choice based reforms in Sweden.

METHODS

The study uses a regional, population health survey from the southern part of Sweden. Non-parametric chi-square tests are used to assess the nature of Internet users, including their gender, age and socioeconomic status. Logistic regression models are specified to analyze the role of IBIS on patient perceptions of care while controlling for other factors.

RESULTS

Actual use of Internet based information sources for health care was relatively low in 2010 and only somewhat higher in 2013. The characteristics of IBIS users varied significantly across different population groups, such that they were younger, more educated, female, and also considered themselves to be in better health compared with those who reported not using this source of health care information. Finally, the average IBIS user was less likely to report having a high level of satisfaction with respect to their primary care use; OR 0.69 [95 % CI: 0.54-0,87] and OR 0.52 [95 % CI: 0,41-0,66], for confidence in provider and perceived access to care, respectively, in 2013.

CONCLUSIONS

Despite health agencies' attempts to make information on health care providers available on the Internet, this source of health care information is not used to any large extent in the current sample. The fact that some people use this source of information more compared with others suggests the need to consider alternative ways of informing the general public about choice options. The use of Internet based sources may also be linked with the experience of actually using health services, which suggests a need to further analyze this complex consumer behavior process.

User Evaluation of Neonatology Ward Design

Objective:

The object of this article is to identify the set of affective and emotional factors behind users’ assessments of a space in a neonatology unit and to propose design guidelines based on these.

Background:

The importance of the neonatology service and the variety of users place great demands on the space at all levels. Despite the repercussions, the emotional aspects of the environment have received less attention.

Methods:

To avoid incurring limitations in the user mental scheme, this study uses two complementary methodologies: focus group and semantic differential. The (qualitative) focus group methodology provides exploratory information and concepts. The (quantitative) semantic differential methodology then uses these concepts to extract the conceptual structures that users employ in their assessment of the space. Of the total 175 subjects, 31 took part in focus groups and 144 in semantic differential.

Results:

Five independent concepts were identified: privacy, functionality and professional nature, spaciousness, lighting, and cleanliness. In relation to the importance of the overall positive assessment of the space, the perception of privacy and sensations of dominance and pleasure are fundamental. Six relevant design aspects were also identified: provide spacious surroundings, facilitate sufficient separation between the different posts or cots, use different colors from those usually found in health-care centers, as some aversion was found to white and especially green, design areas with childhood themes, use warm artificial light, and choose user-friendly equipment.

Conclusions:

Results provide design recommendations of interest and show the possibilities offered by combining both systems to analyze user response.

Doctors' perspectives of informed consent for non-emergency surgical procedures: a qualitative interview study

BACKGROUND

The need to involve patients more in decisions about their care, the ethical imperative and concerns about ligation and complaints has highlighted the issue of informed consent and how it is obtained. In order for a patient to make an informed decision about their treatment, they need appropriate discussion of the risks and benefits of the treatment.

OBJECTIVES

To explore doctors' perspectives of gaining informed consent for routine surgical procedures.

DESIGN

Qualitative study using semi-structured interviews selected by purposive sampling. Data were analysed thematically.

SETTING AND PARTICIPANTS

Twenty doctors in two teaching hospitals in the UK.

RESULTS

Doctors described that while consent could be taken over a series of consultations, it was common for consent to be taken immediately prior to surgery. Juniors were often taking consent when they were unfamiliar with the procedure. Doctors used a range of communication techniques to inform patients about the procedure and its risks including quantifying risks, personalizing risk, simplification of language and use of drawings. Barriers to effective consent taking were reported to be shortage of time, clinician inexperience and patients' reluctance to be involved.

DISCUSSION AND CONCLUSION

Current consent processes do not appear to be ideal for many doctors. In particular, junior doctors are often not confident taking consent for surgical procedures and require more support to undertake this task. This might include written information for junior staff, observation by senior colleagues when undertaking the task and ward-based communication skills teaching on consent taking.

'It just has to click': Internists' views of: what constitutes productive interactions with chronically ill patients

BACKGROUND

According to the Chronic Care Model, productive interactions are crucial to patient outcomes. Despite productive interactions being at the heart of the Model, however, it is unclear what constitutes such an interaction. The aim of this study was to gain a better understanding of physician views of productive interactions with the chronically ill.

METHOD

We conducted a qualitative study and interviewed 20 internists working in an academic hospital. The data were analyzed using a constructivist approach of grounded theory. To categorize the data, a coding process within which a code list was developed and tested with two other coders was conducted.

RESULTS

The participants engaged in goal-directed reasoning when reflecting on productive interactions. This resulted in the identification of four goal orientations: (a) health outcome; (b) satisfaction; (c) medical process; and (d) collaboration. Collaboration appeared to be conditional for reaching medical process goals and ultimately health outcome and satisfaction goals. Achieving rapport with the patient ('clicking,' in the term of the participants) was found to be a key condition that catalyzed collaboration goals. Clicking appeared to be seen as a somewhat unpredictable phenomenon that might or might not emerge, which one had to accept and work with. Goal orientations were found to be related to the specific medical context (i.e., a participant's subspecialty and the nature of a patient's complaint).

CONCLUSIONS

The participants viewed a productive interaction as essentially goal-directed, catalyzed by the two parties clicking, and dependent on the nature of a patient's complaint. Using the findings, we developed a conceptual process model with the four goal orientations as wheels and with clicking in the center as a flywheel. Because clicking was viewed as important, but somewhat unpredictable, teaching physicians how to click, while taking account of the medical context, may warrant greater attention.

Measuring patient-perceived hospital service quality: a conceptual framework

Purpose

Although measuring healthcare service quality is not a new phenomenon, the instruments used to measure are timeworn. With the shift in focus to patient centric processes in hospitals and recognising healthcare to be different compared to other services, service quality measurement needs to be tuned specifically to healthcare. The study’s purpose is to design a conceptual framework for measuring patient perceived hospital service quality, based on existing service quality literature

Design/methodology/approach

Using hospital service quality theories, expanding existing healthcare service models and literature, a conceptual framework is proposed to measure hospital service quality. The article outlines inpatient perceived service quality dimensions

Findings

An instrument for measuring hospital service quality dimensions is developed and compared with other service quality measuring instruments. The latest dimensions are in line with previous studies, but a relationship dimension is added.

Practical implications

The framework empowers managers to assess healthcare quality in corporate, public and teaching hospitals.

Originality/value

The article helps academics and practitioners to assess hospital service quality from a patient perspective.

Squaring the circle: a priority-setting method for evidence-based service development, reconciling research with multiple stakeholder views

BACKGROUND

This study demonstrates a technique to aid the implementation of research findings through an example of improving services and self-management in longer-term depression. In common with other long-term conditions, policy in this field requires innovation to be undertaken in the context of a whole system of care, be cost-effective, evidence-based and to comply with national clinical guidelines. At the same time, successful service development must be acceptable to clinicians and service users and choices must be made within limited resources. This paper describes a novel way of resolving these competing requirements by reconciling different sources and types of evidence and systematically engaging multiple stakeholder views.

METHODS

The study combined results from mathematical modelling of the care pathway, research evidence on effective interventions and findings from qualitative research with service users in a series of workshops to define, refine and select candidate service improvements. A final consensus-generating workshop used structured discussion and anonymised electronic voting. This was followed by an email survey to all stakeholders, to achieve a pre-defined criterion of consensus for six suggestions for implementation.

RESULTS

An initial list of over 20 ideas was grouped into four main areas. At the final workshop, each idea was presented in person, visually and in writing to 40 people, who assigned themselves to one or more of five stakeholder groups: i) service users and carers, ii) clinicians, iii) managers, iv) commissioners and v) researchers. Many belonged to more than one group. After two rounds of voting, consensus was reached on seven ideas and one runner up. The survey then confirmed the top six ideas to be tested in practice.

CONCLUSIONS

The method recruited and retained people with diverse experience and views within a health community and took account of a full range of evidence. It enabled a diverse group of stakeholders to travel together in a direction that converged with the messages coming out of the research and successfully yielded priorities for service improvement that met competing requirements.

Which family physician should I choose? The analytic hierarchy process approach for ranking of criteria in the selection of a family physician

BACKGROUND

Choosing the most appropriate family physician (FP) for the individual, plays a fundamental role in primary care. The aim of this study is to determine the selection criteria for the patients in choosing their family doctors and priority ranking of these criteria by using the multi-criteria decision-making method of the Analytic Hierarchy Process (AHP) model.

METHODS

The study was planned and conducted in two phases. In the first phase, factors affecting the patients' decisions were revealed with a qualitative research. In the next phase, the priorities of FP selection criteria were determined by using AHP model. Criteria were compared in pairs. 96 patient were asked to fill the information forms which contains comparison scores in the Family Health Centres.

RESULTS

According to the analysis of focus group discussions FP selection criteria were congregated in to five groups: Individual Characteristics, Patient-Doctor relationship, Professional characteristics, the Setting, and Ethical Characteristics. For each of the 96 participants, comparison matrixes were formed based on the scores of their information forms. Of these, models of only 5 (5.2 %) of the participants were consistent, in other words, they have been able to score consistent ranking. The consistency ratios (CR) were found to be smaller than 0.10. Therefore the comparison matrix of this new model, which was formed based on the medians of scores only given by these 5 participants, was consistent (CR = 0.06 < 0.10). According to comparison results; with a 0.467 value-weight, the most important criterion for choosing a family physician is his/her 'Professional characteristics'.

CONCLUSIONS

Selection criteria for choosing a FP were put in a priority order by using AHP model. These criteria can be used as measures for selecting alternative FPs in further researches.

Patients' decision-making experiences in the acute healthcare setting--a case study

BACKGROUND

The transition from being an ordinary citizen to a hospitalised patient can be a daunting experience particularly for the uninitiated and inexperienced. Patients are likely to have questions such as 'where do I go?', 'what should I do?', 'when?' and 'who should I ask?' The process for making practical moment-to-moment decisions is often complex and fraught with difficulties. Identifying critical points in the hospitalisation experience may provide insights into the quality of hospital management systems and professional practices from a patient perspective.

OBJECTIVE

This study aimed to identify institutional practices and structures in the context of acute healthcare settings which impact on patient moment-to-moment decision-making experiences.

METHOD

A case study approach was used as the exploratory methodology, and interviews were conducted with three former adult inpatients. In order to gain an understanding of each participant's experiences, data collecting strategies used in this research were a semistructured interview and document analysis of information documents, such as hospital supplied pamphlets, provided to the researcher by the participants.

RESULTS

The study identified five major themes. Identified as being critical to the participants were information sharing by healthcare professionals, professional advice and professional role identification. Less so were environment and everyday life. Associated with these themes were the participant's common experience of being confined in unfamiliar surroundings, adjusting to institutional routines and of being heavily dependent on others.

CONCLUSION

Findings indicate that patient moment-to-moment decision-making may be informed and enhanced in several areas: relevant and timely information sharing, varying the dress code between the different professions, reducing conflicting professional advice, clear signage around the hospital, and flexible visiting hours, telephones and clocks in patient rooms.

Exploring the experiences of client involvement in medication decisions using a shared decision making model: results of a qualitative study

This qualitative study explored a newly introduced model of shared decision making (CommonGround) and how psychiatric medications were experienced by clients, prescribers, case managers and peer support staff. Of the twelve client subjects, six were highly engaged in shared decision-making and six were not. Five notable differences were found between the two groups including the presence of a goal, use of personal medicine, and the behavior of case managers and prescribers. Implications for a shared decision making model in psychiatry are discussed.

Internet based patient education improves informed consent for elective orthopaedic surgery: a randomized controlled trial

Background

Obtaining informed consent is an essential step in the surgical pathway. Providing adequate patient education to enable informed decision making is a continued challenge of contemporary surgical practice. This study investigates whether the use of a patient information website, to augment patient education and informed consent for elective orthopaedic procedures is an effective measure.

Methods

A randomised controlled trial was conducted comparing the quality of informed consent provided by a standard discussion with the treating surgeon compared to augmentation of this discussion with an online education resource (www.orthoanswer.org). Participants were recruited from orthopaedic outpatient clinics. Patients undergoing five common orthopaedic procedures were eligible to participate in the trial. The primary outcome measure was knowledge about their operation. Satisfaction with their informed consent and anxiety relating to their operation were the secondary outcome measures.

Results

There was a statistically significant increase in patient knowledge for the intervention arm as compared to the control arm (p < 0.01). Patients in the intervention arm, had an average score of 69.25% (SD 14.91) correct answers as compared to 47.38% (SD 17.77) in the control arm. Satisfaction was also improved in the intervention arm (p = 0.043). There was no statistically significant difference between the control and intervention arm relating to their anxiety scores (p = 0.195).

Conclusions

The use of a patient education website as an augment to informed consent improves patient knowledge about their planned operation as well as satisfaction with the consent process whilst not increasing their anxiety levels. We recommend that all patients be directed to web based education tools to augment their consent.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12614001058662.

The road to patient experience of care measurement: lessons from the United States

Patient-centered care has become an increasing priority in the United States and plays a prominent role in recent healthcare reforms. One way the country has managed to advance patient-centered care is through establishment of a family of national patient experience surveys (the Consumer Assessment of Healthcare Providers and Systems Plans (CAHPS). CAHPS is publicly reported for several types of providers and was recently tied to hospital reimbursement. This is part of a trend over the last two decades that has shifted provider-patient relationships from a traditional paternal approach to customer service and then to clinical partnership. The health care system in Israel, however, is still struggling to overcome barriers to change in this area. While community based biannual patient experience surveys are conducted by the Myers-JDC-Brookdale Institute, there is no comprehensive national approach to measuring the patient experience across a broad range of settings. Only recently did the Israeli Ministry of Health take its first steps to include patient experience as a dimension of health care quality.

In its current position, Israel should learn from the U.S. experience with policies promoting patient-centered care, and specifically the impact on clinical services of measuring the patient experience. Looking at what has happened in the United States, we suggest three main lessons. First, there is a need for a set of national patient experience surveys that would be publicly reported and eventually tied to provider reimbursement. Secondly, the national survey tools should be customized to the unique characteristics of Israeli society and draw from recent research on patient-centeredness to include new and important domains such as patient activation and shared decision-making. Finally, newer technological approaches should be explored with the aim of increasing response rates and the timeliness and usefulness of the surveys.

Factors associated with nurses’ opinions and practices regarding information and consent

This cross-sectional survey aimed to investigate nurses’ opinions and practices regarding information and consent in the context of a large Italian teaching hospital and to explore potential influences of gender, age, university education, length of professional experience, and care setting. A questionnaire was administered to 282 nurses from six different care settings (Emergency Room, Emergency Medicine, Surgery, Hematology–Oncology, Geriatrics, and Internal Medicine). Overall, 84% (n = 237) of nurses returned the questionnaire (men: 24%; mean age: 36.2 ± 8 years; university degree: 35%; mean length of professional experience: 12 ± 8.2 years). Most respondents regularly informed patients about medications and nursing procedures and asked for consent prior to invasive procedures, but some provided information to relatives instead of patients. Lack of time or opportunity was the main difficulty in informing patients. The work setting was the foremost factor significantly associated with participants’ opinions and practices. Further investigations are needed to confirm these findings in similar and other care settings.

Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures

BACKGROUND

Achieving informed consent is a core clinical procedure and is required before any surgical or invasive procedure is undertaken.  However, it is a complex process which requires patients be provided with information which they can understand and retain, opportunity to consider their options, and to be able to express their opinions and ask questions.  There is evidence that at present some patients undergo procedures without informed consent being achieved.

OBJECTIVES

To assess the effects on patients, clinicians and the healthcare system of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare treatments and procedures.

SEARCH METHODS

We searched the following databases using keywords and medical subject headings: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 5, 2012), MEDLINE (OvidSP) (1950 to July 2011), EMBASE (OvidSP) (1980 to July 2011) and PsycINFO (OvidSP) (1806 to July 2011). We applied no language or date restrictions within the search. We also searched reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials and cluster randomised trials of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. We considered an intervention to be intended to promote informed consent when information delivery about the procedure was enhanced (either by providing more information or through, for example, using new written materials), or if more opportunity to consider or deliberate on the information was provided.

DATA COLLECTION AND ANALYSIS

Two authors assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of outcomes where there were sufficient data.

MAIN RESULTS

We included 65 randomised controlled trials from 12 countries involving patients undergoing a variety of procedures in hospitals. Nine thousand and twenty one patients were randomised and entered into these studies. Interventions used various designs and formats but the main data for results were from studies using written materials, audio-visual materials and decision aids. Some interventions were delivered before admission to hospital for the procedure while others were delivered on admission.Only one study attempted to measure the primary outcome, which was informed consent as a unified concept, but this study was at high risk of bias.  More commonly, studies measured secondary outcomes which were individual components of informed consent such as knowledge, anxiety, and satisfaction with the consent process.  Important but less commonly-measured outcomes were deliberation, decisional conflict, uptake of procedures and length of consultation.Meta-analyses showed statistically-significant improvements in knowledge when measured immediately after interventions (SMD 0.53 (95% CI 0.37 to 0.69) I(2) 73%), shortly afterwards (between 24 hours and 14 days) (SMD 0.68 (95% CI 0.42 to 0.93) I(2) 85%) and at a later date (15 days or more) (SMD 0.78 (95% CI 0.50 to 1.06) I(2) 82%). Satisfaction with decision making was also increased (SMD 2.25 (95% CI 1.36 to 3.15) I(2) 99%) and decisional conflict was reduced (SMD -1.80 (95% CI -3.46 to -0.14) I(2) 99%). No statistically-significant differences were found for generalised anxiety (SMD -0.11 (95% CI -0.35 to 0.13) I(2) 82%), anxiety with the consent process (SMD 0.01 (95% CI -0.21 to 0.23) I(2) 70%) and satisfaction with the consent process (SMD 0.12 (95% CI -0.09 to 0.32) I(2) 76%). Consultation length was increased in those studies with continuous data (mean increase 1.66 minutes (95% CI 0.82 to 2.50) I(2) 0%) and in the one study with non-parametric data (control 8.0 minutes versus intervention 11.9 minutes, interquartile range (IQR) of 4 to 11.9 and 7.2 to 15.0 respectively). There were limited data for other outcomes.In general, sensitivity analyses removing studies at high risk of bias made little difference to the overall results. 

AUTHORS' CONCLUSIONS

Informed consent is an important ethical and practical part of patient care.  We have identified efforts by researchers to investigate interventions which seek to improve information delivery and consideration of information to enhance informed consent.  The interventions used consistently improve patient knowledge, an important prerequisite for informed consent.  This is encouraging and these measures could be widely employed although we are not able to say with confidence which types of interventions are preferable. Our results should be interpreted with caution due to the high levels of heterogeneity associated with many of the main analyses although we believe there is broad evidence of beneficial outcomes for patients with the pragmatic application of interventions. Only one study attempted to measure informed consent as a unified concept.

Individualised medicine from the perspectives of patients using complementary therapies: a meta-ethnography approach

BACKGROUND

Personalised (or individualised) medicine in the days of genetic research refers to molecular biologic specifications in individuals and not to a response to individual patient needs in the sense of person-centred medicine. Studies suggest that patients often wish for authentically person-centred care and personal physician-patient interactions, and that they therefore choose Complementary and Alternative medicine (CAM) as a possibility to complement standard care and ensure a patient-centred approach. Therefore, to build on the findings documented in these qualitative studies, we investigated the various concepts of individualised medicine inherent in patients' reasons for using CAM.

METHODS

We used the technique of meta-ethnography, following a three-stage approach: (1) A comprehensive systematic literature search of 67 electronic databases and appraisal of eligible qualitative studies related to patients' reasons for seeking CAM was carried out. Eligibility for inclusion was determined using defined criteria. (2) A meta-ethnographic study was conducted according to Noblit and Hare's method for translating key themes in patients' reasons for using CAM. (3) A line-of-argument approach was used to synthesize and interpret key concepts associated with patients' reasoning regarding individualized medicine.

RESULTS

(1) Of a total of 9,578 citations screened, 38 studies were appraised with a quality assessment checklist and a total of 30 publications were included in the study. (2) Reasons for CAM use evolved following a reciprocal translation. (3) The line-of-argument interpretations of patients' concepts of individualised medicine that emerged based on the findings of our multidisciplinary research team were "personal growth", "holism", "alliance", "integrative care", "self-activation" and "wellbeing".

CONCLUSIONS

The results of this meta-ethnographic study demonstrate that patients' notions of individualised medicine differ from the current idea of personalised genetic medicine. Our study shows that the "personal" patients' needs are not identified with a specific high-risk group or with a unique genetic profile in the sense of genome-based "personalised" or "individualised" medicine. Thus, the concept of individualised medicine should include the humanistic approach of individualisation as expressed in concepts such as "personal growth", "holistic" or "integrative care", doctor-patient "alliance", "self-activation" and "wellbeing" needs. This should also be considered in research projects and the allocation of healthcare resources.

A questionnaire-based survey to assess patient satisfaction, ease-of-learning, ease-of-use, injection site pain and overall patient satisfaction of the follitropin-alpha (Gonal-f) filled-by-mass (FbM) prefilled pen compared with other systems of gonadotrophin administration

BACKGROUND

Gonadotrophins are used routinely for follicular stimulation during ovarian induction and assisted reproduction techniques. Developments in recombinant follicle-stimulating hormone preparations and their injection devices have improved patient quality of life by enabling patients to self-administer treatment at home. The objective of this study was to investigate patient experiences of learning to use and overall satisfaction with the follitropin-alpha (Gonal-f) filled-by-mass (FbM) prefilled pen.

METHODS

This questionnaire-based survey study was conducted in 23 fertility centres in Japan over a period of 14 months. Patients who were receiving fertility treatment with the follitropin-alpha (FbM) prefilled pen were asked to complete a questionnaire to assess their satisfaction, ease of learning and use, and injection site pain following treatment.

RESULTS

A total of 663 women participated in the study. The majority of patients found the instructions for administering follitropin-alpha with the prefilled pen easy to understand (83.0%; n = 546/658) and patients found that a hands-on demonstration by a nurse or doctor was the most useful tool for learning to use the follitropin-alpha (FbM) prefilled pen (80.0%; n = 497/621). Forty-eight percent (n = 318) of patients in the study had previous experience with different types of fertility medications and the majority of these patients found the follitropin-alpha (FbM) prefilled pen easier to use (75.1%; n = 232/309) and less painful (89.0%; n = 347/390) than their previous medication. The majority (80.2%; n = 521/650) of patients reported overall satisfaction with the follitropin-alpha (FbM) prefilled pen.

CONCLUSIONS

The follitropin-alpha (FbM) prefilled pen is an easy-to-use injection device according to this questionnaire-based survey. Patients who had experience of different types of fertility medication preferred the follitropin-alpha (FbM) prefilled pen to other injection devices.

Patient-related factors influencing satisfaction in the patient-doctor encounters at the general outpatient clinic of the university of calabar teaching hospital, calabar, Nigeria

Medical consultation is at the centre of clinical practice. Satisfaction of a patient with this process is a major determinant of the clinical outcome. This study sought to determine the proportion of patients who were satisfied with their doctor-patient encounter and the patient-related factors that affected patients' satisfaction with the consultation process. A clinic-based, cross-sectional study using a modified version of the General Practice Assessment Questionnaire (GPAQ), which employed a systematic sampling technique, was used. The questionnaires were administered on 430 patients within the ages of 18 years and 65 years. Among the 430 subjects within the ages of 18 years and 65 years studied, 200 (46.5%) were males and 230 (53.5%) were females. Only 59.3% were satisfied with their patient-doctor encounter. The patient's perception of time spent in the consultation, illness understanding after the visit, ability to cope with the illness after the visit, and ability to maintain health after visit were the only factors that affected patient's satisfaction with the consultation. In our environment, nonsatisfaction with the patient-doctor encounter is high. Only few factors considered to encourage a patients satisfaction at primary care consultation contributed to end-of-consultation satisfaction. This calls for refocusing so as to improve the overall patient care in our cultural context and meet the patient needs in our environment.

Satisfaction with patient-doctor relationships in inflammatory bowel diseases: Examining patient-initiated change of specialist

AIM: To assess the reasons for, and factors associated with, patient-initiated changes in treating specialist in inflammatory bowel diseases (IBD).

METHODS: Prospectively identified IBD patients (n = 256) with ≥ 1 encounter at a metropolitan hospital were surveyed, including whether they had changed treating specialist and why. Negative reasons included loss of confidence, disagreement, and/or personality clash with the specialist.

RESULTS: Of 162 respondents, 70 (43%) had ever changed specialists; 30/70 (43%) for negative reasons, 52/70 (74%) in the preceding year. Patients with negative reasons for changing (n = 30) were younger (median, 35.2 years vs 45.3 years) ,had higher IBD knowledge (median, 5.0 years vs 4.0 years), yet had lower medication adherence and satisfaction scores (median, 19.0 years vs 22.0 years, 14.0 years vs 16.0 years respectively, Mann-Whitney tests, all P < 0.05), compared to all other responders (n = 132). Patients with a recent change (for any reason) were more likely to have Crohn’s disease, currently active disease, previous bowel resection and recent hospitalization [OR 2.6, 95% CI (1.3-5.4), 2.2 (1.0-4.7), 5.56 (1.92-16.67), 2.0 (1.3-3.0), each P < 0.05].

CONCLUSION: Changing specialist appears associated with patient- related (age, nonadherence) and contemporaneous disease-related factors (recent relapse) which, where modifiable, may enhance patient-doctor relationships and therefore quality of care.

Shared decision-making in Israel: status, barriers, and recommendations

Shared decision making (SDM) - involving patients in decisions relevant to their health - has been increasingly influential in medical thought and practice around the world. This paper reviews the current status of SDM in Israel, including efforts to promote SDM in the legislation and healthcare system, its influence in medical training and the national health plans, and funding for SDM-related research. Published studies of SDM in Israel are also reviewed. Although informed consent and patients' right to information are regulated by Israeli law, little provision is made for SDM. Further, there are few organized programs to promote SDM among medical professionals or the public, and governmental support of SDM-related research is minimal. Nonetheless, patients have begun to influence litigation in both formal and informal capacities, medical schools have begun to incorporate courses for improving physician-patient communication into their curricula, and the largest national health plan has initiated a plan to increase public awareness. A review of the limited research literature suggests that although patients and physicians express a desire for greater patient involvement, they often have reservations about its implementation. Research also suggests that despite the positive effects of SDM, such an approach may only infrequently be applied in actual clinical practice. In conclusion, though not actively promoting SDM at present, Israel's universal coverage and small number of health plans make rapid, widespread advances in SDM feasible. Israeli policymakers should thus be encouraged to nurture burgeoning initiatives and set plausible milestones. Comparing the status of SDM in Israel with that in other countries may stimulate further advancement.