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Alton A, Flynn D, Burgess D, Ford GA, Price C, James M, McMeekin P, Allen M, Shaw L, White P. Stroke survivor views on ambulance redirection as a strategy to increase access to thrombectomy in England. Br Paramed J 2024; 9:1-9. [PMID: 38946738 PMCID: PMC11210583 DOI: 10.29045/14784726.2024.6.9.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Introduction Intravenous thrombolysis and mechanical thrombectomy are effective time-sensitive treatments for selected cases of acute ischaemic stroke. While thrombolysis is widely available, thrombectomy can only be provided at facilities with the necessary equipment and interventionists. Suitable patients admitted to other hospitals require secondary transfer, causing delays to treatment. Pre-hospital ambulance redirection to thrombectomy facilities may improve access but treatment eligibility cannot be confirmed pre-hospital. Some redirected patients would travel further and be displaced without receiving thrombectomy. This study aimed to elicit stroke survivor and carer/relative views about the possible consequences of introducing a conceptual, idealised ambulance redirection pathway. Methods Focus groups were undertaken using a topic guide describing four hypothetical ambulance redirection scenarios and their possible consequences: earlier treatment with thrombectomy; delayed diagnosis of non-stroke 'mimic' conditions; delayed thrombolysis treatment; and delayed diagnosis of haemorrhagic stroke. Meetings were audio recorded, transcribed verbatim and data analysed thematically using emergent coding. Results Fifteen stroke survivors and carers/relatives participated in three focus groups. There was wide acceptance of possible low-risk consequences of ambulance redirection, including extended travel time, being further from home and experiencing longer hospital stays. Participants were more uncertain about higher-risk consequences, including delays in diagnosis/treatment for patients unsuitable for thrombectomy, but remained positive about ambulance redirection overall. Participants rationalised acceptance of higher-risk consequences by recognising that redirected patients would still access appropriate treatment, even if delayed. In addition, acceptance of ambulance redirection would be increased if there were robust clinical evidence showing net benefit over secondary transfer pathways. Conclusions Participant views were generally supportive of ambulance redirection to facilitate access to thrombectomy. Further research is needed to demonstrate overall benefit in an NHS context.
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Affiliation(s)
- Abigail Alton
- Newcastle University ORCID iD: https://orcid.org/0000-0002-9983-080X
| | - Darren Flynn
- Northumbria University ORCID iD: https://orcid.org/0000-0001-7390-632X
| | - David Burgess
- North East and North Cumbria Stroke Patient & Carer Panel, CRN North East and North Cumbria ORCID iD: https://orcid.org/0009-0003-3248-4601
| | - Gary A Ford
- University of Oxford ORCID iD: https://orcid.org/0000-0001-8719-4968
| | - Chris Price
- Newcastle University ORCID iD: https://orcid.org/0000-0003-3566-3157
| | - Martin James
- Royal Devon & Exeter Hospital/University of Exeter Medical School; NIHR South West Peninsula Applied Research Collaboration ORCID iD: https://orcid.org/0000-0001-6065-6018
| | - Peter McMeekin
- Northumbria University ORCID iD: https://orcid.org/0000-0003-0946-7224
| | - Michael Allen
- University of Exeter Medical School & NIHR South West Peninsula Applied Research Collaboration ORCID iD: https://orcid.org/0000-0002-8746-9957
| | - Lisa Shaw
- Newcastle University ORCID iD: https://orcid.org/0000-0002-9931-7774
| | - Phil White
- Newcastle University ORCID iD: https://orcid.org/0000-0001-6007-6013
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Li Z, Zhang X, Ding L, Jing J, Gu HQ, Jiang Y, Meng X, Du C, Wang C, Wang M, Xu M, Zhang Y, Hu M, Li H, Gong X, Dong K, Zhao X, Wang Y, Liu L, Xian Y, Peterson E, Fonarow GC, Schwamm LH, Wang Y. Rationale and design of the GOLDEN BRIDGE II: a cluster-randomised multifaceted intervention trial of an artificial intelligence-based cerebrovascular disease clinical decision support system to improve stroke outcomes and care quality in China. Stroke Vasc Neurol 2024:svn-2023-002411. [PMID: 37699726 DOI: 10.1136/svn-2023-002411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Given the swift advancements in artificial intelligence (AI), the utilisation of AI-based clinical decision support systems (AI-CDSSs) has become increasingly prevalent in the medical domain, particularly in the management of cerebrovascular disease. AIMS To describe the design, rationale and methods of a cluster-randomised multifaceted intervention trial aimed at investigating the effect of cerebrovascular disease AI-CDSS on the clinical outcomes of patients who had a stroke and on stroke care quality. DESIGN The GOLDEN BRIDGE II trial is a multicentre, open-label, cluster-randomised multifaceted intervention study. A total of 80 hospitals in China were randomly assigned to the AI-CDSS intervention group or the control group. For eligible participants with acute ischaemic stroke in the AI-CDSS intervention group, cerebrovascular disease AI-CDSS will provide AI-assisted imaging analysis, auxiliary stroke aetiology and pathogenesis analysis, and guideline-based treatment recommendations. In the control group, patients will receive the usual care. The primary outcome is the occurrence of new vascular events (composite of ischaemic stroke, haemorrhagic stroke, myocardial infarction or vascular death) at 3 months after stroke onset. The sample size was estimated to be 21 689 with a 26% relative reduction in the incidence of new composite vascular events at 3 months by using multiple quality-improving interventions provided by AI-CDSS. All analyses will be performed according to the intention-to-treat principle and accounted for clustering using generalised estimating equations. CONCLUSIONS Once the effectiveness is verified, the cerebrovascular disease AI-CDSS could improve stroke care and outcomes in China. TRIAL REGISTRATION NUMBER NCT04524624.
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Affiliation(s)
- Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinmiao Zhang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lingling Ding
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chunying Du
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chunjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Meng Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Man Xu
- Hanalytics Artificial Intelligence Research Centre for Neurological Disorders, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yanxu Zhang
- Hanalytics Artificial Intelligence Research Centre for Neurological Disorders, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Meera Hu
- Hanalytics Artificial Intelligence Research Centre for Neurological Disorders, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiping Gong
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kehui Dong
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ying Xian
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eric Peterson
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gregg C Fonarow
- Cardiology, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Clinical Center for Precision Medicine in Stroke, Capital Medical Universit, Beijing, China
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Hassan N, Slight R, Morgan G, Bates DW, Gallier S, Sapey E, Slight S. Road map for clinicians to develop and evaluate AI predictive models to inform clinical decision-making. BMJ Health Care Inform 2023; 30:e100784. [PMID: 37558245 PMCID: PMC10414079 DOI: 10.1136/bmjhci-2023-100784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Predictive models have been used in clinical care for decades. They can determine the risk of a patient developing a particular condition or complication and inform the shared decision-making process. Developing artificial intelligence (AI) predictive models for use in clinical practice is challenging; even if they have good predictive performance, this does not guarantee that they will be used or enhance decision-making. We describe nine stages of developing and evaluating a predictive AI model, recognising the challenges that clinicians might face at each stage and providing practical tips to help manage them. FINDINGS The nine stages included clarifying the clinical question or outcome(s) of interest (output), identifying appropriate predictors (features selection), choosing relevant datasets, developing the AI predictive model, validating and testing the developed model, presenting and interpreting the model prediction(s), licensing and maintaining the AI predictive model and evaluating the impact of the AI predictive model. The introduction of an AI prediction model into clinical practice usually consists of multiple interacting components, including the accuracy of the model predictions, physician and patient understanding and use of these probabilities, expected effectiveness of subsequent actions or interventions and adherence to these. Much of the difference in whether benefits are realised relates to whether the predictions are given to clinicians in a timely way that enables them to take an appropriate action. CONCLUSION The downstream effects on processes and outcomes of AI prediction models vary widely, and it is essential to evaluate the use in clinical practice using an appropriate study design.
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Affiliation(s)
- Nehal Hassan
- School of Pharmacy, Newcastle University School of Pharmacy, Newcastle Upon Tyne, UK
- Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Robert Slight
- Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Graham Morgan
- School of Computing, Newcastle University, Newcastle upon Tyne, UK
| | - David W Bates
- Department of General Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Suzy Gallier
- PIONEER Health Data Research Hub, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Health Informatics, PIONEER Health Data Research Hub, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Sapey
- PIONEER Health Data Research Hub, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Health Informatics, PIONEER Health Data Research Hub, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sarah Slight
- School of Pharmacy, Newcastle University School of Pharmacy, Newcastle Upon Tyne, UK
- Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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4
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Abell B, Naicker S, Rodwell D, Donovan T, Tariq A, Baysari M, Blythe R, Parsons R, McPhail SM. Identifying barriers and facilitators to successful implementation of computerized clinical decision support systems in hospitals: a NASSS framework-informed scoping review. Implement Sci 2023; 18:32. [PMID: 37495997 PMCID: PMC10373265 DOI: 10.1186/s13012-023-01287-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/17/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Successful implementation and utilization of Computerized Clinical Decision Support Systems (CDSS) in hospitals is complex and challenging. Implementation science, and in particular the Nonadoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework, may offer a systematic approach for identifying and addressing these challenges. This review aimed to identify, categorize, and describe barriers and facilitators to CDSS implementation in hospital settings and map them to the NASSS framework. Exploring the applicability of the NASSS framework to CDSS implementation was a secondary aim. METHODS Electronic database searches were conducted (21 July 2020; updated 5 April 2022) in Ovid MEDLINE, Embase, Scopus, PyscInfo, and CINAHL. Original research studies reporting on measured or perceived barriers and/or facilitators to implementation and adoption of CDSS in hospital settings, or attitudes of healthcare professionals towards CDSS were included. Articles with a primary focus on CDSS development were excluded. No language or date restrictions were applied. We used qualitative content analysis to identify determinants and organize them into higher-order themes, which were then reflexively mapped to the NASSS framework. RESULTS Forty-four publications were included. These comprised a range of study designs, geographic locations, participants, technology types, CDSS functions, and clinical contexts of implementation. A total of 227 individual barriers and 130 individual facilitators were identified across the included studies. The most commonly reported influences on implementation were fit of CDSS with workflows (19 studies), the usefulness of the CDSS output in practice (17 studies), CDSS technical dependencies and design (16 studies), trust of users in the CDSS input data and evidence base (15 studies), and the contextual fit of the CDSS with the user's role or clinical setting (14 studies). Most determinants could be appropriately categorized into domains of the NASSS framework with barriers and facilitators in the "Technology," "Organization," and "Adopters" domains most frequently reported. No determinants were assigned to the "Embedding and Adaptation Over Time" domain. CONCLUSIONS This review identified the most common determinants which could be targeted for modification to either remove barriers or facilitate the adoption and use of CDSS within hospitals. Greater adoption of implementation theory should be encouraged to support CDSS implementation.
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Affiliation(s)
- Bridget Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Sundresan Naicker
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.
| | - David Rodwell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Thomasina Donovan
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Amina Tariq
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Melissa Baysari
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Robin Blythe
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Rex Parsons
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
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5
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Cutforth M, Watson H, Brown C, Wang C, Thomson S, Fell D, Dilys V, Scrimgeour M, Schrempf P, Lesh J, Muir K, Weir A, O’Neil AQ. Acute stroke CDS: automatic retrieval of thrombolysis contraindications from unstructured clinical letters. Front Digit Health 2023; 5:1186516. [PMID: 37388253 PMCID: PMC10305776 DOI: 10.3389/fdgth.2023.1186516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/15/2023] [Indexed: 07/01/2023] Open
Abstract
Introduction Thrombolysis treatment for acute ischaemic stroke can lead to better outcomes if administered early enough. However, contraindications exist which put the patient at greater risk of a bleed (e.g. recent major surgery, anticoagulant medication). Therefore, clinicians must check a patient's past medical history before proceeding with treatment. In this work we present a machine learning approach for accurate automatic detection of this information in unstructured text documents such as discharge letters or referral letters, to support the clinician in making a decision about whether to administer thrombolysis. Methods We consulted local and national guidelines for thrombolysis eligibility, identifying 86 entities which are relevant to the thrombolysis decision. A total of 8,067 documents from 2,912 patients were manually annotated with these entities by medical students and clinicians. Using this data, we trained and validated several transformer-based named entity recognition (NER) models, focusing on transformer models which have been pre-trained on a biomedical corpus as these have shown most promise in the biomedical NER literature. Results Our best model was a PubMedBERT-based approach, which obtained a lenient micro/macro F1 score of 0.829/0.723. Ensembling 5 variants of this model gave a significant boost to precision, obtaining micro/macro F1 of 0.846/0.734 which approaches the human annotator performance of 0.847/0.839. We further propose numeric definitions for the concepts of name regularity (similarity of all spans which refer to an entity) and context regularity (similarity of all context surrounding mentions of an entity), using these to analyse the types of errors made by the system and finding that the name regularity of an entity is a stronger predictor of model performance than raw training set frequency. Discussion Overall, this work shows the potential of machine learning to provide clinical decision support (CDS) for the time-critical decision of thrombolysis administration in ischaemic stroke by quickly surfacing relevant information, leading to prompt treatment and hence to better patient outcomes.
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Affiliation(s)
| | - Hannah Watson
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | - Cameron Brown
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, United Kingdom
| | - Chaoyang Wang
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | - Stuart Thomson
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | - Dickon Fell
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | | | | | | | - James Lesh
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | - Keith Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, United Kingdom
| | - Alexander Weir
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | - Alison Q O’Neil
- Canon Medical Research Europe, Edinburgh, United Kingdom
- School of Engineering, University of Edinburgh, Edinburgh, United Kingdom
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6
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Schuster L, Essig F, Daneshkhah N, Herm J, Hellwig S, Endres M, Dirnagl U, Hoffmann F, Michalski D, Pfeilschifter W, Urbanek C, Petzold GC, Rizos T, Kraft A, Haeusler KG. Ability of patients with acute ischemic stroke to recall given information on intravenous thrombolysis: Results of a prospective multicenter study. Eur Stroke J 2023; 8:241-250. [PMID: 37021170 PMCID: PMC10069168 DOI: 10.1177/23969873221143856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/20/2022] [Indexed: 01/09/2023] Open
Abstract
Introduction: Intravenous thrombolysis (IVT) is an on label treatment for selected patients with acute ischemic stroke (AIS). As major bleeding or allergic shock may occur, the need to ensure patients’ informed consent for IVT is a matter of debate. Patients and methods: Prospective investigator-initiated multi-center observational study to assess the ability of AIS patients to recall information, provided by a physician during a standardized educational talk (SET) on IVT use. The recall of 20 pre-defined items was assessed in AIS after 60–90 min ( n = 93) or 23–25 h ( n = 40) after SET. About 40 patients with subacute stroke, 40 non-stroke patients, and 23 relatives of AIS patients served as controls, and were surveyed 60–90 min after SET. Results: Within 60–90 min after SET, AIS patients (median age 70 years, 31% female, median NIHSS score on admission 3 points) who were considered capable to provide informed consent recalled 55% (IQR 40%–66.7%) of the provided SET items. In multivariable linear regression analysis recapitulation by AIS patients was associated with their educational level (β = 6.497, p < 0.001), self-reported excitement level (β = 1.879, p = 0.011) and NIHSS score on admission (β = −1.186, p = 0.001). Patients with subacute stroke (70 years, 40% female, median NIHSS = 2) recalled 70% (IQR 55.7%–83.6%), non-stroke patients (75 years, 40% female) 70% (IQR 60%–78.7%), and AIS relatives (58 years, 83% female) 70% (IQR 60%–85%). Compared to subacute stroke patients, AIS patients less often recalled the frequency of IVT-related bleeding (21% vs 43%), allergic shock (15% vs 39%), and bleeding-related morbidity and mortality (44% vs 78%). AIS patients recalled 50% (IQR 42.3%–67.5%) of the provided items 23–25 h after SET. Conclusion: AIS patients eligible for IVT remember about half of all SET-items after 60–90 min or 23–25 h, respectively. The fact that the recapitulation of IVT-associated risks is particularly poor should be given special consideration.
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Affiliation(s)
- Luzie Schuster
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Fabian Essig
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Naeimeh Daneshkhah
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Juliane Herm
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Germany
| | - Simon Hellwig
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Germany
| | - Ulrich Dirnagl
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- QUEST Center, Berlin Institute of Health (BIH), Berlin, Germany
| | - Frank Hoffmann
- Department of Neurology, Martha-Maria Hospital, Halle/Saale, Germany
| | | | - Waltraud Pfeilschifter
- Department of Neurology, University of Frankfurt, Frankfurt/Main, Germany
- Department of Neurology, Hospital Lüneburg, Lüneburg, Germany
| | - Christian Urbanek
- Department of Neurology, Hospital Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University of Bonn, Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Timolaos Rizos
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Andrea Kraft
- Department of Neurology, Martha-Maria Hospital, Halle/Saale, Germany
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Jessurun CAC, Broekman MLD. True shared decision-making in neurosurgical oncology: does it really exist? Acta Neurochir (Wien) 2023; 165:11-13. [PMID: 36571627 DOI: 10.1007/s00701-022-05452-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Charissa A C Jessurun
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands
| | - Marike L D Broekman
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, Zuid-Holland, The Netherlands.
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, Zuid-Holland, The Netherlands.
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8
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Nguyen C, Naunton M, Thomas J, Todd L, Bushell M. Novel pictograms to improve pharmacist understanding of the number needed to treat (NNT). CURRENTS IN PHARMACY TEACHING & LEARNING 2022; 14:1229-1245. [PMID: 36283794 DOI: 10.1016/j.cptl.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 08/01/2022] [Accepted: 09/06/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Number needed to treat (NNT) is a clinically useful "yardstick" used to gauge the efficacy of therapeutic interventions. The objective of this project was to develop and pilot a series of pictograms and assess their impact on pharmacist understanding of the NNT. METHODS Three decision aids containing NNT pictograms were developed following a preliminary literature review and three focus groups with current Australian-registered pharmacists and pharmacist interns. Pharmacists then tested the pictograms in a research pilot in clinical encounters until (1) ≥ 3 sessions had occurred or (2) a two-week period had elapsed from commencement. Knowledge assessment was administered both pre- and post-pilot. Transcription and inductive thematic analysis were applied to focus group data. Descriptive statistics, Wilcoxon signed rank, and McNemar's tests were used to analyse the pilot data. RESULTS Six core themes regarding NNT decision aid development were identified with >80% consensus across three focus groups (N = 11). Comparison of the pre-post measures (n = 10) showed an increase in median scores after use of NNT decision aids, correlating to a moderate Cohen classified effect size (d = 0.54). Wilcoxon matched pairs test demonstrated a statistically insignificant influence of NNT pictograms on the knowledge assessment survey (P > .05). CONCLUSIONS While the NNT is not a new concept, its incorporation as part of pictograms for health practitioner enrichment is novel. This pilot study suggests that utilizing decision aids with NNT pictograms as counselling adjuncts appears promising in the realm of enhancing pharmacists' understanding of the NNT.
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Affiliation(s)
- Cassandra Nguyen
- University of Canberra, Discipline of Pharmacy, Faculty of Health, Australian Capital Territory, Australia.
| | - Mark Naunton
- Head of School - Health Sciences, University of Canberra, Faculty of Health, Australian Capital Territory, Australia.
| | - Jackson Thomas
- University of Canberra, Discipline of Pharmacy, Faculty of Health, Australian Capital Territory, Australia.
| | - Lyn Todd
- University of Canberra, Discipline of Pharmacy, Faculty of Health, Australian Capital Territory, Australia.
| | - Mary Bushell
- University of Canberra, Discipline of Pharmacy, Faculty of Health, Australian Capital Territory, Australia.
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9
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Prick JCM, van Schaik SM, Deijle IA, Dahmen R, Brouwers PJAM, Hilkens PHE, Garvelink MM, Engels N, Ankersmid JW, Keus SHJ, The R, Takahashi A, van Uden-Kraan CF, van der Wees PJ, Van den Berg-Vos RM, van Schaik S, Brouwers P, Hilkens P, van Dijk G, Gons R, Saxena R, Schut E. Development of a patient decision aid for discharge planning of hospitalized patients with stroke. BMC Neurol 2022; 22:245. [PMID: 35790912 PMCID: PMC9254531 DOI: 10.1186/s12883-022-02679-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/11/2022] [Indexed: 08/14/2024] Open
Abstract
Abstract
Background
Patient involvement in discharge planning of patients with stroke can be accomplished by providing personalized outcome information and promoting shared decision-making. The aim of this study was to develop a patient decision aid (PtDA) for discharge planning of hospitalized patients with stroke.
Methods
A convergent mixed methods design was used, starting with needs assessments among patients with stroke and health care professionals (HCPs). Results of these assessments were used to develop the PtDA with integrated outcome information in several co-creation sessions. Subsequently, acceptability and usability were tested to optimize the PtDA. Development was guided by the International Patient Decision Aids Standards (IPDAS) criteria.
Results
In total, 74 patients and 111 HCPs participated in this study. A three-component PtDA was developed, consisting of:
1) a printed consultation sheet to introduce the options for discharge destinations, containing information that can be specified for each individual patient;
2) an online information and deliberation tool to support patient education and clarification of patient values, containing an integrated “patients-like-me” model with outcome information about discharge destinations;
3) a summary sheet to support actual decision-making during consultation, containing the patient’s values and preferences concerning discharge planning.
In the acceptability test, all qualifying and certifying IPDAS criteria were fulfilled. The usability test showed that patients and HCPs highly appreciated the PtDA with integrated outcome information.
Conclusions
The developed PtDA was found acceptable and usable by patients and HCPs and is currently under investigation in a clinical trial to determine its effectiveness.
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10
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Billah T, Gordon L, Schoenfeld EM, Chang BP, Hess EP, Probst MA. Clinicians' perspectives on the implementation of patient decision aids in the emergency department: A qualitative interview study. J Am Coll Emerg Physicians Open 2022; 3:e12629. [PMID: 35079731 PMCID: PMC8769071 DOI: 10.1002/emp2.12629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Decision aids (DAs) are tools to facilitate and standardize shared decision making (SDM). Although most emergency clinicians (ECs) perceive SDM appropriate for emergency care, there is limited uptake of DAs in clinical practice. The objective of this study was to explore barriers and facilitators identified by ECs regarding the implementation of DAs in the emergency department (ED). METHODS We conducted a qualitative interview study guided by implementation science frameworks. ECs participated in interviews focused on the implementation of DAs for the disposition of patients with low-risk chest pain and unexplained syncope in the ED. Interviews were recorded and transcribed verbatim. We then iteratively developed a codebook with directed qualitative content analysis. RESULTS We approached 25 ECs working in urban New York, of whom 20 agreed to be interviewed (mean age, 41 years; 25% women). The following 6 main barriers were identified: (1) poor DA accessibility, (2) concern for increased medicolegal risk, (3) lack of perceived need for a DA, (4) patient factors including lack of capacity and limited health literacy, (5) skepticism about validity of DAs, and (6) lack of time to use DAs. The 6 main facilitators identified were (1) positive attitudes toward SDM, (2) patient access to follow-up care, (3) potential for improved patient satisfaction, (4) potential for improved risk communication, (5) strategic integration of DAs into the clinical workflow, and (6) institutional support of DAs. CONCLUSIONS ECs identified multiple barriers and facilitators to the implementation of DAs into clinical practice. These findings could guide implementation efforts targeting the uptake of DA use in the ED.
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Affiliation(s)
- Tausif Billah
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
| | - Lauren Gordon
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
| | - Elizabeth M. Schoenfeld
- Department of Emergency MedicineUniversity of Massachusetts Medical School–BaystateSpringfieldMassachusettsUSA
| | - Bernard P. Chang
- Department of Emergency MedicineColumbia University Medical CenterNew YorkNew YorkUSA
| | - Erik P. Hess
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Marc A. Probst
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
- Department of Emergency MedicineColumbia University Medical CenterNew YorkNew YorkUSA
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11
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Walsh CG, McKillop MM, Lee P, Harris JW, Simpson C, Novak LL. Risky business: a scoping review for communicating results of predictive models between providers and patients. JAMIA Open 2021; 4:ooab092. [PMID: 34805776 PMCID: PMC8598291 DOI: 10.1093/jamiaopen/ooab092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 10/01/2021] [Accepted: 10/24/2021] [Indexed: 11/25/2022] Open
Abstract
Objective Given widespread excitement around predictive analytics and the proliferation of machine learning algorithms that predict outcomes, a key next step is understanding how this information is—or should be—communicated with patients. Materials and Methods We conducted a scoping review informed by PRISMA-ScR guidelines to identify current knowledge and gaps in this domain. Results Ten studies met inclusion criteria for full text review. The following topics were represented in the studies, some of which involved more than 1 topic: disease prevention (N = 5/10, 50%), treatment decisions (N = 5/10, 50%), medication harms reduction (N = 1/10, 10%), and presentation of cardiovascular risk information (N = 5/10, 50%). A single study included 6- and 12-month clinical outcome metrics. Discussion As predictive models are increasingly published, marketed by industry, and implemented, this paucity of relevant research poses important gaps. Published studies identified the importance of (1) identifying the most effective source of information for patient communications; (2) contextualizing risk information and associated design elements based on users’ needs and problem areas; and (3) understanding potential impacts on risk factor modification and behavior change dependent on risk presentation. Conclusion An opportunity remains for researchers and practitioners to share strategies for effective selection of predictive algorithms for clinical practice, approaches for educating clinicians and patients in effectively using predictive data, and new approaches for framing patient-provider communication in the era of artificial intelligence.
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Affiliation(s)
- Colin G Walsh
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mollie M McKillop
- Center for AI Research and Evaluation, IBM Watson Health, Cambridge, Massachusetts, USA
| | - Patricia Lee
- Center for Knowledge Management, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joyce W Harris
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher Simpson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laurie Lovett Novak
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Corresponding Author: Laurie Lovett Novak, PhD, MHSA, Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1475, Nashville, TN 37203, USA;
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12
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Cowey E, Schichtel M, Cheyne JD, Tweedie L, Lehman R, Melifonwu R, Mead GE. Palliative care after stroke: A review. Int J Stroke 2021; 16:632-639. [PMID: 33949268 PMCID: PMC8366189 DOI: 10.1177/17474930211016603] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative care is an integral aspect of stroke unit care. In 2016, the American Stroke Association published a policy statement on palliative care and stroke. Since then there has been an expansion in the literature on palliative care and stroke. AIM Our aim was to narratively review research on palliative care and stroke, published since 2015. RESULTS The literature fell into three broad categories: (a) scope and scale of palliative care needs, (b) organization of palliative care for stroke, and (c) shared decision making. Most literature was observational. There was a lack of evidence about interventions that address specific palliative symptoms or improve shared decision making. Racial disparities exist in access to palliative care after stroke. There was a dearth of literature from low- and middle-income countries. CONCLUSION We recommend further research, especially in low- and middle-income countries, including research to explore why racial disparities in access to palliative care exist. Randomized trials are needed to address specific palliative care needs after stroke and to understand how best to facilitate shared decision making.
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Affiliation(s)
- Eileen Cowey
- Nursing & Health Care School, University of Glasgow, Glasgow, UK
| | - Markus Schichtel
- Institute of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Joshua D Cheyne
- Cochrane Stroke Group, Centre for Clinical Brain Sciences (CCBS), University of Edinburgh, Edinburgh, UK
| | | | - Richard Lehman
- Institute of Applied Health Research, Murray Learning Centre, University of Birmingham, Birmingham, UK
| | - Rita Melifonwu
- Life After Stroke Centre, Stroke Action Nigeria, Onitsha, Nigeria
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13
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Nguyen C, Naunton M, Thomas J, Todd L, McEwen J, Bushell M. Availability and use of number needed to treat (NNT) based decision aids for pharmaceutical interventions. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 2:100039. [PMID: 35481125 PMCID: PMC9032485 DOI: 10.1016/j.rcsop.2021.100039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/11/2021] [Accepted: 06/22/2021] [Indexed: 01/13/2023] Open
Abstract
Background The number needed to treat (NNT) is a medical statistic used to gauge the efficacy of therapeutic interventions. The versatility of this absolute effect measure has allowed its use in the formulation of many decision aids to support patients and practitioners in making informed healthcare choices. With the rising number of tools available to health professionals, this review synthesizes what is known of the current NNT-based tools which depict the efficacy of pharmaceutical interventions. Objectives To explore the current spectrum of NNT-based decision aids accessible to health professionals with a focus on the potential utility of these devices by pharmacist practitioners. Methods A literature review was performed in MEDLINE, CINAHL, Web of Science, PsychINFO and Cochrane Library (CENTRAL, Cochrane Database of Systematic Reviews and the Cochrane Methodology Register) for studies published between January 1st 2000 and August 29th 2019. The language was restricted to English unless an appropriate translation existed. Studies that reported NNT-based decision aids of pharmaceutical or therapeutic interventions were included. One author performed study selection and data extraction. Results A total of 365 records were identified, of which 19 NNT-based tools met the eligibility criteria, comprising of 8 tool databases and 11 individual decision aids. Decision aids appeared in multiple forms: databases, pictograms, graphs, interactive applications, calculators and charts. All aids were accessible online with a printer-friendly option, and very few came at a cost (e.g. requiring a subscription or access fee). The main tool innovators were the United Kingdom (UK) and United States (US), with English being the language of choice. Conclusions Evidence that NNT-based decision aids can contribute to greater satisfaction and involvement of patients in medical decision making is limited and inconclusive. A case for the utilization of these tools by pharmacists has yet to be fully examined in the medical research. NNT tools may provide a valuable resource to upskill pharmacists in communication of research evidence.
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Affiliation(s)
- Cassandra Nguyen
- University of Canberra, Discipline of Pharmacy, Faculty of Health, Australia
| | - Mark Naunton
- University of Canberra, Discipline of Pharmacy, Faculty of Health, Australia
| | - Jackson Thomas
- University of Canberra, Discipline of Pharmacy, Faculty of Health, Australia
| | - Lyn Todd
- University of Canberra, Discipline of Pharmacy, Faculty of Health, Australia
| | - John McEwen
- University of Canberra, Discipline of Pharmacy, Faculty of Health, Australia
| | - Mary Bushell
- University of Canberra, Discipline of Pharmacy, Faculty of Health, Australia
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14
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Marnane K, Gustafsson L, Bennett S, Rosbergen I, Grimley R. "Everyone needs rehab, but…": exploring post-stroke rehabilitation referral and acceptance decisions. Disabil Rehabil 2021; 44:4717-4728. [PMID: 33974463 DOI: 10.1080/09638288.2021.1918770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To explore the decision-making processes and experiences of acute and rehabilitation clinicians, regarding referral and acceptance of patients to rehabilitation after stroke. MATERIALS AND METHODS Multi-site rapid ethnography, involving observation of multidisciplinary case conferences, interviews with acute stroke and rehabilitation clinicians, and review of key documents within five (5) acute stroke units (ASUs) in Queensland, Australia. A cyclical, inductive content analysis was performed. RESULTS Seven key themes were identified, revealing the complex nature of post-stroke rehabilitation referral and acceptance decision making. Although the majority of clinicians felt that all patients could benefit from rehabilitation, they acknowledged this could not always be the case. Rehabilitation potential and goals were considered by clinicians, but decision making was impacted by ASU context and team processes, rehabilitation service availability and access procedures, and the relationships between the acute and rehabilitation clinicians. Patients and families were not actively involved in the decision-making processes. CONCLUSIONS Post-stroke rehabilitation decision making in Queensland, Australia involves complex processes and compromise. Decisions are not based solely on patients' rehabilitation needs, and patients and families are not actively involved in the decision-making process. Mechanisms are required to streamline access procedures, and improve shared decision making with patients.IMPLICATIONS FOR REHABILITATIONReferral decision making for post-stroke rehabilitation is complex and not always based solely on patients' needs.Clear and straightforward access procedures and positive relationships between acute and rehabilitation clinicians have a positive impact on referral decision making.Stroke services should review their processes to ensure shared decision making is facilitated when patients require access to rehabilitation.
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Affiliation(s)
- Kerry Marnane
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia.,Community and Oral Health Directorate, Metro North Hospital and Health Service, Herston,Australia
| | - Louise Gustafsson
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia.,School of Allied Health Sciences, Griffith University, Nathan, Australia
| | - Sally Bennett
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia
| | - Ingrid Rosbergen
- Conjoint Research Fellow Physiotherapy, STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Hospital and Health Service, Australia
| | - Rohan Grimley
- School of Medicine, Griffith University, Sunshine Coast, Australia
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15
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Trevena LJ, Bonner C, Okan Y, Peters E, Gaissmaier W, Han PKJ, Ozanne E, Timmermans D, Zikmund-Fisher BJ. Current Challenges When Using Numbers in Patient Decision Aids: Advanced Concepts. Med Decis Making 2021; 41:834-847. [PMID: 33660535 DOI: 10.1177/0272989x21996342] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Decision aid developers have to convey complex task-specific numeric information in a way that minimizes bias and promotes understanding of the options available within a particular decision. Whereas our companion paper summarizes fundamental issues, this article focuses on more complex, task-specific aspects of presenting numeric information in patient decision aids. METHODS As part of the International Patient Decision Aids Standards third evidence update, we gathered an expert panel of 9 international experts who revised and expanded the topics covered in the 2013 review working in groups of 2 to 3 to update the evidence, based on their expertise and targeted searches of the literature. The full panel then reviewed and provided additional revisions, reaching consensus on the final version. RESULTS Five of the 10 topics addressed more complex task-specific issues. We found strong evidence for using independent event rates and/or incremental absolute risk differences for the effect size of test and screening outcomes. Simple visual formats can help to reduce common judgment biases and enhance comprehension but can be misleading if not well designed. Graph literacy can moderate the effectiveness of visual formats and hence should be considered in tool design. There is less evidence supporting the inclusion of personalized and interactive risk estimates. DISCUSSION More complex numeric information. such as the size of the benefits and harms for decision options, can be better understood by using incremental absolute risk differences alongside well-designed visual formats that consider the graph literacy of the intended audience. More research is needed into when and how to use personalized and/or interactive risk estimates because their complexity and accessibility may affect their feasibility in clinical practice.
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Affiliation(s)
- Lyndal J Trevena
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Ask Share Know NHMRC Centre for Research Excellence, The University of Sydney, Australia
| | - Carissa Bonner
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Ask Share Know NHMRC Centre for Research Excellence, The University of Sydney, Australia
| | - Yasmina Okan
- Centre for Decision Research, University of Leeds, Leeds, UK
| | | | | | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA.,School of Medicine, Tufts University, Medford, MA, USA
| | | | - Danielle Timmermans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, North Holland, The Netherlands
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16
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Moshayedi P, Liebeskind DS, Jadhav A, Jahan R, Lansberg M, Sharma L, Nogueira RG, Saver JL. Decision-Making Visual Aids for Late, Imaging-Guided Endovascular Thrombectomy for Acute Ischemic Stroke. J Stroke 2020; 22:377-386. [PMID: 33053953 PMCID: PMC7568977 DOI: 10.5853/jos.2019.03503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 06/22/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Speedy decision-making is important for optimal outcomes from endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Figural decision aids facilitate rapid review of treatment benefits and harms, but have not yet been developed for late-presenting patients selected for EVT based on multimodal computed tomography or magnetic resonance imaging. METHODS For combined pooled study-level randomized trial (DAWN and DEFUSE 3) data, as well as each trial singly, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of EVT for patients with AIS and large vessel occlusion using automated (algorithmic) and expert-guided joint outcome table specification. RESULTS Among imaging-selected patients 6 to 24 hours from last known well, for the full 7-category modified Rankin Scale (mRS), EVT had number needed to treat to benefit 1.9 (interquartile range [IQR], 1.9 to 2.1) and number needed to harm 40.0 (IQR, 29.2 to 58.3). Visual displays of treatment effects among 100 patients showed that, with EVT: 52 patients have better disability outcome, including 32 more achieving functional independence (mRS 0 to 2); three patients have worse disability outcome, including one more experiencing severe disability or death (mRS 5 to 6), mediated by symptomatic intracranial hemorrhage and infarct in new territory. Similar features were present in person-icon figures based on a 6-level mRS (levels 5 and 6 combined) rather than 7-level mRS, and based on the DAWN trial alone and DEFUSE 3 trial alone. CONCLUSIONS Personograph visual decision aids are now available to rapidly educate patients, family, and healthcare providers regarding benefits and risks of EVT for late-presenting, imaging-selected AIS patients.
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Affiliation(s)
- Pouria Moshayedi
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Ashutosh Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Reza Jahan
- Department of Radiology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Latisha Sharma
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
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17
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Patel MD, Namboodri BL, Platts-Mills TF. Modernizing Informed Consent During Emergency Care. Ann Emerg Med 2020; 76:350-352. [DOI: 10.1016/j.annemergmed.2019.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Indexed: 11/27/2022]
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18
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Dorsett M, Cooper RJ, Taira BR, Wilkes E, Hoffman JR. Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emerg Med J 2019; 37:240-245. [PMID: 31874920 DOI: 10.1136/emermed-2019-209031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/25/2019] [Accepted: 12/09/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Maia Dorsett
- Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Richelle J Cooper
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Breena R Taira
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Erin Wilkes
- Kaiser Permanente LAMC, Los Angeles, California, USA
| | - Jerome R Hoffman
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
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19
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Clua-Espuny JL, Abilleira S, Queralt-Tomas L, Gonzalez-Henares A, Gil-Guillen V, Muria-Subirats E, Ballesta-Ors J. Long-Term Survival After Stroke According to Reperfusion Therapy, Cardiovascular Therapy and Gender. Cardiol Res 2019; 10:89-97. [PMID: 31019638 PMCID: PMC6469916 DOI: 10.14740/cr839] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/16/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND A wide variety of factors influence stroke prognosis, including age, stroke severity and comorbid conditions; but most current information about outcomes and safety is derived from patients at 3 - 12 months and mostly coming from the hospital activity. The aim of this study is to evaluate whether treatment strategies have a differential impact on long-survival after acute ischemic stroke among men versus women. METHODS Acute ischemic stroke patients identified from the population-based register between January 1, 2011 and December 31, 2012 were included, and they were classified into: 1) Acute ischemic stroke + intravenous thrombolysis (group I); 2) Acute ischemic stroke + mechanical thrombectomy with or without intravenous thrombolysis (group II); 3) Acute ischemic stroke + medical therapy alone (no reperfusion therapies) (group III). Follow-up went through up until December 2016. The probability of survival was estimated by the Kaplan-Meier method, and the hazard ratio was obtained by using the Cox proportional hazard regression models. Mortality was interpreted as overall mortality. RESULTS A total of 14,368 cases (men 50.1%), 77.1 ± 11.0 years old were included. There was higher survival among those treated with intravenous thrombolysis (P < 0.001); women treated with thrombectomy (P < 0.001); and women < 80 years old without reperfusion therapy. The most common medications were antiplatelets (52.8%), associated with lower survival (P < 0.001); and statins (46.5%), associated with higher survival. The regression model produced the following independent outcome variables associated to mortality: anticoagulant hazard ratio (HR) 1.53 (95% confidence interval (95% CI): 1.44 - 1.63, P < 0.001), diuretics HR 1.71 (95% CI: 1.63 - 1.79, P < 0.001), antiplatelet HR 1.49 (95% CI: 1.42 - 1.56, P < 0.001), statins HR 0.73 (95% CI: 0.70 - 0.77; P < 0.001), angiotensin II receptor antagonists HR 0.93 (95% CI: 0.89 - 0.98, P = 0.008) and reperfusion therapy HR 0.88 (95% CI: 0.81 - 0.97, P = 0.009). CONCLUSIONS Men and women have different prognoses after revascularization treatment for acute ischemic stroke. Under 80 years old the women appear to have a better outcome than men when treated with thrombolysis therapy and/or catheter-based thrombectomy. The chronic cardiovascular pharmacotherapy must be evaluated whether they should be included as factors in the decision to reperfusion.
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Affiliation(s)
- Jose Luis Clua-Espuny
- EAP-Tortosa 1-Est, Catalonian Health Institute, SAP Terres de l’Ebre, Health Department, Generalitat de Catalunya, CAP Temple, 43500 Tortosa, Spain
- Department of Research, ICS Terres de l’Ebre, Research Institute University Primary Care (IDIAP) Jordi Gol, Barcelona, Spain
| | - Sonia Abilleira
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, CIBER Epidemiologia y Salud Publica (CIBERESP), Edifici Salvany, Roc Boronat 81-95, 2a planta 08005, Barcelona, Spain
| | - Lluisa Queralt-Tomas
- EAP-Tortosa-2-Oest, Catalonian Health Institute, SAP Terres de l’Ebre, Health Department, Generalitat de Catalunya, CAP Xerta, Barcelona, 43592 Catalonia, Spain
| | - Antonia Gonzalez-Henares
- Department of Research, ICS Terres de l’Ebre, Research Institute University Primary Care (IDIAP) Jordi Gol, Barcelona, Spain
- EAP-Alcanar-St Carlos de la Rapita, Catalonian Health Institute, SAP Terres de l’Ebre, Health Department, Generalitat de Catalunya, CAP St Carles de la Rapita, 43540, Spain
| | - Vicente Gil-Guillen
- Clinical Evidence Based Medicine and Emotional Department, Miguel Hernandez University, Family and Community Specialty, Crta. Nacional, N-332 s/n, 03550 Sant Joan (Alicante), Spain
| | - Eulalia Muria-Subirats
- UUDD Tortosa-Terres de l’Ebre, Catalonian Health Institute, SAP Terres de l’Ebre, Health Department, Generalitat de Catalunya, CAP Temple, 43500 Tortosa, Spain
| | - Juan Ballesta-Ors
- UUDD Tortosa-Terres de l’Ebre, Catalonian Health Institute, SAP Terres de l’Ebre, Health Department, Generalitat de Catalunya, CAP Temple, 43500 Tortosa, Spain
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20
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De Brún A, Flynn D, Ternent L, Price CI, Rodgers H, Ford GA, Rudd M, Lancsar E, Simpson S, Teah J, Thomson RG. A novel design process for selection of attributes for inclusion in discrete choice experiments: case study exploring variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke. BMC Health Serv Res 2018; 18:483. [PMID: 29929523 PMCID: PMC6013945 DOI: 10.1186/s12913-018-3305-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 06/18/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND A discrete choice experiment (DCE) is a method used to elicit participants' preferences and the relative importance of different attributes and levels within a decision-making process. DCEs have become popular in healthcare; however, approaches to identify the attributes/levels influencing a decision of interest and to selection methods for their inclusion in a DCE are under-reported. Our objectives were: to explore the development process used to select/present attributes/levels from the identified range that may be influential; to describe a systematic and rigorous development process for design of a DCE in the context of thrombolytic therapy for acute stroke; and, to discuss the advantages of our five-stage approach to enhance current guidance for developing DCEs. METHODS A five-stage DCE development process was undertaken. Methods employed included literature review, qualitative analysis of interview and ethnographic data, expert panel discussions, a quantitative structured prioritisation (ranking) exercise and pilot testing of the DCE using a 'think aloud' approach. RESULTS The five-stage process reported helped to reduce the list of 22 initial patient-related factors to a final set of nine variable factors and six fixed factors for inclusion in a testable DCE using a vignette model of presentation. CONCLUSIONS In order for the data and conclusions generated by DCEs to be deemed valid, it is crucial that the methods of design and development are documented and reported. This paper has detailed a rigorous and systematic approach to DCE development which may be useful to researchers seeking to establish methods for reducing and prioritising attributes for inclusion in future DCEs.
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Affiliation(s)
- Aoife De Brún
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK. .,School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland.
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Ternent
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher I Price
- NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Trust and Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Gary A Ford
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Matthew Rudd
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Emily Lancsar
- Department of Health Services Research and Policy, Research School of Population Health, Australian National University, Canberra, Australia
| | | | - John Teah
- The Stroke Association, Gateshead, UK
| | - Richard G Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Gong J, Xiao W, Gao H, Wei W, Zhang W, Lv J, Xiao L, Duan L, Zhang Y, Liu H, Huang Y. How to Best Convey Information About Intensive/Comfort Care to the Family Members of Premature Infants to Enable Unbiased Perinatal Decisions. Front Pediatr 2018; 6:348. [PMID: 30519551 PMCID: PMC6251209 DOI: 10.3389/fped.2018.00348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 10/26/2018] [Indexed: 11/13/2022] Open
Abstract
Background: As the infant's best interests are determined through the perinatal decisions of family members and physicians, it is important to understand the factors that affect such decisions. This paper investigated the separate and combined effects of various factors related to perinatal decision making and sought to determine the best way to convey information in an unbiased manner to family members. Methods: In total, 613 participants were consecutively recruited. Each participant completed a series of surveys. All responses to four items were examined via a latent class analysis (LCA) to identify subgroups of participants with similar preferences for intensive care (IC) and comfort care (CC) regarding their potentially premature infant. Multiple logistic regression analyses were applied to identify the sociodemographic predictors for the classification of participants into different subgroups. Results: χ2-tests indicated that perinatal decision making for Item 2 was influenced by framing information, whereas decision making wasn't affected by presentation modes. Furthermore, the endorsement rates of IC significantly decreased with the information increased from brief to detailed, regardless of framing or presentation mode. The LCA indicated that a 3-subgroup model, which included the IC, CC, and variation subgroups, was optimal. Logistic regression analyses demonstrated that, compared with the IC subgroup, negative framing, higher education, parenthood, and poor numeracy predicted participants' preferences for CC. Meanwhile, worrying about physical or mental disabilities predicted preferences for CC and sensitivity to the amount of information provided regarding treatment options (variation subgroup). Conclusions: Perinatal decision making is affected by many factors, suggesting that more detailed information, improved understandability of numerical data, and a neutral tone of voice regarding therapeutic outcomes would be helpful for the families of premature infants to make unbiased decisions. Our findings should be replicated in future research.
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Affiliation(s)
- Jingjing Gong
- Department of Neurology, PLA Army General Hospital, Beijing, China
| | - Wei Xiao
- Department of Medical Psychology, Air Force Medical University, Xi'an, China
| | - Hongyan Gao
- Department of Medical Administration, PLA Army General Hospital, Beijing, China
| | - Wei Wei
- Department of Neurology, PLA Army General Hospital, Beijing, China
| | - Weiwei Zhang
- Department of Neurology, PLA Army General Hospital, Beijing, China
| | - Jing Lv
- Department of Psychology, PLA General Hospital, Beijing, China
| | - Lijun Xiao
- Department of Paediatrics, PLA Army General Hospital, Beijing, China
| | - Lida Duan
- Department of Medical Administration, PLA Zhurihe Base Hospital, Zhurihe, China
| | - Yan Zhang
- Center of Psychology, Air Force Aviation Medicine Research Institute, Beijing, China
| | - Hongyun Liu
- School of Psychology, Beijing Normal University, Beijing, China
| | - Yonghua Huang
- Department of Neurology, PLA Army General Hospital, Beijing, China
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22
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Tokunboh I, Vales Montero M, Zopelaro Almeida MF, Sharma L, Starkman S, Szeder V, Jahan R, Liebeskind D, Gonzalez N, Demchuk A, Froehler MT, Goyal M, Lansberg MG, Lutsep H, Schwamm L, Saver JL. Visual Aids for Patient, Family, and Physician Decision Making About Endovascular Thrombectomy for Acute Ischemic Stroke. Stroke 2017; 49:90-97. [PMID: 29222229 DOI: 10.1161/strokeaha.117.018715] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 10/18/2017] [Accepted: 10/26/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Rapid decision making optimizes outcomes from endovascular thrombectomy for acute cerebral ischemia. Visual displays facilitate swift review of potential outcomes and can accelerate decision processes. METHODS From patient-level, pooled randomized trial data, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of endovascular thrombectomy for patients with acute cerebral ischemia and large vessel occlusion using (1) automated (algorithmic) and (2) expert-guided joint outcome table specification. RESULTS For the full 7-category modified Rankin Scale, thrombectomy added to IV tPA (intravenous tissue-type plasminogen activator) alone had number needed to treat to benefit 2.9 (95% confidence interval, 2.6-3.3) and number needed to harm 68.9 (95% confidence interval, 40-250); thrombectomy for patients ineligible for IV tPA had number needed to treat to benefit 2.3 (95% confidence interval, 2.1-2.5) and number needed to harm 100 (95% confidence interval, 62.5-250). Visual displays of treatment effects on 100 patients showed: with thrombectomy added to IV tPA alone, 34 patients have better disability outcome, including 14 more normal or near normal (modified Rankin Scale, 0-1); with thrombectomy for patients ineligible for IV tPA, 44 patients have a better disability outcome, including 16 more normal or nearly normal. Displays also showed that harm (increased modified Rankin Scale final disability) occurred in 1 of 100 patients in both populations, mediated by increased new territory infarcts. The person-icon figures integrated these outcomes, and early side-effects, in a single display. CONCLUSIONS Visual decision aids are now available to rapidly educate healthcare providers, patients, and families about benefits and risks of endovascular thrombectomy, both when added to IV tPA in tPA-eligible patients and as the sole reperfusion treatment in tPA-ineligible patients.
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Affiliation(s)
- Ivie Tokunboh
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.).
| | - Marta Vales Montero
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Matheus Fellipe Zopelaro Almeida
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Latisha Sharma
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Sidney Starkman
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Viktor Szeder
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Reza Jahan
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - David Liebeskind
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Nestor Gonzalez
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Andrew Demchuk
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Michael T Froehler
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Mayank Goyal
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Maarten G Lansberg
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Helmi Lutsep
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Lee Schwamm
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
| | - Jeffrey L Saver
- From the Department of Neurology and Comprehensive Stroke Center (I.T., L.S., D.L., J.L.S.), Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center (S.S.), and Department of Radiology and Comprehensive Stroke Center (V.S., R.J.), David Geffen School of Medicine, University of California Los Angeles; Hospital General Universitario Gregorio Marañón with the collaboration of Comité ad-hoc de Neurólogos Jóvenes de la Sociedad Española de Neurología, Madrid, Spain (M.V.M.); School of Medicine at Federal University of São João del-Rei (UFSJ), Brazil (M.F.Z.A.); Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (N.G.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, Foothills Hospital (A.D.) and Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute (M.T.F), University of Calgary, Alberta, Canada; Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.G.); Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L.); Department of Neurology and Stroke Center, Oregon Health & Science University, Portland (H.L.); and Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.S.)
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23
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Probst MA, Kanzaria HK, Schoenfeld EM, Menchine MD, Breslin M, Walsh C, Melnick ER, Hess EP. Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians. Ann Emerg Med 2017; 70:688-695. [PMID: 28559034 PMCID: PMC5834305 DOI: 10.1016/j.annemergmed.2017.03.063] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/22/2017] [Accepted: 03/27/2017] [Indexed: 01/27/2023]
Abstract
Shared decisionmaking has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention shared decisionmaking has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain in regard to the precise meaning of the term, the process, and the conditions under which it is most likely to be valuable. With the help of a patient representative and an interaction designer, we developed a simple framework to illustrate how shared decisionmaking should be approached in clinical practice. We believe it should be the preferred or default approach to decisionmaking, except in clinical situations in which 3 factors interfere. These 3 factors are lack of clinical uncertainty or equipoise, patient decisionmaking ability, and time, all of which can render shared decisionmaking infeasible. Clinical equipoise refers to scenarios in which there are 2 or more medically reasonable management options. Patient decisionmaking ability refers to a patient's capacity and willingness to participate in his or her emergency care decisions. Time refers to the acuity of the clinical situation (which may require immediate action) and the time that the clinician has to devote to the shared decisionmaking conversation. In scenarios in which there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion used as appropriate. If time or patient capacity is lacking, physician-directed decisionmaking will occur. With this framework as the foundation, we discuss the process of shared decisionmaking and how it can be used in practice. Finally, we highlight 5 common misconceptions in regard to shared decisionmaking in the ED. With an improved understanding of shared decisionmaking, this approach should be used to facilitate the provision of high-quality, patient-centered emergency care.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California at San Francisco, San Francisco General Hospital, San Francisco, CA
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, Baystate Medical Center/Tufts School of Medicine, Springfield, MA
| | - Michael D Menchine
- Department of Emergency Medicine, University of Southern California/Keck School of Medicine, Los Angeles, CA
| | | | | | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Erik P Hess
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
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Liberati EG, Ruggiero F, Galuppo L, Gorli M, González-Lorenzo M, Maraldi M, Ruggieri P, Friz HP, Scaratti G, Kwag KH, Vespignani R, Moja L. What hinders the uptake of computerized decision support systems in hospitals? A qualitative study and framework for implementation. Implement Sci 2017; 12:113. [PMID: 28915822 PMCID: PMC5602839 DOI: 10.1186/s13012-017-0644-2] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 09/04/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Advanced Computerized Decision Support Systems (CDSSs) assist clinicians in their decision-making process, generating recommendations based on up-to-date scientific evidence. Although this technology has the potential to improve the quality of patient care, its mere provision does not guarantee uptake: even where CDSSs are available, clinicians often fail to adopt their recommendations. This study examines the barriers and facilitators to the uptake of an evidence-based CDSS as perceived by diverse health professionals in hospitals at different stages of CDSS adoption. METHODS Qualitative study conducted as part of a series of randomized controlled trials of CDSSs. The sample includes two hospitals using a CDSS and two hospitals that aim to adopt a CDSS in the future. We interviewed physicians, nurses, information technology staff, and members of the boards of directors (n = 30). We used a constant comparative approach to develop a framework for guiding implementation. RESULTS We identified six clusters of experiences of, and attitudes towards CDSSs, which we label as "positions." The six positions represent a gradient of acquisition of control over CDSSs (from low to high) and are characterized by different types of barriers to CDSS uptake. The most severe barriers (prevalent in the first positions) include clinicians' perception that the CDSSs may reduce their professional autonomy or may be used against them in the event of medical-legal controversies. Moving towards the last positions, these barriers are substituted by technical and usability problems related to the technology interface. When all barriers are overcome, CDSSs are perceived as a working tool at the service of its users, integrating clinicians' reasoning and fostering organizational learning. CONCLUSIONS Barriers and facilitators to the use of CDSSs are dynamic and may exist prior to their introduction in clinical contexts; providing a static list of obstacles and facilitators, irrespective of the specific implementation phase and context, may not be sufficient or useful to facilitate uptake. Factors such as clinicians' attitudes towards scientific evidences and guidelines, the quality of inter-disciplinary relationships, and an organizational ethos of transparency and accountability need to be considered when exploring the readiness of a hospital to adopt CDSSs.
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Affiliation(s)
- Elisa G. Liberati
- Cambridge Centre for Health Services Research (CCHSR), Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
| | - Francesca Ruggiero
- Unità di Epidemiologia Clinica, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Carlo Pascal 36, 20133 Milan, Italy
| | - Laura Galuppo
- Dipartimento di Psicologia, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 1, 20123 Milan, Italy
| | - Mara Gorli
- Dipartimento di Psicologia, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 1, 20123 Milan, Italy
| | - Marien González-Lorenzo
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Carlo Pascal 36, 20133 Milan, Italy
| | - Marco Maraldi
- Clinica Ortopedica, Università degli Studi di Padova, Via Giustiniani 3, 35128 Padova, Italy
| | - Pietro Ruggieri
- Clinica Ortopedica, Università degli Studi di Padova, Via Giustiniani 3, 35128 Padova, Italy
| | - Hernan Polo Friz
- Dipartimento Internistico, Ospedale di Vimercate, Via Santi Cosma e Damiano 10, 20871 Vimercate, Italy
| | - Giuseppe Scaratti
- Dipartimento di Psicologia, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 1, 20123 Milan, Italy
| | - Koren H. Kwag
- Medical School of International Health, Ben Gurion University of the Negev, P.O. Box 653, 84105 Beersheva, Israel
| | - Roberto Vespignani
- IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Via Piero Maroncelli 40, 47014 Meldola, Italy
| | - Lorenzo Moja
- Unità di Epidemiologia Clinica, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Carlo Pascal 36, 20133 Milan, Italy
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Visvanathan A, Dennis M, Mead G, Whiteley WN, Lawton J, Doubal FN. Shared decision making after severe stroke—How can we improve patient and family involvement in treatment decisions? Int J Stroke 2017; 12:920-922. [DOI: 10.1177/1747493017730746] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
People who are well may regard survival with disability as being worse than death. However, this is often not the case when those surviving with disability (e.g. stroke survivors) are asked the same question. Many routine treatments provided after an acute stroke (e.g. feeding via a tube) increase survival, but with disability. Therefore, clinicians need to support patients and families in making informed decisions about the use of these treatments, in a process termed shared decision making. This is challenging after acute stroke: there is prognostic uncertainty, patients are often too unwell to participate in decision making, and proxies may not know the patients’ expressed wishes (i.e. values). Patients’ values also change over time and in different situations. There is limited evidence on successful methods to facilitate this process. Changes targeted at components of shared decision making (e.g. decision aids to provide information and discussing patient values) increase patient satisfaction. How this influences decision making is unclear. Presumably, a “shared decision-making tool” that introduces effective changes at various stages in this process might be helpful after acute stroke. For example, by complementing professional judgement with predictions from prognostic models, clinicians could provide information that is more accurate. Decision aids that are personalized may be helpful. Further qualitative research can provide clinicians with a better understanding of patient values and factors influencing this at different time points after a stroke. The evaluation of this tool in its success to achieve outcomes consistent with patients’ values may require more than one clinical trial.
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Affiliation(s)
- Akila Visvanathan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Gillian Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - William N Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Julia Lawton
- Usher Institute for Population Sciences, Edinburgh, UK
| | - Fergus Neil Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Armstrong MJ. Shared decision-making in stroke: an evolving approach to improved patient care. Stroke Vasc Neurol 2017; 2:84-87. [PMID: 28959495 PMCID: PMC5600016 DOI: 10.1136/svn-2017-000081] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/10/2017] [Indexed: 11/21/2022] Open
Abstract
Shared decision-making (SDM) occurs when patients, families and clinicians consider patients' values and preferences alongside the best medical evidence and partner to make the best decision for a given patient in a specific scenario. SDM is increasingly promoted within Western contexts and is also being explored outside such settings, including in China. SDM and tools to promote SDM can improve patients' knowledge/understanding, participation in the decision-making process, satisfaction and trust in the healthcare team. SDM has also proposed long-term benefits to patients, clinicians, organisations and healthcare systems. To successfully perform SDM, clinicians must know their patients' values and goals and the evidence underlying different diagnostic and treatment options. This is relevant for decisions throughout stroke care, from thrombolysis to goals of care, diagnostic assessments, rehabilitation strategies, and secondary stroke prevention. Various physician, patient, family, cultural and system barriers to SDM exist. Strategies to overcome these barriers and facilitate SDM include clinician motivation, patient participation, adequate time and tools to support the process, such as decision aids. Although research about SDM in stroke care is lacking, decision aids are available for select decisions, such as anticoagulation for stroke prevention in atrial fibrillation. Future research is needed regarding both cultural aspects of successful SDM and application of SDM to stroke-specific contexts.
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Affiliation(s)
- Melissa J Armstrong
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
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27
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CT and MRI-based door-needle-times for acute stroke patients a quasi-randomized clinical trial. Clin Neurol Neurosurg 2017; 159:42-49. [PMID: 28531828 DOI: 10.1016/j.clineuro.2017.05.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 04/30/2017] [Accepted: 05/08/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Door-Needle-times (DNT) of 20min are feasible when Computer Tomography (CT) is used for first-line brain-imaging to assess stroke-patients' eligibility for intravenous-tissue-Plasminogen-Activator (iv-tPA), but the more time-consuming Magnetic Resonance Imaging (MRI)-based-evaluation is superior in detecting acute ischaemia.
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Thomson RG, De Brún A, Flynn D, Ternent L, Price CI, Rodgers H, Ford GA, Rudd M, Lancsar E, Simpson S, Teah J. Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BackgroundIntravenous thrombolysis for patients with acute ischaemic stroke is underused (only 80% of eligible patients receive it) and there is variation in its use across the UK. Previously, variation might have been explained by structural differences; however, continuing variation may reflect differences in clinical decision-making regarding the eligibility of patients for treatment. This variation in decision-making could lead to the underuse, or result in inappropriate use, of thrombolysis.ObjectivesTo identify the factors which contribute to variation in, and influence, clinicians’ decision-making about treating ischaemic stroke patients with intravenous thrombolysis.MethodsA discrete choice experiment (DCE) using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted to better understand the influence of patient-related and clinician-related factors on clinical decision-making. An online DCE was developed following an iterative five-stage design process. UK-based clinicians involved in final decision-making about thrombolysis were invited to take part via national professional bodies of relevant medical specialties. Mixed-logit regression analyses were conducted.ResultsA total of 138 clinicians responded and opted to offer thrombolysis in 31.4% of cases. Seven patient factors were individually predictive of the increased likelihood of offering thrombolysis (compared with reference levels in brackets): stroke onset time of 2 hours 30 minutes (50 minutes); pre-stroke dependency modified Rankin Scale score (mRS) of 3 (mRS4); systolic blood pressure (SBP) of 185 mmHg (140 mmHg); stroke severity scores of National Institutes of Health Stroke Scale (NIHSS) 5 without aphasia, NIHSS 14 and NIHSS 23 (NIHSS 2 without aphasia); age 85 years (65 years); and Afro-Caribbean (white). Factors predictive of not offering thrombolysis were age 95 years; stroke onset time of 4 hours 15 minutes; severe dementia (no memory problems); and SBP of 200 mmHg. Three clinician-related factors were predictive of an increased likelihood of offering thrombolysis (perceived robustness of the evidence for thrombolysis; thrombolysing more patients in the past 12 months; and high discomfort with uncertainty) and one factor was predictive of a decreased likelihood of offering treatment (clinicians’ being comfortable treating patients outside the licensing criteria).LimitationsWe anticipated a sample size of 150–200. Nonetheless, the final sample of 138 is good considering that the total population of eligible UK clinicians is relatively small. Furthermore, data from the Royal College of Physicians suggest that our sample is representative of clinicians involved in decision-making about thrombolysis.ConclusionsThere was considerable heterogeneity among respondents in thrombolysis decision-making, indicating that clinicians differ in their thresholds for treatment across a number of patient-related factors. Respondents were significantly more likely to treat 85-year-old patients than patients aged 68 years and this probably reflects acceptance of data from Third International Stroke Trial that report benefit for patients aged > 80 years. That respondents were more likely to offer thrombolysis to patients with severe stroke than to patients with mild stroke may indicate uncertainty/concern about the risk/benefit balance in treatment of minor stroke. Findings will be disseminated via peer-review publication and presentation at national/international conferences, and will be linked to training/continuing professional development (CPD) programmes.Future workThe nature of DCE design means that only a subset of potentially influential factors could be explored. Factors not explored in this study warrant future research. Training/CPD should address the impact of non-medical influences on decision-making using evidence-based strategies.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Richard G Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Aoife De Brún
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Ternent
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher I Price
- Stroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- Stroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Matthew Rudd
- Stroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Emily Lancsar
- Centre for Health Economics, Monash University, Melbourne, VIC, Australia
| | | | - John Teah
- The Stroke Association, Gateshead, UK
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Melnick ER, Probst MA, Schoenfeld E, Collins SP, Breslin M, Walsh C, Kuppermann N, Dunn P, Abella BS, Boatright D, Hess EP. Development and Testing of Shared Decision Making Interventions for Use in Emergency Care: A Research Agenda. Acad Emerg Med 2016; 23:1346-1353. [PMID: 27457137 DOI: 10.1111/acem.13045] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 06/30/2016] [Accepted: 07/07/2016] [Indexed: 11/30/2022]
Abstract
Decision aids are evidenced-based tools designed to increase patient understanding of medical options and possible outcomes, facilitate conversation between patients and clinicians, and improve patient engagement. Decision aids have been used for shared decision making (SDM) interventions outside of the ED setting for more than a decade. Their use in the ED has only recently begun to be studied. This article provides background on this topic and the conclusions of the 2016 Academic Emergency Medicine consensus conference SDM in practice work group regarding "Shared Decision Making in the Emergency Department: Development of a Policy-Relevant, Patient-Centered Research Agenda." The goal was to determine a prioritized research agenda for the development and testing of SDM interventions for use in emergency care that was most important to patients, clinicians, caregivers, and other key stakeholders. Using the nominal group technique, the consensus working group proposed prioritized research questions in six key domains: 1) content (i.e., clinical scenario or decision area), 2) level of evidence available, 3) tool design strategies, 4) risk communication, 5) stakeholders, and 6) outcomes.
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Affiliation(s)
- Edward R. Melnick
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Marc A. Probst
- Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
| | | | - Sean P. Collins
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | | | | | - Nathan Kuppermann
- Department of Emergency Medicine; University of California; Davis School of Medicine; Sacramento CA
| | - Pat Dunn
- Patient and Healthcare Innovations and Center for Health Technology and Innovation; American Heart Association; Dallas TX
| | - Benjamin S. Abella
- Department of Emergency Medicine; University of Pennsylvania; Philadelphia PA
| | - Dowin Boatright
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
- Robert Wood Johnson Clinical Scholar Program; Yale University School of Medicine; New Haven CT
| | - Erik P. Hess
- Department of Emergency Medicine; Mayo Clinic College of Medicine; Rochester MN
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Standing H, Exley C, Flynn D, Hughes J, Joyce K, Lobban T, Lord S, Matlock D, McComb JM, Paes P, Thomson RG. A qualitative study of decision-making about the implantation of cardioverter defibrillators and deactivation during end-of-life care. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04320] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background
Implantable cardioverter defibrillators (ICDs) are recommended for patients at high risk of sudden cardiac death or for survivors of cardiac arrest. All ICDs combine a shock function with a pacing function to treat fast and slow heart rhythms, respectively. The pacing function may be very sophisticated and can provide so-called cardiac resynchronisation therapy for the treatment of heart failure using a pacemaker (cardiac resynchronisation therapy with pacemaker) or combined with an ICD [cardiac resynchronisation therapy with defibrillator (CRT-D)]. Decision-making about these devices involves considering the benefit (averting sudden cardiac death), possible risks (inappropriate shocks and psychological problems) and the potential need for deactivation towards the end of life.
Objectives
To explore patients’/relatives’ and clinicians’ views/experiences of decision-making about ICD and CRT-D implantation and deactivation, to establish how and when ICD risks, benefits and consequences are communicated to patients, to identify individual and organisational facilitators and barriers to discussions about implantation and deactivation and to determine information and decision-support needs for shared decision-making (SDM).
Data sources
Observations of clinical encounters, in-depth interviews and interactive group workshops with clinicians, patients and their relatives.
Methods
Observations of consultations with patients being considered for ICD or CRT-D implantation were undertaken to become familiar with the clinical environment and to optimise the sampling strategy. In-depth interviews were conducted with patients, relatives and clinicians to gain detailed insights into their views and experiences. Data collection and analysis occurred concurrently. Interactive workshops with clinicians and patients/relatives were used to validate our findings and to explore how these could be used to support better SDM.
Results
We conducted 38 observations of clinical encounters, 80 interviews (44 patients/relatives, seven bereaved relatives and 29 clinicians) and two workshops with 11 clinicians and 11 patients/relatives. Patients had variable knowledge about their conditions, the risk of sudden cardiac death and the clinical rationale for ICDs, which sometimes resulted in confusion about the potential benefits. Clinicians used various metaphors, verbal descriptors and numerical risk methods, including variable disclosure of the potential negative impact of ICDs on body image and the risk of psychological problems, to convey information to patients/relatives. Patients/relatives wanted more information about, and more involvement in, deactivation decisions, and expressed a preference that these decisions be addressed at the time of implantation. There was no consensus among clinicians about the initiation or timing of such discussions, or who should take responsibility for them. Introducing deactivation discussions prior to implantation was thus contentious; however, trigger points for deactivation discussions embedded within the pathway were suggested to ensure timely discussions.
Limitations
Only two patients who were prospectively considering deactivation and seven bereaved relatives were recruited. The study also lacks the perspectives of primary care clinicians.
Conclusions
There is discordance between patients and clinicians on information requirements, in particular the potential consequences of implantation on psychological well-being and quality of life in the short and long term (deactivation). There were no agreed points across the care pathway at which to discuss deactivation. Codesigned information tools that present balanced information on the benefits, risks and consequences, and SDM skills training for patients/relative and clinicians, would support better SDM about ICDs.
Future work
Multifaceted SDM interventions that focus on skills development for SDM combined with decision-support tools are warranted, and there is a potential central role for heart failure nurses and physiologists in supporting and preparing patients/relatives for such discussions.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Holly Standing
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Julian Hughes
- Policy, Ethics and Life Sciences Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Kerry Joyce
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Trudie Lobban
- Arrhythmia Alliance: The Heart Rhythm Charity, Stratford-upon-Avon, UK
| | - Stephen Lord
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Daniel Matlock
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Janet M McComb
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Paul Paes
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Richard G Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Du HS, Ma JJ, Li M. High-quality Health Information Provision for Stroke Patients. Chin Med J (Engl) 2016; 129:2115-22. [PMID: 27569241 PMCID: PMC5009598 DOI: 10.4103/0366-6999.189065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE High-quality information provision can allow stroke patients to effectively participate in healthcare decision-making, better manage the stroke, and make a good recovery. In this study, we reviewed information needs of stroke patients, methods for providing information to patients, and considerations needed by the information providers. DATA SOURCES The literature concerning or including information provision for patients with stroke in English was collected from PubMed published from 1990 to 2015. STUDY SELECTION We included all the relevant articles on information provision for stroke patients in English, with no limitation of study design. RESULTS Stroke is a major public health concern worldwide. High-quality and effective health information provision plays an essential role in helping patients to actively take part in decision-making and healthcare, and empowering them to effectively self-manage their long-standing chronic conditions. Different methods for providing information to patients have their relative merits and suitability, and as a result, the effective strategies taken by health professionals may include providing high-quality information, meeting patients' individual needs, using suitable methods in providing information, and maintaining active involvement of patients. CONCLUSIONS It is suggested that to enable stroke patients to access high-quality health information, greater efforts need to be made to ensure patients to receive accurate and current evidence-based information which meets their individual needs. Health professionals should use suitable information delivery methods, and actively involve stroke patients in information provision.
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Affiliation(s)
- Hong-Sheng Du
- Department of Neurosurgery, Tianjin First Central Hospital, Tianjin 300192, China
| | - Jing-Jian Ma
- Department of Neurosurgery, Tianjin First Central Hospital, Tianjin 300192, China
| | - Mu Li
- Department of Neurosurgery, Tianjin First Central Hospital, Tianjin 300192, China
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Whiteley WN, Emberson J, Lees KR, Blackwell L, Albers G, Bluhmki E, Brott T, Cohen G, Davis S, Donnan G, Grotta J, Howard G, Kaste M, Koga M, von Kummer R, Lansberg MG, Lindley RI, Lyden P, Olivot JM, Parsons M, Toni D, Toyoda K, Wahlgren N, Wardlaw J, Del Zoppo GJ, Sandercock P, Hacke W, Baigent C. Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis. Lancet Neurol 2016; 15:925-933. [PMID: 27289487 DOI: 10.1016/s1474-4422(16)30076-x] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Randomised trials have shown that alteplase improves the odds of a good outcome when delivered within 4·5 h of acute ischaemic stroke. However, alteplase also increases the risk of intracerebral haemorrhage; we aimed to determine the proportional and absolute effects of alteplase on the risks of intracerebral haemorrhage, mortality, and functional impairment in different types of patients. METHODS We used individual patient data from the Stroke Thrombolysis Trialists' (STT) meta-analysis of randomised trials of alteplase versus placebo (or untreated control) in patients with acute ischaemic stroke. We prespecified assessment of three classifications of intracerebral haemorrhage: type 2 parenchymal haemorrhage within 7 days; Safe Implementation of Thrombolysis in Stroke Monitoring Study's (SITS-MOST) haemorrhage within 24-36 h (type 2 parenchymal haemorrhage with a deterioration of at least 4 points on National Institutes of Health Stroke Scale [NIHSS]); and fatal intracerebral haemorrhage within 7 days. We used logistic regression, stratified by trial, to model the log odds of intracerebral haemorrhage on allocation to alteplase, treatment delay, age, and stroke severity. We did exploratory analyses to assess mortality after intracerebral haemorrhage and examine the absolute risks of intracerebral haemorrhage in the context of functional outcome at 90-180 days. FINDINGS Data were available from 6756 participants in the nine trials of intravenous alteplase versus control. Alteplase increased the odds of type 2 parenchymal haemorrhage (occurring in 231 [6·8%] of 3391 patients allocated alteplase vs 44 [1·3%] of 3365 patients allocated control; odds ratio [OR] 5·55 [95% CI 4·01-7·70]; absolute excess 5·5% [4·6-6·4]); of SITS-MOST haemorrhage (124 [3·7%] of 3391 vs 19 [0·6%] of 3365; OR 6·67 [4·11-10·84]; absolute excess 3·1% [2·4-3·8]); and of fatal intracerebral haemorrhage (91 [2·7%] of 3391 vs 13 [0·4%] of 3365; OR 7·14 [3·98-12·79]; absolute excess 2·3% [1·7-2·9]). However defined, the proportional increase in intracerebral haemorrhage was similar irrespective of treatment delay, age, or baseline stroke severity, but the absolute excess risk of intracerebral haemorrhage increased with increasing stroke severity: for SITS-MOST intracerebral haemorrhage the absolute excess risk ranged from 1·5% (0·8-2·6%) for strokes with NIHSS 0-4 to 3·7% (2·1-6·3%) for NIHSS 22 or more (p=0·0101). For patients treated within 4·5 h, the absolute increase in the proportion (6·8% [4·0% to 9·5%]) achieving a modified Rankin Scale of 0 or 1 (excellent outcome) exceeded the absolute increase in risk of fatal intracerebral haemorrhage (2·2% [1·5% to 3·0%]) and the increased risk of any death within 90 days (0·9% [-1·4% to 3·2%]). INTERPRETATION Among patients given alteplase, the net outcome is predicted both by time to treatment (with faster time increasing the proportion achieving an excellent outcome) and stroke severity (with a more severe stroke increasing the absolute risk of intracerebral haemorrhage). Although, within 4·5 h of stroke, the probability of achieving an excellent outcome with alteplase treatment exceeds the risk of death, early treatment is especially important for patients with severe stroke. FUNDING UK Medical Research Council, British Heart Foundation, University of Glasgow, University of Edinburgh.
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Affiliation(s)
| | - Jonathan Emberson
- Clinical Trial Service Unit & Epidemiological Studies Unit, University of Oxford, Oxford, UK
| | | | - Lisa Blackwell
- Clinical Trial Service Unit & Epidemiological Studies Unit, University of Oxford, Oxford, UK
| | | | | | | | | | | | - Geoffrey Donnan
- Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | | | | | - Markku Kaste
- Clinical Neurosciences, Neurology, University of Helsinki, Helsinki, Finland; Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Masatoshi Koga
- National Cerebral and Cardiovascular Centre, Suita, Japan
| | | | | | - Richard I Lindley
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Patrick Lyden
- Department of Neurology, Cedars-Sinai, Los Angeles, CA, USA
| | | | - Mark Parsons
- University of Newcastle, Newcastle, NSW, Australia
| | | | | | - Nils Wahlgren
- Karolinska Institutet, Clinical Neuroscience, Stockholm, Sweden
| | | | | | | | | | - Colin Baigent
- Clinical Trial Service Unit & Epidemiological Studies Unit, University of Oxford, Oxford, UK.
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Kiechl S, Willeit J. Alteplase in acute ischaemic stroke: no time to slow down. Lancet Neurol 2016; 15:893-895. [DOI: 10.1016/s1474-4422(16)30095-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 05/17/2016] [Indexed: 11/26/2022]
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Gagné ME, Légaré F, Moisan J, Boulet LP. Development of a patient decision aid on inhaled corticosteroids use for adults with asthma. J Asthma 2016; 53:964-74. [PMID: 27115196 DOI: 10.3109/02770903.2016.1166384] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Patient decision aids (PDAs) are used in shared decision making to improve practitioner-patient communication and help patients decide about treatment options. To develop a PDA for adults with asthma considering inhaled corticosteroids, with or without long-acting beta2-agonists, to optimize asthma control. METHODS The PDA was developed based on the International Patient Decision Aid Standards. Step 1: PDA was drafted. Step 2: PDA acceptability was assessed among target users, certified asthma educators (CAEs) and adults with asthma, following an iterative process. a) Participants read the PDA, b) rated its presentation, length, balance, and perceived usefulness, indicated what they liked/disliked about it, and made suggestions for improvement. c) Based on results from (b), PDA was refined. This process was repeated with new participants until no suggestions were made. Step 3: The PDA was field tested with target users. Interviews with CAEs were conducted to identify areas of improvement. Step 4: Final PDA version was written. RESULTS A color-printed, 4-page, letter-sized PDA was drafted. Acceptability testing involved 11 CAEs (women, n = 10) and 20 adults with asthma (women, n = 13; age 22-61 years). Five successive refined versions were produced. Major changes were made to PDA terminology, instructions, paper size, and visual presentation. Two CAEs (women, n = 2) and 26 adults with asthma (women, n = 19; age 20-65 years) field tested PDA. Minor changes were made to language and instructions to ensure usability. The final version was a color-printed, 12-page, A3-sized booklet. CONCLUSION Our newly developed PDA was found acceptable and usable in target users.
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Affiliation(s)
- Myriam E Gagné
- a Knowledge Translation , Education and Prevention Chair in Respiratory and Cardiovascular Health, Laval University , Quebec City , Quebec , Canada.,b Quebec Heart and Lung Institute , Quebec City , Quebec , Canada
| | - France Légaré
- c Canada Research Chair in Implementation of Shared Decision Making in Primary Care , Laval University , Quebec City , Quebec , Canada.,d CHU de Québec Research Center , Population Health and Optimal Health Practices Research Unit , Quebec City , Quebec , Canada.,e Faculty of Medicine , Laval University , Quebec City , Quebec , Canada
| | - Jocelyne Moisan
- d CHU de Québec Research Center , Population Health and Optimal Health Practices Research Unit , Quebec City , Quebec , Canada.,f Chair on Adherence to Treatments , Laval University , Quebec City , Quebec , Canada.,g Faculty of Pharmacy , Laval University , Quebec City , Quebec , Canada
| | - Louis-Philippe Boulet
- a Knowledge Translation , Education and Prevention Chair in Respiratory and Cardiovascular Health, Laval University , Quebec City , Quebec , Canada.,b Quebec Heart and Lung Institute , Quebec City , Quebec , Canada.,e Faculty of Medicine , Laval University , Quebec City , Quebec , Canada
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Hogden A, Greenfield D, Caga J, Cai X. Development of patient decision support tools for motor neuron disease using stakeholder consultation: a study protocol. BMJ Open 2016; 6:e010532. [PMID: 27053272 PMCID: PMC4823454 DOI: 10.1136/bmjopen-2015-010532] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Motor neuron disease (MND) is a terminal, progressive, multisystem disorder. Well-timed decisions are key to effective symptom management. To date, there are few published decision support tools, also known as decision aids, to guide patients in making ongoing choices for symptom management and quality of life. This protocol is to develop and validate decision support tools for patients and families to use in conjunction with health professionals in MND multidisciplinary care. The tools will inform patients and families of the benefits and risks of each option, as well as the consequences of accepting or declining treatment. METHODS AND ANALYSIS The study is being conducted from June 2015 to May 2016, using a modified Delphi process. A 2-stage, 7-step process will be used to develop the tools, based on existing literature and stakeholder feedback. The first stage will be to develop the decision support tools, while the second stage will be to validate both the tools and the process used to develop them. Participants will form expert panels, to provide feedback on which the development and validation of the tools will be based. Participants will be drawn from patients with MND, family carers and health professionals, support association workers, peak body representatives, and MND and patient decision-making researchers. ETHICS AND DISSEMINATION Ethical approval for the study has been granted by Macquarie University Human Research Ethics Committee (HREC), approval number 5201500658. Knowledge translation will be conducted via publications, seminar and conference presentations to patients and families, health professionals and researchers.
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Affiliation(s)
- Anne Hogden
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - David Greenfield
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Jashelle Caga
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Xiongcai Cai
- School of Computer Science and Engineering, University of New South Wales, Sydney, New South Wales, Australia
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McMeekin P, Flynn D, Ford GA, Rodgers H, Gray J, Thomson RG. Development of a decision analytic model to support decision making and risk communication about thrombolytic treatment. BMC Med Inform Decis Mak 2015; 15:90. [PMID: 26560132 PMCID: PMC4642673 DOI: 10.1186/s12911-015-0213-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 10/27/2015] [Indexed: 01/18/2023] Open
Abstract
Background Individualised prediction of outcomes can support clinical and shared decision making. This paper describes the building of such a model to predict outcomes with and without intravenous thrombolysis treatment following ischaemic stroke. Methods A decision analytic model (DAM) was constructed to establish the likely balance of benefits and risks of treating acute ischaemic stroke with thrombolysis. Probability of independence, (modified Rankin score mRS ≤ 2), dependence (mRS 3 to 5) and death at three months post-stroke was based on a calibrated version of the Stroke-Thrombolytic Predictive Instrument using data from routinely treated stroke patients in the Safe Implementation of Treatments in Stroke (SITS-UK) registry. Predictions in untreated patients were validated using data from the Virtual International Stroke Trials Archive (VISTA). The probability of symptomatic intracerebral haemorrhage in treated patients was incorporated using a scoring model from Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) data. Results The model predicts probabilities of haemorrhage, death, independence and dependence at 3-months, with and without thrombolysis, as a function of 13 patient characteristics. Calibration (and inclusion of additional predictors) of the Stroke-Thrombolytic Predictive Instrument (S-TPI) addressed issues of under and over prediction. Validation with VISTA data confirmed that assumptions about treatment effect were just. The C-statistics for independence and death in treated patients in the DAM were 0.793 and 0.771 respectively, and 0.776 for independence in untreated patients from VISTA. Conclusions We have produced a DAM that provides an estimation of the likely benefits and risks of thrombolysis for individual patients, which has subsequently been embedded in a computerised decision aid to support better decision-making and informed consent.
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Affiliation(s)
- Peter McMeekin
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK. .,School of Health, Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK. .,Department of Healthcare, Northumbria University, Newcastle Upon Tyne, UK.
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Gary A Ford
- Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, UK
| | - Helen Rodgers
- Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, UK
| | - Jo Gray
- Department of Healthcare, Northumbria University, Newcastle Upon Tyne, UK
| | - Richard G Thomson
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
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Clua-Espuny JL, Ripolles-Vicente R, Forcadell-Arenas T, Gil-Guillen VF, Queralt-Tomas ML, González-Henares MA, Panisello-Tafalla A, López-Pablo C, Lucas-Noll J. Sex Differences in Long-Term Survival after a First Stroke with Intravenous Thrombolysis: Ebrictus Study. Cerebrovasc Dis Extra 2015; 5:95-102. [PMID: 26648964 PMCID: PMC4662271 DOI: 10.1159/000440734] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/27/2015] [Indexed: 12/29/2022] Open
Abstract
Background A number of large trials have confirmed the benefits of thrombolysis in acute stroke, but there are gender differences. We sought to examine the relationship between sex and outcome after thrombolysis. Methods This was a prospective cohort study including 1,272 incident ischemic strokes (597 in women) from April 1, 2006 to December 31, 2014. Statistical approaches were used for analyzing survival outcomes and their relationship with thrombolysis therapy. Results The death rates were lower (p = 0.003) in the thrombolysis therapy group with an incidence ratio of 0.57 (95% CI 0.39-0.83). 113 (8.8%) patients (53 women) received thrombolysis. They were significantly younger (69.2 ± 12.7 vs. 73.9 ± 12.5 years; p < 0.001), had higher NIHSS score (12.7 ± 6.3 vs. 7.3 ± 7.0; p < 0.001), spent more days in hospital (10.4 ± 8.3 vs. 8.3 ± 7.9; p < 0.001), and had a higher average Barthel score at discharge (85.5 ± 24.4 vs. 79.2 ± 28.6; p = 0.023). The male/female incidence ratio showed a significant decrease (p = 0.01) in the incidence of mortality in women and a better Barthel score. The thrombolysis improved the survival in the overall group with thrombolysis versus without thrombolysis (p = 0.028), in women versus in men with thrombolysis (p = 0.023), and in women with thrombolysis versus in those without thrombolysis (p < 0.001) but not in men with thrombolysis versus in those without thrombolysis (p = 0.743). The protective factors as regards mortality were thrombolysis therapy (95% CI 0.37-0.80; p = 0.002), Barthel score ≥60 (95% CI 0.81-0.94; p = 0.002), and cardiovascular secondary prevention 1 year after stroke (0.13, 95% CI 0.06-0.28). Conclusions The stroke death rates were lower in women after thrombolysis treatment and suggest significant benefit for women in this setting. The overall benefit on survival of the patients treated with thrombolysis might be explained by the beneficial effect of the thrombolysis on the women.
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Affiliation(s)
- José Luis Clua-Espuny
- Health Department, Catalonian Health Institute, SAP Terres de l'Ebre, Generalitat de Catalunya, Elche, Spain
| | - Rosa Ripolles-Vicente
- Health Department, Catalonian Health Institute, SAP Terres de l'Ebre, Generalitat de Catalunya, Elche, Spain
| | - Teresa Forcadell-Arenas
- Health Department, Catalonian Health Institute, SAP Terres de l'Ebre, Generalitat de Catalunya, Elche, Spain
| | - Vicente Francisco Gil-Guillen
- Clinical Evidence Based Medicine and Emotional Department, Miguel Hernández University, Family and Community Speciality, Elche, Spain
| | - Maria Lluïsa Queralt-Tomas
- Health Department, Catalonian Health Institute, SAP Terres de l'Ebre, Generalitat de Catalunya, Elche, Spain
| | | | - Anna Panisello-Tafalla
- Health Department, Catalonian Health Institute, SAP Terres de l'Ebre, Generalitat de Catalunya, Elche, Spain
| | - Carlos López-Pablo
- Department of Research, ICS Terres de l'Ebre, Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol-IISPV, Tortosa, Elche, Spain
| | - Jorgina Lucas-Noll
- Health Department, Catalonian Health Institute, SAP Terres de l'Ebre, Generalitat de Catalunya, Elche, Spain
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