'Not taking medications and taking medication, it was the same thing:' perspectives of antiretroviral therapy among people hospitalised with advanced HIV disease

BACKGROUND

Despite HIV's evolution to a chronic disease, the burden of advanced HIV disease (AHD, defined as a CD4 count of < 200 cells/uL or WHO clinical Stage 3 or 4 disease), remains high among People Living with HIV (PLHIV) who have previously been prescribed antiretroviral therapy (ART). As little is known about the experiences of patients hospitalised with AHD, this study sought to discern social forces driving hospitalisation with AHD. Understanding such forces could inform strategies to reduce HIV-related morbidity and mortality.

METHODS

We conducted a qualitative study with patients hospitalised with AHD who had a history of poor adherence. Semi-structured interviews were conducted between October 1 and November 30, 2023. The Patient Health Engagement and socio-ecological theoretical models were used to guide a thematic analysis of interview transcripts.

RESULTS

Twenty individuals participated in the research. Most reported repeated periods of disengagement with HIV services. The major themes identified as driving disengagement included: 1) feeling physically well; 2) life circumstances and relationships; and 3) health system factors, such as clinic staff attitudes and a perceived lack of flexible care. Re-engagement with care was often driven by new physical symptoms but was mediated through life circumstances/relationships and aspects of the health care system.

CONCLUSIONS

Current practices fail to address the challenges to lifelong engagement in HIV care. A bold strategy for holistic care which involves people living with advanced HIV as active members of the health care team (i.e. 'PLHIV as Partners'), could contribute to ensuring health care services are compatible with their lives, reducing periods of disengagement from care.

Incorporating parental values in complex paediatric and perinatal decisions

Incorporating parental values in complex medical decisions for young children is important but challenging. In this Review, we explore what it means to incorporate parental values in complex paediatric and perinatal decisions. We provide a narrative overview of the paediatric, ethics, and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences. We explain key concepts and definitions, discuss paediatric-specific features, reflect on challenges in learning and expressing values for both parents and health-care providers, and provide recommendations for clinical practice. Decisional values are informed by global and external values and could relate to the child, the parents, and the whole family. These values should inform preferences and assure value-congruent choices. Additionally, parents might hold various meta values on the process of decision making itself. Complex decisions for young children are emotionally taxing, ethically difficult, and often surrounded by uncertainty. These contextual factors make it more likely that values and preferences are initially absent or unstable and need to be constructed or stabilised. Health-care professionals and parents should work together to construct and clarify values and incorporate them into personalised decisions for the child. An open communication style, with unbiased and tailored information in a supportive environment, is helpful. Dedicated training in communication and shared decision making could help to improve the incorporation of parental values in complex decisions for young children.

Development and evaluation of a decision aid for women eligible for organized breast cancer screening according to international standards: A multi-method study

BACKGROUND

and purpose: In France, women lack information to make a shared decision to start breast cancer screening. Decision aids are useful to facilitate this discussion, yet few meet international standards. The objective of this project was to build, validate and measure the quality of a decision aid for organized breast screening in France, in line with international standards, intended for both women and healthcare professionals.

MATERIALS AND METHODS

This mixed-methods study was conducted between January 2017 and June 2022. The prototype was developed from a qualitative study, systematic review and targeted literature review and alpha tested during two Delphi rounds. Readability was evaluated with the Flesch score and content with International Patient Decision Aid Standards Instrument (IPSASi).

RESULTS

An online decision aid, accessible at www.Discutons-mammo.fr, written in French was developed. The content included eligibility, information about breast screening the advantages and disadvantages of screening, patient preferences and a patient-based discussion guide using text, infographics, and videos. The Flesch readability test score was 65.4 and the IPDASi construct quality score was 176 out of 188.

CONCLUSIONS

This decision aid complies with IPDASi standards and could help women eligible for breast screening in France make a shared decision with a specialized healthcare professional about whether or not to participate in organized breast screening.

Integrating Patient Involvement Interventions within Clinical Practice: A Mixed-Methods Study of Health Care Professional Reasoning

Background. Patient involvement interventions are complex interventions that improve patient involvement in treatment and care in health care systems. Studies report several benefits of patient involvement interventions and that health care professionals are positive about using them. However, they have not been explored as a collected group of interventions throughout the continuum of care and treatment. In addition, the relationship between patient involvement interventions and the clinical reasoning process of health care professionals has not been thoroughly studied. Design. This mixed-methods study was conducted at Aarhus University Hospital in Denmark between April and November 2022 using interview data from 12 health care professionals and survey data from 420 health care professionals. Informants were medical doctors, nurses, midwives, dietitians, physiotherapists, and occupational therapists who had direct contact with patients during their daily care and treatment. Quantitative data were analyzed using descriptive statistics; qualitative data were analyzed via inductive and deductive content analysis. Results. Communication and interaction were seen as overarching aspects of patient involvement, with patient involvement interventions being defined as concrete tools and methods to enhance health care professionals' explicit clinical reasoning process. Limitations. It is unclear if results are representative of all health care professionals at the hospital or only those with a positive view of patient involvement interventions. Conclusions. Patient involvement interventions are viewed as beneficial for patients and fit with the clinical reasoning of health care professionals. Clinical reasoning may be an active ingredient in the development and implementation of patient involvement interventions. Implications. In practice, health care professionals need training in person-centered communication and the ability to articulate their clinical reasoning explicitly. In research, a more in-depth understanding of the interrelations between patient involvement interventions and clinical reasoning is needed.

Highlights

Communication and interaction are the fundamental goals of patient involvement in practice, regardless of which patient involvement intervention is being used.Clinical reasoning is often an unconscious process using tacit knowledge, but the use of patient involvement interventions may be a way for health care professionals (at both individual and group levels) to become more explicit about and aware of their reflections.Clinical reasoning can be viewed as a mechanism of change in the development and implementation of patient involvement interventions.

Current models of shared decision-making are insufficient: The "Professionally-Driven Zone of Patient or Surrogate Discretion" offers a defensible way forward

OBJECTIVES

This paper undertakes a critical examination of the concept of "Shared Decision-Making" (SDM) by exploring current understandings of what is meant by the term.

DISCUSSION

In an exploration of SDM, it will become evident that there are significant challenges that can limit shared decision-making's successful implementation in practice. Existing models are examined, and a novel method of SDM is proposed which makes use of a Professionally-Driven Zone of Patient or Surrogate Discretion.

CONCLUSION

A Professionally-Driven Zone of Patient or Surrogate Discretion is a broadly-applicable model of SDM that takes a harm-threshold approach, rather than appealing strictly to best interests. This model avoids or addresses many of the challenges that impede successful implementation of other SDM models.

PRACTICE IMPLICATIONS

The Professionally-Driven Zone of Patient or Surrogate Discretion aims to define the scope of participant roles in SDM better than existing models, and ensures that the treatments or interventions which are pursued in SDM are chosen from a range of ethically-defensible options.

Interventions for Indigenous Peoples making health decisions: a systematic review

BACKGROUND

Shared decision-making facilitates collaboration between patients and health care providers for informed health decisions. Our review identified interventions to support Indigenous Peoples making health decisions. The objectives were to synthesize evidence and identify factors that impact the use of shared decision making interventions.

METHODS

An Inuit and non-Inuit team of service providers and academic researchers used an integrated knowledge translation approach with framework synthesis to coproduce a systematic review. We developed a conceptual framework to organize and describe the shared decision making processes and guide identification of studies that describe interventions to support Indigenous Peoples making health decisions. We conducted a comprehensive search of electronic databases from September 2012 to March 2022, with a grey literature search. Two independent team members screened and quality appraised included studies for strengths and relevance of studies' contributions to shared decision making and Indigenous self-determination. Findings were analyzed descriptively in relation to the conceptual framework and reported using guidelines to ensure transparency and completeness in reporting and for equity-oriented systematic reviews.

RESULTS

Of 5068 citations screened, nine studies reported in ten publications were eligible for inclusion. We categorized the studies into clusters identified as: those inclusive of Indigenous knowledges and governance ("Indigenous-oriented")(n = 6); and those based on Western academic knowledge and governance ("Western-oriented")(n = 3). The studies were found to be of variable quality for contributions to shared decision making and self-determination, with Indigenous-oriented studies of higher quality overall than Western-oriented studies. Four themes are reflected in an updated conceptual framework: 1) where shared decision making takes place impacts decision making opportunities, 2) little is known about the characteristics of health care providers who engage in shared decision making processes, 3) community is a partner in shared decision making, 4) the shared decision making process involves trust-building.

CONCLUSIONS

There are few studies that report on and evaluate shared decision making interventions with Indigenous Peoples. Overall, Indigenous-oriented studies sought to make health care systems more amenable to shared decision making for Indigenous Peoples, while Western-oriented studies distanced shared decision making from the health care settings. Further studies that are solutions-focused and support Indigenous self-determination are needed.

Optimizing the design and implementation of question prompt lists to support person-centred care: A scoping review

INTRODUCTION

Question prompt lists (QPLs) are lists of questions that patients may want to discuss with clinicians. QPLs support person-centred care and have been associated with many beneficial outcomes including improved patient question-asking, and the amount and quality of the information provided by clinicians. The purpose of this study was to review published research on QPLs to explore how QPL design and implementation can be optimized.

METHODS

We performed a scoping review by searching MEDLINE, EMBASE, Scopus, CINAHL, Cochrane Library and Joanna Briggs Database from inception to 8 May 2022, for English language studies of any design that evaluated QPLs. We used summary statistics and text to report study characteristics, and QPL design and implementation.

RESULTS

We included 57 studies published from 1988 to 2022 by authors in 12 countries on a range of clinical topics. Of those, 56% provided the QPL, but few described how QPLs were developed. The number of questions varied widely (range 9-191). Most QPLs were single-page handouts (44%) but others ranged from 2 to 33 pages. Most studies implemented a QPL alone with no other accompanying strategy; most often in a print format before consultations by mail (18%) or in the waiting room (66%). Both patients and clinicians identified numerous benefits to patients of QPLs (e.g., increased patient confidence to ask questions, and patient satisfaction with communication or care received; and reduced anxiety about health status or treatment). To support use, patients desired access to QPLs in advance of clinician visits, and clinicians desired information/training on how to use the QPL and answer questions. Most (88%) studies reported at least one beneficial impact of QPLs. This was true even for single-page QPLs with few questions unaccompanied by other implementation strategies. Despite favourable views of QPLs, few studies assessed outcomes amongst clinicians.

CONCLUSION

This review identified QPL characteristics and implementation strategies that may be associated with beneficial outcomes. Future research should confirm these findings via systematic review and explore the benefits of QPLs from the clinician's perspective.

PATIENT/PUBLIC CONTRIBUTION

Following this review, we used the findings to develop a QPL on hypertensive disorders of pregnancy and interviewed women and clinicians about QPL design including content, format, enablers and barriers of use, and potential outcomes including beneficial impacts and possible harms (will be published elsewhere).

Exploring the shared decision making process of caesarean sections at a teaching hospital in Ghana: a mixed methods study

BACKGROUND

Caesarean section (CS) rates are rising. Shared decision making (SDM) is a component of patient-centered communication which requires adequate information and awareness. Women in Ghana have varying perceptions about the procedure. We sought to explore mothers' knowledge. perceptions and SDM-influencing factors about CSs.

METHODS

A transdisciplinary mixed-methods study was conducted at the maternity unit of Korle-Bu Teaching Hospital in Accra, Ghana from March to May, 2019. Data collection was done in four phases: in-depth interviews (n = 38), pretesting questionnaires (n = 15), three focus group discussions (n = 18) and 180 interviewer administered questionnaires about SDM preferences. Factors associated with SDM were analyzed using Pearson's Chi-square test and multiple logistic regression.

RESULTS

Mothers depicted a high level of knowledge regarding medical indications for their CS but had low level of awareness of SDM. The perception of a CS varied from dangerous, unnatural and taking away their strength to a life-saving procedure. The mothers had poor knowledge about pain relief in labour and at Caesarean section. Health care professionals attributed the willingness of mothers to be involved in SDM to their level of education. Husbands and religious leaders are key stakeholders in SDM. Insufficient consultation time was a challenge to SDM according to health care professionals and post-partum mothers. Women with parity ≥ 5 have a reduced desire to be more involved in shared decision making for Caesarean section. AOR = 0.09, CI (0.02-0.46).

CONCLUSION

There is a high knowledge about the indications for CS but low level of awareness of and barriers to SDM. The fewer antenatal care visits mothers had, the more likely they were to desire more involvement in decision making. Aligned to respectful maternity care principles, greater involvement of pregnant women and their partners in decision making process could contribute to a positive pregnancy experience. Education, including religious leaders and decision- making tools could contribute to the process of SDM.

Shared decision-making and the duration of medical consultations: A systematic review and meta-analysis

OBJECTIVE

1) determine whether increased levels of Shared Decision-Making (SDM) affect consultation duration, 2) investigate the intervention characteristics involved.

METHODS

MEDLINE, EMBASE, CINAHL and Cochrane library were systematically searched for experimental and cross-sectional studies up to December 2021. A best-evidence synthesis was performed, and interventions characteristics that increased at least one SDM-outcome, were pooled and descriptively analyzed.

RESULTS

Sixty-three studies were selected: 28 randomized clinical trials, 8 quasi-experimental studies, and 27 cross-sectional studies. Overall, pooling of data was not possible due to substantial heterogeneity. No differences in consultation duration were found more often than increased or decreased durations. . Consultation times (minutes:seconds) were significantly increased only among interventions that: 1) targeted clinicians only (Mean Difference [MD] 1:30, 95% Confidence Interval [CI] 0:24-2:37); 2) were performed in primary care (MD 2:05, 95%CI 0:11-3:59; 3) used a group format (MD 2:25, 95%CI 0:45-4:05); 4) were not theory-based (MD 4:01, 95%CI 0:38-7:23).

CONCLUSION

Applying SDM does not necessarily require longer consultation durations. Theory-based, multilevel implementation approaches possibly lower the risk of increasing consultation durations.

PRACTICE IMPLICATIONS

The commonly heard concern that time hinders SDM implementation can be contradicted, but implementation demands multifaceted approaches and space for training and adapting work processes.

Implementation strategies for knowledge products in primary healthcare: a systematic review of systematic reviews (Preprint)

Background

The underuse or overuse of knowledge products leads to waste in health care, and primary care is no exception.

Objective

This study aimed to characterize which knowledge products are frequently implemented, the implementation strategies used in primary care, and the implementation outcomes that are measured.

Methods

We performed a systematic review (SR) of SRs using the Cochrane systematic approach to include eligible SRs. The inclusion criteria were any primary care contexts, health care professionals and patients, any Effective Practice and Organization of Care implementation strategies of specified knowledge products, any comparators, and any implementation outcomes based on the Proctor framework. We searched the MEDLINE, EMBASE, CINAHL, Ovid PsycINFO, Web of Science, and Cochrane Library databases from their inception to October 2019 without any restrictions. We searched the references of the included SRs. Pairs of reviewers independently performed selection, data extraction, and methodological quality assessment by using A Measurement Tool to Assess Systematic Reviews 2. Data extraction was informed by the Effective Practice and Organization of Care taxonomy for implementation strategies and the Proctor framework for implementation outcomes. We performed a descriptive analysis and summarized the results by using a narrative synthesis.

Results

Of the 11,101 records identified, 81 (0.73%) SRs were included. Of these 81, a total of 47 (58%) SRs involved health care professionals alone. Moreover, 15 SRs had a high or moderate methodological quality. Most of them addressed 1 type of knowledge product (56/81, 69%), common clinical practice guidelines (26/56, 46%) or management, and behavioral or pharmacological health interventions (24/56, 43%). Mixed strategies were used for implementation (67/81, 83%), predominantly education-based (meetings in 60/81, 74%; materials distribution in 59/81, 73%; and academic detailing in 45/81, 56%), reminder (53/81, 36%), and audit and feedback (40/81, 49%) strategies. Education meetings (P=.13) and academic detailing (P=.11) seemed to be used more when the population was composed of health care professionals alone. Improvements in the adoption of knowledge products were the most commonly measured outcome (72/81, 89%). The evidence level was reported in 12% (10/81) of SRs on 62 outcomes (including 48 improvements in adoption), of which 16 (26%) outcomes were of moderate or high level.

Conclusions

Clinical practice guidelines and management and behavioral or pharmacological health interventions are the most commonly implemented knowledge products and are implemented through the mixed use of educational, reminder, and audit and feedback strategies. There is a need for a strong methodology for the SR of randomized controlled trials to explore their effectiveness and the entire cascade of implementation outcomes.

Shared decision-making in urology and female pelvic floor medicine and reconstructive surgery

Shared decision-making (SDM) is a hallmark of patient-centred care that uses informed consent to help guide patients with making complex health-care decisions. In SDM, patients and providers work together to determine the best course of action based on both the current available evidence and the patient's values and preferences. SDM not only provides a framework for the legal and ethical obligations providers need to fulfil for informed consent, but also leads to improved knowledge of treatment options and satisfaction of decision-making for patients. Tools such as decision aids have been developed to support SDM for complex decisions. Several decision aids are available for use in the field of urology and female pelvic medicine and reconstructive surgery, but these decision aids are also associated with barriers to SDM implementation including patient, provider and systematic challenges. However, solutions to such barriers to SDM include continued development of SDM tools to improve patient engagement, expand training of providers in SDM communication models and a process to encourage implementation of SDM.

The Effect of Physician Communication on Inpatient Satisfaction

(1) Background: The importance of physician-patient communication and its effect on patient satisfaction has become a hot topic and has been studied from various aspects in recent years. However, there is a lack of systematic reviews to integrate recent research findings into patient satisfaction studies with physician communication. Therefore, this study aims to systematically examine physician communication’s effect on patient satisfaction in public hospitals. (2) Methods: Using a keywords search, data was collected from five databases for the papers published until October 2021. Original studies, observational studies, intervention studies, cross-sectional studies, cohort studies, experimental studies, and qualitative studies published in English, peer-reviewed research, and inpatients who communicated with the physician in a hospital met the inclusion criteria. (3) Results: Overall, 11 studies met the inclusion criteria from the 4810 articles found in the database. Physicians and organizations can influence two determinants of inpatient satisfaction in physician communication. Determinants of patient satisfaction that physicians influence consist of amounts of time spent with the patient, verbal and nonverbal indirect interpersonal communication, and understanding the demands of patients. The organization can improve patient satisfaction with physician communication by the organization’s availability of interpreter service and physician workload. Physicians’ communication with inpatients can affect patient satisfaction with hospital services. (4) Conclusions: To improve patient satisfaction with physician communication, physicians and organizational determinants must be considered.

Evaluation of a multilevel implementation program for timeout and shared decision making in breast cancer care: a mixed methods study among 11 hospital teams

OBJECTIVE

Evaluation of a multilevel implementation program on shared decision making (SDM) for breast cancer clinicians.

METHODS

The program was based on the 'Measurement Instrument for Determinants of Innovations-model' (MIDI). Key factors for effective implementation were included. Eleven breast cancer teams selected from two geographical areas participated; first six surgery teams and second five systemic therapy teams. A mixed method evaluation was carried out at the end of each period: Descriptive statistics were used for surveys and thematic content analysis for semi-structured interviews.

RESULTS

Twenty-eight clinicians returned the questionnaire (42%). Clinicians (96%) endorse that SDM is relevant to breast cancer care. The program supported adoption of SDM in their practice. Limited financial means, time constraints and concurrent activities were frequently reported barriers. Interviews (n = 21) showed that using a 4-step SDM model - when reinforced by practical examples, handy cards, feedback and training - helped to internalize SDM theory. Clinicians experienced positive results for their patients and themselves. Task re-assignment and flexible outpatient planning reinforce sustainable change. Patient involvement was valued.

CONCLUSION

Our program supported breast cancer clinicians to adopt SDM.

PRACTICE IMPLICATIONS

To implement SDM, multilevel approaches are needed that reinforce intrinsic motivation by demonstrating benefits for patients and clinicians.

Effectiveness of individual feedback and coaching on shared decision-making consultations in oncology care: Study protocol for a randomized clinical trial (Preprint)

Background

Shared decision-making (SDM) is particularly important in oncology as many treatments involve serious side effects, and treatment decisions involve a trade-off between benefits and risks. However, the implementation of SDM in oncology care is challenging, and clinicians state that it is difficult to apply SDM in their actual workplace. Training clinicians is known to be an effective means of improving SDM but is considered time consuming.

Objective

This study aims to address the effectiveness of an individual SDM training program using the concept of deliberate practice.

Methods

This multicenter, single-blinded randomized clinical trial will be performed at 12 Dutch hospitals. Clinicians involved in decisions with oncology patients will be invited to participate in the study and allocated to the control or intervention group. All clinicians will record 3 decision-making processes with 3 different oncology patients. Clinicians in the intervention group will receive the following SDM intervention: completing e-learning, reflecting on feedback reports, performing a self-assessment and defining 1 to 3 personal learning questions, and participating in face-to-face coaching. Clinicians in the control group will not receive the SDM intervention until the end of the study. The primary outcome will be the extent to which clinicians involve their patients in the decision-making process, as scored using the Observing Patient Involvement–5 instrument. As secondary outcomes, patients will rate their perceived involvement in decision-making, and the duration of the consultations will be registered. All participating clinicians and their patients will receive information about the study and complete an informed consent form beforehand.

Results

This trial was retrospectively registered on August 03, 2021. Approval for the study was obtained from the ethical review board (medical research ethics committee Delft and Leiden, the Netherlands [N20.170]). Recruitment and data collection procedures are ongoing and are expected to be completed by July 2022; we plan to complete data analyses by December 2022. As of February 2022, a total of 12 hospitals have been recruited to participate in the study, and 30 clinicians have started the SDM training program.

Conclusions

This theory-based and blended approach will increase our knowledge of effective and feasible training methods for clinicians in the field of SDM. The intervention will be tailored to the context of individual clinicians and will target the knowledge, attitude, and skills of clinicians. The patients will also be involved in the design and implementation of the study.

Trial Registration

Netherlands Trial Registry NL9647; https://www.trialregister.nl/trial/9647

International Registered Report Identifier (IRRID)

DERR1-10.2196/35543

Decision coaching for people making healthcare decisions

BACKGROUND

Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching.

OBJECTIVES

To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects.

SEARCH METHODS

We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence.

MAIN RESULTS

Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms.  For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low.  For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.

Teaching Shared Decision Making to Undergraduate Medical Students

Despite the wide endorsement of shared decision making (SDM), its integration into clinical practice has been slow. In this paper, we suggest that this integration may be promoted by teaching SDM not only to residents and practicing physicians, but also to undergraduate medical students. The proposed teaching approach assumes that SDM requires effective doctor-patient communication; that such communication requires empathy; and that the doctor's empathy requires an ability to identify the patient's concerns. Therefore, we suggest shifting the focus of teaching SDM from how to convey health-related information to patients, to how to gain an insight into their concerns. In addition, we suggest subdividing SDM training into smaller, sequentially taught units, in order to help learners to elucidate the patient's preferred role in decisions about her/his care, match the patient's preferred involvement in these decisions, present choices, discuss uncertainty, and encourage patients to obtain a second opinion.

The Shared Decision-Making Process in the Pharmacological Management of Depression

Shared decision making (SDM) is a model of interaction between doctors and patients in which both actors contribute to the medical decision-making process. There is an international consensus across medicine about the importance of SDM interventions, which have raised great interest in mental healthcare over the last decade. Yet SDM is not widely adopted, particularly in the field of psychiatry. The purpose of the present article is to examine, from a patient and physician perspective, the importance of SDM in the management of healthcare with a focus on mental health; it reviews the enablers and barriers (and how to overcome them) to implementing a SDM process in psychiatric practice. SDM models have been developed recently for involving patients with depression in the decision-making process, which could result in augmenting the proportion of patients who adhere to their antidepressant or other treatments for a duration that complies with the current recommendations. To implement this approach, more physicians need training in the SDM approach and access to appropriate tools that help engage in collaborative deliberation, and practice generally needs to be reorganized around the principles of patient engagement.

Improving MS patients' understanding of treatment risks and benefits in clinical consultations: A randomised crossover trial

BACKGROUND

Multiple Sclerosis (MS) patients find it difficult to understand the complex risk-benefit profiles of disease-modifying drugs. An evidence-based protocol was designed to improve patient's understanding of treatment information: Benefit and Risk Information for Medication in Multiple Sclerosis (BRIMMS).

OBJECTIVE

A feasibility study to evaluate whether the BRIMMS protocol can improve MS patients' treatment understanding and reduce conflict in treatment decisions compared to consultation as usual.

DESIGN

Single-blind 4-condition 4-period randomised crossover trial. Hypothetical treatment information was presented to MS patients in a faux 20 minute consultation session using the BRIMMS protocol (aural and visual) or as a usual consultation (aural and visual). Patients were randomised to the order in which they received the four consultation styles.

PARTICIPANTS

24 patients diagnosed with relapsing-remitting MS.

MEASURES

Patients were assessed on their comprehension of treatment information, decisional conflict and feedback on consultation styles. Disease and demographic information was also collected.

RESULTS

Treatment understanding was greater for both BRIMMS visual and BRIMMS aural, compared to usual consultations in visual or aural format. Similarly, BRIMMS visual and BRIMMS aural reduced decisional conflict compared to usual consultations in visual or aural formats. All comparisons were p<0.001. Cognitive status was not related to understanding in the BRIMMS protocol, but was negatively related with usual consultation. Conversely, mood influenced understanding on the BRIMMS protocol but not for usual consultation.

CONCLUSIONS

BRIMMS protocol offers an effective, evidence-based tool for presenting treatment information in consultations with MS patients and is not influenced by cognition.

TRIAL REGISTRATION

ISRCTN17318966.

Factors influencing implementation of an insulin patient decision aid at public health clinics in Malaysia: A qualitative study

BACKGROUND

Many patient decision aids (PDAs) are developed in academic settings by academic researchers. Academic settings are different from public health clinics where the focus is on clinical work. Thus, research on implementation in public health settings will provide insights to effective implementation of PDA in real-world settings. This study explores perceived factors influencing implementation of an insulin PDA in five public health clinics.

METHODS

This study adopted a comparative case study design with a qualitative focus to identify similarities and differences of the potential barriers and facilitators to implementing the insulin PDA across different sites. Focus groups and individual interviews were conducted with 28 healthcare providers and 15 patients from five public health clinics under the Ministry of Health in Malaysia. The interviews were transcribed verbatim and analysed using the thematic approach.

RESULTS

Five themes emerged which were: 1) time constraint; 2) PDA costs; 3) tailoring PDA use to patient profile; 4) patient decisional role; and 5) leadership and staff motivation. Based on the interviews and drawing on observations and interview reflection notes, time constraint emerged as the common prominent factor that cut across all the clinics, however, tailoring PDA use to patient profile; patient decisional role; leadership and staff motivation varied due to the distinct challenges faced by specific clinics. Among clinics from semi-urban areas with more patients from limited education and lower socio-economic status, patients' ability to comprehend the insulin PDA and their tendency to rely on their doctors and family to make health decisions were felt to be a prominent barrier to the insulin PDA implementation. Staff motivation appeared to be stronger in most of the clinics where specific time was allocated to diabetes team to attend to diabetes patients and this was felt could be a potential facilitator, however, a lack of leadership might affect the insulin PDA implementation even though a diabetes team is present.

CONCLUSIONS

This study found time constraint as a major potential barrier for PDA implementation and effective implementation of the insulin PDA across different public health clinics would depend on leadership and staff motivation and, the need to tailor PDA use to patient profile. To ensure successful implementation, implementers should avoid a 'one size fits all' approach when implementing health innovations.

Effect of a multilevel implementation programme on shared decision-making in breast cancer care

BACKGROUND

Women with newly diagnosed breast cancer face multiple treatment options. Involving them in a shared decision-making (SDM) process is essential. The aim of this study was to evaluate whether a multilevel implementation programme enhanced the level of SDM behaviour of clinicians observed in consultations.

METHODS

This before-after study was conducted in six Dutch hospitals. Patients with breast cancer who were facing a decision on surgery or neoadjuvant systemic treatment between April 2016 and September 2017 were included, and provided informed consent. Audio recordings of consultations made before and after implementation were analysed using the five-item Observing Patient Involvement in Decision-Making (OPTION-5) instrument to assess whether clinicians adopted new behaviour needed for applying SDM. Patients scored their perceived level of SDM, using the nine-item Shared Decision-Making Questionnaire (SDM-Q-9). Hospital, duration of the consultation(s), age, and number of consultations per patient that might influence OPTION-5 scores were investigated using linear regression analysis.

RESULTS

Consultations of 139 patients were audiotaped, including 80 before and 59 after implementation. Mean (s.d.) OPTION-5 scores, expressed on a 0-100 scale, increased from 38.3 (15.0) at baseline to 53.2 (14.8) 1 year after implementation (mean difference (MD) 14.9, 95 per cent c.i. 9.9 to 19.9). SDM-Q-9 scores of 105 patients (75.5 per cent) (72 before and 33 after implementation) were high and showed no significant changes (91.3 versus 87.6; MD -3.7, -9.3 to 1.9). The implementation programme had an association with OPTION-5 scores (β = 14.2, P < 0.001), hospital (β = 2.2, P = 0.002), and consultation time (β = 0.2, P < 0.001).

CONCLUSION

A multilevel implementation programme supporting SDM in breast cancer care increased the adoption of SDM behaviour of clinicians in consultations.

Assessment of Physicians' Perspective of Shared Decision Making in a Tertiary Care Hospital in Riyadh, Saudi Arabia

Introduction

Shared decision making is an essential component of a patient-centered healthcare system. Several studies have evaluated patients' perception of shared decision making; however, studies reporting physicians' perception of the shared decision-making process are lacking. The objective of this study was to assess physicians' perspectives on shared decision making with their patients in a tertiary care hospital in Riyadh, Saudi Arabia.

Methods

This is a cross-sectional study, in which we adopted the nine-item physician version of the shared decision-making questionnaire (SDM-Q-Doc) to assess physicians' perception of shared decision making. The questionnaire was distributed online and in hard copy form randomly to our institution's physicians.

Results

We collected a total of 125 responses from various specialties. Means and percentage of agreement were tested, with the highest percentage of agreement ranging from 88% to 96.8%. There were significant differences between the groups regarding age and medical degree. There were no significant differences noted for sex or department.

Conclusion

Our findings suggest that most physicians at our institution have a positive attitude toward the process of sharing medical decisions with their patients.

The Role of Antenatal Education in Promoting Maternal and Family Health Literacy

BACKGROUND

Antenatal education (ANE) supports expectant parents in developing their knowledge, skills, and confidence in preparing for childbirth and early parenting. This is called health literacy, and it is part of the global healthcare system agenda that empowers women to participate fully in making decisions about their health and care before, during, and after birth. The aim of this study was to examine the perspectives of educators and ANE class participants on the extent to which existing courses are meeting this goal.

METHODS

A qualitative study, conceptualized within the health literacy framework, was conducted in Australia with 10 antenatal educators and 8 participants from antenatal classes. Data were collected through individual interviews and were analyzed using interpretive description.

RESULTS

The findings revealed five themes relating to the participants' experiences in either providing or attending antenatal classes. These included: “balancing provider influences with participant expectations,” “accommodating participant learning styles and preferences,” “influence of the environment on pedagogy and practice,” “empowering participants for decision-making,” and “reflections on what is and is not meaningful and effective.”

CONCLUSIONS

Findings from this study strongly suggest that to meet the needs of class participants, educators need to be mindful of their expectations. They should adopt a flexible approach to accommodate participants' knowledge, goals, and preferences as well as characteristics of the context. Conceptualizing ANE within the framework of health literacy provides a clear, targeted approach to meeting the information needs of this important population that is focused on evidence-based safe practice across the birthing continuum and beyond.

Does Open Reduction and Internal Fixation Provide a Quality-of-Life Benefit Over Traditional Closed Reduction of Mandibular Condyle Fractures?

PURPOSE

This study sought to estimate patient-reported outcomes and compare quality-of-life (QOL) measures between patients electing for either open reduction internal fixation (ORIF) or closed reduction with intermaxillary fixation (CRIMF).

PATIENTS AND METHODS

This was a retrospective cohort study of patients with unilateral condyle fractures who had undergone either ORIF or CRIMF at the New York University Tisch Hospital and Bellevue Hospital Center. The primary study predictor was treatment choice (ORIF or CRIMF). Other study predictors were patient age, gender, and the presence of any other coexisting facial fractures. The 9 study outcomes were derived from an 11-item postoperative QOL questionnaire evaluating self-reported perceptions of pain and function. Univariate comparisons and multivariate regression models were calculated.

RESULTS

A total of 38 patients (21 CRIMF and 17 ORIF) comprised the study sample. All patients were eligible for either ORIF or CRIMF, and the choice of treatment was decided through shared decision making after a comprehensive discussion of risks and benefits. With respect to pain outcomes, patients who underwent ORIF reported lower overall pain scores at 2 weeks (P < .01) and 2 months (P = .01), less mastication pain at 3 months (P = .01), and a lower rate of persistent headaches after 6 weeks (P = .04). With respect to functional outcomes, patients who underwent ORIF reported better range of motion at 3 months (P = .01), less treatment-related weight loss (P = .01), and more ease when performing physical (P < .01) and work-related (P < .01) activities. In the multivariate regression models, ORIF was independently associated with decreased pain at 2 weeks (P < .01) and decreased difficulty in obtaining nutrition (P < .01), performing physical activities (P = .02), and performing work-related activities (P < .01).

CONCLUSIONS

Patients who underwent ORIF appeared to experience subjective favorable pain and functional QOL outcomes. Given the clinical controversy, the choice of treatment should synthesize patient-reported outcomes and be approached through shared decision making.

Building ground for didactics in a patient decision aid for hip osteoarthritis. Exploring patient-related barriers and facilitators towards shared decision-making

OBJECTIVE

The aim of the present study was to explore patient-related barriers and facilitators towards shared decision-making (SDM) during routine orthopedic outpatient consultations as part of the process of developing a patient decision aid (PDA) for patients with hip osteoarthritis (OA).

METHODS

Consultations comprising nineteen hip OA patients referred to an orthopedic surgeon for treatment decision-making were observed, audio recorded and transcribed. Iterative thematic analysis proceeded, based on a taxonomy of generic patient-related barriers towards SDM grounded in the Theory of Planned Behavior (TPB).

RESULTS

A targeted taxonomy provided a structured overview of 26 factors influencing hip OA patients' intention to engage in SDM. Patients' perceived ability to change the agenda of the visit emerged as seminal factor and was added to the generic taxonomy.

CONCLUSION

Using a TPB-based taxonomy, we were able to identify and structure generic and context specific SDM barriers. Addressing patients' communication self-efficacy should be included as didactic feature in PDAs.

PRACTICE IMPLICATIONS

PDAs for hip OA should be designed for the broad spectrum of decision-making support needs occurring throughout the continuum of the disease. The provided taxonomy may contribute as guidance within implementation strategies that aim to support patients' intentions to engage in SDM.

A review of shared decision-making: A call to arms for health care professionals

OBJECTIVE

To illustrate the use of shared decision-making (SDM) and SDM tools and aids as the essential components in the care of asthma.

DATA SOURCES

We reviewed individual randomized controlled studies conducted between 1998 and 2020 to compare SDM interventions and the use of SDM tools and aids for the care of asthma. All studies were published or translated in English.

STUDY SELECTIONS

We excluded studies of interventions that involved multiple components other than the SDM intervention unless the control group also received these interventions. We evaluated the existing literature on both SDM tools and aids and the process of SDM to summarize in this review.

RESULTS

Shared decision-making tools and aids most commonly clarify the diagnostics and options for a treatment. The 6 elements of SDM were clearly supported. We found no considerable association between the presence of these elements of SDM and asthma outcomes.

CONCLUSION

We found that SDM for asthma and SDM tools and aids were often made to transfer information about asthma treatment options and their harms and benefits. The correlation between their support of SDM key elements and their impact on asthma outcomes is often difficult to ascertain but when present, there was positive correlation to improving risk communication, adherence, patient satisfaction, and possibly decreasing liability.

Engaging patients and families in communication across transitions of care: An integrative review

OBJECTIVE

To determine the current evidence about patient and family engagement in communication with health professionals during transitions of care to, within and from acute care settings.

METHODS

An integrative review using seven international databases was conducted for 2003-2017. Forty eligible studies were analysed and synthesised using framework synthesis.

RESULTS

Four themes: 1) Partnering in care: patients and families should be partners in decision-making and care; 2) Augmenting communication during transitions: intrinsic and extrinsic factors supported transition communication between patients, families and health professionals; 3) Impeding information exchange: the difficulties faced by patients and families taking an active role in transition; and 4) Outcomes of communication during transitions: reported experiences for patients, families and health professionals.

CONCLUSION

While attitudes towards engaging patients and family in transition communication in acute settings are generally positive, current practices are variable. Structural supports for practice are not always present.

PRACTICE IMPLICATIONS

Organisational strategies to improve communication must incorporate an understanding of patient needs. A structured approach which considers timing, privacy, location and appropriateness for patients and families is needed. Communication training is required for patients, families and health professionals. Health professionals must respect a patient's right to be informed by regularly communicating.

Patients' and clinicians' perspectives on shared decision-making regarding treatment decisions for depression, anxiety disorders, and obsessive-compulsive disorder in specialized psychiatric care

RATIONALE, AIMS, AND OBJECTIVES

People worldwide are affected by psychiatric disorders that lack a "best" treatment option. The role of shared decision-making (SDM) in psychiatric care seems evident, yet remains limited. Research on SDM in specialized mental health is scarce, concentrating on patients with depressive disorder or psychiatric disorders in general and less on patients with anxiety and obsessive-compulsive disorder (OCD). Furthermore, recent research concentrates on the evaluation of interventions to promote and measure SDM rather than on the feasibility of SDM in routine practice. This study investigated patients' and clinicians' perspectives on SDM to treat depression, anxiety disorders, and OCD as to better understand SDM in specialized psychiatric care and its challenges in clinical practice.

METHODS

Transcripts of eight focus groups with 17 outpatients and 33 clinicians were coded, and SDM-related codes were analysed using thematic analyses.

RESULTS

Motivators, responsibilities, and preconditions regarding SDM were defined. Patients thought SDM should be common practice given the autonomy they have over their own bodies and felt responsible for their treatments. Clinicians value SDM for obtaining patients' consent, promoting treatment adherence, and establishing a good patient-clinician relationship. Patients and clinicians thought clinicians assumed the most responsibility regarding the initiation and achievement of SDM in clinical practice. According to clinicians, preconditions were often not met, were influenced by illness severity, and formed important barriers (eg, patient's decision-making capacity, treatment availability, and clinicians' preferences), leading to paternalistic decision-making. Patients recognized these difficulties, but felt none of these preclude the implementation of SDM. Personalized information and more consultation time could facilitate SDM.

CONCLUSIONS

Patients and clinicians in specialized psychiatric care value SDM, but adapting it to daily practice remains challenging. Clinicians are vital to the implementation of SDM and should become versed in how to involve patients in the decision-making process, even when this is difficult.

Strategies for implementing shared decision making in elective surgery by health care practitioners: A systematic review

RATIONALE, AIMS AND OBJECTIVES

To summarize relevant international scientific evidence on strategies aimed at facilitating or improving health care practitioners' adoption of shared decision making in elective surgery. The review evaluated the effectiveness of these strategies and described the characteristics of identified strategies.

METHOD

A systematic search of the literature was conducted up to March 2019. The review included interventions that targeted patients, health care practitioners, or health systems/organizations. Main outcomes were measures of decision process and decision outcomes. Two independent reviewers conducted study selection, assessed methodological quality and extracted data.

RESULTS

Fifteen randomized controlled trials, one pseudo-randomized controlled trial, and four quasi-experimental studies were included in this review. The heterogeneity of interventions and the variability of outcomes used to measure the impact of these interventions precluded meta-analysis. All of the interventions included an educational component regarding the medical condition of interest and available treatment options and a supportive component to encourage patients to ask questions and involve themselves in the decision making. Published evidence on shared decision-making interventions in elective surgery is most prevalent in the breast cancer/endocrine and urology specialties, with most studies targeting their shared decision-making interventions at the patient population. The use of multiple media components within an intervention including interactive video appeared to improve patient satisfaction with the shared decision-making process.

CONCLUSIONS

The use of well-developed educational information provided through interactive multimedia, computer or DVD based, may enhance the decision-making process. The evidence suggests that such multimedia can be used prior to the surgical consultation, presenting medical and surgical information relevant to the upcoming consultation. A decision and communication aid also appears to be an effective method to support the surgeon in patient participation and involvement in the decision-making process.

Clinical Practice Guideline: Sudden Hearing Loss (Update)

OBJECTIVE

Sudden hearing loss is a frightening symptom that often prompts an urgent or emergent visit to a health care provider. It is frequently but not universally accompanied by tinnitus and/or vertigo. Sudden sensorineural hearing loss affects 5 to 27 per 100,000 people annually, with about 66,000 new cases per year in the United States. This guideline update provides evidence-based recommendations for the diagnosis, management, and follow-up of patients who present with sudden hearing loss. It focuses on sudden sensorineural hearing loss in adult patients aged ≥18 years and primarily on those with idiopathic sudden sensorineural hearing loss. Prompt recognition and management of sudden sensorineural hearing loss may improve hearing recovery and patient quality of life. The guideline update is intended for all clinicians who diagnose or manage adult patients who present with sudden hearing loss.

PURPOSE

The purpose of this guideline update is to provide clinicians with evidence-based recommendations in evaluating patients with sudden hearing loss and sudden sensorineural hearing loss, with particular emphasis on managing idiopathic sudden sensorineural hearing loss. The guideline update group recognized that patients enter the health care system with sudden hearing loss as a nonspecific primary complaint. Therefore, the initial recommendations of this guideline update address distinguishing sensorineural hearing loss from conductive hearing loss at the time of presentation with hearing loss. They also clarify the need to identify rare, nonidiopathic sudden sensorineural hearing loss to help separate those patients from those with idiopathic sudden sensorineural hearing loss, who are the target population for the therapeutic interventions that make up the bulk of the guideline update. By focusing on opportunities for quality improvement, this guideline should improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients.

METHODS

Consistent with the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition" (Rosenfeld et al. Otolaryngol Head Neck Surg. 2013;148[1]:S1-S55), the guideline update group was convened with representation from the disciplines of otolaryngology-head and neck surgery, otology, neurotology, family medicine, audiology, emergency medicine, neurology, radiology, advanced practice nursing, and consumer advocacy. A systematic review of the literature was performed, and the prior clinical practice guideline on sudden hearing loss was reviewed in detail. Key Action Statements (KASs) were updated with new literature, and evidence profiles were brought up to the current standard. Research needs identified in the original clinical practice guideline and data addressing them were reviewed. Current research needs were identified and delineated.

RESULTS

The guideline update group made strong recommendations for the following: (KAS 1) Clinicians should distinguish sensorineural hearing loss from conductive hearing loss when a patient first presents with sudden hearing loss. (KAS 7) Clinicians should educate patients with sudden sensorineural hearing loss about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy. (KAS 13) Clinicians should counsel patients with sudden sensorineural hearing loss who have residual hearing loss and/or tinnitus about the possible benefits of audiologic rehabilitation and other supportive measures. These strong recommendations were modified from the initial clinical practice guideline for clarity and timing of intervention. The guideline update group made strong recommendations against the following: (KAS 3) Clinicians should not order routine computed tomography of the head in the initial evaluation of a patient with presumptive sudden sensorineural hearing loss. (KAS 5) Clinicians should not obtain routine laboratory tests in patients with sudden sensorineural hearing loss. (KAS 11) Clinicians should not routinely prescribe antivirals, thrombolytics, vasodilators, or vasoactive substances to patients with sudden sensorineural hearing loss. The guideline update group made recommendations for the following: (KAS 2) Clinicians should assess patients with presumptive sudden sensorineural hearing loss through history and physical examination for bilateral sudden hearing loss, recurrent episodes of sudden hearing loss, and/or focal neurologic findings. (KAS 4) In patients with sudden hearing loss, clinicians should obtain, or refer to a clinician who can obtain, audiometry as soon as possible (within 14 days of symptom onset) to confirm the diagnosis of sudden sensorineural hearing loss. (KAS 6) Clinicians should evaluate patients with sudden sensorineural hearing loss for retrocochlear pathology by obtaining magnetic resonance imaging or auditory brainstem response. (KAS 10) Clinicians should offer, or refer to a clinician who can offer, intratympanic steroid therapy when patients have incomplete recovery from sudden sensorineural hearing loss 2 to 6 weeks after onset of symptoms. (KAS 12) Clinicians should obtain follow-up audiometric evaluation for patients with sudden sensorineural hearing loss at the conclusion of treatment and within 6 months of completion of treatment. These recommendations were clarified in terms of timing of intervention and audiometry and method of retrocochlear workup. The guideline update group offered the following KASs as options: (KAS 8) Clinicians may offer corticosteroids as initial therapy to patients with sudden sensorineural hearing loss within 2 weeks of symptom onset. (KAS 9a) Clinicians may offer, or refer to a clinician who can offer, hyperbaric oxygen therapy combined with steroid therapy within 2 weeks of onset of sudden sensorineural hearing loss. (KAS 9b) Clinicians may offer, or refer to a clinician who can offer, hyperbaric oxygen therapy combined with steroid therapy as salvage therapy within 1 month of onset of sudden sensorineural hearing loss.

DIFFERENCES FROM PRIOR GUIDELINE

Incorporation of new evidence profiles to include quality improvement opportunities, confidence in the evidence, and differences of opinion Included 10 clinical practice guidelines, 29 new systematic reviews, and 36 new randomized controlled trials Highlights the urgency of evaluation and initiation of treatment, if treatment is offered, by emphasizing the time from symptom occurrence Clarification of terminology by changing potentially unclear statements; use of the term sudden sensorineural hearing loss to mean idiopathic sudden sensorineural hearing loss to emphasize that >90% of sudden sensorineural hearing loss is idiopathic sudden sensorineural hearing loss and to avoid confusion in nomenclature for the reader Changes to the KASs from the original guideline: KAS 1-When a patient first presents with sudden hearing loss, conductive hearing loss should be distinguished from sensorineural. KAS 2-The utility of history and physical examination when assessing for modifying factors is emphasized. KAS 3-The word "routine" is added to clarify that this statement addresses nontargeted head computerized tomography scan that is often ordered in the emergency room setting for patients presenting with sudden hearing loss. It does not refer to targeted scans, such as temporal bone computerized tomography scan, to assess for temporal bone pathology. KAS 4-The importance of audiometric confirmation of hearing status as soon as possible and within 14 days of symptom onset is emphasized. KAS 5-New studies were added to confirm the lack of benefit of nontargeted laboratory testing in sudden sensorineural hearing loss. KAS 6-Audiometric follow-up is excluded as a reasonable workup for retrocochlear pathology. Magnetic resonance imaging, computerized tomography scan if magnetic resonance imaging cannot be done, and, secondarily, auditory brainstem response evaluation are the modalities recommended. A time frame for such testing is not specified, nor is it specified which clinician should be ordering this workup; however, it is implied that it would be the general or subspecialty otolaryngologist. KAS 7-The importance of shared decision making is highlighted, and salient points are emphasized. KAS 8-The option for corticosteroid intervention within 2 weeks of symptom onset is emphasized. KAS 9-Changed to KAS 9A and 9B. Hyperbaric oxygen therapy remains an option but only when combined with steroid therapy for either initial treatment (9A) or salvage therapy (9B). The timing of initial therapy is within 2 weeks of onset, and that of salvage therapy is within 1 month of onset of sudden sensorineural hearing loss. KAS 10-Intratympanic steroid therapy for salvage is recommended within 2 to 6 weeks following onset of sudden sensorineural hearing loss. The time to treatment is defined and emphasized. KAS 11-Antioxidants were removed from the list of interventions that the clinical practice guideline recommends against using. KAS 12-Follow-up audiometry at conclusion of treatment and also within 6 months posttreatment is added. KAS 13-This statement on audiologic rehabilitation includes patients who have residual hearing loss and/or tinnitus who may benefit from treatment. Addition of an algorithm outlining KASs Enhanced emphasis on patient education and shared decision making with tools provided to assist in same.

Improving Lung Cancer Screening Access for Individuals With Serious Mental Illness

Lung cancer continues to be the leading cause of cancer mortality in the United States across all races and ethnicities, but it does not affect everyone equally. Individuals with serious mental illness (SMI), including schizophrenia and bipolar disorder, experience two to four times greater lung cancer mortality in part due to high rates of smoking, delays in cancer diagnosis, and inequities in cancer treatment. Additionally, adults with SMI experience patient, clinician, and health care system-level barriers to accessing cancer screening, such as cognitive deficits that impact understanding of cancer risk, higher rates of poverty and social isolation, patient-provider communication challenges, decreased access to tobacco cessation, and the fragmentation of primary care and mental health care. Despite the proven benefits and mandated coverage by public and private payers, lung cancer screening participation rates remain low among eligible patients, below 4% a year. Given disparities in other cancer screening modalities, these rates are likely to be even lower among individuals with SMI. This article provides a brief overview of current challenges in lung cancer screening and describes a pilot collaboration between radiology and psychiatry that has potential to improve access to lung cancer screening for individuals with serious mental illness.

Usability and feasibility of multimedia interventions for engaging patients in their care in the context of acute recovery: A narrative review

PURPOSE

The purpose of this narrative review was to examine the usability and feasibility of multimedia intervention as a platform to enable patient participation in the context of acute recovery and to discover what outcomes have been measured.

DATA SOURCES

A narrative review of primary research articles identified through a search of four electronic databases (MEDLINE, CINAHL, EMBASE and PsycInfo) identified peer-reviewed research evidence published in English language with no limitation placed on time period or publication type. Two authors independently assessed articles for inclusion. From the 277 articles identified through the search, 10 papers reporting the outcomes of seven studies were included in this review.

REVIEW METHODS

Articles were independently assessed for quality and relevance by two authors. The most appropriate method for data synthesis for this review was a narrative synthesis.

RESULTS

From the narrative synthesis of study outcomes, two findings emerged as follows: (a) multimedia interventions are feasible and usable in the context of acute care, and (b) multimedia interventions can improve patients' perception of care-related knowledge. Identified gaps included a lack of evidence in relation to the effect of interventions on enhancing patients' ability to participate in their care and the impact on patients' health-related outcomes.

CONCLUSIONS

In conclusion, there is some evidence of the feasibility and usability of multimedia interventions in acute care. That is, patients can use these types of platforms in this context and are satisfied with doing so. Multimedia platforms have a role in the delivery of information for patients during acute recovery; however, the effectiveness of these platforms to engage and enhance patients' capability to participate in their recovery and the impact on outcomes needs to be rigorously evaluated.

Shared decision-making for delivery mode: An OPTION scale observer-based evaluation

OBJECTIVE

Shared decision-making (SDM) may help to reduce the rate of Cesarean Delivery (CD). The aim of the study was to evaluate the extent to which pregnant women are involved in SDM about the mode of delivery, applying the Italian version of the OPTION¹² scale to obstetric consultations.

METHODS

Fifty-eight outpatient consultations were rated; statistical associations between OPTION¹² scores and sociodemographic data of both patient and physicians were determined.

RESULTS

The OPTION¹² total scores showed a skewed distribution in the lower range of total scores. Total scores in a percentage basis ranged from 0 to 69, with a mean of 21.2 (±19.84) and a median of 13.5. Mean and median scores for all the 12 OPTION¹² items never reached the minimum skill level.

CONCLUSION

A low level of patient involvement in deciding between a CD and a Vaginal Delivery (VD) was demonstrated. Interventions aiming at educating obstetricians as well as the adoption of decision aids are requested.

PRACTICE IMPLICATIONS

The OPTION¹² scale may prove useful for testing the extent of pregnant women's involvement in deciding between CD and VD. The awareness of a low patient involvement seems mandatory to improve SDM and may lead to medico-legal protection.

Tuberculosis preventive treatment preferences among care givers of children in Lesotho: a pilot study

BACKGROUND

Shorter-duration regimens for preventing drug-susceptible tuberculosis (TB) have been shown to be safe and efficacious in children, and may improve acceptability, adherence, and treatment completion. While these regimens have been used in children in low TB burden countries, they are not yet widely used in high TB burden countries.

SETTING

Five health facilities in one district in Lesotho, a high TB burden country.

OBJECTIVE

Assess the preventive treatment preferences of care givers of child TB contacts.

DESIGN

Qualitative data were collected using in-depth interviews with 12 care givers whose children completed preventive treatment, and analyzed using grounded theory.

FINDINGS

Care givers were interested in being involved in the children's treatment decisions. Pill burden, treatment duration and related frequency of dosing were identified as important factors that influenced preventive treatment preferences among care givers.

CONCLUSION

Understanding care giver preferences and involving them in treatment decisions may facilitate efforts to implement successful preventive treatment for TB among children in high TB burden countries.

Impact of a Novel Preoperative Patient-centered Surgical Wellness Program

OBJECTIVE

The objective of this study was to evaluate if a preoperative wellness bundle significantly decreases the risk of hospital acquired infections (HAI).

BACKGROUND

HAI threaten patient outcomes and are a significant burden to the healthcare system. Preoperative wellness efforts may significantly decrease the risk of infections.

METHODS

A group of 12,396 surgical patients received a wellness bundle in a roller bag during preoperative screening at an urban academic medical center. The wellness bundle consisted of a chlorhexidine bath solution, immuno-nutrition supplements, incentive spirometer, topical mupirocin for the nostrils, and smoking cessation information. Study staff performed structured patient interviews, observations, and standardized surveys at key intervals throughout the perioperative period. Statistics compare HAI outcomes of patients in the wellness program to a nonintervention group using the Fisher's exact test, logistic regression, and Poisson regression.

RESULTS

Patients in the nonintervention and intervention groups were similar in demographics, comorbidity, and type of operations. Compliance with each element was high (80% mupirocin, 72% immuno-nutrition, 71% chlorhexidine bath, 67% spirometer). The intervention group had statistically significant reductions in surgical site infections, Clostridium difficile, catheter associated urinary tract infections, and patient safety indicator 90.

CONCLUSIONS

A novel, preoperative, patient-centered wellness program dramatically reduced HAI in surgical patients at an urban academic medical center.

Interventions for promoting participation in shared decision-making for children and adolescents with cystic fibrosis

BACKGROUND

Shared decision-making is important in child and adolescent healthcare because there is growing international recognition of children and young people's rights to be included in decisions that affect them. In order for young people to participate effectively in shared decision-making they need to develop the skills of engagement with healthcare professionals and confidence in interacting with them. They also need to learn how to manage their condition and treatments on their own when they move into adulthood. Children and young people who participate in shared decision-making in healthcare are likely to be more informed, feel more prepared, and experience less anxiety about the unknown. Significant improvements in cystic fibrosis (CF) survival over recent decades, due to improved therapies and better management of care, means that young people with CF are routinely transitioning to adult healthcare where increasing emphasis on self-management brings greater complexity in decision-making. We need to know what interventions are effective in promoting shared decision-making for young people with CF.

OBJECTIVES

To assess the effectiveness of interventions that promote participation in shared decision-making for children and adolescents (aged between four and 18 years) with CF.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearches of journals and conference abstract books. We also searched the reference lists of articles and reviews addressing shared decision-making.Date of most recent search: 12 March 2019.We searched PubMed, CINAHL (EBSCO), Embase (Elsevier), PsycINFO (EBSCO), WHO ICTRP, ASSIA (ProQuest), ERIC (ProQuest), ProQuest Dissertations and Theses, and ClinicalTrials.gov. We contacted study authors with published relevant research in shared decision-making for adults to ask if they were aware of any published or ongoing studies on the promotion of the intervention for children or adolescents (or both) with CF.Date of most recent search: 19 March 2019.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs) (but not cross-over RCTs) of interventions promoting shared decision-making for children and adolescents with CF aged between four and 18 years, such as information provision, booklets, two-way interaction, checking understanding (by the participant), preparation to participate in a healthcare decision, decision-aids, and training interventions or educational programs. We planned to include interventions aimed at children or adolescents (or both), parents or healthcare professionals or any combination of these groups provided that the focus was aimed at promoting shared decision-making for children and adolescents with CF.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed papers identified in the searches.

MAIN RESULTS

No eligible RCTs were identified for inclusion in this systematic review.

AUTHORS' CONCLUSIONS

We were unable to identify RCTs with evidence which would support healthcare policy-making and practice related to implementation of shared decision-making for children and adolescents (aged between four and 18 years) with CF). We hope that having identified this gap in research, awareness will increase amongst researchers of the need to design high-quality shared decision-making interventions for young people with CF, perhaps adapted from existing models for adults, and to test these interventions and children's preferences in RCTs. It is also important to target health professionals with evidence-based education programmes on shared decision-making and a need for international consensus on addressing the variability in education programmes.

Decision aids that facilitate elements of shared decision making in chronic illnesses: a systematic review

BACKGROUND

Shared decision making (SDM) is a patient-centered approach in which clinicians and patients work together to find and choose the best course of action for each patient's particular situation. Six SDM key elements can be identified: situation diagnosis, choice awareness, option clarification, discussion of harms and benefits, deliberation of patient preferences, and making the decision. The International Patient Decision Aid Standards (IPDAS) require that a decision aid (DA) support these key elements. Yet, the extent to which DAs support these six key SDM elements and how this relates to their impact remain unknown.

METHODS

We searched bibliographic databases (from inception until November 2017), reference lists of included studies, trial registries, and experts for randomized controlled trials of DAs in patients with cardiovascular, or chronic respiratory conditions or diabetes. Reviewers worked in duplicate and independently selected studies for inclusion, extracted trial, and DA characteristics, and evaluated the quality of each trial.

RESULTS

DAs most commonly clarified options (20 of 20; 100%) and discussed their harms and benefits (18 of 20; 90%; unclear in two DAs); all six elements were clearly supported in 4 DAs (20%). We found no association between the presence of these elements and SDM outcomes.

CONCLUSIONS

DAs for selected chronic conditions are mostly designed to transfer information about options and their harms and benefits. The extent to which their support of SDM key elements relates to their impact on SDM outcomes could not be ascertained.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42016050320 .

[Citizen participation in efforts to improve the quality and safety of care]

Given the changing needs of the user, the model of public service administration that was once constructed in ignorance of the user and his concerns no longer finds its place. There is therefore mention of a reversal of trends and a modernization of public institutions and structures based on a reflective approach that over-emphasizes the user's place in the system as beneficiary, recipient and partner of the care service. The participation and the viewpoint of the user constitute therefore a very important stake in the improvement of the quality of the care and the evaluation of the health technologies. Convinced of the importance of involving users in efforts to improve the quality and safety of healthcare, the High Authority for Health (HAS), as a public institution for health democracy in France, has put in place cooperation projects between health professionals and beneficiaries translated into working groups and committees. Through this approach, the HAS gives the beneficiaries the role of experts enabling them, through their experiential expertise to express themselves in the process of modernization and improvement of certification and quality and safety of care. It is with the aim of understanding the various modalities and the level of involvement of users' representatives in the quality procedures in general and in the certification of healthcare institutions in particular that we will try in this contribution to highlight the obstacles and the means in the health sector in France.

Enhancing Equitable Access to Assistive Technologies in Canada: Insights from Citizens and Stakeholders

Les besoins en technologies d’assistance augmentent au Canada, mais l’accès à ces technologies est inégal et fragmentaire, ce qui ferait en sorte que des besoins demeureraient non comblés. Cette étude visait à identifier les valeurs et préférences des citoyens concernant les moyens à utiliser pour favoriser un accès équitable aux technologies d’assistance. Elle visait également à impliquer les décideurs politiques, les parties prenantes et les chercheurs dans des discussions afin d’élaborer des actions dans ce domaine. Au printemps 2017, nous avons organisé trois panels de citoyens et un dialogue avec les parties prenantes. Les principales conclusions des panels ont été incluses dans une synthèse qui a été partagée avec les participants du dialogue. Trente-sept citoyens ont participé aux panels et ont souligné l’importance de l’accès à de l’information fiable, d’un accès équitable aux technologies d’assistance (et ce, quelle que soit la capacité de payer), et de la collaboration. Les vingt-deux participants au dialogue ont fait valoir la nécessité d’un cadre d’orientation pour appuyer l’évolution des pratiques dans l’ensemble au pays. Le cadre d’orientation proposé combinerait des politiques et programmes simplifiés incluant la collecte et l’évaluation de données robustes pour appuyer l’innovation et l’imputabilité à travers le pays.

The Development and Evaluation of Personalized Training in Shared Decision-making Skills for Rheumatologists

OBJECTIVE

Many factors influence a patient's preference in engaging in shared decision making (SDM). Several training programs have been developed for teaching SDM to physicians, but none of them focused on the patients' preferences. We developed an SDM training program for rheumatologists with a specific focus on patients' preferences and assessed its effects.

METHODS

A training program was developed, pilot tested, and given to 30 rheumatologists. Immediately after the training and 10 weeks later, rheumatologists were asked to complete a questionnaire to evaluate the training. Patients were asked before and after the training to complete a questionnaire on patient satisfaction.

RESULTS

Ten weeks after the training, 57% of the rheumatologists felt they were capable of estimating the need of patients to engage in SDM, 62% felt their communication skills had improved, and 33% reported they engaged more in SDM. Up to 268 patients were included. Overall, patient satisfaction was high, but there were no statistically significant differences in patient satisfaction before and after the training.

CONCLUSION

The training was received well by the participating rheumatologists. Even in a population of rheumatologists that communicates well, 62% reported improvement. The training program increased awareness about the principles of SDM in patients and physicians, and improved physicians' communicative skills, but did not lead to further improvement in patients' satisfaction, which was already high.

"My pharmacist": Creating and maintaining relationship between physicians and pharmacists in primary care settings

BACKGROUND

Pharmacists and physicians are being increasingly encouraged to adopt a collaborative approach to patient care, and delivery of health services. Strong collaboration between pharmacists and physicians is known to improve patient safety, however pharmacists have expressed difficulty in developing interprofessional working relationships. There is not a significant body of knowledge around how relationships influence how and when pharmacists and physicians communicate about patient care.

OBJECTIVES

This paper examines how pharmacists and primary care physicians communicate with each other, specifically when they have or do not have an established relationship.

METHODS

Thematic analysis of data from semi-structured interviews with nine primary care physicians and 25 pharmacists, we examined how pharmacists and physicians talk about their roles and responsibilities in primary care and how they build relationships with each other.

RESULTS

We found that both groups of professionals communicated with each other in relation to the perceived scope of their practice and roles. Three emerging themes emerged in the data focusing on (1) the different ways physicians communicate with pharmacists; (2) insights into barriers discussed by pharmacists; and (3) how relationships shape collaboration and interactions. Pharmacists were also responsible for initiating the relationship as they relied on it more than the physicians. The presence or absence of a personal connection dramatically impacts how comfortable healthcare professionals are with collaboration around care.

CONCLUSION

The findings support and extend the existing literature on pharmacist-physician collaboration, as it relates to trust, relationship, and role. The importance of strong communication is noted, as is the necessity of improving ways to build relationships to ensure strong interprofessional collaboration.

Shared decision-making in mental health care using routine outcome monitoring: results of a cluster randomised-controlled trial

PURPOSE

To investigate the effects of Shared Decision-Making (SDM) using Routine Outcome Monitoring (ROM) primary on patients' perception of Decisional Conflict (DC), which measures patients' engagement in and satisfaction with clinical decisions, and secondary on working alliance and treatment outcomes.

METHOD

Multi-centre two-arm matched-paired cluster randomised-controlled trial in Dutch specialist mental health care. SDM using ROM (SDMR) was compared with Decision-Making As Usual (DMAU). Outcomes were measured at baseline (T0) and 6 months (T1). Multilevel regression and intention-to-treat analyses were used. Post hoc analyses were performed on influence of subgroups and application of SDMR on DC.

RESULTS

Seven teams were randomised to each arm. T0 was completed by 186 patients (51% intervention; 49% control) and T1 by 158 patients (51% intervention, 49% control). DC, working alliance, and treatment outcomes reported by patients did not differ significantly between two arms. Post hoc analyses revealed that SDMR led to less DC among depressed patients (p = 0.047, d =- 0.69). If SDMR was applied well, patients reported less DC (SDM: p = 0.000, d = - 0.45; ROM: p = 0.021, d = - 0.32), which was associated with better treatment outcomes.

CONCLUSION

Except for patients with mood disorders, we found no difference between the arms for patient-reported DC. This might be explained by the less than optimal uptake of this generic intervention, which did not support patients directly. Regarding the positive influence of a higher level of applying SDM and ROM on less DC and better treatment outcomes, the results are encouraging for further investments in patient-oriented development and implementation of SDMR.

Clinical communication and caregivers' satisfaction with child healthcare in Nepal; results from Nepal Health Facility Survey 2015

Background

Patient satisfaction is an important measure of quality of care and a determinant of health service utilisation and the choice of health facility. Measuring patients’ experiences is important for understanding and improving the quality of care at health facilities. The aim of this study was to assess levels and identify associated factors of caregivers’ satisfaction and provider-caregiver communication within child healthcare in Nepal.

Methods

Secondary analysis of Sick Child Exit Interviews (n = 2092) sourced from 2015 Nepal Health Facility Survey data. Satisfaction was measured through caregivers’ satisfaction with services received and their willingness to recommend the health facility visited. Communication indicators were chosen based on the 2014 WHO IMCI guidelines and aggregate communication scores were calculated based on the number of indicators acknowledged during assessments. Logistic regression was used for analysis.

Results

Although most respondents (82.1%) reportedly were satisfied with the care provided, only 35.9% experienced good communication with their providers. Caregivers who had ever attended school were more likely to be satisfied with services (1.44, CI 95% 1.04–1.99). Type of provider, sex of child or who the caregiver was had no association with caregivers’ satisfaction. Having been given a diagnosis doubled the chances of satisfaction (AOR 2.04, 95% CI 1.38–3.00), as did discussion of the child’s growth (OR 1.71, 95% CI 1.06–2.76) and having discussed any of the included topics (AOR 1.98, CI 95% 1.14–3.45).

Conclusions

Interventions to improve healthcare staff’s communication skills are needed in Nepal to further enhance satisfaction with services and increase quality of care. However, this is an area that need further investigation given the high levels of satisfaction displayed despite poor communication. Other factors in the health care exchange between provider and clients are influencing the level of satisfaction and need to be identified and promoted further. High-quality care is no longer a goal for the future or only for high income settings; it is essential for reaching global health goals.

Study protocol of a randomized controlled trial on two new dissemination strategies for a brief, shared-decision-making (SDM) training for oncologists: web-based interactive SDM online-training versus individualized context-based SDM face-to-face training

BACKGROUND

Oncological patients often feel left out of important treatment decisions. However, when physicians engage them in shared decision-making (SDM), patients benefit in many ways and the situation is improved. SDM can effectively be taught to physicians, but participation barriers for SDM physician group trainings are high, making it hard to convince physicians to participate. With this in mind, we aim to develop and evaluate two new dissemination strategies for a brief, SDM training program based upon a proven SDM group-training concept: an individualized context-based SDM face-to-face training (IG I) and a web-based interactive SDM online training (IG II). We aim to analyze which improvements can be achieved by IG I and II compared to a control group (CG) in physician SDM competence and performance as well as the impact on the physician-patient relationship. Furthermore, we analyze differences in satisfaction concerning the two dissemination strategies by means of a training evaluation.

METHODS/DESIGN

We examine - based on a three-armed randomized controlled trial (IG I, IG II, CG) - the effectiveness of two new dissemination strategies for a SDM training program compared to a CG receiving no SDM training (voluntary access to SDM training as an incentive for participation after completion of the study). We aim to include 162 physicians randomized to one of the three arms. There will be two assessment points in time (before intervention: T₀ and post-training: T₁). The main outcome is the SDM competence of physicians as measured by an established observational assessment rating system (OPTION-12) by means of consultations with Standardized Patients. Standardized Patients are individuals trained to act as "real" patients. Secondary outcome measures are the SDM performance (SDM-Q-9) and the Questionnaire on the Quality of Physician-Patient-Interaction (QQPPI) both rated by Standardized Patients as well as the physicians' training evaluation.

DISCUSSION

This trial will assess the effectiveness and acceptability of two new dissemination strategies for a brief, SDM training program for physicians. Opportunities and challenges regarding implementation in daily routines will be discussed.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT02674360 . Prospectively registered on 4 February 2016.