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Aurora T, Bridges C, Porter A, Madni A. Pediatric sickle cell disease: A case for improved clinician-family partnerships. J Hosp Med 2024; 19:146-148. [PMID: 38017233 DOI: 10.1002/jhm.13239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/14/2023] [Accepted: 11/04/2023] [Indexed: 11/30/2023]
Affiliation(s)
- Tarun Aurora
- Division of Hematology/Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Christopher Bridges
- Divison of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Amy Porter
- Division of Hematology/Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Arshia Madni
- Division of Hematology/Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Stacey D, Lewis KB, Smith M, Carley M, Volk R, Douglas EE, Pacheco-Brousseau L, Finderup J, Gunderson J, Barry MJ, Bennett CL, Bravo P, Steffensen K, Gogovor A, Graham ID, Kelly SE, Légaré F, Sondergaard H, Thomson R, Trenaman L, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2024; 1:CD001431. [PMID: 38284415 PMCID: PMC10823577 DOI: 10.1002/14651858.cd001431.pub6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Meg Carley
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robert Volk
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisa E Douglas
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael J Barry
- Informed Medical Decisions Program, Massachusetts General Hospital, Boston, MA, USA
| | - Carol L Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Paulina Bravo
- Education and Cancer Prevention, Fundación Arturo López Pérez, Santiago, Chile
| | - Karina Steffensen
- Center for Shared Decision Making, IRS - Lillebælt Hospital, Vejle, Denmark
| | - Amédé Gogovor
- VITAM - Centre de recherche en santé durable, Université Laval, Quebec, Canada
| | - Ian D Graham
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | | | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Logan Trenaman
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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Chen L, Zhang P, Shen L, Zhu H, Wang Y, Xu K, Tang S, Sun Y, Yan X, Lai B, Ouyang G. Adoption value of support vector machine algorithm-based computed tomography imaging in the diagnosis of secondary pulmonary fungal infections in patients with malignant hematological disorders. Open Life Sci 2023; 18:20220765. [PMID: 38152585 PMCID: PMC10752001 DOI: 10.1515/biol-2022-0765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 12/29/2023] Open
Abstract
This study aimed to assess the feasibility of diagnosing secondary pulmonary fungal infections (PFIs) in patients with hematological malignancies (HM) using computerized tomography (CT) imaging and a support vector machine (SVM) algorithm. A total of 100 patients with HM complicated by secondary PFI underwent CT scans, and they were included in the training group. Concurrently, 80 patients with the same underlying disease who were treated at our institution were included in the test group. The types of pathogens among different PFI patients and the CT imaging features were compared. Radiomic features were extracted from the CT imaging data of patients, and a diagnostic SVM model was constructed by integrating these features with clinical characteristics. Aspergillus was the most common pathogen responsible for PFIs, followed by Candida, Pneumocystis jirovecii, Mucor, and Cryptococcus, in descending order of occurrence. Patients typically exhibited bilateral diffuse lung lesions. Within the SVM algorithm model, six radiomic features, namely the square root of the inverse covariance of the gray-level co-occurrence matrix (square root IV), the square root of the inverse covariance of the gray-level co-occurrence matrix, and small dependency low gray-level emphasis, significantly influenced the diagnosis of secondary PFIs in patients with HM. The area under the curve values for the training and test sets were 0.902 and 0.891, respectively. Therefore, CT images based on the SVM algorithm demonstrated robust predictive capability in diagnosing secondary PFIs in conjunction with HM.
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Affiliation(s)
- Lieguang Chen
- Department of Hematology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
| | - Pisheng Zhang
- Department of Hematology, The Affiliated People’s Hospital of Ningbo University, Ningbo, 315040, Zhejiang, China
| | - Lixia Shen
- Department of Hematology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
| | - Huiling Zhu
- Department of Hematology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
| | - Yi Wang
- Department of Hematology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
| | - Kaihong Xu
- Department of Hematology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
| | - Shanhao Tang
- Department of Hematology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
| | - Yongcheng Sun
- Department of Hematology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
| | - Xiao Yan
- Department of Hematology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
| | - Binbin Lai
- Department of Hematology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
| | - Guifang Ouyang
- Department of Hematology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
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Wheelwright S, Maunsell R, Taylor S, Drinkwater N, Erridge C, Foster C, Hardcastle M, Hogden A, Lawson I, Lisiecka D, Mcdermott C, Morrison KE, Muir C, Recio-Saucedo A, White S. Development of 'gastrostomy tube - is it for me?', a web-based patient decision aid for people living with motor neurone disease considering having a gastrostomy tube placed. Amyotroph Lateral Scler Frontotemporal Degener 2023; 24:1-9. [PMID: 37332172 DOI: 10.1080/21678421.2023.2220743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/28/2023] [Indexed: 06/20/2023]
Abstract
Objective: To develop and pilot a web-based patient decision aid (PDA) to support people living with motor neurone disease (plwMND) considering having a gastrostomy tube placed. Methods: In Phase 1, content and design were informed by semi-structured interviews, literature reviews and a prioritization survey. In Phase 2, the prototype PDA was tested with users and developed iteratively with feedback from surveys and 'think-aloud' interviews. Phase 1 and 2 participants were plwMND, carers and healthcare professionals (HCPs). In Phase 3, the PDA was evaluated by plwMND using validated questionnaires and HCPs provided feedback in focus groups. Results: Sixteen plwMND, 16 carers and 25 HCPs took part in Phases 1 and 2. Interviews and the literature review informed a prioritization survey with 82 content items. Seventy-seven per cent (63/82) of the content of the PDA was retained. A prototype PDA, which conforms to international standards, was produced and improved during Phase 2. In Phase 3, 17 plwMND completed questionnaires after using the PDA. Most plwMND (94%) found the PDA completely acceptable and would recommend it to others in their position, 88% had no decisional conflict, 82% were well prepared and 100% were satisfied with their decision-making. Seventeen HCPs provided positive feedback and suggestions for use in clinical practice. Conclusion: Gastrostomy Tube: Is it for me? was co-produced with stakeholders and found to be acceptable, practical and useful. Freely available from the MND Association website, the PDA is a valuable tool to support the shared decision-making process for gastrostomy tube placement.
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Affiliation(s)
| | - R Maunsell
- Centre for Psychosocial Research in Cancer: CentRIC, University of Southampton, Southampton, UK
| | - S Taylor
- Centre for Psychosocial Research in Cancer: CentRIC, University of Southampton, Southampton, UK
| | - N Drinkwater
- Motor Neurone Disease Association, Northampton, UK
| | - C Erridge
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - C Foster
- Centre for Psychosocial Research in Cancer: CentRIC, University of Southampton, Southampton, UK
| | | | - A Hogden
- School of Population Health, University of New South Wales, Sydney, Australia
| | - I Lawson
- Centre for Psychosocial Research in Cancer: CentRIC, University of Southampton, Southampton, UK
| | - D Lisiecka
- Munster Technological University - Kerry Campus, Republic of Ireland, Tralee, UK
| | | | - K E Morrison
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - C Muir
- Centre for Psychosocial Research in Cancer: CentRIC, University of Southampton, Southampton, UK
| | - A Recio-Saucedo
- Centre for Psychosocial Research in Cancer: CentRIC, University of Southampton, Southampton, UK
| | - S White
- University of Sheffield, Sheffield, UK, and
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Matula KA, Minar P, Daraiseh NM, Lin L, Recker M, Lipstein EA. Pilot trial of iBDecide: Evaluating an online tool to facilitate shared decision making for adolescents and young adults with ulcerative colitis. Health Expect 2022; 25:3105-3113. [PMID: 36161973 DOI: 10.1111/hex.13618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/31/2022] [Accepted: 09/13/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION This pilot, randomized controlled trial aimed to evaluate the usability, among adolescents and young adults (AYAs) with ulcerative colitis (UC), of a web-based tool ('iBDecide') designed to facilitate shared decision making (SDM). METHODS AYAs with UC (n = 35) were randomized to intervention (iBDecide, n = 14) and control (n = 12) arms before a scheduled clinic visit. We measured the usability of iBDecide, SDM, preferred decision-making style, decision conflict and intervention use. RESULTS Participants in the intervention group found iBDecide easy to use and agreed that it made them feel ready to participate in decision making and that they would use it to prepare for appointments. There were 130 visits to iBDecide, lasting on average 3 min, 41 s. The medication and nutrition trackers were among the most-viewed pages. Pages specifically designed to facilitate SDM were viewed only four times. Across groups, too few participants reported making decisions during clinic visits for decision-related measures to be reported. CONCLUSIONS This pilot trial provides evidence for the usability of iBDecide and guidance for developing a larger-scale trial of a combined web-based and in-clinic SDM intervention. Overall, iBDecide shows promise in engaging AYAs with UC in SDM and condition management. PATIENT OR PUBLIC CONTRIBUTION Patients, specifically AYAs with UC, and healthcare providers were involved in the design of this study's intervention, iBDecide. Additionally, the research team, from study conception to manuscript writing, included a young adult with inflammatory bowel disease. CLINICAL TRIAL REGISTRATION This study was registered at clinicaltrials.gov (NCT04207008).
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Affiliation(s)
- Kelly A Matula
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Philip Minar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nancy M Daraiseh
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Li Lin
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Marlee Recker
- Division of Social Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ellen A Lipstein
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Brandow AM, Liem RI. Advances in the diagnosis and treatment of sickle cell disease. J Hematol Oncol 2022; 15:20. [PMID: 35241123 PMCID: PMC8895633 DOI: 10.1186/s13045-022-01237-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/15/2022] [Indexed: 12/12/2022] Open
Abstract
Sickle cell disease (SCD), which affects approximately 100,000 individuals in the USA and more than 3 million worldwide, is caused by mutations in the βb globin gene that result in sickle hemoglobin production. Sickle hemoglobin polymerization leads to red blood cell sickling, chronic hemolysis and vaso-occlusion. Acute and chronic pain as well as end-organ damage occur throughout the lifespan of individuals living with SCD resulting in significant disease morbidity and a median life expectancy of 43 years in the USA. In this review, we discuss advances in the diagnosis and management of four major complications: acute and chronic pain, cardiopulmonary disease, central nervous system disease and kidney disease. We also discuss advances in disease-modifying and curative therapeutic options for SCD. The recent availability of L-glutamine, crizanlizumab and voxelotor provides an alternative or supplement to hydroxyurea, which remains the mainstay for disease-modifying therapy. Five-year event-free and overall survival rates remain high for individuals with SCD undergoing allogeneic hematopoietic stem cell transplant using matched sibling donors. However, newer approaches to graft-versus-host (GVHD) prophylaxis and the incorporation of post-transplant cyclophosphamide have improved engraftment rates, reduced GVHD and have allowed for alternative donors for individuals without an HLA-matched sibling. Despite progress in the field, additional longitudinal studies, clinical trials as well as dissemination and implementation studies are needed to optimize outcomes in SCD.
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Affiliation(s)
- A. M. Brandow
- grid.30760.320000 0001 2111 8460Department of Pediatrics, Section of Pediatric Hematology/Oncology/Bone Marrow Transplantation, Medical College of Wisconsin, Milwaukee, WI USA
| | - R. I. Liem
- grid.413808.60000 0004 0388 2248Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA
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Danila MI, Chen L, Ruderman EM, Owensby JK, O'Beirne R, Melnick JA, Harrold LR, Curtis D, Nowell WB, Curtis JR. Evaluation of an Intervention to Support Patient-Rheumatologist Conversations About Escalating Treatment in Patients with Rheumatoid Arthritis: A Proof-of-Principle Study. ACR Open Rheumatol 2021; 4:279-287. [PMID: 34962093 PMCID: PMC8992469 DOI: 10.1002/acr2.11393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 11/01/2021] [Accepted: 11/09/2021] [Indexed: 12/03/2022] Open
Abstract
Objective This study’s objective was to test whether an online video intervention discussing appropriate treatment escalation improves willingness to change treatment in people living with rheumatoid arthritis (RA). Methods We conducted a controlled, randomized trial among patients with RA enrolled in ArthritisPower, a United States patient registry. We recruited participants by email and surveyed their assessment of disease activity (patient global), satisfaction with disease control (patient acceptable symptom state), attitudes about RA medications, decisional conflict (decisional conflict scale), and willingness to modify RA treatment (choice predisposition scale, higher scores are better) if or when recommended by their rheumatologist. Intervention groups watched educational videos relevant to a treat‐to‐target (T2T) strategy, whereas control groups viewed vaccination‐related videos as an “attention control.” We compared the between‐group difference in patients’ willingness to modify RA treatment (primary outcome) and difference in decisional conflict about changing RA treatment (secondary outcome) after watching the videos using t tests. Results Participants with self‐reported RA (n = 208) were 90% White and 90% women, with a mean (standard deviation) age of 50 (11) years, and 52% reported familiarity with the RA T2T strategy. We found a significant improvement in between‐group difference in willingness to change RA treatment among intervention versus control participants (0.49 [95% confidence interval 0.09‐0.88], P = 0.02). The effect size (Glass’s delta) for the intervention was 0.48. Decisional conflict about treatment change decreased, but the between‐group difference was not significant. Conclusion This novel educational patient‐directed intervention discussing appropriate treatment escalation was associated with improved willingness to change RA treatment if or when recommended by a rheumatologist. Further studies should evaluate whether this change in patients’ predisposition translates into actual treatment escalation.
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Affiliation(s)
- Maria I Danila
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Lang Chen
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Ronan O'Beirne
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Leslie R Harrold
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - David Curtis
- Global Healthy Living Foundation, Upper Nyack, New York
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Yen RW, Smith J, Engel J, Muscat DM, Smith SK, Mancini J, Perestelo-Pérez L, Elwyn G, O'Malley AJ, Leyenaar JK, Mac O, Cadet T, Giguere A, Housten AJ, Langford A, McCaffery K, Durand MA. A Systematic Review and Meta-Analysis of Patient Decision Aids for Socially Disadvantaged Populations: Update from the International Patient Decision Aid Standards (IPDAS). Med Decis Making 2021; 41:870-896. [PMID: 34151614 PMCID: PMC8763253 DOI: 10.1177/0272989x211020317] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The effectiveness of patient decision aids (PtDAs) and other shared decision-making (SDM) interventions for socially disadvantaged populations has not been well studied. PURPOSE To assess whether PtDAs and other SDM interventions improve outcomes or decrease health inequalities among socially disadvantaged populations and determine the critical features of successful interventions. DATA SOURCES MEDLINE, CINAHL, Cochrane, PsycINFO, and Web of Science from inception to October 2019. Cochrane systematic reviews on PtDAs. STUDY SELECTION Randomized controlled trials of PtDAs and SDM interventions that included socially disadvantaged populations. DATA EXTRACTION Independent double data extraction using a standardized form and the Template for Intervention Description and Replication checklist. DATA SYNTHESIS Twenty-five PtDA and 13 other SDM intervention trials met our inclusion criteria. Compared with usual care, PtDAs improved knowledge (mean difference = 13.91, 95% confidence interval [CI] 9.01, 18.82 [I2 = 96%]) and patient-clinician communication (relative risk = 1.62, 95% CI 1.42, 1.84 [I2 = 0%]). PtDAs reduced decisional conflict (mean difference = -9.59; 95% CI -18.94, -0.24 [I2 = 84%]) and the proportion undecided (relative risk = 0.39; 95% CI 0.28, 0.53 [I2 = 75%]). PtDAs did not affect anxiety (standardized mean difference = 0.02, 95% CI -0.22, 0.26 [I2 = 70%]). Only 1 trial looked at clinical outcomes (hemoglobin A1C). Five of the 12 PtDA studies that compared outcomes by disadvantaged standing found that outcomes improved more for socially disadvantaged participants. No evidence indicated which intervention characteristics were most effective. Results were similar for SDM intervention trials. LIMITATIONS Sixteen PtDA studies had an overall unclear risk of bias. Heterogeneity was high for most outcomes. Most studies only had short-term follow-up. CONCLUSIONS PtDAs led to better outcomes among socially disadvantaged populations but did not reduce health inequalities. We could not determine which intervention features were most effective.[Box: see text].
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Affiliation(s)
- Renata W Yen
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Jenna Smith
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jaclyn Engel
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Danielle Marie Muscat
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Sian K Smith
- University of Bath, School of Management, Bath, Somerset, UK
| | - Julien Mancini
- Aix-Marseille Université, APHM, INSERM, IRD, SESSTIM, Marseille, Provence-Alpes-Cote d'Azu, France
| | | | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
- Department of Biomedical Sciences, Dartmouth College, Lebanon, NH, USA
| | - JoAnna K Leyenaar
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Olivia Mac
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tamara Cadet
- School of Social Work, Simmons University, Boston, MA, USA
- Harvard School of Dental Medicine, Boston, MA, USA
| | - Anik Giguere
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec, Canada
| | | | - Aisha Langford
- New York University School of Medicine, Division of Comparative Effectiveness and Decision Science, Department of Population Health, NYU Langone Medical Centre, New York, NY, USA
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
- Faculté de Médecine, Université Toulouse III Paul Sabatier, Toulouse, France
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Mekelenkamp H, Smiers F, Camp N, Stubenrouch F, Lankester A, de Vries M. Decision making for hematopoietic stem cell transplantation in pediatric, adolescent, and young adult patients with a hemoglobinopathy-Shared or not? Pediatr Blood Cancer 2021; 68:e29099. [PMID: 34003573 DOI: 10.1002/pbc.29099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) offers an established curative option for sickle cell disease (SCD) and thalassemia patients but is associated with significant risks. Decision making is a complex process and shared decision making (SDM) could be a fitting approach in case of such preference-sensitive decisions. This study investigated what level of SDM is used in conversations with hemoglobinopathy patients and/or their caregivers considering HSCT as a curative treatment option. METHODS Longitudinal, descriptive study using the Observing-Patient-Involvement-in-Decision-Making scale (OPTION5 ) scale to determine the level of SDM in conversations with 26 hemoglobinopathy patients and/or their caregivers. RESULTS The total mean OPTION5 score was 43%, which is a moderate SDM approach. There was no difference between conversations with thalassemia patients and SCD patients. Conversations needing an interpreter scored worse than nontranslated conversations. The best scoring OPTION5 item was item 3: "informing about the various treatment options" (mean score 2.3 on scale 0-4). For OPTION5 item 4: "eliciting patients' preferences" a more skilled effort was measured for SCD patients compared to thalassemia patients. CONCLUSIONS The mean OPTION5 score of "moderate" was achieved mainly by giving information on available options, which is primarily a one-way communication. The SDM process can be improved by actively inviting patients to deliberate about options and including their elicited preferences in decision making.
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Affiliation(s)
- Hilda Mekelenkamp
- Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frans Smiers
- Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nomie Camp
- Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Arjan Lankester
- Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Martine de Vries
- Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
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Shojaie D, Hoffman AS, Amaku R, Cabanillas ME, Sosa JA, Waguespack SG, Zafereo ME, Hu MI, Grubbs EE. Decision Making When Cancer Becomes Chronic: Needs Assessment for a Web-Based Medullary Thyroid Carcinoma Patient Decision Aid. JMIR Form Res 2021; 5:e27484. [PMID: 34269691 PMCID: PMC8325074 DOI: 10.2196/27484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In cancers with a chronic phase, patients and family caregivers face difficult decisions such as whether to start a novel therapy, whether to enroll in a clinical trial, and when to stop treatment. These decisions are complex, require an understanding of uncertainty, and necessitate the consideration of patients' informed preferences. For some cancers, such as medullary thyroid carcinoma, these decisions may also involve significant out-of-pocket costs and effects on family members. Providers have expressed a need for web-based interventions that can be delivered between consultations to provide education and prepare patients and families to discuss these decisions. To ensure that these tools are effective, usable, and understandable, studies are needed to identify patients', families', and providers' decision-making needs and optimal design strategies for a web-based patient decision aid. OBJECTIVE Following the international guidelines for the development of a web-based patient decision aid, the objectives of this study are to engage potential users to guide development; review the existing literature and available tools; assess users' decision-making experiences, needs, and design recommendations; and identify shared decision-making approaches to address each need. METHODS This study used the decisional needs assessment approach, which included creating a stakeholder advisory panel, mapping decision pathways, conducting an environmental scan of existing materials, and administering a decisional needs assessment questionnaire. Thematic analyses identified current decision-making pathways, unmet decision-making needs, and decision support strategies for meeting each need. RESULTS The stakeholders reported wide heterogeneity in decision timing and pathways. Relevant existing materials included 2 systematic reviews, 9 additional papers, and multiple educational websites, but none of these met the criteria for a patient decision aid. Patients and family members (n=54) emphasized the need for plain language (46/54, 85%), shared decision making (45/54, 83%), and help with family discussions (39/54, 72%). Additional needs included information about uncertainty, lived experience, and costs. Providers (n=10) reported needing interventions that address misinformation (9/10, 90%), foster realistic expectations (9/10, 90%), and address mistrust in clinical trials (5/10, 50%). Additional needs included provider tools that support shared decision making. Both groups recommended designing a web-based patient decision aid that can be tailored to (64/64, 100%) and delivered on a hospital website (53/64, 83%), focuses on quality of life (45/64, 70%), and provides step-by-step guidance (43/64, 67%). The study team identified best practices to meet each need, which are presented in the proposed decision support design guide. CONCLUSIONS Patients, families, and providers report multifaceted decision support needs during the chronic phase of cancer. Web-based patient decision aids that provide tailored support over time and explicitly address uncertainty, quality of life, realistic expectations, and effects on families are needed.
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Affiliation(s)
- Danielle Shojaie
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Aubri S Hoffman
- Department of Gynecological Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ruth Amaku
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Maria E Cabanillas
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Julie Ann Sosa
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mark E Zafereo
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mimi I Hu
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Elizabeth E Grubbs
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Schulz GL, Kelly KP, Holtmann M, Armer JM. Navigating decisional conflict as a family when facing the decision of stem cell transplant for a child or adolescent with sickle cell disease. PATIENT EDUCATION AND COUNSELING 2021; 104:1086-1093. [PMID: 33234442 DOI: 10.1016/j.pec.2020.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 09/04/2020] [Accepted: 10/07/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Patients with sickle cell disease (SCD) face unpredictable disease, with stem cell transplant being a curative treatment option with risks. The aim of this study was to describe the level and source of decisional conflict in families of children/adolescents with SCD facing a transplant decision. METHODS A multiple-case study approach described decisional conflict in various SCD severity/donor risk decisional contexts. Cases included parents, child/adolescent with SCD, and sibling donor. The level and source of conflict was measured via O'Connor's Decisional Conflict Scale and analyzed using pattern-matching and cross-case synthesis. In-depth descriptions of conflict sources were obtained through thematic analysis of observation and interview data. RESULTS Among 11 participants in four cases (i.e. family units) decisional conflict was not unique not to the decisional context. Conflict levels represented a level that can be linked with feeling unsure and decisional delay. The theme, 'navigating decisional conflict together', described how family units discussed uncertainties. CONCLUSION Varying levels and sources of decisional conflict exist in pediatric patients with SCD and their families considering transplant. PRACTICE IMPLICATIONS In our cases, decisional conflict and the transplant decision occurred at the family-level. Clinicians should encourage all family members to participate in discussions concerning transplant.
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Affiliation(s)
- Ginny Lynn Schulz
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA; Siteman Kids at St. Louis Children's Hospital, St. Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
| | - Katherine Patterson Kelly
- Children's National Hospital, Washington, District of Columbia, USA; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Megan Holtmann
- Siteman Kids at St. Louis Children's Hospital, St. Louis, MO, USA; Kaskaskia College, Centralia, IL, USA
| | - Jane Marie Armer
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA; American Lymphedema Framework Project, Columbia, MO, USA
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12
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Hasan MK, Aziz MH, Zarif MII, Hasan M, Hashem M, Guha S, Love RR, Ahamed S. Noninvasive Hemoglobin Level Prediction in a Mobile Phone Environment: State of the Art Review and Recommendations. JMIR Mhealth Uhealth 2021; 9:e16806. [PMID: 33830065 PMCID: PMC8063099 DOI: 10.2196/16806] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 01/20/2020] [Accepted: 02/10/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND There is worldwide demand for an affordable hemoglobin measurement solution, which is a particularly urgent need in developing countries. The smartphone, which is the most penetrated device in both rich and resource-constrained areas, would be a suitable choice to build this solution. Consideration of a smartphone-based hemoglobin measurement tool is compelling because of the possibilities for an affordable, portable, and reliable point-of-care tool by leveraging the camera capacity, computing power, and lighting sources of the smartphone. However, several smartphone-based hemoglobin measurement techniques have encountered significant challenges with respect to data collection methods, sensor selection, signal analysis processes, and machine-learning algorithms. Therefore, a comprehensive analysis of invasive, minimally invasive, and noninvasive methods is required to recommend a hemoglobin measurement process using a smartphone device. OBJECTIVE In this study, we analyzed existing invasive, minimally invasive, and noninvasive approaches for blood hemoglobin level measurement with the goal of recommending data collection techniques, signal extraction processes, feature calculation strategies, theoretical foundation, and machine-learning algorithms for developing a noninvasive hemoglobin level estimation point-of-care tool using a smartphone. METHODS We explored research papers related to invasive, minimally invasive, and noninvasive hemoglobin level measurement processes. We investigated the challenges and opportunities of each technique. We compared the variation in data collection sites, biosignal processing techniques, theoretical foundations, photoplethysmogram (PPG) signal and features extraction process, machine-learning algorithms, and prediction models to calculate hemoglobin levels. This analysis was then used to recommend realistic approaches to build a smartphone-based point-of-care tool for hemoglobin measurement in a noninvasive manner. RESULTS The fingertip area is one of the best data collection sites from the body, followed by the lower eye conjunctival area. Near-infrared (NIR) light-emitting diode (LED) light with wavelengths of 850 nm, 940 nm, and 1070 nm were identified as potential light sources to receive a hemoglobin response from living tissue. PPG signals from fingertip videos, captured under various light sources, can provide critical physiological clues. The features of PPG signals captured under 1070 nm and 850 nm NIR LED are considered to be the best signal combinations following a dual-wavelength theoretical foundation. For error metrics presentation, we recommend the mean absolute percentage error, mean squared error, correlation coefficient, and Bland-Altman plot. CONCLUSIONS We addressed the challenges of developing an affordable, portable, and reliable point-of-care tool for hemoglobin measurement using a smartphone. Leveraging the smartphone's camera capacity, computing power, and lighting sources, we define specific recommendations for practical point-of-care solution development. We further provide recommendations to resolve several long-standing research questions, including how to capture a signal using a smartphone camera, select the best body site for signal collection, and overcome noise issues in the smartphone-captured signal. We also describe the process of extracting a signal's features after capturing the signal based on fundamental theory. The list of machine-learning algorithms provided will be useful for processing PPG features. These recommendations should be valuable for future investigators seeking to build a reliable and affordable hemoglobin prediction model using a smartphone.
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Affiliation(s)
- Md Kamrul Hasan
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, United States
| | - Md Hasanul Aziz
- Department of Computer Science, Marquette University, Milwaukee, WI, United States
| | | | - Mahmudul Hasan
- Department of Computer Science, Stony Brook University, Stony Brook, NY, United States
| | - Mma Hashem
- Department of Computer Science & Engineering, Khulna University of Engineering & Technology, Khulna, Bangladesh
| | - Shion Guha
- Department of Computer Science, Marquette University, Milwaukee, WI, United States
| | - Richard R Love
- Department of Computer Science, Marquette University, Milwaukee, WI, United States
| | - Sheikh Ahamed
- Department of Computer Science, Marquette University, Milwaukee, WI, United States
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13
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Webb J. Social aspects of chronic transfusions: addressing social determinants of health, health literacy, and quality of life. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:175-183. [PMID: 33275666 PMCID: PMC7727521 DOI: 10.1182/hematology.2020000104] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Chronic monthly transfusions are a lifesaving preventative therapy for many patients with sickle cell disease; however, the burden of this therapy for patients and families is high. In the United States, there is overlap in the population affected by sickle cell disease and those with the greatest burden of social needs. Hematology providers caring for patients with SCD have an opportunity to screen for and mitigate social determinants of health, especially in those receiving chronic transfusion therapy given the frequent interactions with the healthcare system and increased demand on already potentially limited resources. Given the complexity of the treatment and medication regimens, providers caring for patients receiving chronic transfusions should implement universal strategies to minimize the impact of low health literacy, as this therapy imposes a significant demand on the health literacy skills of a family. Despite the social and literacy burden of this intervention, it is reassuring that quality of life is preserved as patients with SCD on chronic transfusion therapy often report higher health related quality of life than their peers receiving other disease modifying therapies.
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Bakshi N, Katoch D, Sinha CB, Ross D, Quarmyne MO, Loewenstein G, Krishnamurti L. Assessment of Patient and Caregiver Attitudes and Approaches to Decision-Making Regarding Bone Marrow Transplant for Sickle Cell Disease: A Qualitative Study. JAMA Netw Open 2020; 3:e206742. [PMID: 32469414 PMCID: PMC7260617 DOI: 10.1001/jamanetworkopen.2020.6742] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Bone marrow transplant (BMT) is a potentially curative treatment for sickle cell disease (SCD). Patient and caregiver attitudes toward BMT for SCD and the willingness to accept risks of BMT vary, but these attitudes are not well understood. OBJECTIVE To understand patient and caregiver perceptions of and attitudes toward BMT for SCD and decision-making about BMT. DESIGN, SETTING, AND PARTICIPANTS Qualitative study of interview transcripts from a convenience sample. Transcripts were from adults with SCD and caregivers of patients with SCD recruited from national and regional SCD conferences, symposia, and sickle cell clinics in 2 cities. Interview transcripts were used from the needs assessment phase to develop a patient-decision aid in 2013 to 2014 (group 1) and from the baseline point in 2015 to 2016 (group 2) of the parent trial, a randomized clinical trial of adults and caregivers of patients with SCD to evaluate the effectiveness of a patient decision aid. MAIN OUTCOMES AND MEASURES Participant perspectives on decision-making regarding BMT for SCD. RESULTS Fifty-seven transcripts from adults with SCD and 50 transcripts from caregivers of patients with SCD were included. Median (interquartile range [IQR]) age of adults with SCD was 34 (21-50) years in group 1 and 30 (23-38) years in group 2. The median (IQR) age of caregivers was 42.5 (31-52) years in group 1 and 41 (35-46.5) years in group 2. Most transcripts from adults with SCD (75.0% in group 1 and 72.4% in group 2) and caregivers of patients with SCD (76.7% in group 1 and 85.0% in group 2) were from female participants. Bone marrow transplant was perceived as a treatment option associated with serious risks. Reported attitudes toward BMT occurred on a continuum ranging from unfavorable to favorable. Participants reported serious decisional dilemma regarding BMT for SCD. Most participants expressed interest in learning about BMT or curative treatments. CONCLUSIONS AND RELEVANCE This qualitative study found a continuum in attitudes toward BMT for SCD and highlights the complexity of decision-making in BMT for SCD. Patients and families with SCD expressed an interest in learning about BMT. Future prospective studies of patient decision-making regarding BMT, especially in the context of emerging curative and novel disease-modifying therapies for SCD, are warranted.
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Affiliation(s)
- Nitya Bakshi
- Department of Pediatrics, Division of Hematology-Oncology-BMT, Emory University School of Medicine, Atlanta, Georgia
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Deeksha Katoch
- Department of Pediatrics, Division of Hematology-Oncology-BMT, Emory University School of Medicine, Atlanta, Georgia
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Cynthia B. Sinha
- Department of Pediatrics, Division of Hematology-Oncology-BMT, Emory University School of Medicine, Atlanta, Georgia
| | - Diana Ross
- Department of Pediatrics, Division of Hematology-Oncology-BMT, Emory University School of Medicine, Atlanta, Georgia
| | - Maa-Ohui Quarmyne
- Department of Pediatrics, Division of Hematology-Oncology-BMT, Emory University School of Medicine, Atlanta, Georgia
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - George Loewenstein
- Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Lakshmanan Krishnamurti
- Department of Pediatrics, Division of Hematology-Oncology-BMT, Emory University School of Medicine, Atlanta, Georgia
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Atlanta, Georgia
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