Understanding behavioral intent to participate in shared decision-making in medically uncertain situations

Home-Isolation Care in Newly COVID-19-Positive Elderly Patients: A Caregiver-Centric Explanatory Framework

Objectives: This community-based study aimed to identify the effect of different behavioral factors of family caregivers on the decision for home-isolation-based treatment of a new COVID-19-diagnosed elderly individual. It also explored the facilitators and barriers contributing to the decision-making process. Methods: A mixed-methods design was adopted to study the role of behavioral constructs such as risk tolerance, risk aversion, regret aversion, loss aversion, self-efficacy, and risk perception in healthcare-seeking decisions. By integrating the findings from the quantitative and qualitative parts, a framework was developed. Results: Self-efficacy, risk perception, and risk tolerance related to different issues were crucial factors behind the healthcare decision. However, regarding the various issues under consideration, risk perception followed by risk tolerance were the significant predictors for decision-making. Conclusion: To enhance appropriateness and equity in emergency healthcare-seeking, interventions should target risk tolerance and risk perception, taking into account the awareness levels of caregivers and the target population's risk and regret aversion. Such integrated approaches can improve the quality of care for elderly patients in home-based settings.

Developing an integrated multilevel model of uncertainty in health care: a qualitative systematic review and thematic synthesis

Introduction

Uncertainty is an inevitable part of healthcare and a source of confusion and challenge to decision-making. Several taxonomies of uncertainty have been developed, but mainly focus on decisions in clinical settings. Our goal was to develop a holistic model of uncertainty that can be applied to both clinical as well as public and global health scenarios.

Methods

We searched Medline, Embase, CINAHL, Scopus and Google scholar in March 2021 for literature reviews, qualitative studies and case studies related to classifications or models of uncertainty in healthcare. Empirical articles were assessed for study limitations using the Critical Appraisal Skills Programme (CASP) checklist. We synthesised the literature using a thematic analysis and developed a dynamic multilevel model of uncertainty. We sought patient input to assess relatability of the model and applied it to two case examples.

Results

We screened 4125 studies and included 15 empirical studies, 13 literature reviews and 5 case studies. We identified 77 codes and organised these into 26 descriptive and 11 analytical themes of uncertainty. The themes identified are global, public health, healthcare system, clinical, ethical, relational, personal, knowledge exchange, epistemic, aleatoric and parameter uncertainty. The themes were included in a model, which captures the macro, meso and microlevels and the inter-relatedness of uncertainty. We successfully piloted the model on one public health example and an environmental topic. The main limitations are that the research input into our model predominantly came from North America and Europe, and that we have not yet tested the model in a real-life setting.

Conclusion

We developed a model that can comprehensively capture uncertainty in public and global health scenarios. It builds on models that focus solely on clinical settings by including social and political contexts and emphasising the dynamic interplay between different areas of uncertainty.

Towards a new understanding of uncertainty in medical education

RATIONALE, AIMS, AND OBJECTIVES

Uncertainty is a complex and constant phenomenon in clinical practice. How medical students recognize and respond to uncertainty impacts on their well-being, career choices, and attitudes towards patients. It has been suggested that curricula should do more to prepare medical students for an uncertain world. In order to teach medical students about uncertainty, we need to understand how uncertainty has been conceptualized in the literature to date. The aim of this article is to explore existing models of uncertainty and to develop a framework of clinical uncertainty to aid medical education.

METHOD

A scoping literature review was performed to identify conceptual models of uncertainty in healthcare. Content and inductive analyses were performed to explore three dimensions of clinical uncertainty: sources of uncertainty, subjective influencers and responses to uncertainty.

RESULTS

Nine hundred one references were identified using our search strategy, of which, 24 met our inclusion criteria. It was possible to classify these conceptual models using one or more of three dimensions of uncertainty; sources, subjective influencers, and responses. Exploration and further classification of these dimensions led to the development of a framework of uncertainty for medical education.

CONCLUSION

The developed framework of clinical uncertainty highlights sources, subjective influencers, responses to uncertainty, and the dynamic relationship among these elements. Our framework illustrates the different aspects of knowledge as a source of uncertainty and how to distinguish between those aspects. Our framework highlights the complexity of sources of uncertainty, especially when including uncertainty arising from relationships and systems. These sources can occur in combination. Our framework is also novel in how it describes the impact of influencers such as personal characteristics, experience, and affect on perceptions of and responses to uncertainty. This framework can be used by educators and curricula developers to help understand and teach about clinical uncertainty.

Development of a program theory for shared decision-making: a realist synthesis

BACKGROUND

Shared Decision-making (SDM), a medical decision-making model, was popularized in the late 1980s in reaction to then predominate paternalistic decision-making, aiming to better meet the needs of patients. Extensive research has been conducted internationally examining the benefits of SDM implementation; however, existing theory on how SDM works, for whom, in which circumstances, and why is limited. While literature has shown positive patient, health care provider, and system benefits (SDM outputs), further research is required to understand the nuances of this type of decision-making. As such, we set out to address: "In which situations, how, why, and for whom does SDM between patients and health care providers contribute to improved engagement in the Shared Decision-making process?"

METHODS

To achieve our study goals we conducted a seven-step realist synthesis process, which included: (1) preliminary program theory development, (2) search strategy development, (3) selection and appraisal of literature in accordance with realist methodology, (4) data extraction, (5) identification of relevant formal theories, (6) data analysis and synthesis, and (7) formation of a revised program theory with the input of stakeholders. This process was done in accordance with RAMESES guidelines and publication standards for a realist synthesis. Expert consultations were also held to ensure consistency within the SDM literature.

RESULTS

Through our realist synthesis, we developed a program theory of SDM which includes three contexts (pre-existing relationship, difficulty of decision, and system support), eight mechanism sets (anxiety, trust, perception of other party capacity, perception of time, self-efficacy, world view, perception of capacity to external support, and recognition of decision), and one outcome (engagement in SDM).

CONCLUSIONS

As far as the authors of this paper are aware, this paper is the first to begin unpacking how SDM works, for whom, in which circumstances, and why. By examining key mechanism sets and exploring how they facilitate or inhibit SDM, we have produced a program theory that may assist health care professionals, policy makers, and patients. While further research is suggested to further unpack the concepts identified within this paper, this provides an initial understanding into the theory behind SDM.

REGISTRATION

PROSPERO: CRD42017062609.

From bed to bench: bridging from informatics practice to theory: an exploratory analysis

BACKGROUND

In 2009, Applied Clinical Informatics (ACI)--focused on applications in clinical informatics--was launched as a companion journal to Methods of Information in Medicine (MIM). Both journals are official journals of the International Medical Informatics Association.

OBJECTIVES

To explore which congruencies and interdependencies exist in publications from theory to practice and from practice to theory and to determine existing gaps. Major topics discussed in ACI and MIM were analyzed. We explored if the intention of publishing companion journals to provide an information bridge from informatics theory to informatics practice and vice versa could be supported by this model. In this manuscript we will report on congruencies and interdependences from practice to theory and on major topics in MIM.

METHODS

Retrospective, prolective observational study on recent publications of ACI and MIM. All publications of the years 2012 and 2013 were indexed and analyzed.

RESULTS

Hundred and ninety-six publications were analyzed (ACI 87, MIM 109). In MIM publications, modelling aspects as well as methodological and evaluation approaches for the analysis of data, information, and knowledge in biomedicine and health care were frequently raised - and often discussed from an interdisciplinary point of view. Important themes were ambient-assisted living, anatomic spatial relations, biomedical informatics as scientific discipline, boosting, coding, computerized physician order entry, data analysis, grid and cloud computing, health care systems and services, health-enabling technologies, health information search, health information systems, imaging, knowledge-based decision support, patient records, signal analysis, and web science. Congruencies between journals could be found in themes, but with a different focus on content. Interdependencies from practice to theory, found in these publications, were only limited.

CONCLUSIONS

Bridging from informatics theory to practice and vice versa remains a major component of successful research and practice as well as a major challenge.

Trying to optimise the German version of the OPTION scale regarding the dyadic aspect of shared decision making

OBJECTIVES

The OPTION scale ("observing patient involvement in decision making") assesses the extent to which clinicians involve patients in decisions across a range of situations in clinical practice. It so far just covers physician behavior. We intended to modify the scoring of the OPTION scale to incorporate active patient behavior in consultations.

METHODS

Modification was done on scoring level, attempting a dyadic, relationship-centred approach in that high ratings can be evoked also by the behaviour of active patients. The German version of the OPTION scale was compared with a modified version by analysing video recordings of primary care consultations dealing with cardiovascular prevention. Fifteen general practitioners provided 40 videotaped consultations. Videos were analysed by two rater pairs and two experts in shared decision making (SDM).

RESULTS

Reliability measures of the modified version were lower than those of the original scale. Significant associations of the dichotomised scale with the expert SDM rating as well as with physicians' expertise in SDM were only found for the modified OPTION scale. Receiver Operating Characteristic (ROC) analyses confirmed a valid differentiation between the presence of SDM (yes/no) on total score level, even though the cut-off point was quite low. Standard deviations of the single items in the modified version were higher compared to the original OPTION scale, while the means of total scores were similar.

CONCLUSIONS

The original OPTION scale is physician-centered and neglects the activity and a possible self-involvement of the patient. Our modified instruction was able to capture the dyadic element partially. The development of a separate dyadic instrument might be more promising.