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Nunes JC, Baykaner T, Pundi K, DeSutter K, True Hills M, Mahaffey KW, Sears SF, Morin DP, Lin B, Wang PJ, Stafford RS. Design and development of a digital shared decision-making tool for stroke prevention in atrial fibrillation. JAMIA Open 2023; 6:ooad003. [PMID: 36751465 PMCID: PMC9893868 DOI: 10.1093/jamiaopen/ooad003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/26/2022] [Accepted: 01/07/2023] [Indexed: 02/05/2023] Open
Abstract
Background Shared decision-making (SDM) is an approach in which patients and clinicians act as partners in making medical decisions. Patients receive the information needed to decide and are encouraged to balance risks, benefits, and preferences. Informative materials are vital to SDM. Atrial fibrillation (AF) is the most common cardiac arrhythmia and responsible for 10% of ischemic strokes, however 1/3 of patients are not on appropriate anticoagulation. Decision sharing may facilitate treatment acceptance, improving outcomes. Aims To develop a framework of the components needed to create novel SDM tools and to provide practical examples through a case-study of stroke prevention in AF. Methods We analyze the design values of a web-based SDM tool created to better inform AF patients about anticoagulation. The tool was developed in partnership with patient advocates, multi-disciplinary investigators, and private design firms. It was refined through iterative, recursive testing in patients with AF. Its effectiveness is being evaluated in a multisite clinical trial led by Stanford University and sponsored by the American Heart Association. Findings The main components considered when creating the Stanford AFib tool included: design and software; content identification; information delivery; inclusive communication, user engagement; patient feedback; clinician experience; and anticipation of implementation and dissemination. We also highlight the ethical principles underlying SDM; matters of diversity and inclusion, linguistic variety, accessibility, and health literacy. The Stanford AFib Guide patient tool is available at: https://afibguide.com and the clinician tool at https://afibguide.com/clinician. Conclusion Attention to a range of vital development and design factors can facilitate tool adoption and information acquisition by diverse cultural, educational, and socioeconomic subpopulations. With thoughtful design, digital tools may decrease decision regret and improve treatment outcomes across many decision-making situations in healthcare.
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Affiliation(s)
- Julio C Nunes
- Corresponding Author: Julio C. Nunes, MD, Stanford Center for Clinical Research, Stanford University, 3180 Porter Dr, Palo Alto, CA 94304, USA; ,
| | - Tina Baykaner
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Krishna Pundi
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Katie DeSutter
- Stanford Center for Clinical Research, Stanford University, Palo Alto, California, USA
| | | | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University, Palo Alto, California, USA,Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Samuel F Sears
- Division of Cardiovascular Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Daniel P Morin
- Cardiovascular Research, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Bryant Lin
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Paul J Wang
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Randall S Stafford
- Stanford Prevention Research Center, Stanford University, Palo Alto, California, USA
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Tan NC, Koong Ying Leng A, Phoon Kwong Yun I, Wang Zhen S, Paulpandi M, Lee YK, Furler J, Car J, Ng CJ. Cultural adaptation of a patient decision-aid for insulin therapy. BMJ Open 2020; 10:e033791. [PMID: 32152165 PMCID: PMC7064126 DOI: 10.1136/bmjopen-2019-033791] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Patient decision-aids (PDAs) support patients in selecting evidence-based treatment options. PDA is useful only if the user understands the content to make personalised decisions. Cultural adaptation is a process of adjusting health messages so that the information is accurate, relevant and understandable to users from a different population. A PDA has been developed to assist Malaysian patients with secondary drug failure to initiate insulin therapy to control their type 2 diabetes mellitus (T2DM). Likewise, patients with T2DM in neighbouring Singapore face similar barriers in commencing insulin treatment, which a PDA may facilitate decision-making in selecting personalised therapy. OBJECTIVE The study aimed to explore the views and perceptions of Singaporean primary care providers on the Malaysia PDA to initiate insulin therapy and described the cultural adaptation process used in the design and development of a new PDA, which would be trialled in a Singapore primary healthcare institution. METHOD Qualitative research method was deployed to conduct one-to-one in-depth interviews of the healthcare providers at the trial site (SingHealth Polyclinics-SHP), including six primary care physicians and four nurses to gather their views and feedbacks on the Malaysian PDA. The interviews were transcribed, audited and analysed (standard content analysis) to identify themes relating to the content, layout, concerns of the original PDA and suggestions to the design of the new SHP PDA. RESULTS Cultural adaptation of the new PDA includes change to the overall design, graphics (including pictograms), presentation styles, additional contextualised content (personalisation, subheadings, cost and treatment option), modified phrasing of the subtitles and concerns (choice of words) relevant to the new users. CONCLUSION A PDA on insulin therapy underwent cultural adaptation before its implementation in another population in a neighbouring country. Its relevance and effectiveness will be evaluated in future research.
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Affiliation(s)
- Ngiap Chuan Tan
- Department of Research, SingHealth Polyclinics, Singapore, Singapore
- Duke-NUS, Singapore, Singapore
| | | | | | | | | | - Yew Kong Lee
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - John Furler
- Department of General Practice and Primary Health Care, University of Melbourne, Carlton, Victoria, Australia
| | - Josip Car
- Health Services and Outcomes Research Programme, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Jamoulle M, Roland M, Bae JM, Heleno B, Visentin G, Gusso GDF, Godycki-Ćwirko M, Pizzanell M, Ouvrard P, La Valle R, Gomes LF, Widmer D, Bernstein J, Mariño M, Wagner HL, Rossi I. Ethical, pedagogical, socio-political and anthropological implications of quaternary prevention. REVISTA BRASILEIRA DE MEDICINA DE FAMÍLIA E COMUNIDADE 2018. [DOI: 10.5712/rbmfc13(40)1860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The concept of quaternary prevention, resulting from a reflection on the doctor-patient relationship, is presented as a renewal of the age-old ethical requirement: first, a doctor must do no harm; second, the doctor must control himself/herself. The origin of the concept, its endorsement by the World Organization of Family Doctors (WONCA) and the European Union of General Practitioners (UEMO), its dissemination, and the debates to which it has given rise, are presented by a panel of authors from 10 countries. This collective text deals more specifically with: the bioethics of prevention, the importance of teaching Quaternary prevention and factual medicine, the social and political implications of the concept of quaternary prevention, and its anthropological dimensions.
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Abstract
OBJECTIVE To provide insight into how and in what clinical fields overdiagnosis is studied and give directions for further applied and methodological research. DESIGN Scoping review. DATA SOURCES Medline up to August 2017. STUDY SELECTION All English studies on humans, in which overdiagnosis was discussed as a dominant theme. DATA EXTRACTION Studies were assessed on clinical field, study aim (ie, methodological or non-methodological), article type (eg, primary study, review), the type and role of diagnostic test(s) studied and the context in which these studies discussed overdiagnosis. RESULTS From 4896 studies, 1851 were included for analysis. Half of all studies on overdiagnosis were performed in the field of oncology (50%). Other prevalent clinical fields included mental disorders, infectious diseases and cardiovascular diseases accounting for 9%, 8% and 6% of studies, respectively. Overdiagnosis was addressed from a methodological perspective in 20% of studies. Primary studies were the most common article type (58%). The type of diagnostic tests most commonly studied were imaging tests (32%), although these were predominantly seen in oncology and cardiovascular disease (84%). Diagnostic tests were studied in a screening setting in 43% of all studies, but as high as 75% of all oncological studies. The context in which studies addressed overdiagnosis related most frequently to its estimation, accounting for 53%. Methodology on overdiagnosis estimation and definition provided a source for extensive discussion. Other contexts of discussion included definition of disease, overdiagnosis communication, trends in increasing disease prevalence, drivers and consequences of overdiagnosis, incidental findings and genomics. CONCLUSIONS Overdiagnosis is discussed across virtually all clinical fields and in different contexts. The variability in characteristics between studies and lack of consensus on overdiagnosis definition indicate the need for a uniform typology to improve coherence and comparability of studies on overdiagnosis.
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Affiliation(s)
- Kevin Jenniskens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joris A H de Groot
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Dutch Cochrane Centre, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Dutch Cochrane Centre, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lotty Hooft
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Dutch Cochrane Centre, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiana A Naaktgeboren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Bae JM. Shared decision making: relevant concepts and facilitating strategies. Epidemiol Health 2017; 39:e2017048. [PMID: 29092391 PMCID: PMC5733387 DOI: 10.4178/epih.e2017048] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 10/30/2017] [Indexed: 11/09/2022] Open
Abstract
As the paradigm in healthcare nowadays is the evidence-based, patient-centered decision making, the issue of shared decision making (SDM) is highlighted. The aims of this manuscript were to look at the relevant concepts and suggest the facilitating strategies for overcoming barriers of conducting SDM. While the definitions of SDM were discordant, several concepts such as good communication, individual autonomy, patient participants, and patient-centered decision-making were involved. Further, the facilitating strategies of SDM were to educate and train physician, to apply clinical practice guidelines and patient decision aids, to develop valid measurement tools for evaluation of SDM processes, and to investigate the impact of SDM.
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Affiliation(s)
- Jong-Myon Bae
- Department of Preventive Medicine, Jeju National University Scool of Medicine, Jeju, Korea
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Bae JM. Strategies for Appropriate Patient-centered Care to Decrease the Nationwide Cost of Cancers in Korea. J Prev Med Public Health 2017; 50:217-227. [PMID: 28768400 PMCID: PMC5541273 DOI: 10.3961/jpmph.17.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 06/16/2017] [Indexed: 12/29/2022] Open
Abstract
In terms of years of life lost to premature mortality, cancer imposes the highest burden in Korea. In order to reduce the burden of cancer, the Korean government has implemented cancer control programs aiming to reduce cancer incidence, to increase survival rates, and to decrease cancer mortality. However, these programs may paradoxically increase the cost burden. For examples, a cancer screening program for early detection could bring about over-diagnosis and over-treatment, and supplying medical services in a paternalistic manner could lead to defensive medicine or futile care. As a practical measure to reduce the cost burden of cancer, appropriate cancer care should be established. Ensuring appropriateness requires patient-doctor communication to ensure that utility values are shared and that autonomous decisions are made regarding medical services. Thus, strategies for reducing the cost burden of cancer through ensuring appropriate patient-centered care include introducing value-based medicine, conducting cost-utility studies, and developing patient decision aids.
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Affiliation(s)
- Jong-Myon Bae
- Department of Preventive Medicine, Jeju National University School of Medicine, Jeju, Korea
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Bae JM, Jamoulle M. Primary Care Physicians' Action Plans for Responding to Results of Screening Tests Based on the Concept of Quaternary Prevention. J Prev Med Public Health 2016; 49:343-348. [PMID: 27951627 PMCID: PMC5160136 DOI: 10.3961/jpmph.16.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 10/13/2016] [Indexed: 12/30/2022] Open
Abstract
Since noncommunicable diseases (NCDs) are generally controllable rather than curable, more emphasis is placed on prevention than on treatment. For the early detection of diseases, primary care physicians (PCPs), as well as general practitioners and family physicians, should interpret screening results accurately and provide screenees with appropriate information about prevention and treatment, including potential harms. The concept of quaternary prevention (QP), which was introduced by Jamoulle and Roland in 1995, has been applied to screening results. This article summarizes situations that PCPs encounter during screening tests according to the concept of QP, and suggests measures to face such situations. It is suggested that screening tests be customized to fit individual characteristics instead of being performed based on general guidelines. Since screening tests should not be carried out in some circumstances, further studies based on the concept of prevention levels proposed by Jamoulle and Roland are required for the development of strategies to prevent NCDs, including cancers. Thus, applying the concept of QP helps PCPs gain better insights into screening tests aimed at preventing NCDs and also helps improve the doctor-patient relationship by helping screenees understand medical uncertainties.
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Affiliation(s)
- Jong-Myon Bae
- Department of Preventive Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Marc Jamoulle
- Department of General Practice, University of Liège, Liège, Belgium
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Bae JM. Development and application of patient decision aids. Epidemiol Health 2015; 37:e2015018. [PMID: 25868639 PMCID: PMC4430759 DOI: 10.4178/epih/e2015018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 04/02/2015] [Indexed: 11/29/2022] Open
Abstract
With the current overdiagnosis of thyroid cancer resulting from routine screening in Korea, it is necessary to educate the public that not all cancers are malignant. The exposure to patient decision aids (PtDAs) compared to usual care reduced the number of people choosing to undergo prostate-specific antigen screening. This article introduces the definition, usefulness, and developmental processes of PtDAs and suggests the urgent need for a Korean PtDA related to thyroid cancer screening.
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Affiliation(s)
- Jong-Myon Bae
- Department of Preventive Medicine, Jeju National University School of Medicine, Jeju, Korea
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