Shared Decision Making in Immigrant Patients

Dialysis decision-making process by Chinese American patients at an urban, academic medical center: a retrospective chart review

BACKGROUND

Clinical practice guidelines emphasize shared decision-making for kidney replacement treatment, yet little is known about the influence of cultural differences on that process. We undertook a retrospective chart review to explore the process and timing of dialysis decision making and initiation in Chinese American patients to provide quality kidney care for this population.

DESIGN

Participants received outpatient care at Tufts Medical Center and dialysis at Dialysis Clinic, Inc. Boston or Somerville, MA from 2001-2021. Clinic chart review sourced demographic, clinical, and end-of-life care information from 180 participants (82 Chinese American, 98 other) from stage 4 chronic kidney disease (CKD) and dialysis initiation.

RESULTS

Chinese American participants were older (mean 70 vs. 59, p < 0.0001), less likely to speak English (12% vs. 87%, p < 0.0001), and used interpreter services more (80% vs. 11%, p < 0.0001). Chinese American participants had more visits (median 14 vs. 10, p = 0.005); were more often accompanied by family members (75% vs. 40%, p < 0.001); and had significantly lower rates of healthcare proxy documentation (35% vs. 55%, p = 0.006). There was no statistical difference in months between first CKD 4 visit and first dialysis. Both groups started dialysis at the same average eGFR and with similar rates of permanent dialysis access. Chinese American participants had significantly lower serum albumin at dialysis initiation (mean 3.3 g/dL vs 3.7 g/dL, p = 0.0003). Documentation reflected a low number of conversations about non-dialytic care, end-of-life planning, or palliative care in both groups across all visits.

CONCLUSION

The time between CKD 4 and dialysis initiation was the same in both groups, suggesting a similar overall outcome of care. Chart documentation suggests that Chinese American participants had a significantly higher number of visits with nephrologists where discussion about dialysis was noted and were more likely to have a family member present at the visit. Fewer Chinese American participants completed healthcare proxies. Among all study participants, healthcare proxy, code status, and palliative care discussions were reported less frequently than expected. These findings highlight opportunities for collaboration between palliative care clinicians and nephrologists.

Patients' perspective on shared decision-making in urology: a prospective study at a university hospital

PURPOSE

This study aims to determine the degree of shared decision-making (SDM) from urological patients' perspective and to identify possible predictors.

METHODS

Overall, 469 urological patients of a university outpatient clinic were recruited for this prospective study. Before a medical consultation, clinical and sociodemographic information, and patients' emotional distress were assessed by questionnaires. After the consultation, patients completed the SDM-Questionnaire-9 (SDM-Q-9). The SDM-Q-9 scores of relevant subgroups were compared. Logistic regression was used to identify patients at risk for experiencing low involvement (SDM-Q-9 total score ≤ 66) in SDM.

RESULTS

Data from 372 patients were available for statistical analyses. The SDM-Q-9 mean total score was 77.8 ± 20.6. The majority of patients (n = 271, 73%) experienced a high degree of involvement (SDM-Q-9 total score > 66). The mean score per SDM-Q-9 item was in the upper range (3.9 ± 1.4 out of 5). The most poorly rated item was "My doctor wanted to know how I want to be involved in decision-making" (3.5 ± 1.6). Immigration status (OR 3.7, p = 0.049), and nonscheduled hospital registration (OR 2.1, p = 0.047) were significant predictors for less perceived involvement. Comorbidity, oncological status, and emotional distress did not significantly predict perceived participation.

CONCLUSION

In a university hospital setting, most urological patients feel adequately involved in SDM. Nevertheless, urologists should routinely ask for patients' participation preference. Patients without a scheduled appointment and patients who immigrated may need more support to feel involved in SDM.

Satisfaction with obstetric care in a population of low-educated native Dutch and non-western minority women. Focus group research

Background

Low-educated native Dutch and non-western minority women have inadequate access to obstetric care. Moreover, the care they receive lacks responsiveness to their needs and cultural competences. Gaining a deeper understanding of their experiences and satisfaction with antenatal, birthing and maternity care will help to adjust healthcare responsiveness to meet their needs during pregnancy, childbirth and the postpartum period.

Methods

We combined the World Health Organization conceptual framework of healthcare responsiveness with focus group research to measure satisfaction with antenatal, birthing and maternity care of women with a low-educated native Dutch and non-western ethnic background.

Results

From September 2011 until December 2013, 106 women were recruited for 20 focus group sessions. Eighty-five percent of the women had a non-western immigrant background and 89% a low or intermediate educational attainment. The study population was mostly positive about the provided care during the antenatal phase. They were less positive about the other two phases of care. Moreover, the obstetric healthcare systems’ responsiveness in all phases of care (antenatal, birthing and maternity) did not meet these women’s needs. The ‘respect for persons’ domains ‘autonomy’, ‘communication’ and ‘dignity’ and the ‘client orientation’ domain ‘prompt attention’ were judged most negatively.

Conclusions

The study findings give contextual meaning and starting points for improvement of responsiveness in the provision of obstetric care within a multi-ethnic women’s population.

Post-migration follow-up programme for migrants at increased risk of developing tuberculosis: a cohort study

Following pre-migration screening for tuberculosis (TB), migrants who are deemed to be at a high risk of developing TB must attend post-entry follow-up in Australia. We aimed to evaluate the effectiveness of post-migration TB follow-up in the state of New South Wales to diagnose TB in these high-risk migrants. In this retrospective cohort study, we assessed the risk of TB in migrants who arrived in New South Wales between 2000 and 2015 and were referred for post-migration follow-up. Clinical notes were examined for a nested cohort to determine whether TB was diagnosed via the follow-up programme or via passive case finding. Of the 32 550 migrants referred for follow-up, 428 (1.3%) developed TB. The incidence of TB was 436 per 100 000 person-years (95% CI 384-491 per 100 000 person-years) in the first 2 years after arrival and 128 per 100 000 person-years (95% CI 116-140 per 100 000 person-years) over the mean study observation period of 10.3 years. An estimated 63% of cases were diagnosed via follow-up. TB notifications occurred 0.55 years earlier since time of arrival in Australia in migrants who attended follow-up than in those who did not. Post-migration follow-up detected 63% of TB cases in high-risk migrants and potentially prevented delay of TB diagnosis.

Physicians' perspectives on communication and decision making in clinical encounters for treatment of latent tuberculosis infection

The aim of the study was to explore the views of tuberculosis (TB) physicians on treatment of latent TB infection (LTBI), focusing on decision making and communication in clinical practice.

20 Australian TB physicians participated in a semistructured interview in person or over the telephone. Interviews were recorded, transcribed and analysed thematically.

The study identified challenges that physicians face when discussing treatment for LTBI with patients. These included difficulties explaining the concept of latency (in particular to patients from culturally and linguistically diverse backgrounds) and providing guidance to patients while still framing treatment decisions as a choice. Tailored estimates of the risk of developing TB and the risk of developing an adverse effect from LTBI treatment were considered the most important information for decision making and discussion with patients. Physicians acknowledged that there is a significant amount of unwarranted treatment variation, which they attributed to the lack of evidence about the risk–benefit balance of LTBI treatment in certain scenarios and guidelines that refer to the need for case-by-case decision making in many instances.

In order to successfully implement LTBI treatment at a clinical level, consideration should be given to research on how to best address communication challenges arising in clinical encounters.

Overcoming challenges in clinical encounters is essential for implementation of treatment of latent TB infectionhttp://ow.ly/HEFu30izBUu