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Valentine KD, Leavitt L, Sepucha KR, Atlas SJ, Simmons L, Siegel L, Richter JM, Han PKJ. Uncertainty tolerance among primary care physicians: Relationship to shared decision making-related perceptions, practices, and physician characteristics. Patient Educ Couns 2024; 123:108232. [PMID: 38458091 PMCID: PMC10997439 DOI: 10.1016/j.pec.2024.108232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE Understand how physicians' uncertainty tolerance (UT) in clinical care relates to their personal characteristics, perceptions and practices regarding shared decision making (SDM). METHODS As part of a trial of SDM training about colorectal cancer screening, primary care physicians (n = 67) completed measures of their uncertainty tolerance in medical practice (Anxiety subscale of the Physician's Reactions to Uncertainty Scale, PRUS-A), and their SDM self-efficacy (confidence in SDM skills). Patients (N = 466) completed measures of SDM (SDM Process scale) after a clinical visit. Bivariate regression analyses and multilevel regression analyses examined relationships. RESULTS Higher UT was associated with greater physician age (p = .01) and years in practice (p = 0.015), but not sex or race. Higher UT was associated with greater SDM self-efficacy (p < 0.001), but not patient-reported SDM. CONCLUSION Greater age and practice experience predict greater physician UT, suggesting that UT might be improved through training, while UT is associated with greater confidence in SDM, suggesting that improving UT might improve SDM. However, UT was unassociated with patient-reported SDM, raising the need for further studies of these relationships. PRACTICE IMPLICATIONS Developing and implementing training interventions aimed at increasing physician UT may be a promising way to promote SDM in clinical care.
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Affiliation(s)
- K D Valentine
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lauren Leavitt
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Karen R Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Leigh Simmons
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lydia Siegel
- Harvard Medical School, Boston, MA, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - James M Richter
- Harvard Medical School, Boston, MA, USA; Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Paul K J Han
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA.
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Valentine K, Leavitt L, Simmons L, Sepucha K, Atlas SJ, Korsen N, Han PKJ, Fairfield KM. Talking, not training, increased the accuracy of physicians' diagnosis of their patients' preferences for colon cancer screening. Patient Educ Couns 2024; 119:108047. [PMID: 37976668 PMCID: PMC10841970 DOI: 10.1016/j.pec.2023.108047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/13/2023] [Accepted: 10/29/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE Identify if primary care physicians (PCPs) accurately understand patient preferences for colorectal cancer (CRC) testing, whether shared decision making (SDM) training improves understanding of patient preferences, and whether time spent discussing CRC testing improves understanding of patient preferences. METHODS Secondary analysis of a trial comparing SDM training plus a reminder arm to a reminder alone arm. PCPs and their patients completed surveys after visits assessing whether they discussed CRC testing, patient testing preference, and time spent discussing CRC testing. We compared patient and PCP responses, calculating concordance between patient-physician dyads. Multilevel models tested for differences in preference concordance by arm or time discussing CRC. RESULTS 382 PCP and patient survey dyads were identified. Most dyads agreed on whether CRC testing was discussed (82%). Only 52% of dyads agreed on the patient's preference. SDM training did not impact accuracy of PCPs preference diagnoses (55%v.48%,p = 0.22). PCPs were more likely to accurately diagnose patient's preferences when discussions occurred, regardless of length. CONCLUSION Only half of PCPs accurately identified patient testing preferences. Training did not impact accuracy. Visits where CRC testing was discussed resulted in PCPs better understanding patient preferences. PRACTICE IMPLICATIONS PCPs should take time to discuss testing and elicit patient preferences.
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Affiliation(s)
- Kathrene Valentine
- Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | | | - Leigh Simmons
- Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Karen Sepucha
- Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Steven J Atlas
- Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Neil Korsen
- MaineHealth Institute for Research, Portland, ME, USA
| | | | - Kathleen M Fairfield
- MaineHealth Institute for Research, Portland, ME, USA; MaineHealth Department of Medicine, Portland, ME, USA
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Sepucha K, Han PKJ, Chang Y, Atlas SJ, Korsen N, Leavitt L, Lee V, Percac-Lima S, Mancini B, Richter J, Scharnetzki E, Siegel LC, Valentine KD, Fairfield KM, Simmons LH. Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults (PRIMED Study): a Physician Cluster Randomized Trial. J Gen Intern Med 2023; 38:406-413. [PMID: 35931908 PMCID: PMC9362387 DOI: 10.1007/s11606-022-07738-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/01/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND For adults aged 76-85, guidelines recommend individualizing decision-making about whether to continue colorectal cancer (CRC) testing. These conversations can be challenging as they need to consider a patient's CRC risk, life expectancy, and preferences. OBJECTIVE To promote shared decision-making (SDM) for CRC testing decisions for older adults. DESIGN Two-arm, multi-site cluster randomized trial, assigning physicians to Intervention and Comparator arms. Patients were surveyed shortly after the visit to assess outcomes. Analyses were intention-to-treat. PARTICIPANTS AND SETTING Primary care physicians affiliated with 5 academic and community hospital networks and their patients aged 76-85 who were due for CRC testing and had a visit during the study period. INTERVENTIONS Intervention arm physicians completed a 2-h online course in SDM communication skills and received an electronic reminder of patients eligible for CRC testing shortly before the visit. Comparator arm received reminders only. MAIN MEASURES The primary outcome was patient-reported SDM Process score (range 0-4 with higher scores indicating more SDM); secondary outcomes included patient-reported discussion of CRC screening, knowledge, intention, and satisfaction with the visit. KEY RESULTS Sixty-seven physicians (Intervention n=34 and Comparator n=33) enrolled. Patient participants (n=466) were on average 79 years old, 50% with excellent or very good self-rated overall health, and 66% had one or more prior colonoscopies. Patients in the Intervention arm had higher SDM Process scores (adjusted mean difference 0.36 (95%CI (0.08, 0.64), p=0.01) than in the Comparator arm. More patients in the Intervention arm reported discussing CRC screening during the visit (72% vs. 60%, p=0.03) and had higher intention to follow through with their preferred approach (58.0% vs. 47.1, p=0.03). Knowledge scores and visit satisfaction did not differ significantly between arms. CONCLUSION Physician training plus reminders were effective in increasing SDM and frequency of CRC testing discussions in an age group where SDM is essential. TRIAL REGISTRATION The trial is registered on clinicaltrials.gov (NCT03959696).
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Affiliation(s)
- Karen Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Paul K J Han
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, USA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Neil Korsen
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
| | - Lauren Leavitt
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
| | - Vivian Lee
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
| | - Sanja Percac-Lima
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Brittney Mancini
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
| | - James Richter
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth Scharnetzki
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
| | - Lydia C Siegel
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - K D Valentine
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kathleen M Fairfield
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
| | - Leigh H Simmons
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Sepucha KR, Valentine KD, Atlas SJ, Chang Y, Fairfield KM, Ha J, Leavitt L, Lee V, Percac‐Lima S, Richter JM, Simmons L. Getting patients back for routine colorectal cancer screening: Randomized controlled trial of a shared decision-making intervention. Cancer Med 2022; 12:3555-3566. [PMID: 36052811 PMCID: PMC9939149 DOI: 10.1002/cam4.5172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/11/2022] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
Thousands of colonoscopies were canceled during the initial surge of the COVID-19 pandemic. As facilities resumed services, some patients were hesitant to reschedule. The purpose of this study was to determine whether a decision aid plus telephone coaching would increase colorectal cancer (CRC) screening and improve patient reports of shared decision making (SDM). A randomized controlled trial assigned adults aged 45-75 without prior history of CRC who had a colonoscopy canceled from March to May 2020 to intervention (n = 400) or usual care control (n = 400) arms. The intervention arm received three-page decision aid and call from decision coach from September 2020 through November 2020. Screening rates were collected at 6 months. A subset (n = 250) in each arm was surveyed 8 weeks after randomization to assess SDM (scores range 0-4, higher scores indicating more SDM), decisional conflict, and screening preference. The sample was on average, 60 years old, 53% female, 74% White, non-Hispanic, and 11% Spanish speaking. More intervention arm patients were screened within 6 months (35% intervention vs 23% control, p < 0.001). The intervention respondents reported higher SDM scores (mean difference 0.7 [0.4, 0.9], p < 0.001) and less decisional conflict than controls (-21% [-35%, -7%], p = 0.003). The majority in both arms preferred screening versus delaying (68% intervention vs. 65% control, p = 0.75). An SDM approach that offered alternatives and incorporated patients' preferences resulted in higher screening rates. Patients who are overdue for CRC screening may benefit from proactive outreach with SDM support.
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Affiliation(s)
- Karen R. Sepucha
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Kathrene D. Valentine
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Steven J. Atlas
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Yuchiao Chang
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Jasmine Ha
- Massachusetts General HospitalBostonMassachusettsUSA
| | | | - Vivian Lee
- Massachusetts General HospitalBostonMassachusettsUSA
| | - Sanja Percac‐Lima
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - James M. Richter
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Leigh Simmons
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
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Valentine KD, Leavitt L, Atlas SJ, Chen E, Ha J, Percac-Lima S, Fairfield KM, Korsen N, Han PKJ, Richter JM, Simmons L, Sepucha KR. Cross-sectional Survey Examining Patient Attitudes and Preferences for Rescheduling Screening Colonoscopies Canceled due to the COVID-19 Pandemic. MDM Policy Pract 2022; 7:23814683221141377. [PMID: 36532296 PMCID: PMC9749064 DOI: 10.1177/23814683221141377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/21/2022] [Indexed: 10/06/2023] Open
Abstract
UNLABELLED Background. Early in the COVID-19 pandemic colonoscopies for colorectal cancer (CRC) screening were canceled. Patient perceptions of the benefits and risks of routine screening relative to health concerns associated with the COVID-19 pandemic were unknown. Purpose. Assess patient anxiety, worry, and interest in CRC screening during the COVID-19 pandemic. Methods. A random sample of 200 patients aged 45 to 75 y with colonoscopy cancellation due to COVID-19 in March to May 2020 were surveyed. Anxiety, COVID-19 and CRC risk perceptions, COVID-19 and CRC worry, likelihood of following through with colonoscopy in the next month, and interest in alternatives to colonoscopy were assessed. Subsequent screening was tracked for 12 mo. Results. Respondents (N = 127/200, 63.5%) were on average 60 y old, female (59%), college educated (62% college degree or more), and White (91%). A substantial portion of patients (46%) stated they may not follow through with a colonoscopy in the next month. There was greater interest in stool-based testing than in delaying screening (48% v. 26%). Women, older patients, and patients indicating tolerance of uncertainty due to complexity reported they were less likely to follow through with colonoscopy in the next month. Greater interest in stool-based testing was related to lower perceptions of CRC risk. Greater interest in delaying screening was related to less worry about CRC and less tolerance of risk. Over 12 mo, 60% of participants completed screening. Patients who stated they were more likely to screen in the next month were more likely to complete CRC screening (P = 0.01). Conclusions. Respondents who had a colonoscopy canceled during the COVID-19 pandemic varied in interest in rescheduling the procedure. A shared decision-making approach may help patients address varying concerns and select the best approach to screening for them. HIGHLIGHTS In the wake of the first wave of the COVID-19 pandemic, almost half of patients stated they were not likely to follow through with a colonoscopy in the short term, about half were interested in screening with a stool-based test, and only one-quarter were interested in delaying screening until next year.Patients who perceived themselves at higher risk of colorectal cancer were less interested in stool-based testing, and patients who were more worried about colorectal cancer were less interested in delaying screening.A shared decision-making approach may be necessary to tailor screening discussions for patients during subsequent waves of the pandemic, other occasions where resources are limited and patient preferences vary, or where patients hold conflicting views of screening.
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Affiliation(s)
- K. D. Valentine
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
| | | | - Steven J. Atlas
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
| | | | - Jasmine Ha
- Massachusetts General Hospital, Boston, MA, USA
| | - Sanja Percac-Lima
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
| | | | | | | | - James M. Richter
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
| | - Leigh Simmons
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
| | - Karen R. Sepucha
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Darthmouth College, Hanover, NH, USA
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Valentine KD, Cha T, Giardina JC, Marques F, Atlas SJ, Bedair H, Chen AF, Doorly T, Kang J, Leavitt L, Licurse A, O'Brien T, Sequist T, Sepucha K. Assessing the quality of shared decision making for elective orthopedic surgery across a large healthcare system: cross-sectional survey study. BMC Musculoskelet Disord 2021; 22:967. [PMID: 34798866 PMCID: PMC8605511 DOI: 10.1186/s12891-021-04853-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 11/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background Clinical guidelines recommend engaging patients in shared decision making for common orthopedic procedures; however, limited work has assessed what is occurring in practice. This study assessed the quality of shared decision making for elective hip and knee replacement and spine surgery at four network-affiliated hospitals. Methods A cross-sectional sample of 875 adult patients undergoing total hip or knee joint replacement (TJR) for osteoarthritis or spine surgery for lumbar herniated disc or lumbar spinal stenosis was selected. Patients were mailed a survey including measures of Shared Decision Making (SDMP scale) and Informed, Patient-Centered (IPC) decisions. We examined decision-making across sites, surgeons, and conditions, and whether the decision-making measures were associated with better health outcomes. Analyses were adjusted for clustering of patients within surgeons. Results Six hundred forty-six surveys (74% response rate) were returned with sufficient responses for analysis. Patients who had TJR reported lower SDMP scores than patients who had spine surgery (2.2 vs. 2.8; p < 0.001). Patients who had TJR were more likely to make IPC decisions (OA = 70%, Spine = 41%; p < 0.001). SDMP and IPC scores varied widely across surgeons, but the site was not predictive of SDMP scores or IPC decisions (all p > 0.09). Higher SDMP scores and IPC decisions were associated with larger improvements in global health outcomes for patients who had TJR, but not patients who had spine surgery. Conclusions Measures of shared decision making and decision quality varied among patients undergoing common elective orthopedic procedures. Routine measurement of shared decision making provides insight into areas of strength across these different orthopedic conditions as well as areas in need of improvement. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04853-x.
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Affiliation(s)
- K D Valentine
- Massachusetts General Hospital (MGH), 100 Cambridge Street, 16th floor, Boston, MA, 02114, USA. .,Harvard Medical School (HMS), Boston, MA, USA.
| | - Tom Cha
- Massachusetts General Hospital (MGH), 100 Cambridge Street, 16th floor, Boston, MA, 02114, USA.,Harvard Medical School (HMS), Boston, MA, USA
| | | | - Felisha Marques
- Massachusetts General Hospital (MGH), 100 Cambridge Street, 16th floor, Boston, MA, 02114, USA
| | - Steven J Atlas
- Massachusetts General Hospital (MGH), 100 Cambridge Street, 16th floor, Boston, MA, 02114, USA.,Harvard Medical School (HMS), Boston, MA, USA
| | - Hany Bedair
- Massachusetts General Hospital (MGH), 100 Cambridge Street, 16th floor, Boston, MA, 02114, USA.,North Shore Medical Center, MA, Salem, USA
| | - Antonia F Chen
- Harvard Medical School (HMS), Boston, MA, USA.,Newton Wellesley Hospital, MA, Newton, USA
| | | | - James Kang
- Harvard Medical School (HMS), Boston, MA, USA.,Newton Wellesley Hospital, MA, Newton, USA
| | - Lauren Leavitt
- Massachusetts General Hospital (MGH), 100 Cambridge Street, 16th floor, Boston, MA, 02114, USA
| | - Adam Licurse
- Harvard Medical School (HMS), Boston, MA, USA.,Newton Wellesley Hospital, MA, Newton, USA
| | - Todd O'Brien
- Harvard Medical School (HMS), Boston, MA, USA.,Brigham and Women's Hospital (BWH), MA, Boston, USA
| | - Thomas Sequist
- Harvard Medical School (HMS), Boston, MA, USA.,Department of Quality and Patient Experience, Mass General Brigham Health System, Boston, MA, USA
| | - Karen Sepucha
- Massachusetts General Hospital (MGH), 100 Cambridge Street, 16th floor, Boston, MA, 02114, USA.,Harvard Medical School (HMS), Boston, MA, USA
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Giardina JC, Cha T, Atlas SJ, Barry MJ, Freiberg AA, Leavitt L, Marques F, Sepucha K. Validation of an electronic coding algorithm to identify the primary indication of orthopedic surgeries from administrative data. BMC Med Inform Decis Mak 2020; 20:187. [PMID: 32787849 PMCID: PMC7425151 DOI: 10.1186/s12911-020-01175-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 07/01/2020] [Indexed: 11/24/2022] Open
Abstract
Background Determining the primary indication of a surgical procedure can be useful in identifying patients undergoing elective surgery where shared decision-making is recommended. The purpose of this study was to develop and validate an algorithm to identify patients receiving the following combinations of surgical procedure and primary indication as part of a study to promote shared decision-making: (1) knee arthroplasty to treat knee osteoarthritis (KOA); (2) hip arthroplasty to treat hip osteoarthritis (HOA); (3) spinal surgery to treat lumbar spinal stenosis (SpS); and (4) spinal surgery to treat lumbar herniated disc (HD). Methods Consecutive surgical procedures performed by participating spine, hip, and knee surgeons at four sites within an integrated care network were included. Study staff reviewed electronic medical records to ascertain a “gold standard” determination of the procedure and primary indication status. Electronic algorithms consisting of ICD-10 and CPT codes for each combination of procedure and indication were then applied to records for each case. The primary measures of validity for the algorithms were the sensitivity and specificity relative to the gold standard review. Results Participating surgeons performed 790 procedures included in this study. The sensitivity of the algorithms in determining whether a surgical case represented one of the combinations of procedure and primary indication ranged from 0.70 (HD) to 0.92 (KOA). The specificity ranged from 0.94 (SpS) to 0.99 (HOA, KOA). Conclusion The electronic algorithm was able to identify all four procedure/primary indication combinations of interest with high specificity. Additionally, the sensitivity for the KOA cases was reasonably high. For HOA and the spine conditions, additional work is needed to improve the sensitivity of the algorithm to identify the primary indication for each case.
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Affiliation(s)
- John C Giardina
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, 02115, USA.
| | - Thomas Cha
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Steven J Atlas
- Harvard Medical School, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michael J Barry
- Harvard Medical School, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew A Freiberg
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Lauren Leavitt
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Felisha Marques
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Karen Sepucha
- Harvard Medical School, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
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Simmons L, Leavitt L, Ray A, Fosburgh B, Sepucha K. Shared Decision Making in Common Chronic Conditions: Impact of a Resident Training Workshop. Teach Learn Med 2016; 28:202-9. [PMID: 27064722 DOI: 10.1080/10401334.2016.1146600] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PROBLEM Physicians must be competent in several different kinds of communication skills in order to implement shared decision making; however, these skills are not part of routine medical student education, nor are they formally taught during residency training. INTERVENTION We developed a 1- and 2-hour workshop curriculum for internal medicine residents to promote shared decision making in treatment decisions for four common chronic conditions: diabetes, depression, hypertension, and hyperlipidemia. The workshops included a written case exercise, a short didactic presentation on shared decision-making concepts and strategies for risk communication, and two role-playing exercises focused on decision making for depression and hyperlipidemia treatment. CONTEXT We delivered the workshop as a required component of the resident curriculum in ambulatory medicine. To evaluate the impact of the workshop, we used written course evaluations, tracked the use of the newly introduced Decision Worksheets, and asked preceptors to perform direct observation of treatment decision conversations. OUTCOME Residents were involved in the development of the workshop and helped identify key content, suggested framing for difficult topics, and confirmed the need for the skills workshop. One hundred thirty internal medicine and medicine-pediatrics residents attended 8 workshops over a 4-month period. In written cases completed before the workshop, the majority of residents indicated that they would discuss medications, but few mentioned other treatment options or documented patients' goals and preferences in a sample encounter note with a patient with new depression symptoms. Overall, most participants (89.7%) rated the workshop as excellent or very good, and 93.5% said that they would change their practice based on what they learned. Decision Worksheets addressing diabetes, depression, hyperlipidemia, and hypertension were available on a primary care-focused intranet site and were downloaded almost 1,200 times in the first 8 months following the workshops. Preceptors were able to observe only one consult during which one of the four topics was discussed. LESSONS LEARNED Internal medicine residents had considerable gaps in shared decision-making skills as measured in a baseline written exercise. Residents provided valuable contributions to the development of a Decision Worksheet to be used at the point of care. Participants rated the skills workshop highly, though interns rated the exercise more useful than PGY-2 and PGY-3 residents did. The Decision Worksheets were accessed often following the sessions; however, observing the Decision Worksheets in use in real time was a challenge in the resident-faculty clinic. Additional studies are warranted to examine whether the workshop was successful in increasing residents' ability to implement skills in practice.
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Affiliation(s)
- Leigh Simmons
- a Division of General Internal Medicine , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Lauren Leavitt
- a Division of General Internal Medicine , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Alaka Ray
- a Division of General Internal Medicine , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Blair Fosburgh
- a Division of General Internal Medicine , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Karen Sepucha
- a Division of General Internal Medicine , Massachusetts General Hospital , Boston , Massachusetts , USA
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Huamani J, Willey C, Thotala D, Niermann KJ, Reyzer M, Leavitt L, Jones C, Fleishcher A, Caprioli R, Hallahan DE, Kim DWN. Differential efficacy of combined therapy with radiation and AEE788 in high and low EGFR-expressing androgen-independent prostate tumor models. Int J Radiat Oncol Biol Phys 2008; 71:237-46. [PMID: 18337021 DOI: 10.1016/j.ijrobp.2007.12.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Revised: 12/16/2007] [Accepted: 12/18/2007] [Indexed: 11/19/2022]
Abstract
PURPOSE To determine the efficacy of combining radiation (XRT) with a dual epidermal growth factor receptor (EGFR)/vascular endothelial growth factor receptor inhibitor, AEE788, in prostate cancer models with different levels of EGFR expression. METHODS AND MATERIALS Immunoblotting was performed for EGFR, phosphorylated-EGFR, and phosphorylated-AKT in prostate cancer cells. Clonogenic assays were performed on DU145, PC-3, and human umbilical vein endothelial cells treated with XRT +/- AEE788. Tumor xenografts were established for DU145 and PC-3 on hind limbs of athymic nude mice assigned to four treatment groups: (1) control, (2) AEE788, (3) XRT, and (4) AEE788 + XRT. Tumor blood flow and growth measurements were performed using immunohistochemistry and imaging. RESULTS AEE788 effectively decreased phosphorylated-EGFR and phosphorylated-AKT levels in DU145 and PC-3 cells. Clonogenic assays showed no radiosensitization for DU145 and PC-3 colonies treated with AEE788 + XRT. However, AEE788 caused decreased proliferation in DU145 cells. AEE788 showed a radiosensitization effect in human umbilical vein endothelial cells and increased apoptosis susceptibility. Concurrent AEE788 + XRT compared with either alone led to significant tumor growth delay in DU145 tumors. Conversely, PC-3 tumors derived no added benefit from combined-modality therapy. In DU145 tumors, a significant decrease in tumor blood flow with combination therapy was shown by using power Doppler sonography and tumor blood vessel destruction on immunohistochemistry. Maldi-spectrometry (MS) imaging showed that AEE788 is bioavailable and heterogeneously distributed in DU145 tumors undergoing therapy. CONCLUSIONS AEE788 + XRT showed efficacy in vitro/in vivo with DU145-based cell models, whereas PC-3-based models were adequately treated with XRT alone without added benefit from combination therapy. These findings correlated with differences in EGFR expression and showed effects on both tumor cell proliferation and vascular destruction.
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Affiliation(s)
- Jessica Huamani
- Radiation Oncology, Vanderbilt University, Nashville, TN, USA
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Huamani J, Niermann KJ, Willey C, Leavitt L, Thotala D, Fleischer A, Kim DW, Hallahan DE. 222. Int J Radiat Oncol Biol Phys 2006. [DOI: 10.1016/j.ijrobp.2006.07.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Huamani J, Willey C, Niermann K, Leavitt L, Thotala D, Fleishcher A, Hallahan D, Kim D. 2618. Int J Radiat Oncol Biol Phys 2006. [DOI: 10.1016/j.ijrobp.2006.07.1032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Albert JM, Cao C, Geng L, Leavitt L, Hallahan DE, Lu B. Integrin alpha v beta 3 antagonist Cilengitide enhances efficacy of radiotherapy in endothelial cell and non-small-cell lung cancer models. Int J Radiat Oncol Biol Phys 2006; 65:1536-43. [PMID: 16863930 DOI: 10.1016/j.ijrobp.2006.04.036] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Revised: 04/19/2006] [Accepted: 04/21/2006] [Indexed: 11/18/2022]
Abstract
PURPOSE Integrins alpha v beta 3 and alpha v beta 5 are important in tumor growth and angiogenesis and have been recently explored as targets for cancer therapy. Radiotherapy also inhibits tumor growth and affects vasculature. We explored the combination of integrin antagonist Cilengitide (EMD 121974) and ionizing radiation. METHODS AND MATERIALS Levels of alpha v beta 3 were determined for human umbilical vein endothelial cells (HUVEC), as well as H157 and H460 human non-small-cell lung cancer cells, using FACS analysis and immunofluorescence imaging. Clonogenic assays, Western immunoblots probed for cleaved caspase 3, and Annexin-V probing were used to evaluate cell survival and apoptosis. A cell detachment assay and matrigel assay were used to further examine the effects of treatment. RESULTS Human umbilical vein endothelial cells had the highest alpha v beta 3 level, followed by H157, and H460. Interestingly, we found that 5 Gy irradiation induced expression of alpha v beta 3 in all cell lines. Clonogenic assays showed a radiosensitizing effect with Cilengitide, and calculation of the dose enhancement ratio showed that the effect was highest in HUVECs (1.38), followed by H157 (1.19), and H460 (1.10), corresponding to the levels of target expression. There was an increase in apoptotic cells after combination treatment with Cilengitide and radiation, and there was an increase in detached cells after treatment with Cilengitide. Additionally, there was decreased endothelial tubule formation after combination treatment. CONCLUSIONS We conclude that radiation induces expression of alpha v beta 3 integrin in endothelial and non-small-cell lung cancer models, and that integrin antagonist Cilengitide is a radiosensitizer in proportion to the levels of target integrin expression.
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Affiliation(s)
- Jeffrey M Albert
- Department of Radiation Oncology, Vanderbilt Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN, USA
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