Patient-reported effects of hospital-wide implementation of shared decision-making at a university medical centre in Germany: a pre-post trial

OBJECTIVES

To evaluate the feasibility and effectiveness of the SHARE TO CARE (S2C) programme, a complex intervention designed for hospital-wide implementation of shared decision-making (SDM).

DESIGN

Pre-post study.

SETTING

University Hospital Schleswig-Holstein (UKSH), Kiel Campus.

PARTICIPANTS

Healthcare professionals as well as inpatients and outpatients from 22 departments of the Kiel Campus of UKSH.

INTERVENTIONS

The S2C programme is a comprehensive implementation strategy including four core modules: (1) physician training, (2) SDM support training for and support by nurses as decision coaches, (3) patient activation and (4) evidence-based patient decision aid development and integration into patient pathways. After full implementation, departments received the S2C certificate.

MAIN OUTCOME MEASURES

In this paper, we report on the feasibility and effectiveness outcomes of the implementation. Feasibility was judged by the degree of implementation of the four modules of the programme. Outcome measures for effectiveness are patient-reported experience measures (PREMs). The primary outcome measure for effectiveness is the Patient Decision Making subscale of the Perceived Involvement in Care Scale (PICSPDM). Pre-post comparisons were done using t-tests.

RESULTS

The implementation of the four components of the S2C programme was able to be completed in 18 of the 22 included departments within the time frame of the study. After completion of implementation, PICSPDM showed a statistically significant difference (p<0.01) between the means compared with baseline. This difference corresponds to a small to medium yet clinically meaningful positive effect (Hedges' g=0.2). Consistent with this, the secondary PREMs (Preparation for Decision Making and collaboRATE) also showed statistically significant, clinically meaningful positive effects.

CONCLUSIONS

The hospital-wide implementation of SDM with the S2C-programme proved to be feasible and effective within the time frame of the project. The German Federal Joint Committee has recommended to make the Kiel model of SDM a national standard of care.

Comprehensive Implementation of Shared Decision Making in a Neuromedical Center Using the SHARE TO CARE Program

PURPOSE

SHARE TO CARE (S2C) is a comprehensive, multi-module implementation program for shared decision making (SDM). It is currently applied at the University Hospital Schleswig-Holstein in Kiel, Germany, and among general practitioners at the Federal State of Bremen. This study examines the results of the full implementation of S2C in terms of effectiveness within the Kiel Neuromedical Center comprising the departments of neurology and neurosurgery.

METHOD AND DESIGN

The S2C program consists of four combined intervention modules: 1) multimodal training of physicians; 2) a patient activation campaign including the ASK-3 method; 3) digital evidence-based patient decision aids; and 4) SDM support by nurses, e.g., as decision coaches. The SDM level before and immediately after implementation was retrospectively assessed in consecutively selected patients on the subscale "Patient Decision Making" of the Perceived Involvement in Care Scale (PICS_PDM). Mean scores were compared with t-tests.

RESULTS

Eighty-nine percent of all physicians (N = 56) completed the SDM training. We developed a total of 12 evidence-based digital decision aids in the center, educated two decision coaches to support patients' decision processes by using decision aids. Physicians adjusted patients' pathways to incorporate the use of decision aids. Patients (n = 261) reported a significant increase in participation (p<0.001; Hedges' g = 0.49) in medical decision making.

CONCLUSION

The S2C program has been successfully implemented within the entire Neuromedical Center. Patients reported a medium to small increase of perceived involvement in decision making demonstrating the effectiveness of the implementation. For future research, it might be interesting to investigate the sustainability of the effects of S2C. In addition, it seems useful to complement the patient-based evaluation with observer-based data.

Sustainability of large-scale implementation of shared decision making with the SHARE TO CARE program

Introduction

SHARE TO CARE (S2C) is a comprehensive implementation program for shared decision making (SDM). It is run at the University Hospital Schleswig-Holstein (UKSH) in Kiel, Germany, and consists of four combined intervention modules addressing healthcare professionals and patients: (1) multimodal training of physicians (2) patient activation campaign including the ASK3 method, (3) online evidence-based patient decision aids (4) SDM support by nurses. This study examines the sustainability of the hospital wide SDM implementation by means of the Neuromedical Center comprising the Departments of Neurology and Neurosurgery.

Methods

Between 2018 and 2020, the S2C program was applied initially within the Neuromedical Center: We implemented the patient activation campaign, trained 89% of physicians (N = 56), developed 12 patient decision aids and educated two decision coaches. Physicians adjusted the patients' pathways to facilitate the use of decision aids. To maintain the initial implementation, the departments took care that new staff members received training and decision aids were updated. The patient activation campaign was continued. To determine the sustainability of the initial intervention, the SDM level after a maintenance phase of 6-18 months was compared to the baseline level before implementation. Therefore, in- and outpatients received a questionnaire via mail after discharge. The primary endpoint was the "Patient Decision Making" subscale of the Perceived Involvement in Care Scale (PICS_PDM). Secondary endpoints were an additional scale measuring SDM (CollaboRATE), and the PrepDM scale, which determines patients' perceived health literacy while preparing for decision making. Mean scale scores were compared using t-tests.

Results

Patients reported a significantly increased SDM level (PICS_PDM p = 0.02; Hedges' g = 0.33; CollaboRATE p = 0.05; Hedges' g = 0.26) and improved preparation for decision making (PrepDM p = 0.001; Hedges' g = 0.34) 6-18 months after initial implementation of S2C.

Discussion

The S2C program demonstrated its sustainability within the Neuromedical Center at UKSH Kiel in terms of increased SDM and health literacy. Maintaining the SDM implementation required a fraction of the initial intensity. The departments took on the responsibility for maintenance. Meanwhile, an additional health insurance-based reimbursement for S2C secures the continued application of the program.

Conclusion

SHARE TO CARE promises to be suitable for long-lasting implementation of SDM in hospitals.

Health economic evaluation of the 'Flying Intervention Team' as a novel stroke care concept for rural areas: study protocol of the TEMPiS-GÖA study

INTRODUCTION

Providing comprehensive stroke care poses major organisational and financial challenges to the German healthcare system. The quasi-randomised TEMPiS-Flying Intervention Team (TEMPiS-FIT) study aims to close the gap in the treatment of patients who had ischaemic stroke in rural areas of Southeast Bavaria by flying a team of interventionalists via helicopter directly to patients in the regional TEMPiS hospitals instead of transporting the patients to the next comprehensive stroke centre. The objective of the present paper is to describe the methods for the economic evaluation (TEMPiS-Gesundheitsökonomische Analyse (TEMPiS-GÖA)) alongside the TEMPiS-FIT study to determine whether the new form of care is cost-effective compared with standard care.

METHODS AND ANALYSIS

The within-trial cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) will be performed from a statutory health insurance perspective as well as from a societal perspective over the time horizon of 12 months after the patients' hospital discharge. Direct costs from outpatient and inpatient care are collected from routine data of the participating health insurance funds, while medical and non-medical costs from a patient's perspective are retrieved from primary data collected during the TEMPiS-FIT study and follow-up questionnaires. Results will be presented as incremental cost-effectiveness ratio and incremental cost-utility ratio quantifying the incremental costs and health benefits compared with standard care practice. The outcome of the CEA will be measured in costs per minute reduction in mean process time to thrombectomy. The outcome of the CUA will be presented as costs per quality-adjusted life year gained.

ETHICS AND DISSEMINATION

Ethical approval for the TEMPiS-FIT study was granted by the Bavarian State Medical Association Ethics Committee (# 17056). Results will be disseminated via reports, presentations of the results in publications and at conferences and on the TEMPiS website.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register DRKS00023885. Registered on 2 July 2021 - retrospectively registered.

Acute phase response and energy balance in stable human immunodeficiency virus-infected patients: a doubly labeled water study

We sought to assess possible associations of the acute phase response with energy balance as a cause of malnutrition in uncomplicated HIV-infection. Seven stable HIV-infected patients and 7 control subjects were followed for 2 weeks for blood chemistry, body composition, total and resting energy expenditure (TEE, REE), heart rate, energy intake, and physical activity; 6 patients were investigated for interleukin-2 receptor. TEE, REE, energy intake, and anthropometric data in patients and control subjects were very similar. However, physical activity, total body potassium, and bioimpedance phase angle were decreased (1.41 +/- 0.08 vs 1.55 +/- 0.9, 152 +/- 10 g vs 191 +/- 37 g, and 6.4 +/- 0.8 degrees vs 7.1 +/- 0.5 degrees; each P < .05), and mean heart rate, fibrinogen, and erythrocyte sedimentation rate were increased in HIV-infected patients (84 +/- 6 bpm vs 76 +/- 8 bpm, 4.3 +/- 1.2 g/L vs 2.5 +/- 0.4 g/L, and 21 +/- 13 mm vs 2 +/- 3 mm; P < .05). The deviation between the measured and the predicted REE in the patient group correlated positively with heart rate and serum interleukin-2 receptor concentrations (r = 0.83 and r = 0.91; P < .05). Possible increases in REE caused by an ongoing acute phase response may be counterbalanced by reduced physical activity that results in normal TEE in HIV infection.