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Rubin MA, Riecke J, Heitman E. Futility and Shared Decision-Making. Neurol Clin 2023; 41:455-467. [PMID: 37407099 DOI: 10.1016/j.ncl.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Medical futility is an ancient and yet consistent challenge in clinical medicine. The means of balancing conflicting priorities and stakeholders' preferences has changed as much as the science that powers the understanding and treatment of disease. The introduction of patient self-determination and choice in medical decision-making shifted the locus of power in the physician-patient relationship but did not obviate the physician's responsibilities to provide benefit and prevent harm. As we have refined the process in time, new paradigms, specialists, and tools have been developed to help navigate the ever-changing landscape.
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Affiliation(s)
- Michael A Rubin
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA; Department of Neurological Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA.
| | - Jenny Riecke
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA; Department of Palliative Care, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA
| | - Elizabeth Heitman
- Program in Ethics in Science and Medicine, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, NC5.832, Dallas, TX 75390-9070, USA; Department of Applied Clinical Research, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, NC5.832, Dallas, TX 75390-9070, USA
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O'Rinn SE, Barrett JFR, Parsons JA, Kingdom JC, D'Souza R. Engaging pregnant individuals and healthcare professionals in an international mixed methods study to develop a core outcome set for studies on placenta accreta spectrum disorder (COPAS): a study protocol. BMJ Open 2023; 13:e060699. [PMID: 37185194 PMCID: PMC10151908 DOI: 10.1136/bmjopen-2021-060699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Placenta accreta spectrum (PAS) disorder is a life-threatening condition that may result in serious maternal complications, including mortality. The placenta which is pathologically adherent to the uterine wall, places individuals at high risk of major haemorrhage during the third stage of labour. Current research reports on PAS disorder outcomes have highly variable levels of information, which is therefore difficult for investigators to aggregate to inform practice. There is an urgent need to harmonise data collection in prospective studies to identify and implement best practices for management. One approach to standardise outcomes across any health area via the use of core outcome sets (COSs), which are consensus-derived standardised sets of outcomes that all studies for a particular condition should measure and report. This protocol outlines the steps for developing a COS for PAS disorder (COPAS). METHODS AND ANALYSIS This protocol outlines steps for the creation of COPAS. The first step, a systematic review, will identify all reported outcomes in the scientific literature. The second step will use qualitative one-on-one interviews to identify additional outcomes identified as important by patients and healthcare professionals that are not reported in the published literature. Outcomes from the first two steps will be combined to form an outcome inventory. This outcome inventory will inform the third step which is a Delphi survey that encourages agreement between patients and healthcare professionals on which outcomes are most important for inclusion in the COS. The fourth step, a consensus group meeting of representative participants, will finalise outcomes for inclusion in the PAS disorder COS. ETHICS AND DISSEMINATION This study has obtained Research Ethics Board approval from Sunnybrook Health Sciences Centre (#2338, #1488). We will aim to publish the study findings in an international peer-reviewed OBGYN journal. REGISTRATION DETAILS COMET Core Outcome Set Registration: https://www.comet-initiative.org/Studies/Details/1127. PROSPERO REGISTRATION NUMBER CRD42020173426.
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Affiliation(s)
- Susan E O'Rinn
- Outcomes & Evaluation, Institute of Health, Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- DAN Women & Babies Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Jon F R Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Janet A Parsons
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - John C Kingdom
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Nogueira-Leite D, Cruz-Correia R. Attitudes of Physicians and Individuals Toward Digital Mental Health Tools: Protocol for a Web-Based Survey Research Project. JMIR Res Protoc 2023; 12:e41040. [PMID: 36917172 PMCID: PMC10131781 DOI: 10.2196/41040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/20/2022] [Accepted: 01/09/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Digital transformation is impacting health care delivery. Great market dynamism is bringing opportunities and concerns alike into public discussion. Digital health apps are a vibrant segment where regulation is emerging, with Germany paving the way with its DiGA (Digitale Gesundheitsanwendungen, in German, meaning digital health apps) program. Simultaneously, mental ill-health constitutes a global health concern, and prevalence is expected to worsen due to the COVID-19 pandemic and its containment measures. Portugal and its National Health System may be a useful testbed for digital health interventions. OBJECTIVE The paper outlines the protocol for a research project on the attitudes of physicians and potential users toward digital mental health apps to improve access to care, patient outcomes, and reduce the burden of disease of mental ill-health. METHODS Web surveys will be conducted to acquire data from the main stakeholders (physicians and the academic community). Data analysis will replicate the statistical analysis performed in the studies from Dahlhausen and Borghouts to derive conclusions regarding the relative acceptance and likelihood of successful implementation of digital mental health apps in Portugal. RESULTS The findings of the proposed studies will elicit important information on how physicians and individuals perceive digital mental health app interventions to improve access to care, patient outcomes, and reduce the burden of disease of mental ill-health. Data collection ran between September 26 and November 6, 2022, for the first study and September 20 and October 20, 2022, for the second study. We obtained 160 responses to the first study's survey and 539 answers to the second study's survey. Data analysis is concluded, and both studies' results are expected to be published in 2023. CONCLUSIONS The results of the studies projected in this research protocol will have implications for researchers and academia, industry, and policy makers concerning the adoption and implementation of digital health mental apps and associated interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/41040.
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Affiliation(s)
- Diogo Nogueira-Leite
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal.,Nova School of Business and Economics Health and Economics Knowledge Center, New University of Lisbon, Lisbon, Portugal.,Programme in Health Data Science, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ricardo Cruz-Correia
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
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Becker C, Gross S, Gamp M, Beck K, Amacher SA, Mueller J, Bohren C, Blatter R, Schaefert R, Schuetz P, Leuppi J, Bassetti S, Hunziker S. Patients' Preference for Participation in Medical Decision-Making: Secondary Analysis of the BEDSIDE-OUTSIDE Trial. J Gen Intern Med 2022; 38:1180-1189. [PMID: 36085211 PMCID: PMC10110786 DOI: 10.1007/s11606-022-07775-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/19/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Patients may prefer different levels of involvement in decision-making regarding their medical care which may influence their medical knowledge. OBJECTIVE We investigated associations of patients' decisional control preference (DCP) with their medical knowledge, ward round performance measures (e.g., duration, occurrence of sensitive topics), and perceived quality of care measures (e.g., trust in the healthcare team, satisfaction with hospital stay). DESIGN This is a secondary analysis of a randomized controlled multicenter trial conducted between 2017 and 2019 at 3 Swiss teaching hospitals. PARTICIPANTS Adult patients that were hospitalized for inpatient care. MAIN MEASURES The primary outcome was patients' subjective average knowledge of their medical care (rated on a visual analog scale from 0 to 100). We classified patients as active, collaborative, and passive according to the Control Preference Scale. Data collection was performed before, during, and after the ward round. KEY RESULTS Among the 761 included patients, those with a passive DCP had a similar subjective average (mean ± SD) knowledge (81.3 ± 19.4 points) compared to patients with a collaborative DCP (78.7 ± 20.3 points) and active DCP (81.3 ± 21.5 points), p = 0.25. Regarding patients' trust in physicians and nurses, we found that patients with an active vs. passive DCP reported significantly less trust in physicians (adjusted difference, - 5.08 [95% CI, - 8.69 to - 1.48 points], p = 0.006) and in nurses (adjusted difference, - 3.41 [95% CI, - 6.51 to - 0.31 points], p = 0.031). Also, patients with an active vs. passive DCP were significantly less satisfied with their hospital stay (adjusted difference, - 7.17 [95% CI, - 11.01 to - 3.34 points], p < 0.001). CONCLUSION Patients with active DCP have lower trust in the healthcare team and lower overall satisfaction despite similar perceived medical knowledge. The knowledge of a patient's DCP may help to individualize patient-centered care. A personalized approach may improve the patient-physician relationship and increase patients' satisfaction with medical care. TRIAL REGISTRATION ClinicalTrials.gov (NCT03210987).
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Affiliation(s)
- Christoph Becker
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, CH, Switzerland.,Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Sebastian Gross
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, CH, Switzerland
| | - Martina Gamp
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, CH, Switzerland
| | - Katharina Beck
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, CH, Switzerland
| | - Simon A Amacher
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, CH, Switzerland.,Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Jonas Mueller
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, CH, Switzerland
| | - Chantal Bohren
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, CH, Switzerland
| | - René Blatter
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, CH, Switzerland
| | - Rainer Schaefert
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, CH, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Faculty of Medicine, University of Basel, Basel, Switzerland.,Division of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Joerg Leuppi
- Faculty of Medicine, University of Basel, Basel, Switzerland.,Division of Internal Medicine, Kantonsspital Baselland, Liestal, Switzerland
| | - Stefano Bassetti
- Faculty of Medicine, University of Basel, Basel, Switzerland.,Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, CH, Switzerland. .,Faculty of Medicine, University of Basel, Basel, Switzerland.
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Cleveland Manchanda EC, Marsh RH, Osuagwu C, Decopain Michel J, Dugas JN, Wilson M, Morse M, Lewis E, Wispelwey BP. Heart Failure Admission Service Triage (H-FAST) Study: Racialized Differences in Perceived Patient Self-Advocacy as a Driver of Admission Inequities. Cureus 2021; 13:e13381. [PMID: 33628703 PMCID: PMC7891794 DOI: 10.7759/cureus.13381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Racial inequities in mortality and readmission for heart failure (HF) are well documented. Inequitable access to specialized cardiology care during admissions may contribute to inequity, and the drivers of this inequity are poorly understood. Methodology This prospective observational study explored proposed drivers of racial inequities in cardiology admissions among Black, Latinx, and white adults presenting to the emergency department (ED) with symptoms of HF. Surveys of ED providers examined perceptions of patient self-advocacy, outreach to other clinicians (e.g., outpatient cardiologist), diagnostic uncertainty, and other active co-morbid conditions. Service census, bed availability, prior admission service, and other structural factors were explored through the electronic medical record. Results Complete data were available for 61/135 patients admitted with HF during the study period, which halted early due to coronavirus disease 2019. No significant differences emerged in admission to cardiology versus medicine based on age, sex, insurance status, education level, or perceived race/ethnicity. White patients were perceived as advocating for admission to cardiology more frequently (18.9 vs. 5.6%) and more strenuously than Black patients (p = 0.097). ED clinicians more often reported having spoken with the patient’s outpatient cardiologist for whites than for Black or Latinx patients (24.3 vs. 16.7%, p = 0.069). Conclusions Theorized drivers of racial inequities in admission service did not reach statistical significance, possibly due to underpowering, the Hawthorne effect, or clinician behavior change based on knowledge of previously identified inequities. The observed trend towards racial differences in coordination of care between ED and outpatient providers, as well as in either actual or perceived self-advocacy by patients, may be as-yet undemonstrated components of structural racism driving HF care inequities.
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Affiliation(s)
- Emily C Cleveland Manchanda
- Department of Emergency Medicine, Boston Medical Center, Boston, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, USA
| | - Regan H Marsh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Chidinma Osuagwu
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | | | - Julianne N Dugas
- Department of Emergency Medicine, Boston Medical Center, Boston, USA
| | - Michael Wilson
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Michelle Morse
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Eldrin Lewis
- Division of Cardiology, Stanford University Medical Center, Palo Alto, USA
| | - Bram P Wispelwey
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Desire to Share in Decision-Making Linked to Dissatisfaction with Hospital Care. Am J Nurs 2021; 121:68. [PMID: 33497133 DOI: 10.1097/01.naj.0000734152.65720.b0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
According to this study: Patients who prefer to participate in medical decision-making are more likely to be dissatisfied with hospital care.
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