Novel Statistical Approach to Determine Inflammatory Bowel Disease: Patients' Perspectives on Shared Decision Making

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

OBJECTIVES

In order to improve the degree of shared decision making (SDM) experienced by patients, it is necessary to gain insight into the explanations for the differences in these degrees.

METHODS

A scoping review of the literature on the explanations for differences in the degree of SDM experienced by patients was conducted. We assessed 21,329 references. Ultimately, 308 studies were included. The explanations were divided into micro, meso, and macro levels.

RESULTS

The explanations are mainly related to the micro level. They include explanations related to the patient and healthcare professionals, the relationship between the patient and the physician, and the involvement of the patient's relatives. On the macro level, explanations are related to restrictions within the healthcare system such as time constraints, and adequate information about treatment options. On the meso level, explanations are related to the continuity of care and the involvement of other healthcare professionals.

CONCLUSIONS

SDM is not an isolated process between the physician and patient. Explanations are connected to the macro, meso, and micro levels.

PRACTICE IMPLICATIONS

This scoping review suggests that there could be more focus on explanations related to the macro and meso levels, and on how explanations at different levels are interrelated.

DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making

BACKGROUND AND AIMS

Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients.

METHODS

Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement.

RESULTS

In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting.

CONCLUSIONS

By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.

Interactive Inflammatory Bowel Disease Biologics Decision Aid Does Not Improve Patient Outcomes Over Static Education: Results From a Randomized Trial

INTRODUCTION

To support shared decision-making (SDM) between patients and providers surrounding biologic treatments, we created IBD&me ( ibdandme.org )-a freely available, unbranded, interactive decision aid. We performed a multicenter comparative effectiveness trial comparing the impact of IBD&me on SDM vs a biologics fact sheet developed by the Crohn's & Colitis Foundation.

METHODS

We enrolled patients with inflammatory bowel disease (IBD) being seen at a clinic within IBD Qorus-a multicenter adult IBD learning health system-between March 5, 2019, and May 14, 2021. Eligible patients included those with recent IBD-related symptoms who reported that they wanted to discuss biologics with their provider during their upcoming visit. Patients were randomized 1:1 using stratified block randomization and received an e-mail 1 week before their visit inviting them to review either IBD&me or a fact sheet. The primary outcome was patient perception of SDM as measured by the 9-Item SDM Questionnaire (0-100 scale; higher = better); the Student t test was used to compare outcomes between arms.

RESULTS

Overall, 152 patients were randomized (biologics fact sheet 75, IBD&me 77); most patients had Crohn's disease (66.4%) and were biologic-experienced (82.9%). No differences were seen between groups regarding SDM (fact sheet 72.6 ± 25.6, IBD&me 75.0 ± 20.8; P = .57). Most patients stated they would be likely to recommend the fact sheet (79.6%) or IBD&me (84.9%; P = .48) to another patient with IBD.

DISCUSSION

No differences in outcomes were seen between IBD&me and the biologics fact sheet in this comparative effectiveness study; patients reported high satisfaction with both resources. Further study, particularly among biologic naïve patients, is needed to determine the utility of interactive components to IBD decision aids.

Shared decision-making in the management of patients with inflammatory bowel disease

The rapid progress of research into inflammatory bowel disease (IBD) has resulted in increasingly more treatment options. Different options have different advantages and disadvantages, and the preferences of patients may also differ. If patients can be invited to the formulation of medical decision-making, their compliance and satisfaction would be improved, thus possibly achieving better therapeutic results. The present review aims to summarize the current literature on shared decision-making (SDM) in the management of IBD, with the goal of promoting the application of SDM.

Patient Perspectives of IBD Care and Services: An Integral Part of a Pan-Canadian Quality Improvement Initiative

Background

As beneficiaries of health service improvement initiatives, patients should have their perspectives of and gaps in care elicited to inform and guide the development of quality indicators to assess health care services. The purpose of this study was to identify patient perspectives amenable for conversion into measurable inflammatory bowel disease (IBD) care quality indicators.

Methods

Crohn’s and Colitis Canada’s Promoting Access and Care through Centres of Excellence (PACE) program organized four patient focus groups in three Canadian provinces in 2016 to capture the perspective of patients on IBD care services. The RQDA package in R was used for transcript analysis, theme identification and for building a theme hierarchy based on the number of citations. The main themes were converted into patient-derived quality indicators.

Results

Several perceived unmet needs were elicited from participants that could be converted into measurable quality indicators. These unmet needs addressed the need for information, access to multidisciplinary services and specialized care, and access to psychological support. Patient unmet needs informed the selection of nine quality indicators that were included in the final list of PACE indicators to assess IBD care services across Canada.

Conclusions

Our study provides a detailed description of patient perspectives on IBD care services that were an integral part of the development of measurable indicators of the quality of care in the context of a universal health care system.

The evolution of IBD perceived engagement and care needs across the life-cycle: a scoping review

Background

The chronic and progressive evolution of Inflammatory Bowel Diseases (IBD), with its prototypical fluctuating trend, creates a condition of psycho-social discomfort, impacting the quality of life in terms of personal, working, and interpersonal.

Aims

In this article, we want to identify the nature and extent of the research evidence on the life experiences, the perceived engagement, the psychological, social care and welfare needs of people affected by IBD across the lifecycle.

Methods

Following the approach set out by Arksey and O’Malley and the PRISMA extension for scoping reviews, we conducted a scoping review in March 2019 and closed the review with an update in October 2019. It was performed using electronic databases covering Health and Life Sciences, Social Sciences and Medical Sciences, such as PubMed, Medline, Embase, Scopus, Cochrane, Web of Science, PsycInfo.

Results

We identified 95 peer-reviewed articles published from 2009 to 2019, that allowed to detection the main needs in children (psychological, need to be accepted, physical activity, feeding, parent style, support, social needs), adolescents (to understand, physical and psychological needs, protection, relational, gratitude, respect, and engagement) and adults (information, medical, psychological, social, work-related, practical, future-related, engagement). Although the literature confirms that the majority of the IBD units have planned provision for the different types of transitions, the quality and appropriateness of these services have not been assessed or audited for all the kinds of challenges across the life cycle.

Conclusions

The literature shows the relevance of organizing a flexible, personalized health care process across all the critical phases of the life cycle, providing adequate benchmarks for comparison in a multidisciplinary perspective and ensuring continuity between hospital and territory.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01850-1.

Physician-patient communication affects patient satisfaction in treatment decision-making: a structural equation modelling analysis of a web-based survey in patients with ulcerative colitis

BACKGROUND

The relationship of bidirectional sharing of information between physicians and patients to patient satisfaction with treatment decision-making for ulcerative colitis (UC) has not been examined. Here, we conducted a web-based survey to evaluate this relationship.

METHODS

Patients aged ≥ 20 years with UC were recruited from the IBD Patient Panel and Japanese IBD Patient Association. Patients completed our web-based survey between 11 May and 1 June 2020. The main outcomes were patient satisfaction (assessed by the Decision Regret Scale) and patient trust in physicians (assessed by the Trust in Physician Scale).

RESULTS

In this study (n = 457), a structural equation modelling analysis showed that physician-to-patient and patient-to-physician information significantly affected patient satisfaction with treatment decision-making (standardised path coefficient: 0.426 and 0.135, respectively) and patient trust in physicians (0.587 and 0.158, respectively). Notably, physician-to-patient information had a greater impact. For patient satisfaction with treatment decision-making and patient trust in physicians, information on "disease" (indirect effect: 0.342 and 0.471, respectively), "treatment" (0.335 and 0.461, respectively), and "endoscopy" (0.295 and 0.407, respectively) was particularly important, and the level of this information was adequate or almost adequate. Patient-to-physician information on "anxiety and distress" (0.116 and 0.136, respectively), "intention and desire for treatment" (0.113 and 0.132, respectively), and "future expectations of life" (0.104 and 0.121, respectively) were also important for patient satisfaction with treatment decision-making and patient trust in physicians, but these concerns were not adequately communicated.

CONCLUSIONS

Adequate physician-patient communication, especially physician-to-patient information, enhanced patient satisfaction with treatment decision-making for UC.

Survey to define informational needs of patients undergoing surgery for Crohn's anal fistula

AIM

There are many surgical treatments used in Crohn's anal fistula, although none is perfect. Decisions about surgery in this condition may be preference sensitive. The aim of this study was to identify what information patients would like in order to make treatment decisions and to explore experiences of making decisions in this setting.

METHOD

A survey was designed based upon qualitative interviews and input from patients and clinicians. It included a long list of informational items to be ranked on a scale of importance, a control preference scale, the decision regret scale, and items exploring preferred information formats. This was distributed through 10 English hospitals to patients with recent surgical treatment for Crohn's anal fistula. Results were analysed using principal component analysis, to identify key informational needs, and other appropriate descriptive statistics.

RESULTS

In total 92 questionnaires were returned (response rate 41.8%); 48 (52.5%) respondents were women and 54 (58.7%) had undergone seton insertion. Principal component analysis identified three information needs: wound and aftercare, effect on perianal symptoms, severity of surgery. Decision-making preferences showed a desire to participate in decision-making. Median decision regret score was 25/100 (i.e., low). The preferred format for sharing information to support decision-making was from the surgeon, 80/92 (87.0%), and from a booklet, 58/92 (63.0%).

CONCLUSION

Key informational needs in this condition are wound and after care, effect on perianal symptoms, and severity of surgery. Patients would like this information to help engage in shared decision-making.

Knowledge and awareness of biosimilars and shared decision-making among gastroenterology team members in Colorado, USA

Background: There are gaps in gastroenterologist team members' understanding of various topics related to biosimilars. We aimed to examine perspectives, views, and attitudes toward biosimilar and shared decision-making (SDM) among gastroenterology team members in Colorado, USA. The ultimate goal was to increase knowledge and awareness of biosimilars and SDM. Research design and methods: We developed educational materials focused on biosimilars and SDM and distributed them to each participating gastroenterology office. Subsequently, we conducted a survey of all team members from participating offices. Results: Responses were obtained from 54 gastroenterology team members. Most respondents identified the correct answer regarding biosimilars, the nocebo effect, and SDM. Almost half (47.2%) of respondents scored their level of awareness regarding biosimilars prior to reading our educational materials as poor, and nearly one quarter (26.4%) indicated so for SDM. Improvement in scores after reading our materials was significant for both biosimilars and SDM (i.e. biosimilar: z = 6.276, p-value <0.001 and SDM z = 6.328, p-value <0.001). Conclusions: Educational efforts effectively increased the low baseline knowledge and awareness of biosimilars and SDM among gastroenterology team members. More educational projects focused on biosimilars and SDM are needed to reduce the nocebo effect and prevent hampering of the cost-savings of biosimilars.

Review of normal gastrointestinal tract, ulcerative colitis, proctitis and rectal medication adherence

The gastrointestinal (GI) tract has a number of functions-ingestion, digestion, absorption and elimination. When the GI tract is working normally, it is efficient. However, this can change when disease, such as inflammatory bowel disease (IBD) occurs. IBD is a long-term relapsing and remitting autoimmune disease; it incorporates ulcerative colitis (UC). In UC, part or all the mucosa lining the rectum and colon becomes inflamed and ulcerated. UC that affects the rectum only is called proctitis. Effective treatment is essential. It is better to target the rectal mucosa directly in proctitis, using topical rectal medications in enemas or suppositories, as these have fewer side-effects and resolve symptoms more quickly than systemic drugs. However, patients may not feel clear about aspects of their IBD care and can find it difficult to initiate and comply with treatment and maintenance regimens. Nurses need to educate and support them to achieve optimal therapeutic outcomes in both the immediate and long terms.

The informational and decisional preferences of patients undergoing surgery for Crohn's anal fistula: a qualitative study

AIM

One in three patients with Crohn's disease will develop a perianal fistula, but only a few achieve long-term healing. Treatment is both medical and surgical. Since there is no 'best' surgical procedure, patient preference is important in selecting the appropriate treatment for this condition. The aim of this study was to investigate the informational and decisional preferences of patients when surgical treatment is being considered.

METHOD

Patients who had undergone surgery for Crohn's anal fistula underwent face-to-face semi-structured interviews. These explored the experience of treatments for fistula, of receiving information and of participation in decision-making. Transcripts were analysed by two investigators through inductive thematic analysis. Saturation was assessed for at 12 interviews and then after each subsequent interview.

RESULTS

Seventeen patients completed interviews, and saturation was achieved. Five themes were identified, of which two (desired information and decision-making) were relevant to this study. Other themes included experience of Crohn's disease, experience of receiving information and procedure-specific comments. Participants wanted to have information on any risks, high-level outcomes (e.g. success), impact on day-to-day life and aftercare. Participants felt they did not always receive the information they needed to select the best treatment option. Participants felt uninvolved in treatment decisions and would have liked to trade off operations to reach their treatment goal.

CONCLUSION

Information provided to patients about surgical treatment of Crohn's perianal fistula does not meet their needs. Clinicians should address aftercare, impact on quality of life and the risks and benefits of the any proposed procedure.

Protocol of a multicentric prospective cohort study for the VALIDation of the IBD-disk instrument for assessing disability in inflammatory bowel diseases: the VALIDate study

Background

Inflammatory Bowel Diseases (IBD) affect psychological, family, social and professional dimensions of patients’ life, leading to disability which is essential to quantify as part of Patient-Reported Outcomes (PROs) newly included in the targets to reach in IBD patients. Up to now, the IBD-Disability Index (IBD-DI) was the only validated tool to assess disability, but it is not appropriate for use in clinical practice. The IBD Disk was developed, a shortened and self-administered tool, adapted from the IBD-DI, in order to give immediate representation of patient-reported disability. However, the IBD Disk has not been validated yet in clinical practice. The aims of the VALIDate study are to validate this tool in a large population of IBD patients and to compare it to the already validated IBD-DI.

Methods

The VALIDate study is an ongoing multicentric prospective cohort study launched in April 2018 in 3 French University Hospitals (Nantes, Rennes, Angers), with an objective to reach a sample of 400 patients over a period inclusion of 6 months. Each patient will fill in the two questionnaires IBD Disk and IBD-DI at baseline, then between 3 and 12 months later, during a follow-up visit. Clinical and socio-demographic data will also be collected. During these two consultations, gastroenterologists and patients will evaluate disease activity thanks to a semi-quantitative 4-grade scale, named respectively PGA (Physician Global Assessment) and PtGA (Patient Global Assessment). This cohort will allow to evaluate the validity of the IBD Disk with respect to the IBD-DI in order to generalize its use for clinical practice. Other psychometric criteria of the IBD Disk will also be analysed as its reliability or its discriminant capacity. Close attention will nonetheless be needed to minimize the number of lost to follow-up patients between baseline and follow-up.

Discussion

The VALIDate study is the study designed to validate the IBD Disk, a visual tool easily useable in daily practice to assess disability in IBD patients. The results of this trial should enable the diffusion of this tool.

Trial registration

The trial is registered in ClinicalTrials.Gov with registration number NCT03590639. First posted: July 18, 2018.

Shared Decision Making in Gastroenterology: Challenges and Opportunities

This article reviews the current uses of shared decision making in gastroenterology and discusses additional areas of opportunity for shared decision making, especially in the area of functional gastrointestinal disorders. PubMed, MEDLINE, and Cochrane library databases were searched for articles published during a 10-year period from January 1, 2007, through December 31, 2017. Search terms included shared decision making and gastroenterology, shared decision making in gastrointestinal disease, shared decision making in functional GI disorders, and shared decision making and irritable bowel syndrome. Studies were not included in this review when a health care professional other than a gastroenterologist was involved, eg, an article that reported shared decision making regarding the use of radiation therapy in a patient with advanced rectal cancer in which the health care professional helping to make the decision was an oncologist.

Risk of Early Colorectal Cancers Needs to Be Considered in Inflammatory Bowel Disease Care

BACKGROUND

Current guidelines recommend starting colorectal cancer (CRC) surveillance 8-10 years after inflammatory bowel disease (IBD) onset. Recent studies report that the incidence of CRC within 8-10 years of IBD onset (i.e., early CRC) ranges from 12 to 42%.

AIMS

To describe the current prevalence of early CRC in a tertiary care center IBD cohort with CRC and to identify associated risk factors.

METHODS

We performed a single-center observational study of IBD patients diagnosed with CRC from 2005 to 2015. We compared characteristics of patients with early CRC (diagnosis of CRC within 8 years of initial IBD onset) to those with CRC diagnosed later in their IBD course.

RESULTS

Ninety-three patients met inclusion criteria. Eleven (11.8%) patients developed CRC within 8 years of initial IBD onset. On multivariable logistic regression, age greater than 28 at IBD onset (adjusted OR 12.0; 95% CI 2.30, 62.75) and tobacco use (adjusted OR 8.52; 95% CI 1.38, 52.82) were significant predictors of early CRC. A validation cohort confirmed calibration and discrimination of the model.

CONCLUSIONS

One out of every eight IBD patients with CRC developed their malignancy prior to the currently recommended timeframe for the initiation of surveillance colonoscopy. IBD onset at 28 years or older and tobacco use were identified as predictors of early CRC. Early CRC should be considered in discussions of cancer surveillance in this population. Prospective cohort studies are necessary to further analyze the impact of early CRC in IBD.

Shared Decision-Making and Patient Satisfaction in Japanese Rheumatoid Arthritis Patients: A New "Preference Fit" Framework for Treatment Assessment

INTRODUCTION

We have developed a new framework to assess shared decision-making (SDM) as a tool to improve patient satisfaction. This framework is based on a "preference fit" index that relates SDM to patient treatment preferences and patient satisfaction in a sample of rheumatoid arthritis (RA) patients in Japan.

METHODS

We surveyed 500 RA patients in Japan and explored the interactions between the treatment preference fit index, SDM, and overall patient satisfaction.

RESULTS

Our new preference fit index reveals significant impact on patient satisfaction: the better the fit between SDM and patient preferences, the higher the patient satisfaction with the current treatment. Patients treated with biologic agents were more satisfied. Patients suffering from depression or migraines scored significantly lower both on our preference fit measure and for overall patient satisfaction.

CONCLUSION

The association between depression and a low treatment preference fit suggests that depression may pose challenges to SDM and that doctors in Japan are less attuned to the SDM preferences of depressed patients.

FUNDING

Janssen Pharmaceutical KK.

Inflammatory bowel disease patient perceptions of diagnostic and monitoring tests and procedures

Background

Inflammatory Bowel Disease (IBD) with its high incidence and prevalence rates in Canada generates a heavy burden of tests and procedures. The purpose of this study is to gain a better understanding of the transfer of information from physician to patient, as well as the patient understanding and perceptions about the tests and procedures that are ordered to them in the context of IBD diagnosis and monitoring.

Methods

An online questionnaire was completed by 210 IBD patients in Canada. Information on the five most-often used tests or procedures in IBD diagnosis/monitoring was collected. These include: general blood test, colonoscopy, colon biopsy, medical imaging and stool testing.

Results

The general blood test is both the most ordered and most refused tool. It is also the one with which patients are the least comfortable, the one that generates the least concern and the one about which physicians provide the least information. The stool test is the test/procedure with which patients are the most comfortable. Procedures raise more concerns among patients and physicians provide more information about why they are needed, their impact and the risks they present. Very little information is provided to patients about the risks of having false positives or negative tests.

Conclusions

This study provides an initial understanding of patient perceptions, the transfer of information from a physician to a patient and a patient’s understanding of the tests and procedures that will be required to treat IBD throughout what is a lifelong disease. The present study takes a first step in better understanding the acceptance of the test or procedure by IBD patients, which is essential for them to adhere to the monitoring process.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-0946-8) contains supplementary material, which is available to authorized users.

Factors that Influence Treatment and Non-treatment Decision Making Among Individuals with Inflammatory Bowel Disease: An Integrative Review

Inflammatory bowel disease (IBD) is a chronic illness with periods of varying disease activity called flares and remissions. Since IBD impacts quality of life, patients make IBD disease management decisions every day. Previous research indicates limited insight about factors that influence decisions regarding disease management and the types of decisions IBD patients make. The purpose of this integrative review is to identify types of treatment and non-treatment decisions and the factors that influence decision making regarding disease management among individuals with IBD. An integrative literature review was performed based on the Whittemore and Knafl framework. PubMed, Web of Science, and PsychINFO were searched for relevant articles, from 2010-2016, using the key terms: decision making, patient preferences, self-management, self-care, nutrition, diet, stress, symptom, Colitis, Crohns, and IBD. Twenty-eight articles met the inclusion criteria. From these, research showed two types of decisions: treatment decisions related to medication and surgery, and non-treatment decisions focused on diet modification. Five themes that influence decisions were identified: experiencing symptoms, provider recommendations, convenience attributes, psychosocial factors, and informational needs. Most of the studies found a positive relationship between an increased number of symptoms and a patient's willingness to engage in treatment decisions. Although support from providers is highly influential for treatment decisions, most studies reported that provider recommendations did not align with patient preferences. Future work is needed to understand factors that influence decisions among recently diagnosed patients, to focus on non-treatment-related decisions, and to clarify the role of psychosocial factors in promoting disease decision making among IBD patients. This integrative review identified that, for patients, experiencing symptoms is the most important factor that influences treatment and non-treatment decisions.

Patients' perception of their involvement in shared treatment decision making: Key factors in the treatment of inflammatory bowel disease

OBJECTIVES

This study aims to characterize the relationships between the quality of the information given by the physician, the involvement of the patient in shared decision making (SDM), and outcomes in terms of satisfaction and anxiety pertaining to the treatment of inflammatory bowel disease (IBD).

METHODS

A Web survey was conducted among 200 Canadian patients affected with IBD. The theoretical model of SDM was adjusted using path analysis. SAS software was used for all statistical analyses.

RESULTS

The quality of the knowledge transfer between the physician and the patient is significantly associated with the components of SDM: information comprehension, patient involvement and decision certainty about the chosen treatment. In return, patient involvement in SDM is significantly associated with higher satisfaction and, as a result, lower anxiety as regards treatment selection.

CONCLUSIONS

This study demonstrates the importance of involving patients in shared treatment decision making in the context of IBD.

PRACTICE IMPLICATIONS

Understanding shared decision making may motivate patients to be more active in understanding the relevant information for treatment selection, as it is related to their level of satisfaction, anxiety and adherence to treatment. This relationship should encourage physicians to promote shared decision making.

Qualitative Analysis of Pediatric Patient and Caregiver Perspectives After Recent Diagnosis With Inflammatory Bowel Disease

PURPOSE

A diagnosis of a chronic illness is a life-altering experience for a child and his or her family. The purpose of this study was to elicit children and parent perspectives following a diagnosis of Inflammatory Bowel Disease (IBD).

DESIGN & METHODS

A qualitative description design was employed. Eighteen patients were recruited from a Pediatric IBD Clinic in Western Canada. Interviews were used to gather perceptions, opinions, and attitudes from children and their parents. Transcriptions of the interviews were analyzed using a qualitative content analysis.

RESULTS

Four themes were identified: perspective of diagnosis, roles in care and decision-making, sharing the diagnosis, and treating the disease. Children and parents expressed varied emotions in response to diagnosis. Families articulated the desire to become more active members in the decision-making process on treatment choices. While using conventional medical therapy was seen as an appropriate choice for short-term therapy, many parents hoped that more non-conventional and alternative therapies could be used in the future.

CONCLUSION

Healthcare providers need to provide excellent education on the disease process, treatment options, and the use of CAM therapy in IBD, while at the same time supporting children and parent's voices in treatment decisions.

PRACTICE IMPLICATIONS

Improvement strategies need to be implemented to allow families to feel that they have a voice when making decisions regarding treatment options. Families need to be educated and supported on the use of CAM therapies in IBD.

Provider perspectives on treatment decision-making in nephrotic syndrome

Background

Managing patients with nephrotic syndrome (NS) remains difficult for the practicing nephrologist. This often young patient population is faced with a debilitating, relapsing and remitting disease with non-specific treatment options that are often poorly tolerated. Clinicians managing these complex patients must attempt to apply disease-specific evidence while considering the individual patient's clinical and personal situation.

Methods

We conducted qualitative interviews to ascertain the provider perspectives of NS, treatment options and factors that influence recommendations for disease management, and administered a survey to assess both facilitators and barriers to the implementation of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.

Results

When making treatment recommendations, providers considered characteristics of various treatments such as efficacy, side effects and evaluation of risk versus benefit, taking into account how the specific treatment fit with the individual patient. Time constraints and the complexity of explaining the intricacies of NS were noted as significant barriers to care. Although the availability of guidelines was deemed a facilitator to care, the value of the KDIGO guidelines was limited by the perception of poor quality of evidence.

Conclusions

The complexity of NS and the scarcity of robust evidence to support treatment recommendations are common challenges reported by nephrologists. Future development and use of shared learning platforms may support the integration of best available evidence, patient/family preferences and exchange of information at a pace that is unconstrained by the outpatient clinic schedule.

Development of the IBD Disk: A Visual Self-administered Tool for Assessing Disability in Inflammatory Bowel Diseases

BACKGROUND

The Inflammatory bowel disease (IBD) Disability Index is a validated tool that evaluates functional status; however, it is used mainly in the clinical trial setting. We describe the use of an iterative Delphi consensus process to develop the IBD Disk-a shortened, self-administered adaption of the validated IBD Disability Index-to give immediate visual representation of patient-reported IBD-related disability.

METHODS

In the preparatory phase, the IBD CONNECT group (30 health care professionals) ranked IBD Disability Index items in the perceived order of importance. The Steering Committee then selected 10 items from the IBD Disability Index to take forward for inclusion in the IBD Disk. In the consensus phase, the items were refined and agreed by the IBD Disk Working Group (14 gastroenterologists) using an online iterative Delphi consensus process. Members could also suggest new element(s) or recommend changes to included elements. The final items for the IBD Disk were agreed in February 2016.

RESULTS

After 4 rounds of voting, the following 10 items were agreed for inclusion in the IBD Disk: abdominal pain, body image, education and work, emotions, energy, interpersonal interactions, joint pain, regulating defecation, sexual functions, and sleep. All elements, except sexual functions, were included in the validated IBD Disability Index.

CONCLUSIONS

The IBD Disk has the potential to be a valuable tool for use at a clinical visit. It can facilitate assessment of inflammatory bowel disease-related disability relevant to both patients and physicians, discussion on specific disability-related issues, and tracking changes in disease burden over time.

Patient preferences for inflammatory bowel disease treatment objectives

BACKGROUND

There is currently little evidence about what treatment objectives most interest patients with inflammatory bowel disease (IBD).

AIMS

To determine patient preferences regarding IBD treatment objectives, specially the attributes they value most and the symptoms to be controlled as a priority.

METHODS

Prospective, observational, anonymous study conducted in 117 outpatients with Crohn's disease or ulcerative colitis.

RESULTS

The most important treatment objectives from the patients' perspective were: improving quality of life (40.2% of patients), and completely resolving symptoms (33.3%). Only 12.8% of patients indicated having a completely normal colonoscopy as a preferred objective. The symptoms the patients considered to be most important when prioritizing their control were: abdominal pain (23.1% of patients), and bowel movement urgency (17.1%). The preferred treatment objectives were similar for Crohn's disease and ulcerative colitis patients.

CONCLUSIONS

Improving quality of life and completely controlling symptoms are the priority treatment objectives for IBD patients, with abdominal pain being the most important symptom. Conversely, therapeutic objective target goals proposed by physicians, such as healing the mucosal lesions, are not a priority for most patients. This indicates that there are discrepancies between patient and physician expectations, which should be taken into account if a patient-centered care model is to be implemented.

Shared decision-making for biologic treatment of autoimmune disease: influence on adherence, persistence, satisfaction, and health care costs

BACKGROUND

Shared decision-making (SDM), a process whereby physicians and patients collaborate to select interventions, is not well understood for biologic treatment of autoimmune conditions.

METHODS

This was a cross-sectional survey of adults initiating treatment for Crohn's disease or ulcerative colitis (inflammatory bowel disease, IBD) or psoriatic arthritis or rheumatoid arthritis (RA/PA). Survey data were linked to administrative claims for 6 months before (baseline) and after (follow-up) therapy initiation. Measures included the Shared Decision Making Questionnaire, Patient Activation Measure (PAM), Morisky Medication Adherence Scale (MMAS), general health, and treatment satisfaction. Claims-based Quan-Charlson comorbidity scores, persistence, medication possession ratio (MPR), and health care costs were examined. Patients were compared by participation (SDM) and nonparticipation (non-SDM) in SDM.

RESULTS

Among 453 respondents, 357 were eligible, and 306 patients (204 RA/PA and 102 IBD) were included in all analyses. Overall (n=357), SDM participants (n=120) were more often females (75.0% vs 62.5%, P=0.018), had lower health status (48.0 vs 55.4, P=0.005), and higher Quan-Charlson scores (1.0 vs 0.7, P=0.035) than non-SDM (n=237) participants. Lower MMAS scores (SDM 0.17 vs non-SDM 0.41; P<0.05) indicated greater likelihood of adherence; SDM participants also reported higher satisfaction with medication and had greater activation (PAM: SDM vs non-SDM: 66.9 vs 61.6; P<0.001). Mean MPR did not differ, but persistence was longer among SDM participants (111.2 days vs 102.2 days for non-SDM; P=0.029). Costs did not differ by SDM status overall, or among patients with RA/PA. The patients with IBD, however, experienced lower (P=0.003) total costs ($9,404 for SDM vs $25,071 for non-SDM) during follow-up.

CONCLUSION

This study showed greater likelihood of adherence and satisfaction for patients who engaged in SDM and reduced health care costs among patients with IBD who engaged in SDM. This study provides a basis for defining SDM participation and detecting differences by SDM participation for biologic treatment selection for autoimmune conditions.

Physicians Should Provide Shared Decision-Making for Anti-TNF Therapy to Inflammatory Bowel Disease Patients

Shared decision-making may increase the effectiveness of inflammatory bowel disease (IBD) treatment, as different anti-tumor necrosis factor (anti-TNF) administrations may have different effects on the quality of life (QOL). Patient preference is integral to the selection of anti-TNFs and their routes of administration, however, previous studies on the patient preference to anti-TNFs are inconsistent and limited. We evaluated the predictive factors for preferences to anti-TNF administrations in IBD patients between March and August in 2015. Consecutive adult IBD patients who received care at one of four university hospitals in Korea were invited to participate in this study. Patients were administered questionnaires about their preferences regarding anti-TNF therapy and QOL. During the study period, 322 IBD patients completed the questionnaires. IBD patients preferred intravenous anti-TNFs to subcutaneous anti-TNFs (2.4:1), and 58.4% of patients preferred shared decision-making. When comparing subcutaneous anti-TNF therapy with intravenous anti-TNF therapy, patients with higher income levels, patients who experienced adverse events with prior medication and patients with a longer disease duration preferred subcutaneous anti-TNF therapy over intravenous anti-TNF therapy (P = 0.043, P = 0.000, and P = 0.029, respectively). In a logistic regression analysis, high income level (odds ratio [OR] 2.0; 95% confidence interval [CI] 1.1-3.5; P = 0.026) and an adverse event with prior medication (OR 4.0; 95% CI 2.2-7.2; P = 0.000) and were found to be independent predictors for preference to subcutaneous anti-TNF therapy. Therefore, physicians should share decision-making with their IBD patients regarding the mode of anti-TNF administration.

Information provision and attentive listening as determinants of patient perceptions of shared decision-making around chronic illnesses

Background

While chronic illnesses are a major concern of the health system worldwide, little is known about patients–physicians communication. Growing demand for patient-centered care and shared decision-making have increased the interest for patients–physicians communication. Based on previous literature, we propose a model in which the effect of information provision and attentive listening over patients’ perceptions of shared decision-making (PPSDM) is mediated by the variables self-efficacy and proactivity. Primary data were collected between April and August 2014 through an online survey of patients with haemophilia. Haemophilia is a chronic disease in which many options of treatment are available. The right option depends, to some extent, on patient’s preferences. In this context, great uncertainty exists when choosing treatment option and shared decision-making plays an essential role.

Results

A total of 181 patients with haemophilia participated in the survey. The psychometric properties of the measurement scales were evaluated by means of a confirmatory factor analysis. A structural equation model was designed. Results show that provision of information and attentive listening determine PPSDM through patients’ self-efficacy and proactivity in requesting information.

Conclusions

It is important to incorporate communication training in medical education, particularly provision of information and attentive listening. These skills help the healthcare professional to gain a deeper understanding of the patient. Furthermore, provision of information and attentive listening are fundamental in helping patients not to undervalue their personal knowledge and expertise in relation to their doctors. These strategies encourage them to adopt a more active position in requesting information. Encouraging a proactive behaviour of patients and their relatives helps them to realize the need to participate and to make them feel that they are part of the decision-making process.

Patients with Ulcerative Colitis Are More Concerned About Complications of Their Disease than Side Effects of Medications

BACKGROUND

Patients with ulcerative colitis (UC) are often fearful about medication side effects and how the disease will affect their future. Our aim was to better understand what aspects of UC, and UC management, are most concerning to patients, and how they would like to be informed about treatment options.

METHODS

A Web-based survey was sent to UC patients throughout the United States and Australia. In addition to standard closed-response questions, audio clips were embedded in the survey and respondents showed their strength of agreement or disagreement using moment-to-moment affect-trace methodology. Standard quantitative analysis was used for the survey results, and cluster analysis was performed on the affect-trace responses.

RESULTS

A total of 460 patients with UC (370 patients from the United States and 90 patients from Australia) responded to the survey. Of them, 53% of the respondents were women, with a mean age of 49 (range 19-81) years. Most patients (87%) wanted to share treatment decision making with their doctors. The majority, 98%, wanted more than just a basic understanding of their disease. Patients were most concerned about the risk of colorectal cancer (37%), and the possible need for an ileostomy (29%). Only 14% of patients indicated that side effects from medications were their biggest concern. On affect-trace analysis, the most divergence in opinion centered on the appropriate timing for colectomy.

CONCLUSIONS

To facilitate informed treatment decisions for UC patients, in addition to reviewing the benefits and risks of medications, it is also important to discuss the best strategies for decreasing the risk of colectomy and colorectal cancer.

Gastroenterologists' Views of Shared Decision Making for Patients with Inflammatory Bowel Disease

BACKGROUND

There is limited information on gastroenterologists' perspectives of shared decision making (SDM) in discussions of therapeutic agents with inflammatory bowel disease (IBD) patients.

AIMS

To examine gastroenterologists' perspectives about SDM with IBD patients, using a novel statistical hybrid approach to analyze qualitative data.

METHODS

Physician interviews and online surveys were conducted from a panel of gastroenterologists in April 2012. Gastroenterologists were asked about their barriers to SDM, SDM practices, relationship to their patients, knowledge of SDM, and insights into SDM implementation. Key audio excerpts adapted from the interviews were used for moment-to-moment affect trace analysis in an online survey. Cluster analysis was used to segment gastroenterologists into mutually exclusive provider groups.

RESULTS

One hundred and six gastroenterologists completed the survey (88 % male; 55 % ≤ 50 years of age). Over three-fourths of gastroenterologists were familiar with SDM (77 %). The vast majority of gastroenterologists (80 %) tried to use a form of SDM with their patients; only 12 % stated that they have a systematic, consistent, and formally documented approach to SDM. Three unique physician clusters were identified: SDM Believers (20 %, n = 20); SDM Skeptics (47 %, n = 47); and SDM Enthusiasts (34 %, n = 34). The three key barriers to practicing SDM were lack of the following: time (74 %), reimbursement (70 %), and tools (51 %). Twenty-two percent of gastroenterologists do not currently use SDM tools.

CONCLUSIONS

Gastroenterologists lack the systematic approaches and tools for implementing SDM within their IBD practices. These data offer a foundation for future research in developing and testing SDM programs for gastroenterologists and their IBD patients.