The decision aid is the easy part: workflow challenges of shared decision making in cancer care

Perspectives of family physician educators on shared decision making in preventive health care: A Qualitative Descriptive Inquiry

OBJECTIVE

To explore the views of family physician (FP) educators on shared decision making (SDM).

METHODS

Qualitative descriptive study. Individual interviews were recorded with FPs in active practice who were also educators of Family Medicine residents. Data were analyzed following the phases of practical thematic analysis.

RESULTS

15 practicing FP educators in a clinic setting were interviewed; nine female and six male FPs with practice experience averaging 19 years. We identified five themes, which we then grouped in two major categories: (i) Conceptual ideas about SDM and (ii) Challenges in putting SDM into practice. In the conceptual idea category: (1) Participants held different understandings of SDM and did not have consensus about when SDM should be achieved in clinical practice (difficulty conceptualizing what SDM is, understanding of SDM changes over time, SDM requires clinical equipoise). (2) Participants identified why SDM is important (patient-centred care). Themes in the putting SDM into practice category (ii) were: (3) When to engage in SDM is influenced by multiple factors (system factors, research-based evidence) as well as (4) patient factors (social or contextual factors, discordance or misalignment between doctor and patient on a specific decision, patient safety). (5) Resources and strategies are needed to put SDM into action.

CONCLUSION

An inconsistent understanding of SDM among FP educators, as well as several other challenges, helps explain why SDM has been difficult to implement in practice.

PRACTICE IMPLICATIONS

Physician educators will appreciate how this study unveils challenges to enhancing resident training for the use of SDM in primary care.

Plasma IL-1β Concentration Associates with Sleep Quality and Cognitive Functions in Men with Prostate Cancer

OBJECTIVES

The purpose of this study was to ascertain whether sleep quality is altered in patients with prostate cancer (PCa) during androgen deprivation therapy (ADT) and whether sleep impairment associates with depressive symptoms, cognitive function or frailty syndrome, and if this varies between patients with localized or metastatic disease. The pro-inflammatory cytokine, IL-1β is involved in sleep regulation, we assessed whether sleep quality, depressive symptoms, cognitive function or frailty syndrome are associated with IL-1β concentration.

METHODS

Sleep quality was assessed using the Athens Insomnia Scale (AIS), depressive symptoms using the Yesavage Scale (GDS), and cognitive functions using the MiniMental State Exam (MMSE) and the level of frailty was measured based on the Fried criteria. Plasma IL-1β was measured by enzyme-linked immunoassay. Linear regression lanalyses were performed to determine which variables predict plasma IL-1β is involved in poor sleep quality and higher IL-1β concentration.

RESULTS

A cross-sectional study was carried out between 2021 and 2023. Sixty-seven men with PCa (N=36 (53.7%) with localized disease and N=31 (46.3%) with metastatic disease) were enrolled in the study. Plasma IL-1β concentration correlated with poorer sleep quality in all sample and, men with metastatic PCa had poorer sleep quality compared to men with localized disease. Analysis of self-reported sleep quality revealed that half of them had insomnia symptoms and 19.4% reported clinically relevant insomnia disorder (mean value of AIS 3.39±0.44). Poor sleep quality significantly predicted the concentration of IL-1β in plasma. In contrast, a better cognitive function significantly (P = .037) predicted IL-1β concentration. Detailed analysis of AIS items showed that score in the item "Sleep induction" and "Sleepiness during the da) significantly predicted IL-1β concentrations (P = .001 and P0=.044, respectively).

CONCLUSIONS

Plasma IL-1β levels may be useful to address the presence of insomnia in patients with PCa who are receiving ADT and to monitor the effect of interventions to improve sleep problems in these patients.

IMPLICATIONS FOR NURSING PRACTICE

Nurses will play a critical role in educating patients about their risk for specific symptoms based on an evaluation of specific biomarkers such as IL-1β and sleep quality. Nurses will be involved in using biomarker data to titrate medications and to evaluate the effect of nonpharmacological interventions to improve sleep quality in patients with PCa.

Social Media as a Platform for Cancer Care Decision-Making Among Women: Internet Survey-Based Study on Trust, Engagement, and Preferences

BACKGROUND

Decision aids improve patient and clinician decision-making but are underused and often restricted to clinical settings.

OBJECTIVE

Given limited studies analyzing the feasibility of disseminating decision aids through social media, this study aimed to evaluate the acceptability, trust, and engagement of women with social media as a tool to deliver online decision aids for cancer treatment.

METHODS

To prepare for potential dissemination of a breast cancer decision aid via social media, a cross-sectional survey in February 2023 was conducted via Prime Panels, an online market research platform, of women aged 35-75 years in the United States. Demographics, health, cancer information-seeking behaviors, social media use, trust in social media for health information, as well as the likelihood of viewing cancer-related health information and clicking on decision aids through social media, were assessed. Statistical analyses included descriptive statistics, correlations, and multivariable ordinal regression.

RESULTS

Of 607 respondents, 397 (65.4%) had searched for cancer information, with 185 (46.6%) using the internet as their primary source. Facebook (Meta) was the most popular platform (511/607, 84.2%). Trust in social media for health information was higher among Black (14/72, 19.4%) and Asian respondents (7/27, 25.9%) than among White respondents (49/480, 10.2%; P=.003). Younger respondents aged 35-39 years (17/82, 20.7%) showed higher trust than those aged 70-79 years (12/70, 17.1%; P<.001). Trust in social media for health information was linked to a higher likelihood of viewing cancer information and accessing a decision aid online (P<.001). Participants who rated social media as "Trustworthy" (n=73) were more likely to view cancer information (61/73, 83.6%) and click on decision aids (61/73, 83.6%) than those who found it "Untrustworthy" (n=277; view: 133/277, 48.0%; click: 125/277, 45.1%). Engagement with social media positively correlated with viewing online cancer information (Spearman ρ=0.20, P<.001) and willingness to use decision aids (ρ=0.21, P<.001). Multivariable ordinal regression analyses confirmed that perception of social media's trustworthiness is a significant predictor of engagement with decision aids (untrustworthy vs trustworthy β=-1.826, P<.001; neutral vs trustworthy β=-0.926, P=.007) and of viewing cancer information (untrustworthy vs trustworthy β=-1.680, P<.001, neutral vs trustworthy β=-0.581, P=.098), while age and employment status were not significant predictors.

CONCLUSIONS

This exploratory study suggests that social media platforms may increase access to health information and decision aids. No significant differences were observed between demographic variables and the use or trust in social media for health information. However, trust in social media emerged as a mediating factor between demographics and engagement with cancer information online. Before disseminating decision aids on social media, groups should identify existing trust and engagement patterns with different platforms within their target demographic.

Feasibility of implementing a decision aid for advanced cancer patients in a comprehensive cancer centers' outpatient setting: Valuable lessons learned

BACKGROUND

Decision aids (DAs) have been proposed as tools to empower patients in decision-making. However, implementing DA for decisions in advanced cancer is challenging. This study focuses on perspectives of oncologists and other healthcare providers on the hindering and facilitating factors for implementing a customizable DA. This DA is designed to support discussions about whether patients with advanced, incurable cancers should pursue or forgo further anticancer treatment.

METHODS

This qualitative study utilized content analysis following Sandelowski's approach on two different datasets derived from research projects on decision-making in advanced cancer. To inform the development of a DA and understand challenges related to its implementation, we conducted semi-structured interviews with 24 oncologists (Dataset 1) and three focus groups with various healthcare professionals (n = 19) and in addition post-implementation semi-structured interviews with oncologists who used the DA in conversations with their cancer patients (n = 5) (Dataset 2). Furthermore, the insights from process evaluation of developing and implementing the DA in an outpatients' settings was incorporated, enriching the analytical framework.

RESULTS

Two overall themes emerged: (1) Tension between standardizing the use of a DA and responding to individual patient needs. To address this conflict, a two-part DA was developed, combining structured elements with flexibility. (2) Prerequisites for the use of the DA in outpatients' settings: Senior physicians' support, education in palliative care options and in the use of the DA, and organizational conditions.

CONCLUSION

Oncologists identified both structural and content-related aspects for a successful implementation of a DA for patients with advanced cancer. While the content-related aspects were factored into the development of the DA, structural (organizational) issues need to be especially focused on during implementation.

Effectiveness of patient decision aids in patients with advanced kidney disease: a meta-analysis based on randomized controlled trials

PURPOSE

To systematically evaluate the decision effectiveness of patient decision aids (PtDAs) on the decision-making effect of patients with advanced chronic kidney disease.

METHOD

Two authors independently searched ten electronic databases [Web of science, PubMed, the Cochrane Library, Embase, CINAHL, EBSCO, CBM, CNKI, WanFang DATA and Vip database], to include randomized controlled trials of interventions through PtDAs in patients with advanced chronic kidney disease published from the inception of the database until April 2024. Two authors conducted a comprehensive quality evaluation (Cochrane 5.1.0) before independently extracting and analyzing the data with RevMan 5.2.

RESULTS

The study included 11 randomized controlled trials with a total of 1613 patients. According to the results, PtDAs can improve the decision knowledge [SMD = 0.53, 95% CI (0.26, 0.80), P = 0.0002] and decision preparation [SMD = 2.34, 95% CI (2.04, 2.65), P < 0.00001] of patients with advanced chronic kidney disease. Additionally, there was a substantial decrease in the levels of decision regret [SMD = - 1.33, 95% CI (- 2.11, - 0.55), P < 0.05] and decision conflict [SMD = - 0.88, 95% CI (- 1.47, - 0.28), P = 0.004].

CONCLUSION

The current available evidence indicates that PtDAs can significantly enhance the decision knowledge and decision preparation of patients with advanced chronic kidney disease. Additionally, PtDAs can reduce the levels of decision regret and decision conflict.

TRIAL REGISTRY

CRD42023433798.

A randomized controlled trial of shared decision-making treatment planning process to enhance shared decision-making in patients with MBC

PURPOSE

Opportunities exist for patients with metastatic breast cancer (MBC) to engage in shared decision-making (SDM). Presenting patient-reported data, including patient treatment preferences, to oncologists before or during a treatment plan decision may improve patient engagement in treatment decisions.

METHODS

This randomized controlled trial evaluated the standard-of-care treatment planning process vs. a novel treatment planning process focused on SDM, which included oncologist review of patient-reported treatment preferences, prior to or during treatment decisions among women with MBC. The primary outcome was patient perception of shared decision-making. Secondary outcomes included patient activation, treatment satisfaction, physician perception of treatment decision-making, and use of treatment plans.

RESULTS

Among the 109 evaluable patients from December 2018 to June 2022, 28% were Black and 12% lived in a highly disadvantaged neighborhood. Although not reaching statistical significance, patients in the intervention arm perceived SDM more often than patients in the control arm (63% vs. 59%; Cramer's V = 0.05; OR 1.19; 95% CI 0.55-2.57). Among patients in the intervention arm, 31% were at the highest level of patient activation compared to 19% of those in the control arm (V = 0.18). In 82% of decisions, the oncologist agreed that the patient-reported data helped them engage in SDM. In 45% of decision, they reported changing management due to patient-reported data.

CONCLUSIONS

Oncologist engagement in the treatment planning process, with oncologist review of patient-reported data, is a promising approach to improve patient participation in treatment decisions which should be tested in larger studies.

TRIAL REGISTRATION

NCT03806738.

Patient Perspectives on a Decision Aid for Systemic Lupus Erythematosus: Insights and Future Considerations

OBJECTIVE

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a wide spectrum of clinical manifestations. A decision aid (DA) for SLE was developed and implemented in 15 rheumatology clinics throughout the United States. This study explored the experiences of patients who viewed the DA to understand how patients engage with and respond to the SLE DA.

METHODS

We conducted a qualitative descriptive study using semistructured interviews with a convenience sample of 24 patients during May to July 2022.

RESULTS

Patients recognized the value of the SLE DA in providing general knowledge about SLE and different treatment options. However, patients expressed a desire for more comprehensive lifestyle information to better manage their condition. Another theme was the importance of having multiple formats available to cater to their different needs, as well as tailoring the DA to different stages of SLE.

CONCLUSION

This study contributes to a broader understanding of how to provide patient-centered care for patients with SLE by offering practical insights that can inform the development of more effective, patient-centric health information technologies for managing chronic diseases, ultimately improving patient outcomes. Overall, this study underscores the significance of optimizing both the information content and determining the appropriate delivery of the tool for its future sustainability.

Achieving Goals of Care Decisions in Chronic Critical Illness: A Multi-Institutional Qualitative Study

BACKGROUND

Physicians, patients, and families alike perceive a need to improve how goals of care (GOC) decisions occur in chronic critical illness (CCI), but little is currently known about this decision-making process.

RESEARCH QUESTION

How do intensivists from various health systems facilitate decision-making about GOC for patients with CCI? What are barriers to, and facilitators of, this decision-making process?

STUDY DESIGN AND METHODS

We conducted semistructured interviews with a purposeful sample of intensivists from the United States and Canada using a mental models approach adapted from decision science. We analyzed transcripts inductively using qualitative description.

RESULTS

We interviewed 29 intensivists from six institutions. Participants across all sites described GOC decision-making in CCI as a complex, longitudinal, and iterative process that involved substantial preparatory work, numerous stakeholders, and multiple family meetings. Intensivists required considerable time to collect information on prior events and conversations, and to arrive at a prognostic consensus with other involved physicians prior to meeting with families. Many intensivists stressed the importance of scheduling multiple family meetings to build trust and relationships prior to explicitly discussing GOC. Physician-identified barriers to GOC decision-making included 1-week staffing models, limited time and cognitive bandwidth, difficulty eliciting patient values, and interpersonal challenges with care team members or families. Potential facilitators included scheduled family meetings at regular intervals, greater interprofessional involvement in decisions, and consistent messaging from care team members.

INTERPRETATION

Intensivists described a complex time- and labor-intensive group process to achieve GOC decision-making in CCI. System-level interventions that improve how information is shared between physicians and decrease logistical and relational barriers to timely and consistent communication are key to improving GOC decision-making in CCI.

Workflow analysis of breast cancer treatment decision-making: challenges and opportunities for informatics to support patient-centered cancer care

Objective

Decision support can improve shared decision-making for breast cancer treatment, but workflow barriers have hindered widespread use of these tools. The goal of this study was to understand the workflow among breast cancer teams of clinicians, patients, and their family caregivers when making treatment decisions and identify design guidelines for informatics tools to better support treatment decision-making.

Materials and Methods

We conducted observations of breast cancer clinicians during routine clinical care from February to August 2022. Guided by the work system model, a human factors engineering model that describes the elements of work, we recorded all aspects of clinician workflow using a tablet and smart pencil. Observation notes were transcribed and uploaded into Dedoose. Two researchers inductively coded the observations. We identified themes relevant to the design of decision support that we classified into the 4 components of workflow (ie, flow of information, tasks, tools and technologies, and people).

Results

We conducted 20 observations of breast cancer clinicians (total: 79 hours). We identified 10 themes related to workflow that present challenges and opportunities for decision support design. We identified approximately 48 different decisions discussed during breast cancer visits. These decisions were often interdependent and involved collaboration across the large cancer treatment team. Numerous patient-specific factors (eg, work, hobbies, family situation) were discussed when making treatment decisions as well as complex risk and clinical information. Patients were frequently asked to remember and relay information across the large cancer team.

Discussion and Conclusion

Based on these findings, we proposed design guidelines for informatics tools to support the complex workflows involved in breast cancer care. These guidelines should inform the design of informatics solutions to better support breast cancer decision-making and improve patient-centered cancer care.

Integrating human factors engineering into your pediatric radiology practice

Human factors engineering involves the study and development of methods aimed at enhancing performance, improving safety, and optimizing user satisfaction. The focus of human factors engineering encompasses the design of work environments and an understanding of human mental processes to prevent errors. In this review, we summarize the history, applications, and impacts of human factors engineering on the healthcare field. To illustrate these applications and impacts, we provide several examples of how successful integration of a human factors engineer in our pediatric radiology department has positively impacted various projects. The successful integration of human factors engineering expertise has contributed to projects including improving response times for portable radiography requests, deploying COVID-19 response resources, informing the redesign of scheduling workflows, and implementation of a virtual ergonomics program for remote workers. In sum, the integration of human factors engineering insight into our department has resulted in tangible benefits and has also positioned us as proactive contributors to broader hospital-wide improvements.

Improving shared decision making for lung cancer treatment by developing and validating an open-source web based patient decision aid for stage I-II non-small cell lung cancer

The aim of this study was to develop and evaluate a proof-of-concept open-source individualized Patient Decision Aid (iPDA) with a group of patients, physicians, and computer scientists. The iPDA was developed based on the International Patient Decision Aid Standards (IPDAS). A previously published questionnaire was adapted and used to test the user-friendliness and content of the iPDA. The questionnaire contained 40 multiple-choice questions, and answers were given on a 5-point Likert Scale (1-5) ranging from "strongly disagree" to "strongly agree." In addition to the questionnaire, semi-structured interviews were conducted with patients. We performed a descriptive analysis of the responses. The iPDA was evaluated by 28 computer scientists, 21 physicians, and 13 patients. The results demonstrate that the iPDA was found valuable by 92% (patients), 96% (computer scientists), and 86% (physicians), while the treatment information was judged useful by 92%, 96%, and 95%, respectively. Additionally, the tool was thought to be motivating for patients to actively engage in their treatment by 92%, 93%, and 91% of the above respondents groups. More multimedia components and less text were suggested by the respondents as ways to improve the tool and user interface. In conclusion, we successfully developed and tested an iPDA for patients with stage I-II Non-Small Cell Lung Cancer (NSCLC).