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Ubbink DT, Matthijssen M, Lemrini S, van Etten-Jamaludin FS, Bloemers FW. Systematic review of barriers, facilitators, and tools to promote shared decision making in the emergency department. Acad Emerg Med 2024. [PMID: 39180226 DOI: 10.1111/acem.14998] [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: 05/30/2024] [Revised: 07/24/2024] [Accepted: 07/24/2024] [Indexed: 08/26/2024]
Abstract
OBJECTIVE The objective was to systematically review all studies focusing on barriers, facilitators, and tools currently available for shared decision making (SDM) in emergency departments (EDs). BACKGROUND Implementing SDM in EDs seems particularly challenging, considering the fast-paced environment and sometimes life-threatening situations. Over 10 years ago, a previous review revealed only a few patient decision aids (PtDAs) available for EDs. METHODS Literature searches were conducted in MEDLINE, Embase, and Cochrane library, up to November 2023. Observational and interventional studies were included to address barriers or facilitators for SDM or to investigate effects of PtDAs on the level of SDM for patients visiting an ED. RESULTS We screened 1946 studies for eligibility, of which 33 were included. PtDAs studied in EDs address chest pain, syncope, analgesics usage, lumbar puncture, ureterolithiasis, vascular access, concussion/brain bleeding, head-CT choice, coaching for elderly people, and activation of patients with appendicitis. Only the primary outcome was meta-analyzed, showing that PtDAs significantly increased the level of SDM (18.8 on the 100-point OPTION scale; 95% CI 12.5-25.0). PtDAs also tended to increase patient knowledge, decrease decisional conflict and decrease health care services usage, with no obvious effect on overall patient satisfaction. Barriers and facilitators were identified on three levels: (1) patient level-emotions, health literacy, and their own proactivity; (2) clinician level-fear of medicolegal consequences, lack of SDM skills or knowledge, and their ideas about treatment superiority; and (3) system level-time constraints, institutional guidelines, and availability of PtDAs. CONCLUSIONS Circumstances in EDs are generally less favorable for SDM. However, PtDAs for conditions seen in EDs are helpful in overcoming barriers to SDM and are welcomed by patients. Even in EDs, SDM is feasible and supported by an increasing number of tools for patients and physicians.
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Affiliation(s)
- Dirk T Ubbink
- Department of Surgery, Amsterdam University Medical Center at the University of Amsterdam, Location AMC, Amsterdam, the Netherlands
| | | | - Samia Lemrini
- Faculty of Medicine, University of Amsterdam, Amsterdam, the Netherlands
| | - Faridi S van Etten-Jamaludin
- Amsterdam University Medical Center at the University of Amsterdam, Location AMC, Research Support Medical Library, Amsterdam, the Netherlands
| | - Frank W Bloemers
- Department of Trauma Surgery, Amsterdam University Medical Center at the University of Amsterdam, Location AMC, Amsterdam, the Netherlands
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Knudsen BM, Søndergaard SR, Stacey D, Steffensen KD. Impact of timing and format of patient decision aids for breast cancer patients on their involvement in and preparedness for decision making - the IMPACTT randomised controlled trial protocol. BMC Cancer 2024; 24:336. [PMID: 38475758 DOI: 10.1186/s12885-024-12086-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND After curative surgery for early-stage breast cancer, patients face a decision on whether to undergo surgery alone or to receive one or more adjuvant treatments, which may lower the risk of recurrence. Variations in survival outcomes are often marginal but there are differences in the side effects and other features of the options that patients may value differently. Hence, the patient's values and preferences are critical in determining what option to choose. It is well-researched that the use of shared decision making and patient decision aids can support this choice in a discussion between patient and clinician. However, it is still to be investigated what impact the timing and format of the patient decision aid have on shared decision making outcomes. In this trial, we aim to investigate the impact of a digital pre-consult compared to a paper-based in-consult patient decision aid on patients' involvement in shared decision making, decisional conflict and preparedness to make a decision. METHODS The study is a randomised controlled trial with 204 patients at two Danish oncology outpatient clinics. Eligible patients are newly diagnosed with early-stage breast cancer and offered adjuvant treatments after curative surgery to lower the risk of recurrence. Participants will be randomised to receive either an in-consult paper-based patient decision aid or a pre-consult digital patient decision aid. Data collection includes patient and clinician-reported outcomes as well as observer-reported shared decision making based on audio recordings of the consultation. The primary outcome is the extent to which patients are engaged in a shared decision making process reported by the patient. Secondary aims include the length of consultation, preparation for decision making, preferred role in shared decision making and decisional conflict. DISCUSSION This study is the first known randomised, controlled trial comparing a digital, pre-consult patient decision aid to an identical paper-based, in-consult patient decision aid. It will contribute evidence on the impact of patient decision aids in terms of investigating if pre-consult digital patient decisions aids compared to in-consult paper-based decision aids support the cancer patients in being better prepared for decision making. TRIAL REGISTRATION ClinicalTrials.gov (NCT05573022).
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Affiliation(s)
- Bettina Mølri Knudsen
- Center for Shared Decision Making, Lillebaelt Hospital - University Hospital of Southern Denmark, Beriderbakken 4, 7100, Vejle, Denmark.
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.
| | - Stine Rauff Søndergaard
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
- Department of Oncology, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Beriderbakken 4, 7100, Vejle, Denmark
| | - Dawn Stacey
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
- School of Nursing, University of Ottawa, 451 Smyth Rd, Ottawa, ON, K1H 8M5, Canada
- Centre for Implementation Research, Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON, K1Y 4E9, Canada
| | - Karina Dahl Steffensen
- Center for Shared Decision Making, Lillebaelt Hospital - University Hospital of Southern Denmark, Beriderbakken 4, 7100, Vejle, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
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Stacey D, Lewis KB, Smith M, Carley M, Volk R, Douglas EE, Pacheco-Brousseau L, Finderup J, Gunderson J, Barry MJ, Bennett CL, Bravo P, Steffensen K, Gogovor A, Graham ID, Kelly SE, Légaré F, Sondergaard H, Thomson R, Trenaman L, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2024; 1:CD001431. [PMID: 38284415 PMCID: PMC10823577 DOI: 10.1002/14651858.cd001431.pub6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Meg Carley
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robert Volk
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisa E Douglas
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael J Barry
- Informed Medical Decisions Program, Massachusetts General Hospital, Boston, MA, USA
| | - Carol L Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Paulina Bravo
- Education and Cancer Prevention, Fundación Arturo López Pérez, Santiago, Chile
| | - Karina Steffensen
- Center for Shared Decision Making, IRS - Lillebælt Hospital, Vejle, Denmark
| | - Amédé Gogovor
- VITAM - Centre de recherche en santé durable, Université Laval, Quebec, Canada
| | - Ian D Graham
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | | | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Logan Trenaman
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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Sheng AY, Gottlieb M, Bautista JR, Trueger NS, Westafer LM, Gisondi MA. The role of emergency physicians in the fight against health misinformation: Implications for resident training. AEM EDUCATION AND TRAINING 2023; 7:S48-S57. [PMID: 37383831 PMCID: PMC10294217 DOI: 10.1002/aet2.10877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/21/2022] [Accepted: 11/01/2022] [Indexed: 06/30/2023]
Abstract
Emergency physicians on the frontlines of the COVID-19 pandemic are first-hand witnesses to the direct impact of health misinformation and disinformation on individual patients, communities, and public health at large. Therefore, emergency physicians naturally have a crucial role to play to steward factual information and combat health misinformation. Unfortunately, most physicians lack the communications and social media training needed to address health misinformation with patients and online, highlighting an obvious gap in emergency medicine training. We convened an expert panel of academic emergency physicians who have taught and conducted research about health misinformation at the Society for Academic Emergency Medicine (SAEM) Annual Meeting in New Orleans, LA, on May 13, 2022. The panelists represented geographically diverse institutions including Baystate Medical Center/Tufts University, Boston Medical Center, Northwestern University, Rush Medical College, and Stanford University. In this article, we describe the scope and impact of health misinformation, introduce methods for addressing misinformation in the clinical environment and online, acknowledge the challenges of tackling misinformation from our physician colleagues, demonstrate strategies for debunking and prebunking, and highlight implications for education and training in emergency medicine. Finally, we discuss several actionable interventions that define the role of the emergency physician in the management of health misinformation.
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Affiliation(s)
- Alexander Y. Sheng
- Department of Emergency MedicineBoston Medical CenterBostonMassachusettsUSA
- School of Medicine, Boston UniversityBostonMassachusettsUSA
- Department of Emergency MedicineAlpert Medical School at Brown UniversityRhode IslandProvidenceUSA
| | - Michael Gottlieb
- Emergency Ultrasound Division, Department of Emergency MedicineRush University Medical CenterChicagoIllinoisUSA
| | | | - N. Seth Trueger
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Lauren M. Westafer
- Department of Emergency Medicine, Department of Healthcare Delivery and Population ScienceUniversity of Massachusetts Chan Medical School–BaystateSpringfieldMassachusettsUSA
| | - Michael A. Gisondi
- The Precision Education and Assessment Research Lab, Department of Emergency MedicineStanford UniversityPalo AltoCaliforniaUSA
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Hsiao CY, Wu JC, Lin PC, Yang PY, Liao F, Guo SL, Hou WH. Effectiveness of interprofessional shared decision-making training: A mixed-method study. PATIENT EDUCATION AND COUNSELING 2022; 105:3287-3297. [PMID: 35927112 DOI: 10.1016/j.pec.2022.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 07/04/2022] [Accepted: 07/15/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This study evaluated the learning effects and examined the participants' perceptions of an interprofessional shared decision-making (IP-SDM) training program. METHODS This mixed-method study used a quasi-experimental pretest-posttest design in the quantitative phase and semi-structured interviews in the qualitative phase. The 6-week curriculum design, based on Kolb's experiential learning cycle, consisted of two simulated objective structured clinical examinations with standardized patients and blended teaching methods through various course modules. RESULTS A total of 39 multidisciplinary healthcare personnel completed the 6-week training program, and 32 of them participated in qualitative interviews. The IP-SDM training program effectively improved the SDM process competency of the participants from the perspectives of the participants, standardized patients, and clinical teachers. The interviews illustrated how the curriculum design enhanced learning; the effectiveness results indicated improvements in learners' attitude, knowledge, skills, and teamwork. CONCLUSION This IP-SDM training program improved multidisciplinary healthcare personnel's competency, self-efficacy, and intention to engage in IP-SDM. PRACTICE IMPLICATIONS Applying Kolb's experiential learning cycle and blended teaching methods to develop and implement the IP-SDM training program can improve multidisciplinary healthcare personnel's knowledge, attitude, skills, and teamwork in IP-SDM.
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Affiliation(s)
- Chih-Yin Hsiao
- School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Jeng-Cheng Wu
- Department of Urology, Taipei Medical University Hospital, Taipei, Taiwan; Department of Education, Taipei Medical University Hospital, Taipei, Taiwan; Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan; Department of Health Promotion and Health Education, College of Education, National Taiwan Normal University, Taipei, Taiwan
| | - Pi-Chu Lin
- School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing & Graduate Institute of Nursing, Asia University, Taichung, Taiwan; Department of Nursing, Meiho University, Pingtung, Taiwan
| | - Pang-Yuan Yang
- School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Faith Liao
- Department of Education, Taipei Medical University Hospital, Taipei, Taiwan; Graduate Institute of Humanities in Medicine, College of Humanities and Social Sciences, Taipei Medical University, Taipei, Taiwan; Department of Humanities in Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Shu-Liu Guo
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan
| | - Wen-Hsuan Hou
- School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Education, Taipei Medical University Hospital, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation & Geriatrics and Gerontology, Taipei Medical University Hospital, Taipei, Taiwan; College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Probst MA, Janke AT, Haimovich AD, Venkatesh AK, Lin MP, Kocher KE, Nemnom MJ, Thiruganasambandamoorthy V. Development of a Novel Emergency Department Quality Measure to Reduce Very Low-Risk Syncope Hospitalizations. Ann Emerg Med 2022; 79:509-517. [PMID: 35487840 PMCID: PMC9117517 DOI: 10.1016/j.annemergmed.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE Emergency department (ED) evaluations for syncope are common, representing 1.3 million annual US visits and $2 billion in related hospitalizations. Despite evidence supporting risk stratification and outpatient management, variation in syncope hospitalization rates persist. We sought to develop a new quality measure for very low-risk adult ED patients with syncope that could be applied to administrative data. METHODS We developed this quality measure in 2 phases. First, we used an existing prospective, observational ED patient data set to identify a very low-risk cohort with unexplained syncope using 2 variables: age less than 50 years and no history of heart disease. We then applied this to the 2019 Nationwide Emergency Department Sample (NEDS) to assess its potential effect, assessing for hospital-level factors associated with hospitalization variation. RESULTS Of the 8,647 adult patients in the prospective cohort, 3,292 (38%) patients fulfilled these 2 criteria: age less than 50 years and no history of heart disease. Of these, 15 (0.46%) suffered serious adverse events within 30 days. In the NEDS, there were an estimated 566,031 patients meeting these 2 criteria, of whom 15,507 (2.7%; 95% confidence interval [CI] 2.48% to 3.00%) were hospitalized. We found substantial variation in the hospitalization rates for this very low-risk cohort, with a median rate of 1.7% (range 0% to 100%; interquartile range 0% to 3.9%). Factors associated with increased hospitalization rates included a yearly ED volume of more than 80,000 (odds ratio [OR] 3.14; 95% CI 2.02 to 4.89) and metropolitan teaching status (OR 1.5; 95% CI 1.24 to 1.81). CONCLUSION In summary, our novel syncope quality measure can assess variation in low-value hospitalizations for unexplained syncope. The application of this measure could improve the value of syncope care.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Columbia University Medical Center, New York, NY.
| | - Alexander T Janke
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Adrian D Haimovich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Michelle P Lin
- Department of Emergency Medicine and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keith E Kocher
- Department of Emergency Medicine and Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Almulhim KN. The Characteristics of Syncope-Related Emergency Department Visits: Resource Utilization and Admission Rate Patterns in Emergency Departments. Cureus 2022; 14:e22039. [PMID: 35340474 PMCID: PMC8913182 DOI: 10.7759/cureus.22039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 11/05/2022] Open
Abstract
Background and objective Decision-making about syncope patients presenting to the emergency department (ED) is challenging since physicians must balance the minimal risks of life-threatening conditions with the unessential use of expensive imaging or unnecessary hospitalizations. This study aimed to determine the characteristics of ED visits, resource utilization, and admission rate patterns related to syncope in the United States (US) during the period 2005-2015. Methods Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) on ED visits during the 11-year period from 2005 to 2015 were retrieved. ED visits for syncope were identified and compared against non-syncope ED visits. The demographic and clinical characteristics of patients, as well data on resource allocation and admission trends were captured and described for the syncope and the non-syncope groups. Results Syncope accounted for 1.11% of the total ED visits during the study period from 2005 to 2015. The incidence of syncope-related ED visits was higher among elderly females, whites, and non-Hispanics. The trend of admission rates showed a decline from about 30% in 2005-2010 to less than 20% in 2014 and 2015. Advanced imaging (CT or MRI) was ordered for 34% of syncope patients. Conclusion The percentage of syncope-related ED visits remained stable during the study period, but the admission rates declined while the use of advanced imaging in syncope-related ED visits remained substantially high despite the advances in research and availability of clinical guidelines. Future research is needed to rationalize healthcare utilization in syncope-related ED visits and precisely identify the high-risk population.
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Billah T, Gordon L, Schoenfeld EM, Chang BP, Hess EP, Probst MA. Clinicians' perspectives on the implementation of patient decision aids in the emergency department: A qualitative interview study. J Am Coll Emerg Physicians Open 2022; 3:e12629. [PMID: 35079731 PMCID: PMC8769071 DOI: 10.1002/emp2.12629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Decision aids (DAs) are tools to facilitate and standardize shared decision making (SDM). Although most emergency clinicians (ECs) perceive SDM appropriate for emergency care, there is limited uptake of DAs in clinical practice. The objective of this study was to explore barriers and facilitators identified by ECs regarding the implementation of DAs in the emergency department (ED). METHODS We conducted a qualitative interview study guided by implementation science frameworks. ECs participated in interviews focused on the implementation of DAs for the disposition of patients with low-risk chest pain and unexplained syncope in the ED. Interviews were recorded and transcribed verbatim. We then iteratively developed a codebook with directed qualitative content analysis. RESULTS We approached 25 ECs working in urban New York, of whom 20 agreed to be interviewed (mean age, 41 years; 25% women). The following 6 main barriers were identified: (1) poor DA accessibility, (2) concern for increased medicolegal risk, (3) lack of perceived need for a DA, (4) patient factors including lack of capacity and limited health literacy, (5) skepticism about validity of DAs, and (6) lack of time to use DAs. The 6 main facilitators identified were (1) positive attitudes toward SDM, (2) patient access to follow-up care, (3) potential for improved patient satisfaction, (4) potential for improved risk communication, (5) strategic integration of DAs into the clinical workflow, and (6) institutional support of DAs. CONCLUSIONS ECs identified multiple barriers and facilitators to the implementation of DAs into clinical practice. These findings could guide implementation efforts targeting the uptake of DA use in the ED.
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Affiliation(s)
- Tausif Billah
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
| | - Lauren Gordon
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
| | - Elizabeth M. Schoenfeld
- Department of Emergency MedicineUniversity of Massachusetts Medical School–BaystateSpringfieldMassachusettsUSA
| | - Bernard P. Chang
- Department of Emergency MedicineColumbia University Medical CenterNew YorkNew YorkUSA
| | - Erik P. Hess
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Marc A. Probst
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
- Department of Emergency MedicineColumbia University Medical CenterNew YorkNew YorkUSA
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Amin S, Gupta V, Du G, McMullen C, Sirrine M, Williams MV, Smyth SS, Chadha R, Stearley S, Li J. Developing and Demonstrating the Viability and Availability of the Multilevel Implementation Strategy for Syncope Optimal Care Through Engagement (MISSION) Syncope App: Evidence-Based Clinical Decision Support Tool. J Med Internet Res 2021; 23:e25192. [PMID: 34783669 PMCID: PMC8663445 DOI: 10.2196/25192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/05/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Syncope evaluation and management is associated with testing overuse and unnecessary hospitalizations. The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Syncope Guideline aims to standardize clinical practice and reduce unnecessary services. The use of clinical decision support (CDS) tools offers the potential to successfully implement evidence-based clinical guidelines. However, CDS tools that provide an evidence-based differential diagnosis (DDx) of syncope at the point of care are currently lacking. OBJECTIVE With input from diverse health systems, we developed and demonstrated the viability of a mobile app, the Multilevel Implementation Strategy for Syncope optImal care thrOugh eNgagement (MISSION) Syncope, as a CDS tool for syncope diagnosis and prognosis. METHODS Development of the app had three main goals: (1) reliable generation of an accurate DDx, (2) incorporation of an evidence-based clinical risk tool for prognosis, and (3) user-based design and technical development. To generate a DDx that incorporated assessment recommendations, we reviewed guidelines and the literature to determine clinical assessment questions (variables) and likelihood ratios (LHRs) for each variable in predicting etiology. The creation and validation of the app diagnosis occurred through an iterative clinician review and application to actual clinical cases. The review of available risk score calculators focused on identifying an easily applied and valid evidence-based clinical risk stratification tool. The review and decision-making factors included characteristics of the original study, clinical variables, and validation studies. App design and development relied on user-centered design principles. We used observations of the emergency department workflow, storyboard demonstration, multiple mock review sessions, and beta-testing to optimize functionality and usability. RESULTS The MISSION Syncope app is consistent with guideline recommendations on evidence-based practice (EBP), and its user interface (UI) reflects steps in a real-world patient evaluation: assessment, DDx, risk stratification, and recommendations. The app provides flexible clinical decision making, while emphasizing a care continuum; it generates recommendations for diagnosis and prognosis based on user input. The DDx in the app is deemed a pragmatic model that more closely aligns with real-world clinical practice and was validated using actual clinical cases. The beta-testing of the app demonstrated well-accepted functionality and usability of this syncope CDS tool. CONCLUSIONS The MISSION Syncope app development integrated the current literature and clinical expertise to provide an evidence-based DDx, a prognosis using a validated scoring system, and recommendations based on clinical guidelines. This app demonstrates the importance of using research literature in the development of a CDS tool and applying clinical experience to fill the gaps in available research. It is essential for a successful app to be deliberate in pursuing a practical clinical model instead of striving for a perfect mathematical model, given available published evidence. This hybrid methodology can be applied to similar CDS tool development.
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Affiliation(s)
- Shiraz Amin
- Performance Analytics Center of Excellence, University of Kentucky HealthCare, Lexington, KY, United States
| | - Vedant Gupta
- Department of Cardiovascular Medicine, University of Kentucky HealthCare, Lexington, KY, United States
| | - Gaixin Du
- Center for Health Services Research, University of Kentucky, Lexington, KY, United States
| | - Colleen McMullen
- Department of Cardiovascular Medicine, University of Kentucky HealthCare, Lexington, KY, United States.,Gill Heart & Vascular Institute, University of Kentucky HealthCare, Lexington, KY, United States
| | - Matthew Sirrine
- Center for Health Services Research, University of Kentucky, Lexington, KY, United States
| | - Mark V Williams
- Division of Hospital Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Susan S Smyth
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Romil Chadha
- Division of Hospital Medicine, University of Kentucky HealthCare, Lexington, KY, United States
| | - Seth Stearley
- Department of Emergency Medicine, University of Kentucky HealthCare, Lexington, KY, United States
| | - Jing Li
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
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Chartash D, Sharifi M, Emerson B, Frank R, Schoenfeld EM, Tanner J, Brandt C, Taylor RA. Documentation of Shared Decisionmaking in the Emergency Department. Ann Emerg Med 2021; 78:637-649. [PMID: 34340873 DOI: 10.1016/j.annemergmed.2021.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE While patient-centered communication and shared decisionmaking are increasingly recognized as vital aspects of clinical practice, little is known about their characteristics in real-world emergency department (ED) settings. We constructed a natural language processing tool to identify patient-centered communication as documented in ED notes and to describe visit-level, site-level, and temporal patterns within a large health system. METHODS This was a 2-part study involving (1) the development and validation of an natural language processing tool using regular expressions to identify shared decisionmaking and (2) a retrospective analysis using mixed effects logistic regression and trend analysis of shared decisionmaking and general patient discussion using the natural language processing tool to assess ED physician and advanced practice provider notes from 2013 to 2020. RESULTS Compared to chart review of 600 ED notes, the accuracy rates of the natural language processing tool for identification of shared decisionmaking and general patient discussion were 96.7% (95% CI 94.9% to 97.9%) and 88.9% (95% confidence interval [CI] 86.1% to 91.3%), respectively. The natural language processing tool identified shared decisionmaking in 58,246 (2.2%) and general patient discussion in 590,933 (22%) notes. From 2013 to 2020, natural language processing-detected shared decisionmaking increased 300% and general patient discussion increased 50%. We observed higher odds of shared decisionmaking documentation among physicians versus advanced practice providers (odds ratio [OR] 1.14, 95% CI 1.07 to 1.23) and among female versus male patients (OR 1.13, 95% CI 1.11 to 1.15). Black patients had lower odds of shared decisionmaking (OR 0.8, 95% CI 0.84 to 0.88) compared with White patients. Shared decisionmaking and general patient discussion were also associated with higher levels of triage and commercial insurance status. CONCLUSION In this study, we developed and validated an natural language processing tool using regular expressions to extract shared decisionmaking from ED notes and found multiple potential factors contributing to variation, including social, demographic, temporal, and presentation characteristics.
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Affiliation(s)
- David Chartash
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT
| | - Mona Sharifi
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT; Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Beth Emerson
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Robert Frank
- Department of Linguistics, Yale University, New Haven, CT
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School - Baystate Institute for Healthcare Delivery and Population Science, Springfield, MS
| | - Jason Tanner
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Cynthia Brandt
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Richard A Taylor
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
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11
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White JL. Commentary on "Syncope in the Emergency Department: A Guide for Clinicians". J Emerg Nurs 2021; 47:208-210. [PMID: 33558075 DOI: 10.1016/j.jen.2020.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 12/22/2020] [Indexed: 11/15/2022]
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12
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El-Hussein MT, Cuncannon A. Syncope in the Emergency Department: A Guide for Clinicians. J Emerg Nurs 2020; 47:342-351. [PMID: 33317859 DOI: 10.1016/j.jen.2020.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/11/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
Syncope is a common presenting symptom to emergency departments, but its evaluation and initial management can be challenging for ED practitioners and particularly urgent in the presence of high-risk features that increase the likelihood of cardiac etiology. Even after thorough clinical evaluation, syncope may remain unexplained. In such instances, practitioners' clinical judgment and risk assessments are critical to guide further management. In this article, evidence-informed strategies are outlined to approach the diagnosis of syncope and provide an overview of syncope clinical decision rules and shared decision-making. By incorporating risk stratification and shared decision-making into syncope care, practitioners can more confidently engage patients and families in disposition decisions to organize appropriate outpatient and follow-up care, observation, or admission.
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