Barriers to shared decision-making with women of reproductive age affected by a chronic inflammatory disease: a mixed-methods needs assessment of dermatologists and rheumatologists

Equity, expense, and expertise in biologic commissioning: adding the patient to the equation

INTRODUCTION

Immune-mediated inflammatory diseases (IMIDs) are increasingly managed effectively with biologic medicines. However, with relatively high unit costs, there remains a meaningful pressure to ensure streamlined, equitable, and inclusive prescription of biologics in the UK. Despite an increased awareness of the benefits of patient-centric shared decision making, patients remain on the periphery of biologic selection for the treatment of IMIDs.

AREAS COVERED

We provide a patient perspective on core issues in the commissioning, prescription, and decision making around biologics for IMIDs in the UK, focusing on England. In particular, the crucial aspect of determining 'value' for different stakeholders, who necessarily have different priorities, is considered.

EXPERT OPINION

There are disparities in commissioning, access to, and prescription of biologics for IMIDs in the UK. This creates an unequal treatment model and drives patient dissatisfaction with an 'experience lottery' for the management of disease. A more transparent approach to prescribing decisions, made in close consultation with patients, is essential for improving equity and experience with biologic treatment of IMIDs.

"We will be the ones bearing the consequences": A qualitative study of barriers and facilitators to shared decision-making in hospital-based maternity care

BACKGROUND

Pregnant women involved in decisions about their care report better health outcomes for themselves and their children. Shared decision-making (SDM) is a priority for health services; however, there is limited research on factors that help and hinder SDM in hospital-based maternity settings. The purpose of this study was to explore barriers and facilitators to SDM in a large tertiary maternity care service from the perspectives of multiple stakeholders.

METHODS

Qualitative semi-structured interviews were undertaken with 39 participants including women, clinicians, health service administrators and decision-makers, and government policymakers. The interview guide and thematic analysis were based on the Theoretical Domains Framework to identify barriers and facilitators to SDM.

RESULTS

Women expect to be included in decisions about their care. Health service administrators and decision-makers, government policymakers, and most clinicians want to include them in decisions. Key barriers to SDM included lack of care continuity, knowledge, and clinician skills, as well as professional role and decision-making factors. Key facilitators pertained to policy and guideline changes, increased knowledge, professional role factors, and social influences.

CONCLUSION

This study revealed common barriers and facilitators to SDM and highlighted the need to consider perspectives outside the patient-clinician dyad. It adds to the limited literature on barriers and facilitators to SDM in hospital care settings. Organizational- and system-wide changes to service delivery are necessary to facilitate SDM. These changes may be enabled by education and training, changes to policies and guidelines to include and support SDM, and adequately timed information provision to enable SDM conversations.

Shared decision-making and satisfaction with care in patients with psoriasis: A population-based study in the United States

BACKGROUND

Shared decision-making (SDM) is a critical component of the patient-physician relationship. Although SDM has been reported to improve patient knowledge in other fields, it is still relatively unknown in dermatology.

OBJECTIVE

To determine the association between SDM and satisfaction with care among patients with psoriasis.

METHODS

Cross-sectional study using data from the 2014 to 2017 and 2019 Medical Expenditure Panel Survey.

RESULTS

A weighted total of 3,715,027 patients with psoriasis were identified. The average SDM score was 3.6 (of 4), and the average satisfaction with care score was 8.6 (of 10). Approximately 42% of the cohort reported having a high SDM (score, ≥3.9). Patients who had high SDM had, on average, 85% higher satisfaction with care (P < .001) after adjusting for covariates.

LIMITATIONS

The results of our study should be interpreted within the context of the Medical Expenditure Panel Survey database. The ability to measure SDM was limited by the 7 items from Medical Expenditure Panel Survey, which may not fully capture active participation in shared decision-making.

CONCLUSION

A majority of patients with psoriasis are not participating in highly SDM. It is important to construct a framework for carrying out SDM efficiently to enhance physician-patient communication and improve patient outcomes.

Prescribing for pregnancy: inflammatory rheumatic disease

Inflammatory rheumatic disease during pregnancy requires careful management. Key factors for successful pregnancy outcome are disease remission at the time of conception and optimal disease control during pregnancy. This article forms part of a series on prescribing for pregnancy and discusses the impact of inflammatory arthritis on pregnancy and the influence pregnancy may have on inflammatory arthritis. It highlights the importance of prepregnancy care and collaborative working between obstetric and rheumatology specialties as well as focusing on prescribing before, during and after pregnancy.

Implementation of a novel shared decision-making intervention in women with chronic hypertension in pregnancy: multiple-site multiple-method investigation

BACKGROUND

Many women with chronic hypertension are conflicted about antihypertensive medication during pregnancy and some are non-adherent to prescribed medication.

OBJECTIVES

Codesign, implement and evaluate a novel shared decision-making (SDM) intervention for use with pregnant women with chronic hypertension.

SETTING AND PARTICIPANTS

Pregnant women with chronic hypertension and their principal healthcare professionals (obstetricians, midwives, and physicians), at three National Health Service hospital trusts with different models of care.

MAIN OUTCOME MEASURES

The RE-AIM framework guided the evaluation. Primary: Decisional conflict scale, medication intention survey and women's acceptability. Secondary: Healthcare professionals' acceptability and the barriers and facilitators to SDM implementation with pregnant women with chronic hypertension.

RESULTS

Fifty women participated. Nearly half (46 %; n = 23) of women were from Black and Asian backgrounds. The SDM intervention was effective at reducing decisional conflict (mean reduction from baseline 42 %, 95 % CI 35-49, p ≤ 0.05). In 36 women (72 %), the reduction was of clinical importance. 24 women (48 %) were uncertain about or planned not to take antihypertensives prior to the SDM intervention, compared to two women (4 %) after the intervention. The intervention was acceptable to women and healthcare professionals. 10 of 14 healthcare professionals felt that the in-consultation aid facilitated SDM in current antenatal contexts, a similar proportion (10/14) felt the length of consultations hindered SDM.

CONCLUSION

A novel codesigned SDM intervention reduced decisional conflict and increased women's intention to take antihypertensive agents during pregnancy. This intervention could be adopted into practice for women making pregnancy decisions where there is uncertainty around the medication management option.

Barriers to shared decision making

Overview of: Murray S, Augustyniak M, Murase JE, et al Barriers to shared decision-making with women of reproductive age affected by a chronic inflammatory disease: a mixed-methods needs assessment of dermatologists and rheumatologists. BMJ Open 2021;11:e043960.