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Hoesseini A, Sewnaik A, van den Besselaar BN, Zhang J, van Leeuwen N, Hardillo JA, Baatenburg de Jong RJ, Offerman MPJ. Prognostic model for overall survival of head and neck cancer patients in the palliative phase. BMC Palliat Care 2024; 23:54. [PMID: 38395897 PMCID: PMC10893612 DOI: 10.1186/s12904-023-01325-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/08/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Patients with head and neck squamous cell carcinoma (HNSCC) enter the palliative phase when cure is no longer possible or when they refuse curative treatment. The mean survival is five months, with a range of days until years. Realistic prognostic counseling enables patients to make well-considered end-of-life choices. However, physicians tend to overestimate survival. The aim of this study was to develop a prognostic model that calculates the overall survival (OS) probability of palliative HNSCC patients. METHODS Patients diagnosed with incurable HNSCC or patients who refused curative treatment for HNSCC between January 1st 2006 and June 3rd 2019 were included (n = 659). Three patients were lost to follow-up. Patients were considered to have incurable HNSCC due to tumor factors (e.g. inoperability with no other curative treatment options, distant metastasis) or patient factors (e.g. the presence of severe comorbidity and/or poor performance status).Tumor and patients factors accounted for 574 patients. An additional 82 patients refused curative treatment and were also considered palliative. The effect of 17 candidate predictors was estimated in the univariable cox proportional hazard regression model. Using backwards selection with a cut-off P-value < 0.10 resulted in a final multivariable prediction model. The C-statistic was calculated to determine the discriminative performance of the model. The final model was internally validated using bootstrapping techniques. RESULTS A total of 647 patients (98.6%) died during follow-up. Median OS time was 15.0 weeks (95% CI: 13.5;16.6). Of the 17 candidate predictors, seven were included in the final model: the reason for entering the palliative phase, the number of previous HNSCC, cT, cN, cM, weight loss in the 6 months before diagnosis, and the WHO performance status. The internally validated C-statistic was 0.66 indicating moderate discriminative ability. The model showed some optimism, with a shrinkage factor of 0.89. CONCLUSION This study enabled the development and internal validation of a prognostic model that predicts the OS probability in HNSCC patients in the palliative phase. This model facilitates personalized prognostic counseling in the palliative phase. External validation and qualitative research are necessary before widespread use in patient counseling and end-of-life care.
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Affiliation(s)
- Arta Hoesseini
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands.
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Boyd N van den Besselaar
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Jang Zhang
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Nikki van Leeuwen
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jose A Hardillo
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Robert Jan Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Marinella P J Offerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
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2
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Broadbridge E, Greene K, Venetis MK, Lee LE, Banerjee SC, Saraiya B, Devine KA. Facilitating psychological adjustment for breast cancer patients through empathic communication and uncertainty reduction. PATIENT EDUCATION AND COUNSELING 2023; 114:107791. [PMID: 37244129 PMCID: PMC11046425 DOI: 10.1016/j.pec.2023.107791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVES This study examined the degree to which breast cancer patients' psychological well-being is facilitated through empathic provider communication. We explored symptom/prognostic uncertainty reduction as a mechanism through which provider communication influences patient psychological adjustment. Additionally, we tested if treatment status moderates this relationship. METHODS Informed by uncertainty in illness theory, current (n = 121) and former (n = 187) breast cancer patients completed questionnaires about perceptions of their oncologists' empathy and their symptom burden, uncertainty, and adjustment to their diagnosis. Structural equation modeling (SEM) was conducted to test hypothesized relationships between perceived provider empathic communication, uncertainty, symptom burden, and psychological adjustment. RESULTS SEM supported the following: (1) higher symptom burden was associated with increased uncertainty and reduced psychological adjustment, (2) lower uncertainty was associated with increased adjustment, and (3) increased empathic communication was associated with lower symptom burden and uncertainty for all patients (χ2(139) = 307.33, p < .001; RMSEA = .063 (CI .053, .072); CFI = .966; SRMR = .057). Treatment status moderated these relationships (Δχ2 = 264.07, Δdf = 138, p < .001) such that the strength of the relationship between uncertainty and psychological adjustment was stronger for former patients than for current patients. CONCLUSIONS Results of this study reinforce the importance of perceptions of provider empathic communication as well as the potential benefits of eliciting and addressing patient uncertainty about treatment and prognosis throughout the cancer care continuum. PRACTICE IMPLICATIONS Patient uncertainty should be a priority for cancer-care providers both throughout and post-treatment for breast cancer patients.
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Affiliation(s)
| | - Kathryn Greene
- Department of Communication, Rutgers University, New Brunswick, NJ, USA.
| | - Maria K Venetis
- Department of Communication, Rutgers University, New Brunswick, NJ, USA
| | - Lauren E Lee
- Department of Communication, Rutgers University, New Brunswick, NJ, USA
| | - Smita C Banerjee
- Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Biren Saraiya
- Division of Medical Oncology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Katie A Devine
- Division of Pediatric Hematology/Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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3
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Bagautdinova D, Wang S, Brito JP, Bylund CL, Edwards C, Silver N, Danan D, Treise D, Maraka S, Hargraves I, Singh Ospina N. Thyroid Cancer Risk Communication in Patients with Thyroid Nodules. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2023; 38:1234-1240. [PMID: 36602695 PMCID: PMC10319912 DOI: 10.1007/s13187-022-02253-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/11/2022] [Indexed: 05/05/2023]
Abstract
The objective of this study is to evaluate thyroid cancer risk clinician-patient communication among patients receiving usual counseling and counseling enhanced by a conversation aid. A secondary analysis of clinical visit recordings and post-visit surveys obtained during a trial assessing the impact of a conversation aid for patients with thyroid nodules was conducted. We assessed how thyroid cancer risk was communicated, different risk communication strategies between groups, and predictors of accurate cancer risk perception. Fifty-nine patients were analyzed. Most were women (90%) and middle-aged (median 57 years). A verbal description of thyroid cancer risk was present most frequently (83%) and was more frequent in the conversation aid than the usual care group (100% vs. 63%, p < 0.001). A numerical description using percentages was present in 41% of visits and was more frequent in the conversation aid group (59% vs. 19%, p = 0.012). Natural frequencies (7%) and positive/negative framing (10%) were utilized less commonly. Uncertainty about risks was not discussed. No predictors of accurate risk perception were identified. Clinicians most commonly present a verbal description of thyroid cancer risk. Less commonly, natural frequencies, negative/positive framing, or uncertainty is discussed. Clinicians caring for patients with thyroid nodules should be aware of different strategies for communicating thyroid cancer risk.
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Affiliation(s)
- Diliara Bagautdinova
- College of Journalism and Communications, University of Florida, Gainesville, FL, USA
| | - Shu Wang
- Center & Department of Biostatistics, University of Florida Health Cancer Center, University of Florida, Gainesville, FL, USA
| | - Juan P Brito
- Division of Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Carma L Bylund
- Health Outcomes & Biomedical Informatics, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Catherine Edwards
- Division of Endocrinology and Metabolism, Department of Medicine, University of Florida, 1600 SW Archer Road, Room H2, Gainesville, FL, 32606, USA
| | - Natalie Silver
- Center for Immunotherapy & Precision Immuno-Oncology, Head & Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Deepa Danan
- Ear, Nose & Throat, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Debbie Treise
- College of Journalism and Communications, University of Florida, Gainesville, FL, USA
| | - Spyridoula Maraka
- Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Mayo Clinic, Rochester, MN, USA
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Endocrine Section, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Ian Hargraves
- Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Mayo Clinic, Rochester, MN, USA
| | - Naykky Singh Ospina
- Division of Endocrinology and Metabolism, Department of Medicine, University of Florida, 1600 SW Archer Road, Room H2, Gainesville, FL, 32606, USA.
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Costa N, Mescouto K, Dillon M, Olson R, Butler P, Forbes R, Setchell J. The ubiquity of uncertainty in low back pain care. Soc Sci Med 2022; 313:115422. [PMID: 36215924 DOI: 10.1016/j.socscimed.2022.115422] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 01/26/2023]
Abstract
Despite clinicians being important actors in the context of uncertainty, their experiences navigating uncertainty remain largely unexplored. Drawing on a theory-driven post-qualitative approach, we used Mol's logic of choice/care as a lens through which we made sense of interviews with 22 clinicians who work with patients who experience low back pain (LBP). Our analysis suggests that uncertainty is ubiquitous in LBP care and not limited to particular domains. Clinicians navigated uncertainty when considering patients' personal and social contexts; making therapeutic decisions; navigating emotions and mental health; communicating with, and educating, patients, among others. These uncertainties are intertwined with clinical aspects such as treatment choices and evidence-based education about LBP. At times, clinicians resolved these uncertainties by producing certainty at the cost of attending to human aspects of care. We argue that epistemic shifts, theorisation and practical engagement with theory in training, research and clinical practice may prompt clinicians to embrace uncertainty and enact the logic of care.
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Affiliation(s)
- Nathalia Costa
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia; The University of Sydney, Sydney School of Public Health, Menzies Centre for Health Policy and Economics, Sydney, New South Wales, Australia.
| | - Karime Mescouto
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia
| | - Miriam Dillon
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia; Physiotherapy Department, Royal Brisbane and Women's Hospital, Australia
| | - Rebecca Olson
- The University of Queensland, School of Social Science, Brisbane, Queensland, Australia
| | - Prudence Butler
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia; Physiotherapy Department, Royal Brisbane and Women's Hospital, Australia
| | - Roma Forbes
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia
| | - Jenny Setchell
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia
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5
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Vromans RD, Tillier CN, Pauws SC, van der Poel HG, van de Poll-Franse LV, Krahmer EJ. Communication, perception, and use of personalized side-effect risks in prostate cancer treatment-decision making: An observational and interview study. PATIENT EDUCATION AND COUNSELING 2022; 105:2731-2739. [PMID: 35534301 DOI: 10.1016/j.pec.2022.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/26/2022] [Accepted: 04/29/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE We investigated how healthcare professionals (HPs) communicate personalized risks of treatment side-effects to patients with localized prostate cancer during consultations, and explored how these patients perceive and use such risks during treatment decision-making. METHODS Patient consultations with nurse practitioners and urologists discussing personalized risks of urinary incontinence after prostatectomy were audiotaped, transcribed, and coded. Patients (n = 27) were then interviewed to explore their perceptions and use of personalized side-effect risks. RESULTS HPs explained personalized risks by discussing risk factors, which was appreciated and recalled by patients. Personalized risks were typically communicated both numerically and verbally (70%). When using numbers, HPs always used percentages, but rarely used natural frequencies (14%). Uncertainty was disclosed in only 34% of consultations. One-third of patients used personalized risks in their treatment decision-making by either switching to another treatment or sticking to their initial preference. CONCLUSIONS Patients value and use personalized side-effect risks during treatment decision-making. Clearly explaining the relationship between risk factors and personalized risk estimates may help patients understand and recall those. Practice implications HPs should not only give patients specific and precise numerical risk information, but should also put effort in explaining how the personalized side-effect risks are determined.
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Affiliation(s)
- Ruben D Vromans
- Department of Communication and Cognition, Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, The Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands.
| | - Corinne N Tillier
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Steffen C Pauws
- Department of Communication and Cognition, Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, The Netherlands; Department of Remote Patient Management and Chronic Care, Philips Research, Eindhoven, The Netherlands.
| | - Henk G van der Poel
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Lonneke V van de Poll-Franse
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands; Department of Medical and Clinical Psychology, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands; Division of Psychosocial Research & Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Emiel J Krahmer
- Department of Communication and Cognition, Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, The Netherlands.
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Petrillo LA, Shimer SE, Zhou AZ, Sommer RK, Feldman JE, Hsu KE, Greer JA, Traeger LN, Temel JS. Prognostic communication about lung cancer in the precision oncology era: A multiple-perspective qualitative study. Cancer 2022; 128:3120-3128. [PMID: 35731234 DOI: 10.1002/cncr.34369] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although most patients with cancer prefer to know their prognosis, prognostic communication between oncologists and patients is often insufficient. Targeted therapies for lung cancer improve survival yet are not curative and produce variable responses. This study sought to describe how oncologists communicate about prognosis with patients receiving targeted therapies for lung cancer. METHODS This qualitative study included 39 patients with advanced lung cancer with targetable mutations, 14 caregivers, and 10 oncologists. Semistructured interviews with patients and caregivers and focus groups or interviews with oncologists were conducted to explore their experiences with prognostic communication. One oncology follow-up visit was audio-recorded per patient. A framework approach was used to analyze interview transcripts, and a content analysis of patient-oncologist dialogue was conducted. Themes were identified within each source and then integrated across sources to create a multidimensional description of prognostic communication. RESULTS Six themes in prognostic communication were identified: Patients with targetable mutations develop a distinct identity in the lung cancer community that affects their information-seeking and self-advocacy; oncologists set high expectations for targeted therapy; the uncertain availability of new therapies complicates prognostic discussions; patients and caregivers have variable information preferences; patients raise questions about progression by asking about physical symptoms or scan results; and patients' expectations of targeted therapy influence their medical decision-making. CONCLUSIONS Optimistic patient-oncologist communication shapes the expectations of patients receiving targeted therapy for lung cancer and affects their decision-making. Further research and clinical guidance are needed to help oncologists to communicate uncertain outcomes effectively.
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Affiliation(s)
- Laura A Petrillo
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sophia E Shimer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ashley Z Zhou
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert K Sommer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Kelly E Hsu
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lara N Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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7
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van Strien-Knippenberg IS, Boshuizen MCS, Determann D, de Boer JH, Damman OC. Cocreation with Dutch patients of decision-relevant information to support shared decision-making about adjuvant treatment in breast cancer care. Health Expect 2022; 25:1664-1677. [PMID: 35579109 PMCID: PMC9327829 DOI: 10.1111/hex.13510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 11/30/2022] Open
Abstract
Background To support patients in shared decision‐making about treatment options, patient decision aids (PtDAs) usually provide benefit/harm information and value clarification methods (VCMs). Recently, personalized risk information from prediction models is also being integrated into PtDAs. This study aimed to design decision‐relevant information (i.e., personalized survival rates, harm information and VCMs) about adjuvant breast cancer treatment in cocreation with patients, in a way that suits their needs and is easily understandable. Methods Three cocreation sessions with breast cancer patients (N = 7–10; of whom N = 5 low health literate) were performed. Participants completed creative assignments and evaluated prototypes of benefit/harm information and VCMs. Prototypes were further explored through user testing with patients (N = 10) and healthcare providers (N = 10). The researchers interpreted the collected data, for example, creative and homework assignments, and participants' presentations, to identify key themes. User tests were transcribed and analysed using ATLAS.ti to assess the understanding of the prototypes. Results Important information needs were: (a) need for overview/structure of information directly after diagnosis and; (b) need for transparent benefit/harm information for all treatment options, including detailed harm information. Regarding VCMs, patients stressed the importance of a summary/conclusion. A bar graph seemed the most appropriate way of displaying personalized survival rates; the impact of most other formats was perceived as too distressful. The concept of ‘personalization’ was not understood by multiple patients. Conclusions A PtDA about adjuvant breast cancer treatment should provide patients with an overview of the steps and treatment options, with layers for detailed information. Transparent information about the likelihood of benefits and harm should be provided. Given the current lack of information on the likelihood of side effects/late effects, efforts should be made to collect and share these data with patients. Further quantitative studies are needed to validate the results and to investigate how the concept of ‘personalization’ can be communicated. Patient or Public Contribution Ten breast cancer patients participated in three cocreation sessions to develop decision‐relevant information. Subsequent user testing included 10 patients. The Dutch Breast Cancer Association (BVN) was involved as an advisor in the general study design.
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Affiliation(s)
- Inge S van Strien-Knippenberg
- Department of Public and Occupational Health, Amsterdam UMC, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | | | - Jasmijn H de Boer
- Department of Public and Occupational Health, Amsterdam UMC, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Olga C Damman
- Department of Public and Occupational Health, Amsterdam UMC, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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8
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Hoesseini A, van Leeuwen N, Sewnaik A, Steyerberg EW, Baatenburg de Jong RJ, Lingsma HF, Offerman MPJ. Key Aspects of Prognostic Model Development and Interpretation From a Clinical Perspective. JAMA Otolaryngol Head Neck Surg 2021; 148:180-186. [PMID: 34882175 DOI: 10.1001/jamaoto.2021.3505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Prognostication is an important aspect of clinical decision-making, but it is often challenging. Previous studies show that both patients and physicians tend to overestimate survival chances. Prediction models may assist in estimating and quantifying prognosis. However, insufficient understanding of the development, possibilities, and limitations of such models can lead to misinterpretations. Although many excellent books and comprehensive methodological articles on prognostic model research are published, they may not be accessible enough for the clinical audience. Our aim is to provide an overview on the main issues regarding prediction research for health care professionals to achieve better interpretation and increase the use of prognostic models in daily clinical practice. Observations The first steps of model development include coding of predictors, model specification, and estimation. Next, we discuss the assessment of the performance of a prediction model, including discrimination and calibration aspects, followed by approaches to internal and external validation and updating. Finally, model reporting, presentation, and steps toward clinical implementation are presented. Conclusions and Relevance After thorough consideration of the research question, data inspection, and coding of predictors, one can start with the specification of a prediction model. The number of candidate predictors should be kept limited, in view of the number of events in the data, to prevent overfitting. Calibration and discrimination are 2 aspects of model performance that complement each other and should be assessed preferably at external validation. Model development should be accompanied by qualitative research among patients and physicians to facilitate the development of a valuable tool and maximize possibilities for successful implementation. After model presentation is optimized, impact studies are required to assess the clinical value of a prediction model.
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Affiliation(s)
- Arta Hoesseini
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nikki van Leeuwen
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - Robert Jan Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Marinella P J Offerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
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9
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Vromans RD, van Eenbergen MC, Geleijnse G, Pauws S, van de Poll-Franse LV, Krahmer EJ. Exploring Cancer Survivor Needs and Preferences for Communicating Personalized Cancer Statistics From Registry Data: Qualitative Multimethod Study. JMIR Cancer 2021; 7:e25659. [PMID: 34694237 PMCID: PMC8576563 DOI: 10.2196/25659] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 05/30/2021] [Accepted: 09/25/2021] [Indexed: 12/14/2022] Open
Abstract
Background Disclosure of cancer statistics (eg, survival or incidence rates) based on a representative group of patients can help increase cancer survivors’ understanding of their own diagnostic and prognostic situation, and care planning. More recently, there has been an increasing interest in the use of cancer registry data for disclosing and communicating personalized cancer statistics (tailored toward personal and clinical characteristics) to cancer survivors and relatives. Objective The aim of this study was to explore breast cancer (BCa) and prostate cancer (PCa) survivor needs and preferences for disclosing (what) and presenting (how) personalized statistics from a large Dutch population-based data set, the Netherlands Cancer Registry (NCR). Methods To elicit survivor needs and preferences for communicating personalized NCR statistics, we created different (non)interactive tools visualizing hypothetical scenarios and adopted a qualitative multimethod study design. We first conducted 2 focus groups (study 1; n=13) for collecting group data on BCa and PCa survivor needs and preferences, using noninteractive sketches of what a tool for communicating personalized statistics might look like. Based on these insights, we designed a revised interactive tool, which was used to further explore the needs and preferences of another group of cancer survivors during individual think-aloud observations and semistructured interviews (study 2; n=11). All sessions were audio-recorded, transcribed verbatim, analyzed using thematic (focus groups) and content analysis (think-aloud observations), and reported in compliance with qualitative research reporting criteria. Results In both studies, cancer survivors expressed the need to receive personalized statistics from a representative source, with especially a need for survival and conditional survival rates (ie, survival rate for those who have already survived for a certain period). Personalized statistics adjusted toward personal and clinical factors were deemed more relevant and useful to know than generic or average-based statistics. Participants also needed support for correctly interpreting the personalized statistics and putting them into perspective, for instance by adding contextual or comparative information. Furthermore, while thinking aloud, participants experienced a mix of positive (sense of hope) and negative emotions (feelings of distress) while viewing the personalized survival data. Overall, participants preferred simplicity and conciseness, and the ability to tailor the type of visualization and amount of (detailed) statistical information. Conclusions The majority of our sample of cancer survivors wanted to receive personalized statistics from the NCR. Given the variation in patient needs and preferences for presenting personalized statistics, designers of similar information tools may consider potential tailoring strategies on multiple levels, as well as effective ways for providing supporting information to make sure that the personalized statistics are properly understood. This is encouraging for cancer registries to address this unmet need, but also for those who are developing or implementing personalized data-driven information tools for patients and relatives.
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Affiliation(s)
- Ruben D Vromans
- Department of Communication and Cognition, Tilburg University, Tilburg, Netherlands.,Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
| | - Mies C van Eenbergen
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
| | - Gijs Geleijnse
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
| | - Steffen Pauws
- Department of Communication and Cognition, Tilburg University, Tilburg, Netherlands.,Department of Remote Patient Management and Chronic Care, Philips Research, Eindhoven, Netherlands
| | - Lonneke V van de Poll-Franse
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands.,Division of Psychosocial Research & Epidemiology, The Netherlands Cancer Institute, Amsterdam, Netherlands.,Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands
| | - Emiel J Krahmer
- Department of Communication and Cognition, Tilburg University, Tilburg, Netherlands
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Brotzman LE, Crookes DM, Austin JD, Neugut AI, Shelton RC. Patient perspectives on treatment decision-making under clinical uncertainty: chemotherapy treatment decisions among stage II colon cancer patients. Transl Behav Med 2021; 11:1905-1914. [PMID: 34042154 PMCID: PMC8541697 DOI: 10.1093/tbm/ibab040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The decision to use adjuvant chemotherapy (ACT) after surgical resection for stage II colon cancer remains an area of clinical uncertainty. Many patients diagnosed with stage II colon cancer receive ACT, despite inconclusive evidence of long-term clinical benefit. This study investigates patient experiences and perceptions of treatment decision-making and shared decision making (SDM) for ACT among patients diagnosed with stage II colon cancer. Stage II colon cancer patients engaged in treatment or follow-up care aged >18 years were recruited from two large NYC health systems. Patients participated in 30-60-min semi-structured interviews. All interviews were transcribed, translated, coded, and analyzed using a thematic analysis approach. We interviewed 31 patients, of which 42% received ACT. Overall, patient perspectives indicate provider inconsistency in communicating ACT harms, benefits, and uncertainties, and poor elicitation of patient preferences and values. Patients reported varying perceptions and understanding of personal risk and clinical benefits of ACT. For many patients, receiving a clear treatment recommendation from the provider limited their participation in the decision-making process, whether it aligned with their decisional support preferences or not. Findings advance understanding of perceived roles and preferences of patients in SDM processes for cancer treatment under heightened clinical uncertainty, and indicate a notable gap in understanding for decisions made using SDM models in the context of clinical uncertainty. Educational and communication strategies and training are needed to support providers in communicating uncertainty, risk, treatment options, and implementing clinical guidelines to support patient awareness and informed decisions.
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Affiliation(s)
- Laura E Brotzman
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Danielle M Crookes
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Jessica D Austin
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Alfred I Neugut
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
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11
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Quinlan E, Deane FP. A longitudinal study of trainee psychologists’ tolerance of uncertainty, state anxiety and confidence in case formulation. AUSTRALIAN PSYCHOLOGIST 2021. [DOI: 10.1080/00050067.2021.1965855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Elly Quinlan
- Discipline of Psychological Sciences, Australian College of Applied Psychology, Sydney, Australia
| | - Frank P. Deane
- School of Psychology, University of Wollongong, Wollongong, Australia
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12
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Medendorp NM, Stiggelbout AM, Aalfs CM, Han PKJ, Smets EMA, Hillen MA. A scoping review of practice recommendations for clinicians' communication of uncertainty. Health Expect 2021; 24:1025-1043. [PMID: 34101951 PMCID: PMC8369117 DOI: 10.1111/hex.13255] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/21/2021] [Accepted: 03/23/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Health-care providers increasingly have to discuss uncertainty with patients. Awareness of uncertainty can affect patients variably, depending on how it is communicated. To date, no overview existed for health-care professionals on how to discuss uncertainty. OBJECTIVE To generate an overview of available recommendations on how to communicate uncertainty with patients during clinical encounters. SEARCH STRATEGY A scoping review was conducted. Four databases were searched following the PRISMA-ScR statement. Independent screening by two researchers was performed of titles and abstracts, and subsequently full texts. INCLUSION CRITERIA Any (non-)empirical papers were included describing recommendations for any health-care provider on how to orally communicate uncertainty to patients. DATA EXTRACTION Data on provided recommendations and their characteristics (eg, target group and strength of evidence base) were extracted. Recommendations were narratively synthesized into a comprehensible overview for clinical practice. RESULTS Forty-seven publications were included. Recommendations were based on empirical findings in 23 publications. After narrative synthesis, 13 recommendations emerged pertaining to three overarching goals: (a) preparing for the discussion of uncertainty, (b) informing patients about uncertainty and (c) helping patients deal with uncertainty. DISCUSSION AND CONCLUSIONS A variety of recommendations on how to orally communicate uncertainty are available, but most lack an evidence base. More substantial research is needed to assess the effects of the suggested communicative approaches. Until then, health-care providers may use our overview of communication strategies as a toolbox to optimize communication about uncertainty with patients. PATIENT OR PUBLIC CONTRIBUTION Results were presented to stakeholders (physicians) to check and improve their practical applicability.
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Affiliation(s)
- Niki M. Medendorp
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
| | - Anne M. Stiggelbout
- Medical Decision MakingDepartment of Biomedical Data SciencesLeiden University Medical CenterLeidenThe Netherlands
| | - Cora M. Aalfs
- Division of Biomedical GeneticsDepartment of GeneticsUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Paul K. J. Han
- Center for Outcomes Research and EvaluationMaine Medical Center Research InstitutePortlandMEUSA
| | - Ellen M. A. Smets
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
| | - Marij A. Hillen
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
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13
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van der Velden NCA, van der Kleij MBA, Lehmann V, Smets EMA, Stouthard JML, Henselmans I, Hillen MA. Communication about Prognosis during Patient-Initiated Second Opinion Consultations in Advanced Cancer Care: An Observational Qualitative Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115694. [PMID: 34073341 PMCID: PMC8199300 DOI: 10.3390/ijerph18115694] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 11/16/2022]
Abstract
Prognostic communication is essential for patients with advanced cancer to enable informed medical decision-making and end-of-life planning. Discussing prognosis is challenging, and might be especially complex for oncologists conducting a second opinion (SO). Survival data are often lacking, and consulting oncologists need to consider previously conveyed information and patients’ relationship with the referring oncologist. We qualitatively investigated how advanced cancer patients and consulting oncologists discuss prognosis during audio-recorded SO consultations (N = 60), including prognostic information received from the referring oncologist. Our results show that patients regularly expressed implicit cues to discuss prognosis or posed explicit questions tentatively. Consulting oncologists were mostly unresponsive to patients’ cues and cautious to prognosticate. They also seemed cautious when patients brought up the referring oncologist. Consulting oncologists checked which prognostic information patients had received from the referring oncologist, before estimating prognosis. They agreed with the first opinion or rectified discrepancies carefully. Altogether, this study exposes missed opportunities for open prognostic discussions in SOs. Consulting oncologists could explicitly explore patients’ information preferences and perceptions of prognosis. If desired, they can provide tailored, independent information to optimise patients’ prognostic awareness and informed medical decision-making. They may additionally support patients in dealing with prognosis and the uncertainties associated with it.
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Affiliation(s)
- N. C. A. van der Velden
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
- Correspondence:
| | - M. B. A. van der Kleij
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
| | - V. Lehmann
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - E. M. A. Smets
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - J. M. L. Stouthard
- Department of Medical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands;
| | - I. Henselmans
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - M. A. Hillen
- Amsterdam University Medical Centers, Department of Medical Psychology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.B.A.v.d.K.); (V.L.); (E.M.A.S.); (I.H.); (M.A.H.)
- Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, University of Amsterdam, VU University Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, VU University Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
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Sisk BA, Friedrich AB, DuBois J, Mack JW. Characteristics of uncertainty in advanced pediatric cancer conversations. PATIENT EDUCATION AND COUNSELING 2021; 104:1066-1074. [PMID: 33109428 PMCID: PMC8052385 DOI: 10.1016/j.pec.2020.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/11/2020] [Accepted: 10/05/2020] [Indexed: 05/14/2023]
Abstract
OBJECTIVES To describe the initiation, response, and content of communication about uncertainty in advanced pediatric cancer. METHODS Qualitative analysis of 35 audio-recorded outpatient consultations between physicians and families of children whose cancer recently progressed. We defined uncertainty as "future-oriented lack of clarity in which answers are unknown to all participants involved in the conversation." RESULTS Conversations contained a median of 14 (interquartile range 8.5-19) uncertainty statements related to 6 topics: appropriateness of treatments, acute toxicities and morbidities, prognosis or response to treatment, diagnostic uncertainty, logistical uncertainty, and long-term toxicities. Physicians initiated 63 % of statements (303/489), parents initiated 33 % (165/489), and children initiated 2% (10/489). We identified 14 unique responses to uncertainty: 11 responses provided space for discussion, 3 responses reduced space. Physicians most commonly responded by providing additional information (38 %, 361/947). Parents most often responded with continuing statements, such as "um" or "yeah" (50 %, 313/622). Children seldom responded (<1%, 12/1697). CONCLUSION Physicians initiated most uncertainty discussions, and their responses often provided space for further discussion. Children were seldom involved in these conversations. PRACTICE IMPLICATIONS Clinicians should consider maintaining open conversations about uncertainties in advanced pediatric cancer, and consider engaging children in these discussions.
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Affiliation(s)
- Bryan A Sisk
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
| | - Annie B Friedrich
- Albert Gnaegi Center for Health Care Ethics, Saint Louis University, St. Louis, MO, USA
| | - James DuBois
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jennifer W Mack
- Pediatric Oncology and Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, and Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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15
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Bonner C, Trevena LJ, Gaissmaier W, Han PKJ, Okan Y, Ozanne E, Peters E, Timmermans D, Zikmund-Fisher BJ. Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles. Med Decis Making 2021; 41:821-833. [PMID: 33660551 DOI: 10.1177/0272989x21996328] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids. METHODS Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team. RESULTS Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy. DISCUSSION Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental "nudging" toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.
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Affiliation(s)
- Carissa Bonner
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,ASK-GP NHMRC Centre of Research Excellence, The University of Sydney, Australia
| | - Lyndal J Trevena
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,ASK-GP NHMRC Centre of Research Excellence, The University of Sydney, Australia
| | | | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA.,School of Medicine, Tufts University, USA
| | - Yasmina Okan
- Centre for Decision Research, University of Leeds, Leeds, UK
| | | | - Ellen Peters
- Center for Science Communication Research, University of Oregon, Eugene, OR, USA
| | - Daniëlle Timmermans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, North Holland, The Netherlands
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16
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Hoesseini A, Dronkers EAC, Sewnaik A, Hardillo JAU, Baatenburg de Jong RJ, Offerman MPJ. Head and neck cancer patients' preferences for individualized prognostic information: a focus group study. BMC Cancer 2020; 20:399. [PMID: 32380962 PMCID: PMC7203788 DOI: 10.1186/s12885-020-6554-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 01/17/2020] [Indexed: 12/20/2022] Open
Abstract
Background Head and Neck cancer (HNC) is characterized by significant mortality and morbidity. Treatment is often invasive and interferes with vital functions, resulting in a delicate balance between survival benefit and deterioration in quality of life (QoL). Therefore, including prognostic information during patient counseling can be of great importance. The first aim of this study was to explore HNC patients’ preferences for receiving prognostic information: both qualitative (general terms like “curable cancer”), and quantitative information (numbers, percentages). The second aim of this study was to explore patients’ views on “OncologIQ”, a prognostic model developed to estimate overall survival in newly diagnosed HNC patients. Methods We conducted a single center qualitative study by organizing five focus groups with HNC patients (n = 21) and their caregivers (n = 19), categorized in: 1) small laryngeal carcinomas treated with radiotherapy or laser, 2) extensive oral cavity procedures, 3) total laryngectomy, 4) chemoradiation, 5) other treatments. The patients’ perspective was the main focus. The interview guide consisted of two main topics: life-expectancy and the prognostic model OncologIQ. All focus groups were recorded, transcribed and coded. Themes were derived using content analysis. Results While all patients considered it somewhat to very important to receive information about their life-expectancy, only some of them wanted to receive quantitative information. Disclosing qualitative prognostic information like “the cancer is curable” would give enough reassurance for most patients. Overall, patients thought life-expectancy should not be discussed shortly after cancer diagnosis disclosure, as a certain time is needed to process the first shock. They had a stronger preference for receiving prognostic information in case of a poor prognosis. Prognostic information should also include information on the expected QoL. The pie chart was the most preferred chart for discussing survival rates. Conclusions The participants found it important to receive information on their life-expectancy. While most patients were enough reassured by qualitative prognostic information, some wanted to receive quantitative information like OncologIQs’ estimates. A tailor-made approach is necessary to provide customized prognostic information. A clinical practice guideline was developed to support professionals in sharing prognostic information, aiming to improve shared decision making and patient-centered care.
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Affiliation(s)
- Arta Hoesseini
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands.
| | - Emilie A C Dronkers
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Jose A U Hardillo
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Robert J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Marinella P J Offerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
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17
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Risk communication in a patient decision aid for radiotherapy in breast cancer: How to deal with uncertainty? Breast 2020; 51:105-113. [PMID: 32298961 PMCID: PMC7375609 DOI: 10.1016/j.breast.2020.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/13/2020] [Accepted: 04/01/2020] [Indexed: 12/21/2022] Open
Abstract
Background and aim Patient decision aids for oncological treatment options, provide information on the effect on recurrence rates and/or survival benefit, and on side-effects and/or burden of different treatment options. However, often uncertainty exists around the probability estimates for recurrence/survival and side-effects which is too relevant to be ignored. Evidence is lacking on the best way to communicate these uncertainties. The aim of this study is to develop a method to incorporate uncertainties in a patient decision aid for breast cancer patients to support their decision on radiotherapy. Methods Firstly, qualitative interviews were held with patients and health care professionals. Secondly, in the development phase, thinking aloud sessions were organized with four patients and 12 health care professionals, individual and group-wise. Results Consensus was reached on a pictograph illustrating the whole range of uncertainty for local recurrence risks, in combination with textual explanation that a more exact personalized risk would be given by their own physician. The pictograph consisted of 100 female icons in a 10 x 10 array. Icons with a stepwise gradient color indicated the uncertainty margin. The prevalence and severity of possible side-effects were explained using verbal labels. Conclusions We developed a novel way of visualizing uncertainties in recurrence rates in a patient decision aid. The effect of this way of communicating risk uncertainty is currently being tested in the BRASA study (NCT03375801). There exists uncertainty around local recurrence risks for breast cancer patients. Little is known on how to communicate uncertainty to patients. Patient decision aids can help communicating risks and uncertainty. We developed pictographs to communicate numerical uncertainty in recurrence risks. The effect of the pictographs is currently being tested in the BRASA study.
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18
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Simonovic N, Taber JM, Klein WMP, Ferrer RA. Evidence that perceptions of and tolerance for medical ambiguity are distinct constructs: An analysis of nationally representative US data. Health Expect 2020; 23:603-613. [PMID: 32097530 PMCID: PMC7321721 DOI: 10.1111/hex.13037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 01/16/2020] [Accepted: 01/31/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Medical information is often conflicting and consequently perceived as ambiguous. There are individual differences both in how much people perceive ambiguity and in their tolerance for such ambiguity. Little is known about how these constructs are related to each other and with other beliefs. OBJECTIVE To examine the association between (a) perceived medical ambiguity, (b) tolerance for medical ambiguity and (c) their associations with various medical and cancer-specific judgement and decision-making correlates. METHOD AND PARTICIPANTS We conducted secondary data analyses using the cross-sectional, nationally representative Health Information National Trends Survey 4, Cycle 4 (n = 3,433, 51.0% female, Mage = 46.5). Analyses statistically controlled for age, sex, race, education and health-care coverage. MAIN VARIABLES STUDIED Perceived medical ambiguity, tolerance for medical ambiguity, cancer perceptions, health-care experiences and preferences, and information-seeking styles and beliefs. RESULTS Perceived medical ambiguity and tolerance for medical ambiguity were statistically independent. Higher perceived ambiguity was associated with lower perceived cancer preventability, lower reliance on doctors, lower perceived health and information-seeking self-efficacy, lower perceived quality of the cancer information-seeking process, and greater cancer information avoidance. Lower tolerance for ambiguity was associated with lower cancer worry, lower trust in doctors, lower likelihood of seeking health information, and lower engagement in medical research. DISCUSSION AND CONCLUSIONS Perceived medical ambiguity and tolerance for medical ambiguity seem to be distinct constructs. Findings have implications for how people make medical decisions when they perceive and prefer to avoid conflicting medical information.
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Affiliation(s)
- Nicolle Simonovic
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - Jennifer M Taber
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - William M P Klein
- Behavioral Research Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rebecca A Ferrer
- Behavioral Research Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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Gärtner FR, Portielje JE, Langendam M, Hairwassers D, Agoritsas T, Gijsen B, Liefers GJ, Pieterse AH, Stiggelbout AM. Role of patient preferences in clinical practice guidelines: a multiple methods study using guidelines from oncology as a case. BMJ Open 2019; 9:e032483. [PMID: 31811009 PMCID: PMC6924854 DOI: 10.1136/bmjopen-2019-032483] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Many treatment decisions are preference-sensitive and call for shared decision-making, notably when benefits are limited or uncertain, and harms impact quality of life. We explored if clinical practice guidelines (CPGs) acknowledge preference-sensitive decisions in how they motivate and phrase their recommendations. DESIGN We performed a qualitative analysis of the content of CPGs and verified the results in semistructured interviews with CPG panel members. SETTING Dutch oncology CPGs issued in 2010 or later, concerning primary treatment with curative intent. PARTICIPANTS 14 CPG panel members. MAIN OUTCOMES For treatment recommendations from six CPG modules, two researchers extracted the following: strength of recommendation in terms of the Grading of Recommendations Assessment, Development and Evaluation and its consistency with the CPG text; completeness of presentation of benefits and harms; incorporation of patient preferences; statements on the panel's benefits-harm trade-off underlying recommendation; and advice on patient involvement in decision-making. RESULTS We identified 32 recommendations, 18 were acknowledged preference-sensitive decisions. Three of 14 strong recommendations should have been weak based on the module text. The reporting of benefits and harms, and their probabilities, was sufficiently complete and clear to inform the strength of the recommendation in one of the six modules only. Numerical probabilities were seldom presented. None of the modules presented information on patient preferences. CPG panel's preferences were not made explicit, but appeared to have impacted 15 of 32 recommendations. Advice to involve patients and their preferences in decision-making was given for 20 recommendations (14 weak). Interviewees confirmed these findings. Explanations for lack of information were, for example, that clinicians know the information and that CPGs must be short. Explanations for trade-offs made were cultural-historical preferences, compliance with daily care, presumed role of CPGs and lack of time. CONCLUSIONS The motivation and phrasing of CPG recommendations do not stimulate choice awareness and a neutral presentation of options, thus hindering shared decision-making.
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Affiliation(s)
- Fania R Gärtner
- Medical Decision Making, Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanneke E Portielje
- Clinical Oncology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Miranda Langendam
- Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, North Holland, The Netherlands
| | | | - Thomas Agoritsas
- Division of General Internal Medicine and Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Brigitte Gijsen
- Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | | | - Arwen H Pieterse
- Medical Decision Making, Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Anne M Stiggelbout
- Medical Decision Making, Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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20
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Engelhardt EG, Smets EMA, Sorial I, Stiggelbout AM, Pieterse AH, Hillen MA. Is There a Relationship between Shared Decision Making and Breast Cancer Patients' Trust in Their Medical Oncologists? Med Decis Making 2019; 40:52-61. [PMID: 31789100 PMCID: PMC7433397 DOI: 10.1177/0272989x19889905] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background. Adjuvant systemic treatment for early stage breast cancer significantly reduces the risk of mortality but is associated with side effects, reducing patients’ quality of life. Decisions about adjuvant treatment are preference sensitive and are thus ideally suited to a shared decision making (SDM) approach. Whether and how SDM affects patients’ trust in their oncologist is currently unknown. We investigated the association between patients’ trust in their oncologist and 1) observed level of SDM in the consultation, 2) congruence between patients’ preferred and perceived level of participation, and 3) patient and oncologist characteristics. Methods. Decision consultations (n = 101) between breast cancer patients and their medical oncologist were audio-recorded and transcribed verbatim. Patients’ trust in their oncologist was measured using the Trust in Oncologist Scale (TiOS). The observed level of SDM was scored using the 12-item Observing Patient Involvement In Decision Making scale (OPTION-12), preferred level of participation with the Control Preferences Scale, and perceived level of participation with an open question in telephonic interviews. Results. The average TiOS score was high overall (mean [SD] = 4.1 [.56]; range, 2.6–5.0). Low levels of SDM were observed (mean [SD] = 16 [11.6]; range, 2–56). Neither observed nor perceived level of participation in SDM was associated with trust. Patients’ preferred and perceived role in decision making was incongruent in almost 50% of treatment decisions. Congruence was not related to trust. A larger tumor size (β = 4.5, P = 0.03) and the use of a risk prediction model during the consultation (β = 4.1, P = 0.04) were associated with stronger trust. Conclusion. Patients reported strong trust in their oncologist. While low levels of SDM were observed, SDM was not associated with trust. These findings suggest it may not be necessary to worry about negative consequences for trust of using SDM or risk prediction models in oncological consultations. Considering the increased emphasis on implementing SDM, it is important to further explore how SDM affects trust in clinical practice.
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Affiliation(s)
- Ellen G Engelhardt
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, the Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Noord-Holland, the Netherlands
| | - Irini Sorial
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Noord-Holland, the Netherlands
| | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, the Netherlands
| | - Arwen H Pieterse
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, the Netherlands
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Noord-Holland, the Netherlands
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21
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Raphael DB, Ter Stege JA, Russell NS, Boersma LJ, van der Weijden T. What do patients and health care professionals view as important attributes in radiotherapy decisions? Input for a breast cancer patient decision aid. Breast 2019; 49:149-156. [PMID: 31812074 PMCID: PMC7375659 DOI: 10.1016/j.breast.2019.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 12/20/2022] Open
Abstract
Background and aim There is increased attention for shared decision making (SDM) when deciding on radiotherapy for selected patients with Stage 0–2 breast cancer. This study aimed to explore patients' and health care professionals’ experiences, decisional attributes and needs as input for the development of a patient decision aid to facilitate SDM. Methods Qualitative semi-structured interviews were held with fifteen breast cancer patients, being confronted with a radiotherapy decision one month to eight years earlier. Another fifteen interviews were held with professionals specialized in breast cancer care. Interviews were transcribed verbatim and independently coded by two researchers, who agreed upon relevant issues. Results Most patients made their decision by weighing the advantages of radiotherapy, i.e. comparing the decrease in recurrence risk with and without radiotherapy, and disadvantages, i.e. possible side effects. Patients and professionals agreed that recurrence risks should be communicated, but not on how to deal with uncertainty. There was wide variation in which, and how, side effects were explained by professionals. The most common side effects mentioned by both patients and professionals were skin toxicity, fatigue and breast deformity. Conclusion Patients and professionals appeared to agree on what type of attributes should be communicated during SDM on radiotherapy, but how this should be done is up for discussion. To ensure the patient's voice these attributes and needs need to be incorporated in the risk communication and value elicitation part of the patient decision aid. The format in which the attributes are communicated should be critically evaluated. Patients and professionals agree on most important attributes. These attributes need to be used in a patient decision aid. There is unwarranted inter doctor variation in informing about side effects. Professionals differ in opinion how to inform patients about epistemic uncertainties.
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Affiliation(s)
- D B Raphael
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands; Department of Family Medicine, CAPHRI School for Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands; Department of Radiotherapy, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands.
| | - J A Ter Stege
- Department of Psychosocial Research and Epidemiology Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands.
| | - N S Russell
- Department of Radiotherapy, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands.
| | - L J Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - T van der Weijden
- Department of Family Medicine, CAPHRI School for Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands.
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22
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Visser LNC, Pelt SAR, Kunneman M, Bouwman FH, Claus JJ, Kalisvaart KJ, Hempenius L, de Beer MH, Roks G, Boelaarts L, Kleijer M, van der Flier WM, Smets EMA, Hillen MA. Communicating uncertainties when disclosing diagnostic test results for (Alzheimer's) dementia in the memory clinic: The ABIDE project. Health Expect 2019; 23:52-62. [PMID: 31638322 PMCID: PMC6978856 DOI: 10.1111/hex.12964] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 02/06/2023] Open
Abstract
Background The development of novel diagnostics enables increasingly earlier diagnosis of Alzheimer's disease (AD). Timely diagnosis may benefit patients by reducing their uncertainty regarding the cause of symptoms, yet does not always provide patients with the desired certainty. Objective To examine, using both quantitative and qualitative methods, uncertainty communicated by memory clinic clinicians in post‐diagnostic testing consultations with patients and their caregivers. Methods First, we identified all uncertainty expressions of 22 clinicians in audiotaped post‐diagnostic testing consultations with 78 patients. Second, we statistically explored relationships between patient/clinician characteristics and uncertainty expressions. Third, the transcribed uncertainty expressions were qualitatively analysed, determining the topic to which they pertained, their source and initiator/elicitor (clinicians/patients/caregivers). Results Within 57/78 (73%) consultations, clinicians expressed in total 115 uncertainties, of which 37% elicited by the patient or caregiver. No apparent relationships were found between patient/clinician characteristics and whether or not, and how often clinicians expressed uncertainty. Uncertainty expressions pertained to ten different topics, most frequently patient's diagnosis and symptom progression. Expressed uncertainty was mostly related to the unpredictability of the future and limits to available knowledge. Discussion and conclusions The majority of clinicians openly discussed the limits of scientific knowledge and diagnostic testing with patients and caregivers in the dementia context. Noticeably, clinicians did not discuss uncertainty in about one quarter of consultations. More evidence is needed on the beneficial and/or harmful effects on patients of discussing uncertainty with them. This knowledge can be used to support clinicians to optimally convey uncertainty and facilitate patients' uncertainty management.
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Affiliation(s)
- Leonie N C Visser
- Department of Medical Psychology, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Neurology, Alzheimer Center Amsterdam, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Sophie A R Pelt
- Department of Medical Psychology, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Neurology, Alzheimer Center Amsterdam, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marleen Kunneman
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA.,Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke H Bouwman
- Department of Neurology, Alzheimer Center Amsterdam, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jules J Claus
- Department of Neurology, Tergooi Hospital, Blaricum, The Netherlands
| | - Kees J Kalisvaart
- Department of Clinical Geriatrics, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Liesbeth Hempenius
- Geriatric Center, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Marlijn H de Beer
- Department of Neurology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Gerwin Roks
- Department of Neurology, ETZ Hospital, Tilburg, The Netherlands
| | - Leo Boelaarts
- Geriatric Department, NoordWest Ziekenhuis Groep, Alkmaar, The Netherlands
| | - Mariska Kleijer
- Department of Neurology, LangeLand Ziekenhuis, Zoetermeer, The Netherlands
| | - Wiesje M van der Flier
- Department of Neurology, Alzheimer Center Amsterdam, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
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23
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Han PKJ, Babrow A, Hillen MA, Gulbrandsen P, Smets EM, Ofstad EH. Uncertainty in health care: Towards a more systematic program of research. PATIENT EDUCATION AND COUNSELING 2019; 102:1756-1766. [PMID: 31227333 DOI: 10.1016/j.pec.2019.06.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To promote a more systematic approach to research on uncertainty in health care, and to explore promising starting points and future directions for this research. METHODS We examine three fundamental aspects of medical uncertainty that a systematic research program should ideally address: its nature, effects, and communication. We summarize key insights from past empirical research and explore existing conceptual models that can help guide future research. RESULTS A diverse body of past research on medical uncertainty has produced valuable empirical insights and conceptual models that provide useful starting points for future empirical and theoretical work. However, these insights need to be more fully developed and integrated to answer remaining questions about what uncertainty is, how it affects people, and how and why it should be communicated. CONCLUSION Uncertainty in health care is an extremely important but incompletely understood phenomenon. Improving our understanding of the many important aspects of uncertainty in health care will require a more systematic program of research based upon shared, integrative conceptual models and active, collaborative engagement of the broader research community. PRACTICE IMPLICATIONS A more systematic approach to investigating uncertainty in health care can help elucidate how the clinical communication of uncertainty might be improved.
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Affiliation(s)
- Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, USA; Tufts University School of Medicine, Boston, USA.
| | - Austin Babrow
- School of Communication Studies, Ohio University, Athens, USA
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Pål Gulbrandsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; HØKH Research Center, Akershus University Hospital, Lørenskog, Norway
| | - Ellen M Smets
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Eirik H Ofstad
- Department of Medicine, Nordland Hospital Trust, Bodø, Norway; Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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24
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Derry HM, Epstein AS, Lichtenthal WG, Prigerson HG. Emotions in the room: common emotional reactions to discussions of poor prognosis and tools to address them. Expert Rev Anticancer Ther 2019; 19:689-696. [PMID: 31382794 DOI: 10.1080/14737140.2019.1651648] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Advanced cancer patients often want prognostic information, and discussions of prognosis have been shown to enhance patient understanding of their illness. Such discussions can lead to high-quality, value-consistent care at the end of life, yet they are also often emotionally challenging. Despite how common and normal it is for patients to experience transient emotional distress when receiving 'bad news' about prognosis, emotional responses have been under-addressed in existing literature on prognostic discussions. Areas covered: Drawing upon psychology research, principles of skilled clinical communication, and published approaches to discussions of serious illness, we summarize patients' common emotional reactions and coping strategies. We then provide suggestions for how to respond to them in clinic. Expert opinion: Ultimately, effective management of emotional reactions to bad news may lead to earlier, more frequent, and more transparent discussions of prognosis, thus promoting cancer patients' understanding of, and adjustment to, their illness and improving the quality of their end-of-life care.
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Affiliation(s)
| | - Andrew S Epstein
- Weill Cornell Medicine , New York , NY , USA.,Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Wendy G Lichtenthal
- Weill Cornell Medicine , New York , NY , USA.,Memorial Sloan Kettering Cancer Center , New York , NY , USA
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25
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Vromans R, Tenfelde K, Pauws S, van Eenbergen M, Mares-Engelberts I, Velikova G, van de Poll-Franse L, Krahmer E. Assessing the quality and communicative aspects of patient decision aids for early-stage breast cancer treatment: a systematic review. Breast Cancer Res Treat 2019; 178:1-15. [PMID: 31342311 PMCID: PMC6790198 DOI: 10.1007/s10549-019-05351-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/05/2019] [Indexed: 12/12/2022]
Abstract
Purpose Decision aids (DAs) support patients in shared decision-making by providing balanced evidence-based treatment information and eliciting patients’ preferences. The purpose of this systematic review was to assess the quality and communicative aspects of DAs for women diagnosed with early-stage breast cancer. Methods Twenty-one currently available patient DAs were identified through both published literature (MEDLINE, Embase, CINAHL, CENTRAL, and PsycINFO) and online sources. The DAs were reviewed for their quality by using the International Patient Decision Aid Standards (IPDAS) checklist, and subsequently assessed to what extent they paid attention to various communicative aspects, including (i) information presentation, (ii) personalization, (iii) interaction, (iv) information control, (v) accessibility, (vi) suitability, and (vii) source of information. Results The quality of the DAs varied substantially, with many failing to comply with all components of the IPDAS criteria (mean IPDAS score = 64%, range 31–92%). Five aids (24%) did not include any probability information, 10 (48%) presented multimodal descriptions of outcome probabilities (combining words, numbers, and visual aids), and only 2 (10%) provided personalized treatment outcomes based on patients and tumor characteristics. About half (12; 57%) used interaction methods for eliciting patients’ preferences, 16 (76%) were too lengthy, and 5 (24%) were not fully accessible. Conclusions In addition to the limited adherence to the IPDAS checklist, our findings suggest that communicative aspects receive even less attention. Future patient DA developments for breast cancer treatment should include communicative aspects that could influence the uptake of DAs in daily clinical practice. Electronic supplementary material The online version of this article (10.1007/s10549-019-05351-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ruben Vromans
- Department of Communication and Cognition, Tilburg University, Warandelaan 2, 5035 AB Tilburg, The Netherlands
| | - Kim Tenfelde
- Department of Communication and Cognition, Tilburg University, Warandelaan 2, 5035 AB Tilburg, The Netherlands
| | - Steffen Pauws
- Department of Communication and Cognition, Tilburg University, Warandelaan 2, 5035 AB Tilburg, The Netherlands
- Chronic Disease Management, Philips Research, Eindhoven, The Netherlands
| | - Mies van Eenbergen
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Ingeborg Mares-Engelberts
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Surgery, Sint Franciscus Vlietland Group, Rotterdam, The Netherlands
| | - Galina Velikova
- Leeds Institute of Medical Research at St Jame’s, University of Leeds, Leeds, UK
| | - Lonneke van de Poll-Franse
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
- Division of Psychosocial Research & Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Emiel Krahmer
- Department of Communication and Cognition, Tilburg University, Warandelaan 2, 5035 AB Tilburg, The Netherlands
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26
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Peoples HA, Boone B, Blumenthal-Barby JS, Bruce CR. How Clinician-Family Interactions Potentially Impact Clinicians' Conceptualization and Discussions Regarding Prognostic Uncertainties. J Palliat Care 2019; 35:29-33. [PMID: 31039670 DOI: 10.1177/0825859719845005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Little is known about how clinicians perceive prognostic uncertainty. Our study objective was to identify factors that influence how prognostic uncertainty is viewed by physicians, as it relates to their communications with families. DESIGN Thirty semi-structured interviews with qualitative content analysis (9 surgeons, 16 intensivists, 3 nurse practitioners, and 2 "other" clinicians). We analyzed interviews using qualitative description with constant comparative techniques. SETTING Open medical, surgical, neurosurgical, and cardiovascular intensive care units (ICUs) in a 900-bed academic, tertiary Houston hospital. INTERVENTIONS None. MAIN RESULTS We identified 2 main factors that influence how clinicians perceive prognostic uncertainty and their perceptions about whether and why they communicate prognostic uncertainties to families: (1) Communicating Uncertainty to "Soften the Blow"; and (2) Communicating Uncertainty in Response to Clinicians' Interpretations of Surrogate Decision Makers' Perceptions of Prognostic Uncertainty. We also identified several subthemes. CONCLUSIONS Clinician-family interactions influence how clinicians perceive prognostic uncertainty in their communications with patients or families. We discuss ethical and clinical implications of our findings.
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Affiliation(s)
- Hayley A Peoples
- Department of Orthopaedic Surgery and Scoliosis, Clinical Care Center, Baylor College of Medicine, Center for Medical Ethics & Health Policy, Texas Children's Hospital, Houston, TX, USA
| | | | - Jennifer S Blumenthal-Barby
- Department of Orthopaedic Surgery and Scoliosis, Clinical Care Center, Baylor College of Medicine, Center for Medical Ethics & Health Policy, Texas Children's Hospital, Houston, TX, USA
| | - Courtenay R Bruce
- Department of Orthopaedic Surgery and Scoliosis, Clinical Care Center, Baylor College of Medicine, Center for Medical Ethics & Health Policy, Texas Children's Hospital, Houston, TX, USA.,Houston Methodist System, Bioethics Program, Houston, TX, USA
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27
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Wöhlke S, Schaper M, Schicktanz S. How Uncertainty Influences Lay People's Attitudes and Risk Perceptions Concerning Predictive Genetic Testing and Risk Communication. Front Genet 2019; 10:380. [PMID: 31080458 PMCID: PMC6497735 DOI: 10.3389/fgene.2019.00380] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/09/2019] [Indexed: 12/11/2022] Open
Abstract
The interpretation of genetic information in clinical settings raises moral issues about adequate risk communication and individual responsibility about one's health behavior. However, it is not well-known what role numeric probabilities and/or the conception of disease and genetics play in the lay understanding of predictive genetic diagnostics. This is an important question because lay understanding of genetic risk information might have particular implications for self-responsibility of the patients. Aim: Analysis of lay attitudes and risk perceptions of German lay people on genetic testing with a special focus on how they deal with the numerical information. Methods: We conducted and analyzed seven focus group discussions (FG) with lay people (n = 43). Results: Our participants showed a positive attitude toward predictive genetic testing. We identified four main topics: (1) Anumeric risk instead of statistical information; (2) Treatment options as a factor for risk evaluation; (3) Epistemic and aleatory uncertainty as moral criticism; (4) Ambivalence as a sign of uncertainty. Conclusion: For lay people, risk information, including the statistical numeric part, is perceived as highly normatively charged, often as an emotionally significant threat. It seems necessary to provide lay people with a deeper understanding of risk information and of the limitations of genetic knowledge with respect to one's own health responsibility.
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Affiliation(s)
- Sabine Wöhlke
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
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28
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Medendorp NM, Hillen MA, Murugesu L, Aalfs CM, Stiggelbout AM, Smets EMA. Uncertainty in consultations about genetic testing for cancer: an explorative observational study. PATIENT EDUCATION AND COUNSELING 2018; 101:2083-2089. [PMID: 30082116 DOI: 10.1016/j.pec.2018.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/18/2018] [Accepted: 08/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Persons seeking cancer genetic counseling mainly aim to obtain information and certainty about their medical situation. However, the information that counselees receive often involves many uncertainties. To develop strategies to enable optimal communication about uncertainties, the spectrum of uncertainty expressed within cancer genetic counseling needs to be established. This study aimed to gain insight into the uncertainties verbally expressed by counselors and counselees. METHODS Twenty-five consultations were audiotaped, transcribed and qualitatively analyzed. A coding scheme identifying all uncertainties was developed parallel to the coding of the transcripts. RESULTS Several uncertainties were identified varying in their source (i.e. the cause of uncertainty) and the issues involved (i.e. the topic to which uncertainty pertained). The main sources of uncertainty were the unpredictability of the future and a lack of knowledge. Counselees also expressed uncertainty related to the amount and complexity of the information. Counselors expressed uncertainties mainly related to scientific issues, whereas counselees' uncertainty mainly related to personal and practical issues. CONCLUSION A wide range of uncertainties was expressed by both groups. Counselors differ from counselees in the degree and types of uncertainty they express. PRACTICE IMPLICATIONS Counselors should address scientific uncertainties during genetic counseling to increase awareness and understanding in counselees.
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Affiliation(s)
- Niki M Medendorp
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Cancer Centre Amsterdam, Amsterdam, The Netherlands.
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Laxsini Murugesu
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Cora M Aalfs
- Department of Clinical Genetics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Clinical Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Cancer Centre Amsterdam, Amsterdam, The Netherlands
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Haltaufderheide J, Wäscher S, Bertlich B, Vollmann J, Reinacher-Schick A, Schildmann J. "I need to know what makes somebody tick …": Challenges and Strategies of Implementing Shared Decision-Making in Individualized Oncology. Oncologist 2018; 24:555-562. [PMID: 30190300 DOI: 10.1634/theoncologist.2017-0615] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 07/06/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Shared decision-making (SDM) has been advocated as an ethical framework for decision-making in cancer care. According to SDM, patients make decisions in light of their values and based on the available evidence. However, SDM is difficult to implement in cancer care. A lack of applicability in practice is often reported. This empirical-ethical study explores factors potentially relevant to current difficulties in translating the concept of SDM into clinical practice. METHODS This study was conducted with nonparticipant observation of the decision-making process in patients with gastrointestinal cancers for whom the benefit of adjuvant chemotherapy was uncertain according to clinical guidelines. Triangulation of qualitative data analysis was conducted by means of semistructured interviews subsequent to the observation. Observation notes and interview transcripts were analyzed according to the principles of grounded theory. RESULTS Deviating from the concept of SDM, oncologists initiated a process of eliciting values and medical information prior to conveying information. The purpose of this approach was to select and individualize information relevant to the treatment decision. In doing so, the oncologists observed used two strategies: "biographical communication" and a "metacommunicative approach." Both strategies could be shown to be effective or to fail depending on patients' characteristics such as their view of the physicians' role and the relevance of value-related information for medical decision-making. CONCLUSION In contrast to the conceptual account of SDM, oncologists are in need of patient-related information prior to conveying information. Both strategies observed to elicit such information are in principle justifiable but need to be adapted in accordance with patient preferences and decision-making styles. IMPLICATIONS FOR PRACTICE This study showed that knowledge of patients' values and preferences is very important to properly adapt the giving of medical information and to further the process of shared decision-making. Shared decision-making (SDM) trainings should consider different strategies of talking about values. The right strategy depends largely on the patient's preferences in communication. To be aware of the role of values in SDM and to be able to switch communicative strategies might prove to be of particular value. A more systematic evaluation of the patient's decision-making preferences as part of routine procedures in hospitals might help to reduce value-related barriers in communication.
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Affiliation(s)
| | - Sebastian Wäscher
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland
| | - Bernhard Bertlich
- Department of Hematology, Oncology and Palliative Care, St. Josef-Hospital, Ruhr-University, Bochum, Germany
| | - Jochen Vollmann
- Department for Medical Ethics and History of Medicine, Ruhr-University, Bochum, Germany
| | - Anke Reinacher-Schick
- Department of Hematology, Oncology and Palliative Care, St. Josef-Hospital, Ruhr-University, Bochum, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Martin Luther University, Halle-Wittengerg, Germany
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30
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Zahuranec DB, Anspach RR, Roney ME, Fuhrel-Forbis A, Connochie DM, Chen EP, Thompson BB, Varelas PN, Morgenstern LB, Fagerlin A. Surrogate Decision Makers' Perspectives on Family Members' Prognosis after Intracerebral Hemorrhage. J Palliat Med 2018; 21:956-962. [PMID: 29608394 DOI: 10.1089/jpm.2017.0604] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Surrogate communication with providers about prognosis in the setting of acute critical illness can impact both patient treatment decisions and surrogate outcomes. OBJECTIVES To examine surrogate decision maker perspectives on provider prognostic communication after intracerebral hemorrhage (ICH). DESIGN Semistructured interviews were conducted and analyzed qualitatively for key themes. SETTING/SUBJECTS Surrogate decision makers for individuals admitted with ICH were enrolled from five acute care hospitals. RESULTS Fifty-two surrogates participated (mean age = 54, 60% women, 58% non-Hispanic white, 13% African American, 21% Hispanic). Patient status at interview was hospitalized (17%), in rehabilitation/nursing facility (37%), deceased (38%), hospice (4%), or home (6%). Nineteen percent of surrogates reported receiving discordant prognoses, leading to distress or frustration in eight cases (15%) and a change in decision for potentially life-saving brain surgery in three cases (6%). Surrogates were surprised or confused by providers' use of varied terminology for the diagnosis (17%) (e.g., "stroke" vs. "brain hemorrhage" or "brain bleed") and some interpreted "stroke" as having a more negative connotation. Surrogates reported that physicians expressed uncertainty in prognosis in 37%; with physician certainty in 56%. Surrogate reactions to uncertainty were mixed, with some surrogates expressing a negative emotional response (e.g., anxiety) and others reporting understanding or acceptance of uncertainty. CONCLUSIONS Current practice of prognostic communication in acute critical illness has many gaps, leading to distress for surrogates and variability in critical treatment decisions. Further work is needed to limit surrogate distress and improve the quality of treatment decisions.
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Affiliation(s)
- Darin B Zahuranec
- 1 Stroke Program, Department of Neurology, Michigan Medicine , Ann Arbor, Michigan.,2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan
| | - Renee R Anspach
- 3 Department of Sociology, University of Michigan College of Literature, Science, and the Arts, Ann Arbor, Michigan
| | - Meghan E Roney
- 2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan
| | - Andrea Fuhrel-Forbis
- 2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan
| | - Daniel M Connochie
- 2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan
| | - Emily P Chen
- 1 Stroke Program, Department of Neurology, Michigan Medicine , Ann Arbor, Michigan.,2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan
| | - Bradford B Thompson
- 4 Department of Neurology, Alpert Medical School at Brown University , Providence, Rhode Island.,5 Department of Neurosurgery, Alpert Medical School at Brown University , Providence, Rhode Island
| | - Panayiotis N Varelas
- 6 Department of Neurology and Neurosurgery, Henry Ford Hospital , Detroit, Michigan
| | - Lewis B Morgenstern
- 1 Stroke Program, Department of Neurology, Michigan Medicine , Ann Arbor, Michigan.,7 Department of Epidemiology, University of Michigan School of Public Health , Ann Arbor, Michigan.,8 Department of Emergency Medicine, Michigan Medicine , Ann Arbor, Michigan
| | - Angela Fagerlin
- 2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan.,9 Department of Population Health Sciences, University of Utah School of Medicine , Salt Lake City, Utah.,10 Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance (IDEAS) , Salt Lake City, Utah
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Ménard C, Libert Y, Canivet D, Van Achte L, Farvacques C, Liénard A, Merckaert I, Reynaert C, Slachmuylder JL, Durieux JF, Klastersky J, Razavi D. Development of the Multi-Dimensional Analysis of Patient Outcome Predictions (MD.POP) during medical encounters. PATIENT EDUCATION AND COUNSELING 2018; 101:52-58. [PMID: 28784286 DOI: 10.1016/j.pec.2017.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 07/02/2017] [Accepted: 07/06/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Our first objective was to develop the Multi-Dimensional analysis of Patient Outcome Predictions (MD.POP), an interaction analysis system that assesses how HCPs discuss precisely and exclusively patient outcomes during medical encounters. The second objective was to study its interrater reliability. METHOD The MD.POP was developed by consensus meetings. Forty simulated medical encounters between physicians and an actress portraying a patient were analysed. Interrater reliability analysis was conducted on 20 of those simulated encounters. RESULTS The MD.POP includes six dimensions: object, framing, value, domain, probability and form of POP. The coding method includes four steps: 1) transcription of the encounter, 2) POP identification, 3) POP dimension coding and 4) POP scoring. Descriptive analyses show that the MD.POP is able to describe verbal expressions addressing the patient's outcomes. Statistical analyses show excellent interrater reliability (Cohen's Kappa ranging from 0.92 to 0.94). CONCLUSION The MD.POP is a reliable interaction analysis system that assesses how HCPs discuss patient medical, psychological or social outcomes during medical encounters. PRACTICAL IMPLICATION The MD.POP provides a measure for researchers to study how HCPs communicate with patients about potential outcomes. Results of such studies will allow to provide recommendations to improve HCP's communication about patients' outcomes.
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Affiliation(s)
- Catherine Ménard
- Unité de Recherche en Psychosomatique et en Psycho-oncologie, Université Libre de Bruxelles, Brussels, Belgium.
| | - Yves Libert
- Unité de Recherche en Psychosomatique et en Psycho-oncologie, Université Libre de Bruxelles, Brussels, Belgium; Institut Jules Bordet, Brussels, Belgium.
| | - Delphine Canivet
- Unité de Recherche en Psychosomatique et en Psycho-oncologie, Université Libre de Bruxelles, Brussels, Belgium; Hôpital Universitaire Erasme, Brussels, Belgium
| | - Laetitia Van Achte
- Faculté de Psychologie, Université Catholique de Louvain, Louvain-La-Neuve, Belgium
| | | | | | - Isabelle Merckaert
- Unité de Recherche en Psychosomatique et en Psycho-oncologie, Université Libre de Bruxelles, Brussels, Belgium; Institut Jules Bordet, Brussels, Belgium
| | - Christine Reynaert
- Faculté de Psychologie, Université Catholique de Louvain, Louvain-La-Neuve, Belgium
| | | | | | | | - Darius Razavi
- Unité de Recherche en Psychosomatique et en Psycho-oncologie, Université Libre de Bruxelles, Brussels, Belgium; Institut Jules Bordet, Brussels, Belgium
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32
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Bansback N, Bell M, Spooner L, Pompeo A, Han PKJ, Harrison M. Communicating Uncertainty in Benefits and Harms: A Review of Patient Decision Support Interventions. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2016; 10:311-319. [DOI: 10.1007/s40271-016-0210-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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