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Spurling GK, Dooley L, Clark J, Askew DA. Immediate versus delayed versus no antibiotics for respiratory infections. Cochrane Database Syst Rev 2023; 10:CD004417. [PMID: 37791590 PMCID: PMC10548498 DOI: 10.1002/14651858.cd004417.pub6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND Concerns exist regarding antibiotic prescribing for respiratory tract infections (RTIs) owing to adverse reactions, cost and antibacterial resistance. One proposed strategy to reduce antibiotic prescribing is to provide prescriptions, but to advise delay in antibiotic use with the expectation that symptoms will resolve first. This is an update of a Cochrane Review originally published in 2007, and updated in 2010, 2013 and 2017. OBJECTIVES To evaluate the effects on duration and/or severity of clinical outcomes (pain, malaise, fever, cough and rhinorrhoea), antibiotic use, antibiotic resistance and patient satisfaction of advising a delayed prescription of antibiotics in respiratory tract infections. SEARCH METHODS From May 2017 until 20 August 2022, this was a living systematic review with monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL and Web of Science. We also searched the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov on 20 August 2022. Due to the abundance of evidence supporting the review's key findings, it ceased being a living systematic review on 21 August 2022. SELECTION CRITERIA Randomised controlled trials involving participants of all ages with an RTI, where delayed antibiotics were compared to immediate or no antibiotics. We defined a delayed antibiotic as advice to delay the filling of an antibiotic prescription by at least 48 hours. We considered all RTIs regardless of whether antibiotics were recommended or not. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. MAIN RESULTS For this 2022 update, we added one new trial enrolling 448 children (436 analysed) with uncomplicated acute RTIs. Overall, this review includes 12 studies with a total of 3968 participants, of which data from 3750 are available for analysis. These 12 studies involved acute RTIs including acute otitis media (three studies), streptococcal pharyngitis (three studies), cough (two studies), sore throat (one study), common cold (one study) and a variety of RTIs (two studies). Six studies involved only children, two only adults and four included both adults and children. Six studies were conducted in primary care, four in paediatric clinics and two in emergency departments. Studies were well reported and appeared to provide moderate-certainty evidence. Randomisation was not adequately described in two trials. Four trials blinded the outcome assessor, and three included blinding of participants and doctors. We conducted meta-analyses for pain, malaise, fever, adverse effects, antibiotic use and patient satisfaction. Cough (four studies): we found no differences amongst delayed, immediate and no prescribed antibiotics for clinical outcomes in any of the four studies. Sore throat (six studies): for the outcome of fever with sore throat, four of the six studies favoured immediate antibiotics, and two found no difference. For the outcome of pain related to sore throat, two studies favoured immediate antibiotics, and four found no difference. Two studies compared delayed antibiotics with no antibiotic for sore throat, and found no difference in clinical outcomes. Acute otitis media (four studies): two studies compared immediate with delayed antibiotics - one found no difference for fever, and the other favoured immediate antibiotics for pain and malaise severity on Day 3. Two studies compared delayed with no antibiotics: one found no difference for pain and fever severity on Day 3, and the other found no difference for the number of children with fever on Day 3. Common cold (two studies): neither study found differences for clinical outcomes between delayed and immediate antibiotic groups. One study found delayed antibiotics were probably favoured over no antibiotics for pain, fever and cough duration (moderate-certainty evidence). ADVERSE EFFECTS there were either no differences for adverse effects or results may have favoured delayed over immediate antibiotics with no significant differences in complication rates (low-certainty evidence). Antibiotic use: delayed antibiotics probably resulted in a reduction in antibiotic use compared to immediate antibiotics (odds ratio (OR) 0.03, 95% confidence interval (CI) 0.01 to 0.07; 8 studies, 2257 participants; moderate-certainty evidence). However, a delayed antibiotic was probably more likely to result in reported antibiotic use than no antibiotics (OR 2.52, 95% CI 1.69 to 3.75; 5 studies, 1529 participants; moderate-certainty evidence). Patient satisfaction: patient satisfaction probably favoured delayed over no antibiotics (OR 1.45, 1.08 to 1.96; 5 studies, 1523 participants; moderate-certainty evidence). There was probably no difference in patient satisfaction between delayed and immediate antibiotics (OR 0.77, 95% CI 0.45 to 1.29; 7 studies, 1927 participants; moderate-certainty evidence). No studies evaluated antibiotic resistance. Reconsultation rates and use of alternative medicines were similar for delayed, immediate and no antibiotic strategies. In one of the four studies reporting use of alternative medicines, less paracetamol was used in the immediate group compared to the delayed group. AUTHORS' CONCLUSIONS For many clinical outcomes, there were no differences between prescribing strategies. Symptoms for acute otitis media and sore throat were modestly improved by immediate antibiotics compared with delayed antibiotics. There were no differences in complication rates. Delaying prescribing did not result in significantly different levels of patient satisfaction compared with immediate provision of antibiotics (86% versus 91%; moderate-certainty evidence). However, delay was favoured over no antibiotics (87% versus 82%). Delayed antibiotics achieved lower rates of antibiotic use compared to immediate antibiotics (30% versus 93%). The strategy of no antibiotics further reduced antibiotic use compared to delaying prescription for antibiotics (13% versus 27%). Delayed antibiotics for people with acute respiratory infection reduced antibiotic use compared to immediate antibiotics, but was not shown to be different to no antibiotics in terms of symptom control and disease complications. Where clinicians feel it is safe not to prescribe antibiotics immediately for people with RTIs, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use while maintaining similar patient satisfaction and clinical outcomes to delayed antibiotics. Where clinicians are not confident in not prescribing antibiotics, delayed antibiotics may be an acceptable compromise in place of immediate prescribing to significantly reduce unnecessary antibiotic use for RTIs, while maintaining patient safety and satisfaction levels. Further research into antibiotic prescribing strategies for RTIs may best be focused on identifying patient groups at high risk of disease complications, enhancing doctors' communication with patients to maintain satisfaction, ways of increasing doctors' confidence to not prescribe antibiotics for RTIs, and policy measures to reduce unnecessary antibiotic prescribing for RTIs.
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Affiliation(s)
- Geoffrey Kp Spurling
- General Practice Clinical Unit, Medical School, The University of Queensland, Brisbane, Australia
| | - Liz Dooley
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Deborah A Askew
- General Practice Clinical Unit, Medical School, The University of Queensland, Brisbane, Australia
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Ben Charif A, Croteau J, Adekpedjou R, Zomahoun HTV, Adisso EL, Légaré F. Implementation Research on Shared Decision Making in Primary Care: Inventory of Intracluster Correlation Coefficients. Med Decis Making 2019; 39:661-672. [PMID: 31423898 DOI: 10.1177/0272989x19866296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Cluster randomized trials are important sources of information on evidence-based practices in primary care. However, there are few sources of intracluster correlation coefficients (ICCs) for designing such trials. We inventoried ICC estimates for shared decision-making (SDM) measures in primary care. Methods. Data sources were studies led by the Canada Research Chair in Shared Decision Making and Knowledge Transition. Eligible studies were conducted in primary care, included at least 2 hierarchical levels, included SDM measures for individual units nested under any type of cluster (area, clinic, or provider), and were approved by an ethics committee. We classified measures into decision antecedents, decision processes, and decision outcomes. We used Bayesian random-effect models to estimate mode ICCs and the 95% highest probability density interval (HPDI). We summarized estimates by calculating median and interquartile range (IQR). Results. Six of 14 studies were included. There were 97 ICC estimates for 17 measures. ICC estimates ranged from 0 to 0.5 (median, 0.03; IRQ, 0-0.07). They were higher for process measures (median, 0.03; IQR, 0-0.07) than for antecedent measures (0.02; 0-0.07) or outcome measures (0.02; 0-0.06), for which, respectively, "decisional conflict" (mode, 0.48; 95% HPDI, 0.39-0.57), "reluctance to disclose uncertainty to patients" (0.5; 0.11-0.89), and "quality of the decision" (0.45; 0.14-0.84) had the highest ICCs. ICCs for provider-level clustering (median, 0.06; IQR, 0-0.13) were higher than for other levels. Limitations. This convenience sample of studies may not reflect all potential ICC ranges for primary care SDM measures. Conclusions. Our inventory of ICC estimates for SDM measures in primary care will improve the ease and accuracy of power calculations in cluster randomized trials and inspire its further expansion in SDM contexts.
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Affiliation(s)
- Ali Ben Charif
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Quebec, QC, Canada.,Health and Social Services Systems, Knowledge Translation and Implementation component of the Quebec SPOR-SUPPORT Unit, Université Laval, Quebec, QC, Canada.,Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval, Quebec, QC, Canada.,Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada
| | - Jordie Croteau
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Quebec, QC, Canada.,Health and Social Services Systems, Knowledge Translation and Implementation component of the Quebec SPOR-SUPPORT Unit, Université Laval, Quebec, QC, Canada.,Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval, Quebec, QC, Canada
| | - Rhéda Adekpedjou
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Quebec, QC, Canada.,Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval, Quebec, QC, Canada
| | - Hervé Tchala Vignon Zomahoun
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Quebec, QC, Canada.,Health and Social Services Systems, Knowledge Translation and Implementation component of the Quebec SPOR-SUPPORT Unit, Université Laval, Quebec, QC, Canada
| | - Evehouenou Lionel Adisso
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Quebec, QC, Canada.,Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval, Quebec, QC, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Quebec, QC, Canada.,Health and Social Services Systems, Knowledge Translation and Implementation component of the Quebec SPOR-SUPPORT Unit, Université Laval, Quebec, QC, Canada.,Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval, Quebec, QC, Canada.,Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada
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Giguere AMC, Lawani MA, Fortier-Brochu É, Carmichael PH, Légaré F, Kröger E, Witteman HO, Voyer P, Caron D, Rodríguez C. Tailoring and evaluating an intervention to improve shared decision-making among seniors with dementia, their caregivers, and healthcare providers: study protocol for a randomized controlled trial. Trials 2018; 19:332. [PMID: 29941020 PMCID: PMC6019313 DOI: 10.1186/s13063-018-2697-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 05/17/2018] [Indexed: 11/13/2022] Open
Abstract
Background The increasing prevalence of Alzheimer’s disease and other forms of dementia raises new challenges to ensure that healthcare decisions are informed by research evidence and reflect what is important for seniors and their caregivers. Therefore, we aim to evaluate a tailored intervention to help healthcare providers empower seniors and their caregivers in making health-related decisions. Methods In two phases, we will: (1) design and tailor the intervention; and (2) implement and evaluate it. We will use theory and user-centered design to tailor an intervention comprising a distance professional training program on shared decision-making and five shared decision-making tools dealing with difficult decisions often faced by seniors with dementia and their caregivers. Each tool will be designed in two versions, one for clinicians and one for patients. We will recruit 49 clinicians and 27 senior/caregiver to participate in three cycles of design-evaluation-feedback of each intervention components. Besides think-aloud and interview approaches, users will also complete questionnaires based on the Theory of Planned Behavior to identify the factors most likely to influence their adoption of shared decision-making after exposure to the intervention. We will then modify the intervention by adding/enhancing behavior-change techniques targeting these factors. We will evaluate the effectiveness of this tailored intervention before/after implementation, in a two-armed, clustered randomized trial. We will enroll a convenience sample of six primary care clinics (unit of randomization) in the province of Quebec and recruit the clinicians who practice there (mostly family physicians, nurses, and social workers). These clinics will then be randomized to immediate exposure to the intervention or delayed exposure. Overall, we will recruit 180 seniors with dementia, their caregivers, and their healthcare providers. We will evaluate the impact of the intervention on patient involvement in the decision-making process, decisional comfort, patient and caregiver personal empowerment in relation to their own healthcare, patient quality of life, caregiver burden, and decisional regret. Discussion The intervention will empower patients and their caregivers in their healthcare, by fostering their participation as partners during the decision-making process and by ensuring they make informed decisions congruent with their values and priorities. Trial registration ClinicalTrials.org, NCT02956694. Registered on 31 October 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2697-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anik M C Giguere
- Department of Family Medicine and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, room 2881-C, 1050 avenue de la Médecine, Quebec, QC, G1V 0A6, Canada. .,Quebec Centre for Excellence on Aging, St-Sacrement Hospital, Room L2-21, 1050, chemin Sainte-Foy, Quebec City, Quebec, Canada. .,Laval University Research Centre on Primary Care and Services, Quebec City, Quebec, Canada. .,Research Axis of Population Health and Practice-Changing Research Group, CHU de Quebec Research Centre, Quebec city, QC, Canada.
| | - Moulikatou Adouni Lawani
- Department of Family Medicine and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, room 2881-C, 1050 avenue de la Médecine, Quebec, QC, G1V 0A6, Canada.,Quebec Centre for Excellence on Aging, St-Sacrement Hospital, Room L2-21, 1050, chemin Sainte-Foy, Quebec City, Quebec, Canada.,Laval University Research Centre on Primary Care and Services, Quebec City, Quebec, Canada
| | - Émilie Fortier-Brochu
- Department of Family Medicine and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, room 2881-C, 1050 avenue de la Médecine, Quebec, QC, G1V 0A6, Canada.,Quebec Centre for Excellence on Aging, St-Sacrement Hospital, Room L2-21, 1050, chemin Sainte-Foy, Quebec City, Quebec, Canada.,Laval University Research Centre on Primary Care and Services, Quebec City, Quebec, Canada
| | - Pierre-Hugues Carmichael
- Quebec Centre for Excellence on Aging, St-Sacrement Hospital, Room L2-21, 1050, chemin Sainte-Foy, Quebec City, Quebec, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, room 2881-C, 1050 avenue de la Médecine, Quebec, QC, G1V 0A6, Canada.,Faculty of Nursing Sciences, Laval University, Pavillon Ferdinand-Vandry, room 2881-C, 1050, avenue de la Médecine, Quebec, QC, G1V 0A6, Canada
| | - Edeltraut Kröger
- Quebec Centre for Excellence on Aging, St-Sacrement Hospital, Room L2-21, 1050, chemin Sainte-Foy, Quebec City, Quebec, Canada.,Research Axis of Population Health and Practice-Changing Research Group, CHU de Quebec Research Centre, Quebec city, QC, Canada.,Faculty of Pharmacy, Laval University, St-Sacrement Hospital, Room L2-30, 1050, Chemin Sainte-Foy, Québec, QC, G1S 4L8, Canada
| | - Holly O Witteman
- Department of Family Medicine and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, room 2881-C, 1050 avenue de la Médecine, Quebec, QC, G1V 0A6, Canada.,Quebec Centre for Excellence on Aging, St-Sacrement Hospital, Room L2-21, 1050, chemin Sainte-Foy, Quebec City, Quebec, Canada.,Research Axis of Population Health and Practice-Changing Research Group, CHU de Quebec Research Centre, Quebec city, QC, Canada
| | - Philippe Voyer
- Quebec Centre for Excellence on Aging, St-Sacrement Hospital, Room L2-21, 1050, chemin Sainte-Foy, Quebec City, Quebec, Canada.,Faculty of Nursing Sciences, Laval University, Pavillon Ferdinand-Vandry, room 2881-C, 1050, avenue de la Médecine, Quebec, QC, G1V 0A6, Canada
| | - Danielle Caron
- Department of Family Medicine and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, room 2881-C, 1050 avenue de la Médecine, Quebec, QC, G1V 0A6, Canada
| | - Charo Rodríguez
- Department of Family Medicine, Faculty of Medicine, McGill University, 5858 chemin de la Cote-des-Neiges, 3rd floor, Suite 300, Room 328, Montreal, Quebec, Canada
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Spurling GK, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotic prescriptions for respiratory infections. Cochrane Database Syst Rev 2017; 9:CD004417. [PMID: 28881007 PMCID: PMC6372405 DOI: 10.1002/14651858.cd004417.pub5] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Concerns exist regarding antibiotic prescribing for respiratory tract infections (RTIs) owing to adverse reactions, cost, and antibacterial resistance. One proposed strategy to reduce antibiotic prescribing is to provide prescriptions, but to advise delay in antibiotic use with the expectation that symptoms will resolve first. This is an update of a Cochrane Review originally published in 2007, and updated in 2010 and 2013. OBJECTIVES To evaluate the effects on clinical outcomes, antibiotic use, antibiotic resistance, and patient satisfaction of advising a delayed prescription of antibiotics in respiratory tract infections. SEARCH METHODS For this 2017 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 4, 2017), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register; Ovid MEDLINE (2013 to 25 May 2017); Ovid Embase (2013 to 2017 Week 21); EBSCO CINAHL Plus (1984 to 25 May 2017); Web of Science (2013 to 25 May 2017); WHO International Clinical Trials Registry Platform (1 September 2017); and ClinicalTrials.gov (1 September 2017). SELECTION CRITERIA Randomised controlled trials involving participants of all ages defined as having an RTI, where delayed antibiotics were compared to immediate antibiotics or no antibiotics. We defined a delayed antibiotic as advice to delay the filling of an antibiotic prescription by at least 48 hours. We considered all RTIs regardless of whether antibiotics were recommended or not. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. Three review authors independently extracted and collated data. We assessed the risk of bias of all included trials. We contacted trial authors to obtain missing information. MAIN RESULTS For this 2017 update we added one new trial involving 405 participants with uncomplicated acute respiratory infection. Overall, this review included 11 studies with a total of 3555 participants. These 11 studies involved acute respiratory infections including acute otitis media (three studies), streptococcal pharyngitis (three studies), cough (two studies), sore throat (one study), common cold (one study), and a variety of RTIs (one study). Five studies involved only children, two only adults, and four included both adults and children. Six studies were conducted in a primary care setting, three in paediatric clinics, and two in emergency departments.Studies were well reported, and appeared to be of moderate quality. Randomisation was not adequately described in two trials. Four trials blinded the outcomes assessor, and three included blinding of participants and doctors. We conducted meta-analysis for antibiotic use and patient satisfaction.We found no differences among delayed, immediate, and no prescribed antibiotics for clinical outcomes in the three studies that recruited participants with cough. For the outcome of fever with sore throat, three of the five studies favoured immediate antibiotics, and two found no difference. For the outcome of pain related to sore throat, two studies favoured immediate antibiotics, and three found no difference. One study compared delayed antibiotics with no antibiotic for sore throat, and found no difference in clinical outcomes.Three studies included participants with acute otitis media. Of the two studies with an immediate antibiotic arm, one study found no difference for fever, and the other study favoured immediate antibiotics for pain and malaise severity on Day 3. One study including participants with acute otitis media compared delayed antibiotics with no antibiotics and found no difference for pain and fever on Day 3.Two studies recruited participants with common cold. Neither study found differences for clinical outcomes between delayed and immediate antibiotic groups. One study favoured delayed antibiotics over no antibiotics for pain, fever, and cough duration (moderate quality evidence for all clinical outcomes - GRADE assessment).There were either no differences for adverse effects or results favoured delayed antibiotics over immediate antibiotics (low quality evidence - to GRADE assessment) with no significant differences in complication rates. Delayed antibiotics resulted in a significant reduction in antibiotic use compared to immediate antibiotics prescription (odds ratio (OR) 0.04, 95% confidence interval (CI) 0.03 to 0.05). However, a delayed antibiotic was more likely to result in reported antibiotic use than no antibiotics (OR 2.55, 95% CI 1.59 to 4.08) (moderate quality evidence - GRADE assessment).Patient satisfaction favoured delayed over no antibiotics (OR 1.49, 95% CI 1.08 to 2.06). There was no significant difference in patient satisfaction between delayed antibiotics and immediate antibiotics (OR 0.65, 95% CI 0.39 to 1.10) (moderate quality evidence - GRADE assessment).None of the included studies evaluated antibiotic resistance. AUTHORS' CONCLUSIONS For many clinical outcomes, there were no differences between prescribing strategies. Symptoms for acute otitis media and sore throat were modestly improved by immediate antibiotics compared with delayed antibiotics. There were no differences in complication rates. Delaying prescribing did not result in significantly different levels of patient satisfaction compared with immediate provision of antibiotics (86% versus 91%) (moderate quality evidence). However, delay was favoured over no antibiotics (87% versus 82%). Delayed antibiotics achieved lower rates of antibiotic use compared to immediate antibiotics (31% versus 93%) (moderate quality evidence). The strategy of no antibiotics further reduced antibiotic use compared to delaying prescription for antibiotics (14% versus 28%). Delayed antibiotics for people with acute respiratory infection reduced antibiotic use compared to immediate antibiotics, but was not shown to be different to no antibiotics in terms of symptom control and disease complications. Where clinicians feel it is safe not to prescribe antibiotics immediately for people with respiratory infections, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use while maintaining similar patient satisfaction and clinical outcomes to delaying prescription of antibiotics. Where clinicians are not confident in using a no antibiotic strategy, a delayed antibiotics strategy may be an acceptable compromise in place of immediate prescribing to significantly reduce unnecessary antibiotic use for RTIs, and thereby reduce antibiotic resistance, while maintaining patient safety and satisfaction levels.Editorial note: As a living systematic review, this review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Geoffrey Kp Spurling
- Discipline of General Practice, School of Medicine, The University of Queensland, Herston, Brisbane, Queensland, Australia, 4029
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5
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Wyatt KD, List B, Brinkman WB, Prutsky Lopez G, Asi N, Erwin P, Wang Z, Domecq Garces JP, Montori VM, LeBlanc A. Shared Decision Making in Pediatrics: A Systematic Review and Meta-analysis. Acad Pediatr 2015; 15:573-83. [PMID: 25983006 DOI: 10.1016/j.acap.2015.03.011] [Citation(s) in RCA: 196] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Little is known about the impact of interventions to support shared decision making (SDM) with pediatric patients. OBJECTIVES To summarize the efficacy of SDM interventions in pediatrics on patient-centered outcomes. DATA SOURCES We searched Ovid Medline, Ovid Embase, Ovid Cochrane Library, Web of Science, Scopus, and Ovid PsycInfo from database inception to December 30, 2013, and performed an environmental scan. STUDY ELIGIBILITY CRITERIA We included interventions designed to engage pediatric patients, parents, or both in a medical decision, regardless of study design or reported outcomes. STUDY APPRAISAL AND SYNTHESIS METHODS We reviewed all studies in duplicate for inclusion, data extraction, and risk of bias assessment. Meta-analysis was performed on 3 outcomes: knowledge, decisional conflict, and satisfaction. RESULTS Sixty-one citations describing 54 interventions met eligibility criteria. Fifteen studies reported outcomes such that they were eligible for inclusion in meta-analysis. Heterogeneity across studies was high. Meta-analysis revealed SDM interventions significantly improved knowledge (standardized mean difference [SMD] 1.21, 95% confidence interval [CI] 0.26 to 2.17, P = .01) and reduced decisional conflict (SMD -1.20, 95% CI -2.01 to -0.40, P = .003). Interventions showed a nonsignificant trend toward increased satisfaction (SMD 0.37, 95% CI -0.04 to 0.78, P = .08). LIMITATIONS Included studies were heterogeneous in nature, including their conceptions of SDM. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS A limited evidence base suggests that pediatric SDM interventions improve knowledge and decisional conflict, but their impact on other outcomes is unclear. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42013004761 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004761).
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Affiliation(s)
- Kirk D Wyatt
- Pediatric and Adolescent Medicine Residency Program, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, Minn; Mayo Medical School, Mayo Clinic, Rochester, Minn; Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn
| | - Betsy List
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William B Brinkman
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Gabriela Prutsky Lopez
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Unidad de Conocimiento y Evidencia, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine/Detroit Medical Center, Detroit, Mich
| | - Noor Asi
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn
| | | | - Zhen Wang
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn
| | - Juan Pablo Domecq Garces
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Unidad de Conocimiento y Evidencia, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Internal Medicine, Henry Ford Hospital, Detroit, Mich
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minn; Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minn
| | - Annie LeBlanc
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minn.
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Bragard I, Fleet R, Etienne AM, Archambault P, Légaré F, Chauny JM, Lévesque JF, Ouimet M, Poitras J, Dupuis G. Quality of work life of rural emergency department nurses and physicians: a pilot study. BMC Res Notes 2015; 8:116. [PMID: 25889231 PMCID: PMC4392803 DOI: 10.1186/s13104-015-1075-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 03/19/2015] [Indexed: 11/30/2022] Open
Abstract
Background Information about recruitment and retention factors and quality of work life (QWL) in rural emergency departments (EDs) is limited. A pilot study was used to determine the feasibility of a large-scale study of these variables in Quebec EDs. Methods Two EDs, approximately 10,000 and 30,000 patients per year respectively, were selected as convenience samples. An online survey containing the Quality of Work Life Systemic Inventory (QWLSI; 34 items) and the Recruitment and Retention Factors Questionnaire (39 items) was sent to ED nurses and physicians of these two EDs. Descriptive statistics of percentage, mean and standard deviation and correlations were used to analyse the data. Results Forty out of 64 eligible workers (62%) gave their consent to participate, but only 20 had completed both questionnaires. Participants’ mean age was 42 years (SD = 11.6). The average participants satisfaction with their access to continuing education was low (Mean = 1.6, SD = 0.8). However, their satisfaction with technical resources (Mean = 2.4, SD = 0.7), pre-hospital and inter-hospital transfer services (Mean = 2.5, SD = 0.6), relationships with colleagues (Mean = 2.7, SD = 0.6) and managers (Mean = 2.2, SD = 0.7), work-life balance (Mean = 2.4, SD = 0.6) and emergency patient access to other departments (Mean = 3.7, SD = 0.6) was in the average. The impact of several aspects of the rural environment (e.g. tranquility) on quality of life was also in the average (Mean = 2.5, SD = 0.7). QWL was in the average, excepted subscale ‘support offered to employee’ for which the QWL was lower. Conclusions Data collection was difficult and the larger study will require strategies to improve recruitment such as a paper alternative. The study showed globally good recruitment and retention factors and QWL for these ED nurses and physicians. These results will help hospital administrations better plan initiatives aimed at improving retention and QWL.
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Affiliation(s)
- Isabelle Bragard
- Health Psychology Unit, Liège, Université de Liège, Liège, Belgium.
| | - Richard Fleet
- Department of Family and Emergency Medicine, Research Centre of the Hôtel-Dieu de Lévis Hospital, Université Laval, Lévis, Canada. .,Research Centre of the Hôtel-Dieu de Lévis Hospital, Université Laval, 143 Wolfe Street, Lévis, QC, G6V 3Z1, Canada.
| | | | - Patrick Archambault
- Department of Family and Emergency Medicine, Research Centre of the Hôtel-Dieu de Lévis Hospital, Université Laval, Lévis, Canada.
| | - France Légaré
- Department of Family and Emergency Medicine, Knowledge Transfer and Health Technology Assessment of the CHUQ Research Centre (CRCHUQ), Unité de Recherche Evaluative, Université Laval, Quebec City, Canada.
| | - Jean-Marc Chauny
- Department of Family and Emergency Medicine, Research Centre of the Hôtel-Dieu de Lévis Hospital, Université Laval, Lévis, Canada.
| | - Jean-Frédéric Lévesque
- Direction des Systèmes de soins et services, Institut national de santé publique du Québec, Montréal, Québec, Canada.
| | - Mathieu Ouimet
- Département de science politique, Pavillon Charles-De Koninck, Université Laval, Quebec City, Canada.
| | - Julien Poitras
- Department of Family and Emergency Medicine, Research Centre of the Hôtel-Dieu de Lévis Hospital, Université Laval, Lévis, Canada.
| | - Gilles Dupuis
- Department of Psychology, Université du Québec à Montréal, Montreal, QC, Canada. .,Centre de liaison sur l'intervention et la prévention psychosociales (CLIPP), Montreal, QC, Canada.
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Mustafa M, Wood F, Butler CC, Elwyn G. Managing expectations of antibiotics for upper respiratory tract infections: a qualitative study. Ann Fam Med 2014; 12:29-36. [PMID: 24445101 PMCID: PMC3896536 DOI: 10.1370/afm.1583] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Communication experts have suggested that it is good practice to ask patients' directly whether they expect to receive antibiotics as part of asking about the triad of ideas, concerns, and expectations for health care. Our aim was to explore the views and experiences of family physicians about using this strategy with their patients, focusing the interview on the problem of eliciting expectations of antibiotics as a possible treatment for upper respiratory tract infections. METHODS We conducted a qualitative study using semistructured interviews with 20 family physicians in South Wales, United Kingdom, and performing thematic analysis. RESULTS Family physicians assumed most patients or parents wanted antibiotics, as well as wanting to be "checked out" to make sure the illness was "nothing serious." Physicians said they did not ask direct questions about expectations, as that might lead to confrontation. They preferred to elicit expectations for antibiotics in an indirect manner, before performing a physical examination. The majority described reporting their findings of the examination as a "running commentary" so as to influence expectations and help avoid generating resistance to a soon-to-be-made-explicit plan not to prescribe antibiotics. The physicians used the running commentary to preserve and enhance the physician-patient relationship. CONCLUSIONS Real-world family physicians use indirect methods to explore expectations for treatment and, on the basis of their physical examination, build an argument for reassuring the patient or parent. In contrast to proposed models in the communication literature, interventions to promote appropriate antibiotic prescribing might include a focus on training in communication skills that (1) integrates these indirect methods as part of building collaborative physician-patient relationships and (2) uses the running commentary of examination findings to facilitate participation in clinical decisions.
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Affiliation(s)
- Mohammed Mustafa
- Cochrane Institute of Primary Care and Public Health, Cardiff University School of Medicine, Cardiff, United Kingdom
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Légaré F, Guerrier M, Nadeau C, Rhéaume C, Turcotte S, Labrecque M. Impact of DECISION + 2 on patient and physician assessment of shared decision making implementation in the context of antibiotics use for acute respiratory infections. Implement Sci 2013; 8:144. [PMID: 24369771 PMCID: PMC3879432 DOI: 10.1186/1748-5908-8-144] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 12/23/2013] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND DECISION + 2, a training program for physicians, is designed to implement shared decision making (SDM) in the context of antibiotics use for acute respiratory tract infections (ARTIs). We evaluated the impact of DECISION + 2 on SDM implementation as assessed by patients and physicians, and on physicians' intention to engage in SDM. METHODS From 2010 to 2011, a multi-center, two-arm, parallel randomized clustered trial appraised the effects of DECISION + 2 on the decision to use antibiotics for patients consulting for ARTIs. We randomized 12 family practice teaching units (FPTUs) to either DECISION + 2 or usual care. After the consultation, both physicians and patients independently completed questionnaires based on the D-Option scale regarding SDM behaviors during the consultation. Patients also answered items assessing the role they assumed during the consultation (active/collaborative/passive). Before and after the intervention, physicians completed a questionnaire based on the Theory of Planned Behavior to measure their intention to engage in SDM. To account for the cluster design, we used generalized estimating equations and generalized linear mixed models to assess the impact of DECISION + 2 on the outcomes of interest. RESULTS A total of 270 physicians (66% women) participated in the study. After DECISION + 2, patients' D-Option scores were 80.1 ± 1.1 out of 100 in the intervention group and 74.9 ± 1.1 in the control group (p = 0.001). Physicians' D-Option scores were 79.7 ± 1.8 in the intervention group and 76.3 ± 1.9 in the control group (p = 0.2). However, subgroup analyses showed that teacher physicians D-Option scores were 79.7 ± 1.5 and 73.0 ± 1.4 respectively (p = 0.001). More patients reported assuming an active or collaborative role in the intervention group (67.1%), than in the control group (49.2%) (p = 0.04). There was a significant relation between patients' and physicians' D-Option scores (p < 0.01) and also between patient-reported assumed roles and both D-Option scores (as assessed by patients, p < 0.01; and physicians, p = 0.01). DECISION + 2 had no impact on the intention of physicians to engage in SDM. CONCLUSION DECISION + 2 positively influenced SDM behaviors as assessed by patients and teacher physicians. Physicians' intention to engage in SDM was not affected by DECISION + 2. TRIAL REGISTRATION ClinicalTrials.gov trials register no. NCT01116076.
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Affiliation(s)
- France Légaré
- Research Center of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d’Assise, 10, Rue Espinay, Quebec City, QC G1L 3 L5, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, QC, Canada
| | - Mireille Guerrier
- Research Center of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d’Assise, 10, Rue Espinay, Quebec City, QC G1L 3 L5, Canada
| | - Catherine Nadeau
- Research Center of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d’Assise, 10, Rue Espinay, Quebec City, QC G1L 3 L5, Canada
| | - Caroline Rhéaume
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, QC, Canada
- Research Center of Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, QC, Canada
| | - Stéphane Turcotte
- Research Center of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d’Assise, 10, Rue Espinay, Quebec City, QC G1L 3 L5, Canada
| | - Michel Labrecque
- Research Center of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d’Assise, 10, Rue Espinay, Quebec City, QC G1L 3 L5, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, QC, Canada
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Abstract
BACKGROUND Concerns exist regarding antibiotic prescribing for acute respiratory tract infections (ARTIs) owing to adverse reactions, cost and antibacterial resistance. One strategy to reduce antibiotic prescribing is to provide prescriptions but to advise delay in the hope symptoms will resolve first. This is an update of a Cochrane Review originally published in 2007 and updated in 2010. OBJECTIVES To evaluate the use of delayed antibiotics compared to immediate or no antibiotics as a prescribing strategy for ARTIs. We evaluated clinical outcomes including duration and severity measures for pain, malaise, fever, cough and rhinorrhoea in sore throat, acute otitis media, bronchitis (cough) and the common cold. We also evaluated the outcomes of antibiotic use, patient satisfaction, antibiotic resistance and re-consultation rates and use of alternative therapies. SEARCH METHODS We searched CENTRAL (The Cochrane Library 2013, Issue 2), which includes the Acute Respiratory Infection Group's Specialised Register; Ovid MEDLINE (January 1966 to February Week 3 2013); Ovid MEDLINE In-Process & Other Non-Indexed Citations (28 February 2013); EMBASE (1990 to 2013 Week 08); Science Citation Index - Web of Science (2007 to May 2012) and EBSCO CINAHL (1982 to 28 February 2013). SELECTION CRITERIA Randomised controlled trials (RCTs) involving participants of all ages defined as having an ARTI, where delayed antibiotics were compared to antibiotics used immediately or no antibiotics. DATA COLLECTION AND ANALYSIS Three review authors independently extracted and collected data. Important adverse effects, including adverse effects of antibiotics and complications of disease, were included as secondary outcomes. We assessed the risk of bias of all included trials. We contacted trial authors to obtain missing information where available. MAIN RESULTS Ten studies, with a total of 3157 participants, were included in this review. Heterogeneity of the 10 included studies and their results generally precluded meta-analysis with patient satisfaction being an exception.There was no difference between delayed, immediate and no prescribed antibiotics for the clinical outcomes evaluated in cough and common cold. In patients with acute otitis media (AOM) and sore throat immediate antibiotics were more effective than delayed for fever, pain and malaise in some studies. There were only minor differences in adverse effects with no significant difference in complication rates.Delayed antibiotics resulted in a significant reduction in antibiotic use compared to immediate antibiotics. A strategy of no antibiotics resulted in least antibiotic use.Patient satisfaction favoured immediate antibiotics over delayed (odds ratio (OR) 0.52; 95% confidence interval (CI) 0.35 to 0.76). Delayed and no antibiotics had similar satisfaction rates with both strategies achieving over 80% satisfaction (OR 1.44; 95% CI 0.99 to 2.10).There was no difference in re-consultation rates for immediate and delayed groups.None of the included studies evaluated antibiotic resistance. AUTHORS' CONCLUSIONS Most clinical outcomes show no difference between strategies. Delay slightly reduces patient satisfaction compared to immediate antibiotics (87% versus 92%) but not compared to none (87% versus 83%). In patients with respiratory infections where clinicians feel it is safe not to prescribe antibiotics immediately, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use, while maintaining similar patient satisfaction and clinical outcomes to delayed antibiotics.
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Körner M, Ehrhardt H, Steger AK, Bengel J. Interprofessional SDM train-the-trainer program "Fit for SDM": provider satisfaction and impact on participation. PATIENT EDUCATION AND COUNSELING 2012; 89:122-128. [PMID: 22647558 DOI: 10.1016/j.pec.2012.04.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 04/03/2012] [Accepted: 04/09/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE The aim of the study was to evaluate the interprofessional SDM training program "Fit for SDM" in medical rehabilitation, which was implemented in two steps: (1) university staff trained providers in executive positions as trainers and (2) the providers trained their staff. METHODS For the evaluation of the first step a questionnaire for shared decision-making (SDM) skills and satisfaction with the training was completed by the providers in executive positions. A staff survey was used in a cluster-randomized controlled study to determine the overall impact of the train-the-trainer program on internal and external participation in the team. RESULTS The providers in the six clinics evaluated their SDM competences and satisfaction very positively after training (step 1). External participation was enhanced by application of the training content, with significant changes recorded for females and nurses in particular. However, it had no direct influence on internal participation. CONCLUSIONS This is the first interprofessional SDM train-the-trainer program in Germany to bridge interprofessionalism (internal participation) and SDM (external participation); it was implemented successfully and evaluated positively. PRACTICE IMPLICATIONS Establishing interprofessional SDM training programs should be encouraged for all health care professionals. Implementation in the interprofessional setting should consider interprofessional team factors.
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Affiliation(s)
- Mirjam Körner
- Department of Medical Psychology and Medical Sociology, University of Freiburg, Freiburg, Germany.
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Giguère A, Labrecque M, Njoya M, Thivierge R, Légaré F. Development of PRIDe: a tool to assess physicians' preference of role in clinical decision making. PATIENT EDUCATION AND COUNSELING 2012; 88:277-283. [PMID: 22543001 DOI: 10.1016/j.pec.2012.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 02/11/2012] [Accepted: 03/02/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To develop and evaluate items for inclusion in PRIDe (Preferred Role in Decision Making), a new tool to assess changes of role preference among professionals exposed to training in shared decision making (SDM). METHODS This study was part of a pilot trial to evaluate the effectiveness of SDM training on the doctors' prescription of antibiotics for acute respiratory infections. Thirty-nine family physicians were randomized to immediate exposure to training or to delayed exposure. Potential items for PRIDe and a questionnaire about physicians' intention to engage in SDM were administered at baseline and at follow-up. RESULTS Following analysis, we retained five items that captured a change in physicians' preference. The items' scores were pooled and the resulting tool showed limited internal consistency (Cronbach's alpha = 0.41) but significant test-retest reliability (immediate group: P = 0.03; delayed group: P = 0.008) and acceptable discriminant validity, with patients involved in decision making more actively after training than before (Fisher's test, P = .02). CONCLUSION This initial step to develop an evaluation tool to assess changes in doctors' preference of role in decision making following SDM training shows promising results. The next step is to develop more clinical vignettes followed by questions inspired from this analysis. PRACTICE IMPLICATIONS The PRIDe instrument can be used in the assessment of health professionals' attitude towards shared decision making after training in shared decision making. Additional research is needed to evaluate its validity before it can be recommended for use.
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Affiliation(s)
- Anik Giguère
- Health Information Research Unit, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
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Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ 2012; 184:E726-34. [PMID: 22847969 DOI: 10.1503/cmaj.120568] [Citation(s) in RCA: 154] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Few interventions have proven effective in reducing the overuse of antibiotics for acute respiratory infections. We evaluated the effect of DECISION+2, a shared decision-making training program, on the percentage of patients who decided to take antibiotics after consultation with a physician or resident. METHODS We performed a randomized trial, clustered at the level of family practice teaching unit, with 2 study arms: DECISION+2 and control. The DECISION+2 training program included a 2-hour online tutorial followed by a 2-hour interactive seminar about shared decision-making. The primary outcome was the proportion of patients who decided to use antibiotics immediately after consultation. We also recorded patients' perception that shared decision-making had occurred. Two weeks after the initial consultation, we assessed patients' adherence to the decision, repeat consultation, decisional regret and quality of life. RESULTS We compared outcomes among 181 patients who consulted 77 physicians in 5 family practice teaching units in the DECISION+2 group, and 178 patients who consulted 72 physicians in 4 family practice teaching units in the control group. The percentage of patients who decided to use antibiotics after consultation was 52.2% in the control group and 27.2% in the DECISION+2 group (absolute difference 25.0%, adjusted relative risk 0.48, 95% confidence interval 0.34-0.68). DECISION+2 was associated with patients taking a more active role in decision-making (Z = 3.9, p < 0.001). Patient outcomes 2 weeks after consultation were similar in both groups. INTERPRETATION The shared decision-making program DECISION+2 enhanced patient participation in decision-making and led to fewer patients deciding to use antibiotics for acute respiratory infections. This reduction did not have a negative effect on patient outcomes 2 weeks after consultation. ClinicalTrials.gov trial register no. NCT01116076.
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Affiliation(s)
- France Légaré
- Research Centre of the Centre Hospitalier Universitaire de Québec, Québec, Canada.
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Allaire AS, Labrecque M, Giguere A, Gagnon MP, Légaré F. What motivates family physicians to participate in training programs in shared decision making? THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2012; 32:98-107. [PMID: 22733637 DOI: 10.1002/chp.21132] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Little is known about the factors that influence family physician (FP) participation in continuing professional development (CPD) programs in shared decision making (SDM). We sought to identify the factors that motivate FPs to participate in DECISION+, a CPD program in SDM. METHODS In 2007-2008, we collected data from 39 FPs who participated in a pilot randomized trial of DECISION+. In 2010, we collected data again from 11 of those participants and from 12 new subjects. Based on the theory of planned behavior, our questionnaire assessed FPs' intentions to participate in a CPD program in SDM and evaluated FPs' attitudes, subjective norms and perceived behavioral control. We also conducted 4 focus groups to explore FPs' salient beliefs. RESULTS In 2010, FPs' mean intention to participate in a CPD program in SDM was relatively strong (2.6 ± 0.5 on a scale from -3 = "strongly disagree" to +3 = "strongly agree"). Affective attitude was the only factor significantly associated with intention (r = .51, p = .04). FPs identified the attractions of participating in a CPD program in SDM as (1) its interest, (2) the pleasure of learning, and (3) professional stimulation. Facilitators of their participation were (1) a relevant clinical topic, (2) an interactive program, (3) an accessible program, and (4) decision support tools. DISCUSSION To attract FPs to a CPD program in SDM, CPD developers should make the program interesting, enjoyable, and professionally stimulating. They should choose a clinically relevant topic, ensure that the program is interactive and accessible, and include decision support tools.
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Affiliation(s)
- Anne-Sophie Allaire
- Research Centre of the Centre Hospitalier Universitaire de Québec, Quebec City, Quebec, G1L 3L5, Canada
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Légaré F, Labrecque M, LeBlanc A, Njoya M, Laurier C, Côté L, Godin G, Thivierge RL, O'Connor A, St-Jacques S. Training family physicians in shared decision making for the use of antibiotics for acute respiratory infections: a pilot clustered randomized controlled trial. Health Expect 2011; 14 Suppl 1:96-110. [PMID: 20629764 PMCID: PMC3073122 DOI: 10.1111/j.1369-7625.2010.00616.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Experts estimate that the prevalence of antibiotics use exceeds the prevalence of bacterial acute respiratory infections (ARIs). OBJECTIVE To develop, adapt and validate DECISION+ and estimate its impact on the decision of family physicians (FPs) and their patients on whether to use antibiotics for ARIs. DESIGN Two-arm parallel clustered pilot randomized controlled trial. SETTING AND PARTICIPANTS Four family medicine groups were randomized to immediate DECISION+ participation (the experimental group) or delayed DECISION+ participation (the control group). Thirty-three FPs and 459 patients participated. INTERVENTION DECISION+ is a multiple-component, continuing professional development program in shared decision making that addresses the use of antibiotics for ARIs. MAIN OUTCOME MEASURES Throughout the pilot trial, DECISION+ was adapted in response to participant feedback. After the consultation, patients and FPs independently self-reported the decision (immediate use, delayed use, or no use of antibiotics) and its quality. Agreement between their decisional conflict was assessed. Two weeks later, patients assessed their decisional regret and health status. RESULTS Compared to the control group, the experimental group reduced its immediate use of antibiotics (49 vs. 33% absolute difference = 16%; P = 0.08). Decisional conflict agreement was stronger in the experimental group (absolute difference of Pearson's r = 0.26; P = 0.06). Decisional regret and perceptions of the quality of the decision and of health status in the two groups were similar. DISCUSSION AND CONCLUSIONS DECISION+ was developed successfully and appears to reduce the use of antibiotics for ARIs without affecting patients' outcomes. A larger trial is needed to confirm this observation.
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Affiliation(s)
- France Légaré
- Research Centre of the Centre Hospitalier Universitaire de Québec, Québec, QC, Canada.
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Légaré F, Labrecque M, Godin G, LeBlanc A, Laurier C, Grimshaw J, Castel J, Tremblay I, Frémont P, Cauchon M, Lemieux K, Rhéaume C. Training family physicians and residents in family medicine in shared decision making to improve clinical decisions regarding the use of antibiotics for acute respiratory infections: protocol for a clustered randomized controlled trial. BMC FAMILY PRACTICE 2011; 12:3. [PMID: 21269509 PMCID: PMC3041682 DOI: 10.1186/1471-2296-12-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 01/26/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND To explore ways to reduce the overuse of antibiotics for acute respiratory infections (ARIs), we conducted a pilot clustered randomized controlled trial (RCT) to evaluate DECISION+, a training program in shared decision making (SDM) for family physicians (FPs). This pilot project demonstrated the feasibility of conducting a large clustered RCT and showed that DECISION+ reduced the proportion of patients who decided to use antibiotics immediately after consulting their physician. Consequently, the objective of this study is to evaluate, in patients consulting for ARIs, if exposure of physicians to a modified version of DECISION+, DECISION+2, would reduce the proportion of patients who decide to use antibiotics immediately after consulting their physician. METHODS/DESIGN The study is a multi-center, two-arm, parallel clustered RCT. The 12 family practice teaching units (FPTUs) in the network of the Department of Family Medicine and Emergency Medicine of Université Laval will be randomized to a DECISION+2 intervention group (experimental group) or to a no-intervention control group. These FPTUs will recruit patients consulting family physicians and residents in family medicine enrolled in the study. There will be two data collection periods: pre-intervention (baseline) including 175 patients with ARIs in each study arm, and post-intervention including 175 patients with ARIs in each study arm (total n = 700). The primary outcome will be the proportion of patients reporting a decision to use antibiotics immediately after consulting their physician. Secondary outcome measures include: 1) physicians and patients' decisional conflict; 2) the agreement between the parties' decisional conflict scores; and 3) perception of patients and physicians that SDM occurred. Also in patients, at 2 weeks follow-up, adherence to the decision, consultation for the same reason, decisional regret, and quality of life will be assessed. Finally, in both patients and physicians, intention to engage in SDM in future clinical encounters will be assessed. Intention-to-treat analyses will be applied and account for the nested design of the trial will be taken into consideration. DISCUSSION DECISION+2 has the potential to reduce antibiotics use for ARIs by priming physicians and patients to share decisional process and empowering patients to make informed, value-based decisions.
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Affiliation(s)
- France Légaré
- Research Center of Centre Hospitalier Universitaire de Québec, Hospital St-François D'Assise, Knowledge Transfer and Health Technology Assessment Research Group, 10 Espinay, Québec, QC, G1L 3L5, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Michel Labrecque
- Research Center of Centre Hospitalier Universitaire de Québec, Hospital St-François D'Assise, Knowledge Transfer and Health Technology Assessment Research Group, 10 Espinay, Québec, QC, G1L 3L5, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Gaston Godin
- Faculty of Nursing, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Annie LeBlanc
- Knowledge and Encounter Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Claudine Laurier
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, Montréal, QC, H3T 1J4, Canada
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, Ottawa, ON, K1Y 4E9, Canada
| | - Josette Castel
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Isabelle Tremblay
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Pierre Frémont
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Michel Cauchon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Kathleen Lemieux
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Caroline Rhéaume
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
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Leblanc A, Légaré F, Labrecque M, Godin G, Thivierge R, Laurier C, Côté L, O'Connor AM, Rousseau M. Feasibility of a randomised trial of a continuing medical education program in shared decision-making on the use of antibiotics for acute respiratory infections in primary care: the DECISION+ pilot trial. Implement Sci 2011; 6:5. [PMID: 21241514 PMCID: PMC3033351 DOI: 10.1186/1748-5908-6-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 01/18/2011] [Indexed: 12/02/2022] Open
Abstract
Background The misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect. Shared decision-making could be a promising strategy to improve appropriate antibiotic use for ARIs, but very little is known about its implementation processes and outcomes in clinical settings. In this matter, pilot studies have played a key role in health science research over the past years in providing information for the planning, justification, and/or refinement of larger studies. The objective of our study was to assess the feasibility and acceptability of the study design, procedures, and intervention of the DECISION+ program, a continuing medical education program in shared decision-making among family physicians and their patients on the optimal use of antibiotics for treating ARIs in primary care. Methods A pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program. Results Among 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians (18 in the two experimental and 21 in the three control FMGs) and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% (50% for the experimental group and 43% for the control group), and the overall mean level of satisfaction regarding the workshops was 94%. Conclusions This trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making. Trial Registration Clinicaltrials.Gov NCT00354315
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Affiliation(s)
- Annie Leblanc
- Knowledge Transfer and Evaluation of Health Technologies and Interventions Unit, Research Centre of the Centre Hospitalier Universitaire de Québec, Québec, Canada.
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Allaire AS, Labrecque M, Giguère A, Gagnon MP, Grimshaw J, Légaré F. Barriers and facilitators to the dissemination of DECISION+, a continuing medical education program for optimizing decisions about antibiotics for acute respiratory infections in primary care: a study protocol. Implement Sci 2011; 6:3. [PMID: 21214919 PMCID: PMC3023690 DOI: 10.1186/1748-5908-6-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 01/07/2011] [Indexed: 11/28/2022] Open
Abstract
Background In North America, acute respiratory infections are the main reason for doctors' visits in primary care. Family physicians and their patients overuse antibiotics for treating acute respiratory infections. In a pilot clustered randomized trial, we showed that DECISION+, a continuing medical education program in shared decision making, has the potential to reduce the overuse of antibiotics for treating acute respiratory infections. DECISION+ learning activities consisted of three interactive sessions of three hours each, reminders at the point of care, and feedback to doctors on their agreement with patients about comfort with the decision whether to use antibiotics. The objective of this study is to identify the barriers and facilitators to physicians' participation in DECISION+ with the goal of disseminating DECISION+ on a larger scale. Methods/design This descriptive study will use mixed methods and retrospective and prospective components. All analyses will be based on an adapted version of the Ottawa Model of Research Use. First, we will use qualitative methods to analyze the following retrospective data from the pilot study: the logbooks of eight research assistants, the transcriptions of 15 training sessions, and 27 participant evaluations of the DECISION+ training sessions. Second, we will collect prospective data in semi-structured focus groups composed of family physicians to identify barriers and facilitators to the dissemination of a future training program similar to DECISION+. All 39 family physicians exposed to DECISION+ during the pilot project will be eligible to participate. We will use a self-administered questionnaire based on Azjen's Theory of Planned Behaviour to assess participants' intention to take part in future training programs similar to DECISION+. Discussion Barriers and facilitators identified in this project will guide modifications to DECISION+, a continuing medical education program in shared decision making regarding the use of antibiotics in acute respiratory infections, to facilitate its dissemination in primary care on a large scale. Our results should help continuing medical educators develop a continuing medical education program in shared decision making for other clinically relevant topics. This will help optimize clinical decisions in primary care.
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Affiliation(s)
- Anne-Sophie Allaire
- Research Center of Centre Hospitalier Universitaire de Québec, Hospital St-François D'Assise, Knowledge Transfer an Health Technology Assessment Research Group, 10 rue de l'Espinay, Québec, QC, G1L 3L5, Canada.
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Bieber C, Nicolai J, Hartmann M, Blumenstiel K, Ringel N, Schneider A, Härter M, Eich W, Loh A. Training physicians in shared decision-making-who can be reached and what is achieved? PATIENT EDUCATION AND COUNSELING 2009; 77:48-54. [PMID: 19403258 DOI: 10.1016/j.pec.2009.03.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Revised: 03/03/2009] [Accepted: 03/06/2009] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To report on experiences with a general shared decision-making (SDM) physician training program offered to physicians throughout Germany. METHODS This study enrolled 150 physicians in an 8-h SDM training program. Physicians were assessed with standardized instruments before and after training. Main variables of interest were physician professional attributes, personality characteristics, attitudes, measures of training success (quality rating, knowledge, competency ratings), and variables associated with training success. RESULTS The SDM training obtained positive quality ratings, led to an amelioration in an objective SDM knowledge test (p<.001), and highly improved physicians' confidence in their SDM competencies (p<0.001). It attracted experienced, middle-aged (45 years), male and female (46%) physicians, mostly office-based (2/3) general practitioners and internists (2/3). Most physicians (94%) reported positive attitudes towards SDM. They were securely attached (63%) with predominant social career choice motives (46%). Physicians with personality characteristics clashing with the SDM concept benefited mostly from the training. CONCLUSION A voluntary SDM training program is attractive to practicing physicians and effective in increasing SDM-related confidence and knowledge. PRACTICE IMPLICATIONS Even physicians who are highly motivated to use SDM can improve their skills and benefit from SDM training. The dissemination of SDM training programs should be encouraged.
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Affiliation(s)
- Christiane Bieber
- University of Heidelberg, Department of Psychosomatic and General Internal Medicine, Heidelberg, Germany.
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Légaré F. Establishing patient decision aids in primary care: update on the knowledge base. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2009; 102:427-30. [PMID: 19209570 DOI: 10.1016/j.zefq.2008.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In recent years, many industrialised countries have moved forward initiatives to reinforce their primary healthcare sector. At the same time, there has been an increased emphasis on the engagement of patients as partners in their care. Consequently, the process by which patients are engaged to share their preferences and become involved in healthcare decisions is changing and pushing the needs for a new kind of knowledge tools, namely patients decision aids. We argue that for shared decision making to be adopted in primary care practices, patient decision aids will need to be embedded in routine clinical care. Subsequently, the objectives of this paper are twofold: to briefly review the knowledge base regarding the implementation of shared decision making in clinical practice and to identify the gaps in knowledge that will need to be addressed for the effective implementation of shared decision making in clinical practice to occur.
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Affiliation(s)
- France Légaré
- Department of Family Medicine, Université Laval, Québec, Canada.
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Légaré F, Stewart M, Frosch D, Grimshaw J, Labrecque M, Magnan M, Ouimet M, Rousseau M, Stacey D, van der Weijden T, Elwyn G. EXACKTE(2): exploiting the clinical consultation as a knowledge transfer and exchange environment: a study protocol. Implement Sci 2009; 4:14. [PMID: 19284659 PMCID: PMC2663542 DOI: 10.1186/1748-5908-4-14] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 03/13/2009] [Indexed: 11/12/2022] Open
Abstract
Background While the evidence suggests that the way physicians provide information to patients is crucial in helping patients decide upon a course of action, the field of knowledge translation and exchange (KTE) is silent about how the physician and the patient influence each other during clinical interactions and decision-making. Consequently, based on a novel relationship-centered model, EXACKTE2 (EXploiting the clinicAl Consultation as a Knowledge Transfer and Exchange Environment), this study proposes to assess how patients and physicians influence each other in consultations. Methods We will employ a cross-sectional study design involving 300 pairs of patients and family physicians from two primary care practice-based research networks. The consultation between patient and physician will be audio-taped and transcribed. Following the consultation, patients and physicians will complete a set of questionnaires based on the EXACKTE2 model. All questionnaires will be similar for patients and physicians. These questionnaires will assess the key concepts of our proposed model based on the essential elements of shared decision-making (SDM): definition and explanation of problem; presentation of options; discussion of pros and cons; clarification of patient values and preferences; discussion of patient ability and self-efficacy; presentation of doctor knowledge and recommendation; and checking and clarifying understanding. Patients will be contacted by phone two weeks later and asked to complete questionnaires on decisional regret and quality of life. The analysis will be conducted to compare the key concepts in the EXACKTE2 model between patients and physicians. It will also allow the assessment of how patients and physicians influence each other in consultations. Discussion Our proposed model, EXACKTE2, is aimed at advancing the science of KTE based on a relationship process when decision-making has to take place. It fosters a new KTE paradigm by putting forward a relationship-centered perspective and has the potential to reveal unknown mechanisms that underline effective KTE in clinical contexts. This will result in better understanding of the mechanisms that may promote a new generation of knowledge transfer strategies.
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Affiliation(s)
- France Légaré
- Research Center of the Centre Hospitalier Universitaire de Québec, Québec, Canada.
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21
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Lewis CL, Pignone MP. Promoting informed decision-making in a primary care practice by implementing decision aids. N C Med J 2009; 70:136-139. [PMID: 19489371 PMCID: PMC3213756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Empowering patients to be effective advocates for their health requires that they have adequate information and understanding about their health conditions. Many patients have limited health literacy which is a marker for vulnerability and a risk factor for poor health outcomes. Providing vulnerable patients with information in a format they can easily access is challenging. One novel approach is to modify processes of clinical care so that medical practices deliver necessary and accessible information to patients in conjunction with their provider’s visit. The goal is to improve the quality of medical care in clinical practice by promoting informed decision-making.
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Affiliation(s)
- Carmen L Lewis
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, USA.
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Légaré F, Elwyn G, Fishbein M, Frémont P, Frosch D, Gagnon MP, Kenny DA, Labrecque M, Stacey D, St-Jacques S, van der Weijden T. Translating shared decision-making into health care clinical practices: proof of concepts. Implement Sci 2008; 3:2. [PMID: 18194521 PMCID: PMC2265300 DOI: 10.1186/1748-5908-3-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 01/14/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is considerable interest today in shared decision-making (SDM), defined as a decision-making process jointly shared by patients and their health care provider. However, the data show that SDM has not been broadly adopted yet. Consequently, the main goal of this proposal is to bring together the resources and the expertise needed to develop an interdisciplinary and international research team on the implementation of SDM in clinical practice using a theory-based dyadic perspective. METHODS Participants include researchers from Canada, US, UK, and Netherlands, representing medicine, nursing, psychology, community health and epidemiology. In order to develop a collaborative research network that takes advantage of the expertise of the team members, the following research activities are planned: 1) establish networking and on-going communication through internet-based forum, conference calls, and a bi-weekly e-bulletin; 2) hold a two-day workshop with two key experts (one in theoretical underpinnings of behavioral change, and a second in dyadic data analysis), and invite all investigators to present their views on the challenges related to the implementation of SDM in clinical practices; 3) conduct a secondary analyses of existing dyadic datasets to ensure that discussion among team members is grounded in empirical data; 4) build capacity with involvement of graduate students in the workshop and online forum; and 5) elaborate a position paper and an international multi-site study protocol. DISCUSSION This study protocol aims to inform researchers, educators, and clinicians interested in improving their understanding of effective strategies to implement shared decision-making in clinical practice using a theory-based dyadic perspective.
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Affiliation(s)
- France Légaré
- Centre hospitalier universitaire de Québec, Hôpital St-François D'Assise, Unité de recherche évaluative, 10 rue de l'Espinay, Québec, Québec, G1L 3L5, Canada
| | - Glyn Elwyn
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park CF 14 4YS, UK
| | - Martin Fishbein
- Annenberg School for Communication, University of Pennsylvania, 3620 Walnut Street, Philadelphia, PA 19104, USA
| | - Pierre Frémont
- Centre hospitalier universitaire de Québec, Hôpital St-François D'Assise, Unité de recherche évaluative, 10 rue de l'Espinay, Québec, Québec, G1L 3L5, Canada
| | - Dominick Frosch
- UCLA Med-GIM & HSR, BOX 951736, 911 Broxton, Los Angeles, CA 90095-1736, USA
| | - Marie-Pierre Gagnon
- Centre hospitalier universitaire de Québec, Hôpital St-François D'Assise, Unité de recherche évaluative, 10 rue de l'Espinay, Québec, Québec, G1L 3L5, Canada
| | - David A Kenny
- Department of Psychology, University of Connecticut, 406 Babbidge Road Unit 1020 Storrs, CT 06269-1020, USA
| | - Michel Labrecque
- Centre hospitalier universitaire de Québec, Hôpital St-François D'Assise, Unité de recherche évaluative, 10 rue de l'Espinay, Québec, Québec, G1L 3L5, Canada
| | - Dawn Stacey
- School of Nursing, University of Ottawa, 451 Smyth, Room RGN 3247A Ottawa, ON K1H 8M5, Canada
| | - Sylvie St-Jacques
- Centre hospitalier universitaire de Québec, Hôpital St-François D'Assise, Unité de recherche évaluative, 10 rue de l'Espinay, Québec, Québec, G1L 3L5, Canada
| | - Trudy van der Weijden
- Department of General Practice/School of Public Health and Primary Care Caphri, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
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Abstract
BACKGROUND Modest benefits of antibiotics for acute upper respiratory tract infections have to be weighed against common adverse reactions, cost and antibacterial resistance. There has been interest in ways to reduce antibiotic prescribing. One strategy is to provide the prescription, but advise delay of more than 48 hours before use, in the hope symptoms resolve first. Advocates suggest this will preserve patient satisfaction. This review asks what effect delayed antibiotics have on clinical outcomes of respiratory infections, antibiotic use and patient satisfaction. OBJECTIVES To evaluate the prescribing strategy of delayed antibiotics for acute respiratory tract infections compared to immediate or no antibiotics for clinical outcomes, antibiotic use and patient satisfaction. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2006); MEDLINE (January 1966 to January Week 2, 2007), EMBASE (1990 to Week 2, 2007) and Current Contents - ISI Web of Knowledge (1998 to January 2007). SELECTION CRITERIA Randomised controlled trials (RCTs) involving patients of all ages defined as having an acute respiratory infection were included in which delayed antibiotics were compared to antibiotics used immediately or no antibiotics. Outcomes measured included clinical outcomes, antibiotic use and patient satisfaction. DATA COLLECTION AND ANALYSIS Data were collected and analysed by three review authors. MAIN RESULTS Nine trials were eligible on the basis of design and relevant outcomes. For most clinical outcomes there was no difference between delayed, immediate and no antibiotics. Antibiotics prescribed immediately were more effective than delayed for fever, pain and malaise in some studies of patients with acute otitis media and sore throat but for other studies there was no difference. There was no difference for the common cold and bronchitis. Delaying antibiotic prescriptions reduced antibiotic use, and in three studies, reduced patient satisfaction compared to immediate antibiotics. In the other two studies comparing delayed and immediate antibiotics measuring satisfaction, there was no difference. Two studies also included a 'no antibiotics' arm for bronchitis and sore throat: there was no difference in symptom resolution nor patient satisfaction from antibiotic delay. In one study, but not the other, antibiotic use was significantly decreased with no, rather than delayed, antibiotics. AUTHORS' CONCLUSIONS For most clinical outcomes there is no difference between the strategies. Immediate antibiotics was the strategy most likely to provide the best clinical outcomes in patients with sore throat and otitis media. Delaying or avoiding antibiotics, rather than providing them immediately, reduces antibiotic use for acute respiratory infections. Delay also reduced patient satisfaction in three trials, compared to immediate antibiotics with no difference in two other trials. Delaying antibiotics seems to have little advantage over avoiding them altogether where it is safe to do so.
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Affiliation(s)
- G K P Spurling
- University of Queensland, Discipline of General Practice, Level 2, Edith Cavell Building, Royal Brisbane Hospital, Brisbane, Queensland, Australia, 4029.
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