Eliciting patient views on the allocation of limited healthcare resources: a deliberation on hepatitis C treatment in the Veterans Health Administration

A 4-Site Public Deliberation Project on the Acceptability of Youth Self-Consent in Biomedical HIV Prevention Trials: Assessment of Facilitator Fidelity to Key Principles

BACKGROUND

Public deliberation is an approach used to engage persons with diverse perspectives in discussions and decision-making about issues affecting the public that are controversial or value laden. Because experts have identified the need to evaluate facilitator performance, our research team developed a framework to assess the fidelity of facilitator remarks to key principles of public deliberation.

OBJECTIVE

This report describes how the framework was used to assess facilitator fidelity in a 4-site public deliberation project on the acceptability of minor self-consent in biomedical HIV prevention research.

METHODS

A total of 88 individuals participated in 4 deliberation sessions held in 4 cities throughout the United States. The sessions, facilitated by 18 team members, were recorded and transcribed verbatim. Facilitator remarks were highlighted, and predetermined coding rules were used to code the remarks to 1 of 6 principles of quality deliberations. A variety of display tables were used to organize the codes and calculate the number of facilitator remarks that were consistent or inconsistent with each principle during each session across all sites. A content analysis was conducted on the remarks to describe how facilitator remarks aligned or failed to align with each principle.

RESULTS

In total, 735 remarks were coded to one of the principles; 516 (70.2%) were coded as consistent with a principle, and 219 (29.8%) were coded as inconsistent. A total of 185 remarks were coded to the principle of equal participation (n=138, 74.6% as consistent; n=185, 25.4% as inconsistent), 158 were coded to expression of diverse opinions (n=110, 69.6% as consistent; n=48, 30.4% as inconsistent), 27 were coded to respect for others (n=27, 100% as consistent), 24 were coded to adoption of a societal perspective (n=11, 46% as consistent; n=13, 54% as inconsistent), 99 were coded to reasoned justification of ideas (n=81, 82% as consistent; n=18, 18% as inconsistent), and 242 were coded to compromise or movement toward consensus (n=149, 61.6% as consistent; n=93, 38.4% as inconsistent). Therefore, the counts provided affirmation that most of the facilitator remarks were aligned with the principles of deliberation, suggesting good facilitator fidelity. By considering how the remarks aligned or failed to align with the principles, areas where facilitator fidelity can be strengthened were identified. The results indicated that facilitators should focus more on encouraging quieter members to participate, refraining from expressing personal opinions, promoting the adoption of a societal perspective and reasoned justification of opinions, and inviting deliberants to articulate their areas of common ground.

CONCLUSIONS

The results provide an example of how a framework for assessing facilitator fidelity was used in a 4-site deliberation project. The framework will be refined to better address issues related to balancing personal and public perspectives, managing plurality, and mitigating social inequalities.

Public deliberation to assess patient views on biosimilar medication switching for the treatment of inflammatory bowel disease

BACKGROUND

Biosimilars are highly similar, but not identical, versions of originator biologic medications. Switching patients to biosimilars presents an opportunity to mitigate rising drug costs and expand patient access to important biologic therapies. However, decreased patient acceptance and adherence to biosimilar medications have been reported, which can lead to loss of treatment response, adverse reactions, and inefficient resource utilization. Understanding patient perceptions of biosimilars and biosimilar switching is needed to inform patient-centered care strategies that promote efficient resource utilization.

METHODS

We used democratic deliberation methods to solicit the informed and considered opinions of patients regarding biosimilar switching. Patients with inflammatory bowel disease (IBD; n = 29) from the Veterans Health Administration (VHA) participated in 5-hour deliberation sessions over two days. Following educational presentations with experts, participants engaged in facilitated small group discussions. Transcripts and facilitators' notes were used to identify key themes. Participants completed surveys pre- and post-deliberation to collect sociodemographic and clinical features as well as to assess IBD treatment knowledge and attitudes toward care and approaches to biosimilar switching.

RESULTS

Five major themes emerged from the small group discussions in the context of biosimilar switching: 1) concerns about adverse consequences and unclear risk-benefit balance; (2) importance of communication and transparency; (3) desire for shared decision making and patient involvement in treatment decisions; (4) balancing cost-saving with competing priorities; and (5) advocating for individualized care and prioritization based on risk levels. These views led participants to favor approaches that prioritize switching the sickest patients last (i.e., those with poorly controlled disease) and that offer patients control and choices around biosimilar switching. Participants also expressed preferences for combining elements of different approaches to maximize fairness.

CONCLUSIONS

Approaches to biosimilar switching should consider patients' desires for transparency and effective communication about biosimilar switching and engagement in their medical decision-making as part of patient-centered care. Incorporating patient preferences around biosimilar switching is critical when navigating the quality and affordability of care in resource constrained settings, both within the VHA and in other healthcare systems.

Patient Values and Preferences for Managing Acute Dental Pain Elicited through Online Deliberation

INTRODUCTION

Patient values and preferences (PVP) are among multiple sources of information panelists synthesize when developing clinical practice guidelines (CPG). Patient and public involvement (PPI) can be critical for learning PVP; however, the methodology for engaging patients in CPG development is lacking. Deliberative engagement is effective for obtaining public views on complex topics that require people to consider ethics, values, and competing perspectives.

OBJECTIVE

Elicit comprehensive understanding of PVP concerning oral analgesics for managing acute dental pain consecutive to toothache and simple and surgical dental extractions, with consideration of associated outcomes, both desirable and undesirable.

METHODS

Multistage engagement involving 2 electronic surveys and a 90-min online small group deliberative engagement. Adults who have experienced acute dental pain deliberated about 3 hypothetical scenarios stratified according to expected pain intensity, completed a postdeliberation survey, and validated a PVP statement developed by researchers based on review of qualitative data from deliberations and quantitative data from surveys.

RESULTS

Participants affirmed the PVP statement reflected their small group deliberations and their individual views. Most indicated that pain relief is critical to deciding which pain relief medicine they would want regardless of expected pain level. Most also identify as critical concerns about substance abuse or misuse, although many believe it unlikely that they will experience these outcomes over the brief prescription timeframe for acute dental pain. Participants identified agency in decision-making, consultation including "better communication" of options, and treatment actions tailored to life circumstances as key values.

CONCLUSIONS

Participants preferred nonprescription and nonopioid pain relief options. As expected pain levels increased, more participants expressed willingness to accept opioids, but more also mentioned rescue analgesia as a third outcome critical to decision-making. Online deliberative method provided opportunities for obtaining informed perspectives. Guideline developers and policymakers may find online deliberations useful for eliciting PVP related to health outcomes.

KNOWLEDGE TRANSFER STATEMENT

Study results informed the US Food and Drug Administration-funded clinical practice guideline on the management of acute dental pain. Findings may be a resource for clinicians in decision-making conversations with patients regarding expectations for pain relief and positive and negative outcomes of differing pain relief medications. Further research should pursue applicability of online deliberative engagement as a method to elicit patient values and preferences.

Best Practices for an Equitable Covid-19 Vaccination Program

An array of factors hamper equitable Covid-19 vaccine deployment in the United States along racial, ethnic, age, and geographic lines. The Puget Sound Veterans Affairs facility developed a multidisciplinary vaccine delivery strategy to forestall systematic inequities in receipt of vaccination among veterans using methods that can be used by other health care organizations. The VA Puget Sound Health Care System deployed targeted outreach to individual patients on the basis of a simple score consisting of the sum of risk factors for severe Covid-19 disease and high-risk race or ethnicity. The health system then conducted sequential outreach using multiple communication modalities; worked with trusted community stakeholders to publicize and deploy mobile clinics to underserved areas; and monitored vaccination coverage rates by age, race, sex, and rural status at prespecified intervals and adjusted operations to ensure equity. Vaccination rates were highest in Black, multiracial, and Hispanic veterans compared with white veterans during the vaccine drive, a finding that persisted after the drive.

Patients' Willingness to Share Limited Endoscopic Resources: A Brief Report on the Results of a Large Regional Survey

Background. In some health care systems, patients face long wait times for screening colonoscopy. We sought to assess whether patients at low risk for colorectal cancer (CRC) would be willing to delay their own colonoscopy so higher-risk peers could undergo colonoscopy sooner. Methods. We surveyed 1054 Veterans regarding their attitudes toward repeat colonoscopy and risk-based prioritization. We used multivariable regression to identify patient factors associated with willingness to delay screening for a higher-risk peer. Results. Despite a physician recommendation to stop screening, 29% of respondents reported being "not at all likely" to stop. However, 94% reported that they would be willing to delay their own colonoscopy for a higher-risk peer. Greater trust in physician and greater health literacy were positively associated with willingness to wait, while greater perceived threat of CRC and Black or Latino race/ethnicity were negatively associated with willingness to wait. Conclusion. Despite high enthusiasm for repeat screening, patients were willing to delay their own colonoscopy for higher-risk peers. Appealing to altruism could be effective when utilizing scarce resources.