1
|
Neuman MD, Elwyn G, Graff V, Schmitz V, Politi MC. My anesthesia Choice-HF: development and preliminary testing of a tool to facilitate conversations about anesthesia for hip fracture surgery. BMC Anesthesiol 2024; 24:165. [PMID: 38693498 PMCID: PMC11061990 DOI: 10.1186/s12871-024-02547-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 04/19/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Patients often desire involvement in anesthesia decisions, yet clinicians rarely explain anesthesia options or elicit preferences. We developed My Anesthesia Choice-Hip Fracture, a conversation aid about anesthesia options for hip fracture surgery and tested its preliminary efficacy and acceptability. METHODS We developed a 1-page, tabular format, plain-language conversation aid with feedback from anesthesiologists, decision scientists, and community advisors. We conducted an online survey of English-speaking adults aged 50 and older. Participants imagined choosing between spinal and general anesthesia for hip fracture surgery. Before and after viewing the aid, participants answered a series of questions regarding key outcomes, including decisional conflict, knowledge about anesthesia options, and acceptability of the aid. RESULTS Of 364/409 valid respondents, mean age was 64 (SD 8.9) and 59% were female. The proportion indicating decisional conflict decreased after reviewing the aid (63-34%, P < 0.001). Median knowledge scores increased from 50% correct to 67% correct (P < 0.001). 83% agreed that the aid would help them discuss options and preferences. 76.4% would approve of doctors using it. CONCLUSION My Anesthesia Choice-Hip Fracture decreased decisional conflict and increased knowledge about anesthesia choices for hip fracture surgery. Respondents assessed it as acceptable for use in clinical settings. PRACTICE IMPLICATIONS Use of clinical decision aids may increase shared decision-making; further testing is warranted.
Collapse
Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, 308 Blockley Hall 423 Guardian Drive, Philadelphia, PA, 19106, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA.
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA.
- Department of Medicine, Division of Geriatric Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA.
| | | | - Veena Graff
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, 308 Blockley Hall 423 Guardian Drive, Philadelphia, PA, 19106, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Viktoria Schmitz
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, USA
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, USA
| |
Collapse
|
2
|
Holzer KJ, Bartosiak KA, Calfee RP, Hammill CW, Haroutounian S, Kozower BD, Cordner TA, Lenard EM, Freedland KE, Tellor Pennington BR, Wolfe RC, Miller JP, Politi MC, Zhang Y, Yingling MD, Baumann AA, Kannampallil T, Schweiger JA, McKinnon SL, Avidan MS, Lenze EJ, Abraham J. Perioperative mental health intervention for depression and anxiety symptoms in older adults study protocol: design and methods for three linked randomised controlled trials. BMJ Open 2024; 14:e082656. [PMID: 38569683 DOI: 10.1136/bmjopen-2023-082656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION Preoperative anxiety and depression symptoms among older surgical patients are associated with poor postoperative outcomes, yet evidence-based interventions for anxiety and depression have not been applied within this setting. We present a protocol for randomised controlled trials (RCTs) in three surgical cohorts: cardiac, oncological and orthopaedic, investigating whether a perioperative mental health intervention, with psychological and pharmacological components, reduces perioperative symptoms of depression and anxiety in older surgical patients. METHODS AND ANALYSIS Adults ≥60 years undergoing cardiac, orthopaedic or oncological surgery will be enrolled in one of three-linked type 1 hybrid effectiveness/implementation RCTs that will be conducted in tandem with similar methods. In each trial, 100 participants will be randomised to a remotely delivered perioperative behavioural treatment incorporating principles of behavioural activation, compassion and care coordination, and medication optimisation, or enhanced usual care with mental health-related resources for this population. The primary outcome is change in depression and anxiety symptoms assessed with the Patient Health Questionnaire-Anxiety Depression Scale from baseline to 3 months post surgery. Other outcomes include quality of life, delirium, length of stay, falls, rehospitalisation, pain and implementation outcomes, including study and intervention reach, acceptability, feasibility and appropriateness, and patient experience with the intervention. ETHICS AND DISSEMINATION The trials have received ethics approval from the Washington University School of Medicine Institutional Review Board. Informed consent is required for participation in the trials. The results will be submitted for publication in peer-reviewed journals, presented at clinical research conferences and disseminated via the Center for Perioperative Mental Health website. TRIAL REGISTRATION NUMBERS NCT05575128, NCT05685511, NCT05697835, pre-results.
Collapse
Affiliation(s)
- Katherine J Holzer
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Kimberly A Bartosiak
- Department of Orthopaedics, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Ryan P Calfee
- Department of Orthopaedics, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Chet W Hammill
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Benjamin D Kozower
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Theresa A Cordner
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Emily M Lenard
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Kenneth E Freedland
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Bethany R Tellor Pennington
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Rachel C Wolfe
- Department of Pharmacy, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - J Philip Miller
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - Mary C Politi
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Yi Zhang
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Michael D Yingling
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Ana A Baumann
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - Julia A Schweiger
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Sherry L McKinnon
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| |
Collapse
|
3
|
Dodson EA, Parks RG, Jacob RR, An R, Eyler AA, Lee N, Morshed AB, Politi MC, Tabak RG, Yan Y, Brownson RC. Effectively communicating with local policymakers: a randomized trial of policy brief dissemination to address obesity. Front Public Health 2024; 12:1246897. [PMID: 38525334 PMCID: PMC10957535 DOI: 10.3389/fpubh.2024.1246897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 02/05/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction Evidence-based policies are a powerful tool for impacting health and addressing obesity. Effectively communicating evidence to policymakers is critical to ensure evidence is incorporated into policies. While all public health is local, limited knowledge exists regarding effective approaches for improving local policymakers' uptake of evidence-based policies. Methods Local policymakers were randomized to view one of four versions of a policy brief (usual care, narrative, risk-framing, and narrative/risk-framing combination). They then answered a brief survey including questions about their impressions of the brief, their likelihood of using it, and how they determine legislative priorities. Results Responses from 331 participants indicated that a majority rated local data (92%), constituent needs/opinions (92%), and cost-effectiveness data (89%) as important or very important in determining what issues they work on. The majority of respondents agreed or strongly agreed that briefs were understandable (87%), believable (77%), and held their attention (74%) with no brief version rated significantly higher than the others. Across the four types of briefs, 42% indicated they were likely to use the brief. Logistic regression models showed that those indicating that local data were important in determining what they work on were over seven times more likely to use the policy brief than those indicating that local data were less important in determining what they work on (aOR = 7.39, 95% CI = 1.86,52.57). Discussion Among local policymakers in this study there was no dominant format or type of policy brief; all brief types were rated similarly highly. This highlights the importance of carefully crafting clear, succinct, credible, and understandable policy briefs, using different formats depending on communication objectives. Participants indicated a strong preference for receiving materials incorporating local data. To ensure maximum effect, every effort should be made to include data relevant to a policymaker's local area in policy communications.
Collapse
Affiliation(s)
- Elizabeth A. Dodson
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO, United States
| | - Renee G. Parks
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO, United States
| | - Rebekah R. Jacob
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO, United States
| | - Ruopeng An
- Brown School, Washington University in St. Louis, St. Louis, MO, United States
| | - Amy A. Eyler
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO, United States
| | | | - Alexandra B. Morshed
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO, United States
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Rachel G. Tabak
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO, United States
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, United States
| | - Ross C. Brownson
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO, United States
- Department of Surgery, Division of Public Health Sciences, and Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States
| |
Collapse
|
4
|
Kinzer H, Lee CN, Cooksey K, Myckatyn T, Olsen MA, Foraker R, Johnson AR, Politi MC. Financial Toxicity Considerations in Breast Reconstruction: Recommendations for Research and Practice. Womens Health Issues 2024:S1049-3867(24)00005-7. [PMID: 38413293 DOI: 10.1016/j.whi.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/21/2024] [Accepted: 01/31/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Hannah Kinzer
- Washington University in St Louis, School of Medicine, St. Louis, Missouri.
| | - Clara N Lee
- University of North Carolina-Chapel Hill, School of Medicine, Chapel Hill, North Carolina
| | - Krista Cooksey
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
| | - Terence Myckatyn
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
| | - Margaret A Olsen
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
| | - Randi Foraker
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
| | - Anna Rose Johnson
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
| | - Mary C Politi
- Washington University in St Louis, School of Medicine, St. Louis, Missouri
| |
Collapse
|
5
|
Abraham J, Holzer KJ, Lenard EM, Meng A, Pennington BRT, Wolfe RC, Haroutounian S, Calfee R, Hammil CW, Kozower BD, Cordner TA, Schweiger J, McKinnon S, Yingling M, Baumann AA, Politi MC, Kannampallil T, Miller JP, Avidan MS, Lenze EJ. A Perioperative Mental Health Intervention for Depressed and Anxious Older Surgical Patients: Results From a Feasibility Study. Am J Geriatr Psychiatry 2024; 32:205-219. [PMID: 37798223 PMCID: PMC10852892 DOI: 10.1016/j.jagp.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVES The perioperative period is challenging and stressful for older adults. Those with depression and/or anxiety have an increased risk of adverse surgical outcomes. We assessed the feasibility of a perioperative mental health intervention composed of medication optimization and a wellness program following principles of behavioral activation and care coordination for older surgical patients. METHODS We included orthopedic, oncologic, and cardiac surgical patients aged 60 and older. Feasibility outcomes included study reach, the number of patients who agreed to participate out of the total eligible; and intervention reach, the number of patients who completed the intervention out of patients who agreed to participate. Intervention efficacy was assessed using the Patient Health Questionnaire for Anxiety and Depression (PHQ-ADS). Implementation potential and experiences were collected using patient surveys and qualitative interviews. Complementary caregiver feedback was also collected. RESULTS Twenty-three out of 28 eligible older adults participated in this study (mean age 68.0 years, 65% women), achieving study reach of 82% and intervention reach of 83%. In qualitative interviews, patients (n = 15) and caregivers (complementary data, n = 5) described overwhelmingly positive experiences with both the intervention components and the interventionist, and reported improvement in managing depression and/or anxiety. Preliminary efficacy analysis indicated improvement in PHQ-ADS scores (F = 12.13, p <0.001). CONCLUSIONS The study procedures were reported by participants as feasible and the perioperative mental health intervention to reduce anxiety and depression in older surgical patients showed strong implementation potential. Preliminary data suggest its efficacy for improving depression and/or anxiety symptoms. A randomized controlled trial assessing the intervention and implementation effectiveness is currently ongoing.
Collapse
Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO; Institute for Informatics (JA, TK, JPM), Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO.
| | - Katherine J Holzer
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Emily M Lenard
- Department of Psychiatry (EML, JS, MY, EJ), Washington University School of Medicine, St. Louis, MO
| | - Alicia Meng
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Bethany R Tellor Pennington
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Rachel C Wolfe
- Department of Pharmacy (RCW), Barnes-Jewish Hospital, St. Louis, MO
| | - Simon Haroutounian
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Ryan Calfee
- Department of Orthopaedic Surgery (RC), Washington University School of Medicine, St. Louis, MO
| | - Chet W Hammil
- Department of Surgery (CWH, BDK, AAB, MCP), Washington University School of Medicine, St. Louis, MO
| | - Benjamin D Kozower
- Department of Surgery (CWH, BDK, AAB, MCP), Washington University School of Medicine, St. Louis, MO
| | - Theresa A Cordner
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Julia Schweiger
- Department of Psychiatry (EML, JS, MY, EJ), Washington University School of Medicine, St. Louis, MO
| | - Sherry McKinnon
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Michael Yingling
- Department of Psychiatry (EML, JS, MY, EJ), Washington University School of Medicine, St. Louis, MO
| | - Ana A Baumann
- Department of Surgery (CWH, BDK, AAB, MCP), Washington University School of Medicine, St. Louis, MO
| | - Mary C Politi
- Department of Surgery (CWH, BDK, AAB, MCP), Washington University School of Medicine, St. Louis, MO
| | - Thomas Kannampallil
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO; Institute for Informatics (JA, TK, JPM), Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - J Philip Miller
- Institute for Informatics (JA, TK, JPM), Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - Michael S Avidan
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Eric J Lenze
- Department of Psychiatry (EML, JS, MY, EJ), Washington University School of Medicine, St. Louis, MO
| |
Collapse
|
6
|
Said AM, Zubovic E, Pfeifauf KD, Skolnick GB, Agboada J, Acayo-Laker P, Naidoo SD, Politi MC, Smyth M, Patel KB. Shared Decision-Making: Process for Design and Implementation of a Decision Aid for Patients With Craniosynostosis. Cleft Palate Craniofac J 2024; 61:138-143. [PMID: 36128842 DOI: 10.1177/10556656221128413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
To describe the process of developing a craniosynostosis decision aid. We conducted a mixed-methods exploratory study between August 2019 and March 2020 to develop a decision aid about surgical treatment for single suture craniosynostosis. A single tertiary care academic children's hospital. The decision aid development team consisted of surgeons, research fellows, a clinical nurse practitioner, clinical researchers with expertise in decision science, and a university-affiliated design school. Qualitative interviews (N = 5) were performed with families, clinicians (N = 2), and a helmeting orthotist to provide feedback on decision aid content, format, and usability. After cycles of revisions and iterations, 3 related decision aids were designed and approved by the marketing arm of our institution. Distinct booklets were created to enable focused discussion of treatment options for the 3 major types of single suture craniosynostosis (sagittal, metopic, unicoronal). Three decision aids representing the 3 most common forms of single suture craniosynostosis were developed. Clinicians found the decision aids could help facilitate discussions about families' treatment preferences, goals, and concerns. We developed a customizable decision aid for single suture craniosynostosis treatment options. This tool lays the foundation for shared decision-making by assessing family preferences and providing clear, concise, and credible information regarding surgical treatment. Future research can evaluate this tool's impact on patient-clinician discussions about families' goals and preferences for treatment.
Collapse
Affiliation(s)
- Abdullah M Said
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Ema Zubovic
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Kristin D Pfeifauf
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Jude Agboada
- Graphic Design, Lindquist College of Arts & Humanities, Weber State University, Ogden, UT, USA
| | - Penina Acayo-Laker
- Communication Design, Sam Fox School of Design & Visual Arts, Washington University in St. Louis, St. Louis, MO, USA
| | - Sybill D Naidoo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Matthew Smyth
- Department of Neurosurgery, Johns Hopkins University Division of Pediatric Neurosurgery, Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Kamlesh B Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| |
Collapse
|
7
|
Durkin MJ, Schmitz V, Hsueh K, Troubh Z, Politi MC. Older adults' and caregivers' perceptions about urinary tract infection and asymptomatic bacteriuria guidelines: a qualitative exploration. Antimicrob Steward Healthc Epidemiol 2023; 3:e224. [PMID: 38156231 PMCID: PMC10753467 DOI: 10.1017/ash.2023.498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 12/30/2023]
Abstract
Objective To explore older adults' and caregivers' knowledge and perceptions of guidelines for appropriate antibiotics use for bacteria in the urine. Design Semi-structured qualitative interviews. Setting Infectious disease clinics, community senior living facilities, memory care clinics, and general public. Participants Patients 65 years or older diagnosed with a urinary tract infection (UTI) in the past two years, or caregivers of such patients. Methods We conducted interviews between March and July 2023. We developed an interview guide based on the COM-B (capability, opportunity, motivation-behavior) behavior change framework. We thematically analyzed written transcripts of audio-recorded interviews using inductive and deductive coding techniques. Results Thirty participants (21 patients, 9 caregivers) enrolled. Most participants understood UTI symptoms such as pain during urination and frequent urination. However, communication with multiple clinicians, misinformation, and unclear symptoms that overlapped with other health issues clouded their understanding of asymptomatic bacteriuria (ASB) and UTIs. Some participants worried that clinicians would be dismissive of symptoms if they suggested a diagnosis of ASB without prescribing antibiotics. Many participants felt that the benefits of taking antibiotics for ASB outweighed harms, though some mentioned fears of personal antibiotic resistance if taking unnecessary antibiotics. No participants mentioned the public health impact of potential antibiotic resistance. Most participants trusted information from clinicians over brochures or websites but wanted to review information after clinical conversations. Conclusion Clinician-focused interventions to reduce antibiotic use for ASB should also address patient concerns during clinical visits, and provide standardized high-quality educational materials at the end of the visit.
Collapse
Affiliation(s)
- Michael J. Durkin
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Viktoria Schmitz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Kevin Hsueh
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Zoe Troubh
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
8
|
Rubens ME, Mayo TP, Smith RK, Glasgow SC, Politi MC. A Qualitative Exploration of Stakeholders' Preferences for Early-Stage Rectal Cancer Treatment. Ann Surg Open 2023; 4:e364. [PMID: 38144488 PMCID: PMC10735060 DOI: 10.1097/as9.0000000000000364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/28/2023] [Indexed: 12/26/2023] Open
Abstract
As treatment options for patients with rectal cancer evolve, patients with early-stage rectal cancer may have a treatment choice between surgery and a trial of nonoperative management. Patients must consider the treatments' clinical tradeoffs alongside their personal goals and preferences. Shared decision-making (SDM) between patients and clinicians can improve decision quality when patients are faced with preference-sensitive care options. We interviewed 28 stakeholders (13 clinicians and 15 patients) to understand their perspectives on early-stage rectal cancer treatment decision-making. Clinicians included surgeons, medical oncologists, and radiation oncologists who treat rectal cancer. Adult patients included those diagnosed with early-stage rectal cancer in the past 5 years, recruited from an institutional database. A semi-structured interview guide was developed based on a well-established decision support framework and reviewed by the research team and stakeholders. Interviews were conducted between January 2022 and January 2023. Transcripts were coded by 2 raters and analyzed using thematic analysis. Both clinicians and patients recognized the importance of SDM to support high-quality decisions about the treatment of early-stage rectal cancer. Barriers to SDM included variable clinician motivation due to lack of training or perception of patients' desires or abilities to engage, as well as time-constrained encounters. A decision aid could help facilitate SDM for early-stage rectal cancer by providing standardized, evidence-based information about treatment options that align with clinicians' and patients' decision needs.
Collapse
Affiliation(s)
| | | | | | | | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St. Louis, MO
| |
Collapse
|
9
|
Hu X, Pennington BRT, Avidan MS, Kheterpal S, deBourbon NG, Politi MC. Description of the Content and Quality of Publicly Available Information on the Internet About Inhaled Volatile Anesthesia and Total Intravenous Anesthesia: Descriptive Study. JMIR Perioper Med 2023; 6:e47714. [PMID: 37917148 PMCID: PMC10654911 DOI: 10.2196/47714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND More than 300 million patients undergo surgical procedures requiring anesthesia worldwide annually. There are 2 standard-of-care general anesthesia administration options: inhaled volatile anesthesia (INVA) and total intravenous anesthesia (TIVA). There is limited evidence comparing these methods and their impact on patient experiences and outcomes. Patients often seek this information from sources such as the internet. However, the majority of websites on anesthesia-related topics are not comprehensive, updated, and fully accurate. The quality and availability of web-based patient information about INVA and TIVA have not been sufficiently examined. OBJECTIVE This study aimed to (1) assess information on the internet about INVA and TIVA for availability, readability, accuracy, and quality and (2) identify high-quality websites that can be recommended to patients to assist in their anesthesia information-seeking and decision-making. METHODS Web-based searches were conducted using Google from April 2022 to November 2022. Websites were coded using a coding instrument developed based on the International Patient Decision Aids Standards criteria and adapted to be appropriate for assessing websites describing INVA and TIVA. Readability was calculated with the Flesch-Kincaid (F-K) grade level and the simple measure of Gobbledygook (SMOG) readability formula. RESULTS A total of 67 websites containing 201 individual web pages were included for coding and analysis. Most of the websites provided a basic definition of general anesthesia (unconsciousness, n=57, 85%; analgesia, n=47, 70%). Around half of the websites described common side effects of general anesthesia, while fewer described the rare but serious adverse events, such as intraoperative awareness (n=31, 46%), allergic reactions or anaphylaxis (n=29, 43%), and malignant hyperthermia (n=18, 27%). Of the 67 websites, the median F-K grade level was 11.3 (IQR 9.5-12.8) and the median SMOG score was 13.5 (IQR 12.2-14.4), both far above the American Medical Association (AMA) recommended reading level of sixth grade. A total of 51 (76%) websites distinguished INVA versus TIVA as general anesthesia options. A total of 12 of the 51 (24%) websites explicitly stated that there is a decision to be considered about receiving INVA versus TIVA for general anesthesia. Only 10 (20%) websites made any direct comparisons between INVA and TIVA, discussing their positive and negative features. A total of 12 (24%) websites addressed the concept of shared decision-making in planning anesthesia care, but none specifically asked patients to think about which features of INVA and TIVA matter the most to them. CONCLUSIONS While the majority of websites described INVA and TIVA, few provided comparisons. There is a need for high-quality patient education and decision support about the choice of INVA versus TIVA to provide accurate and more comprehensive information in a format conducive to patient understanding.
Collapse
Affiliation(s)
- Xinwen Hu
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Bethany R Tellor Pennington
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | | | - Mary C Politi
- Department of Surgery, Washington University in St Louis School of Medicine, St Louis, MO, United States
| |
Collapse
|
10
|
Abraham J, Meng A, Baumann A, Holzer KJ, Lenard E, Freedland KE, Lenze EJ, Avidan MS, Politi MC. A multi- and mixed-method adaptation study of a patient-centered perioperative mental health intervention bundle. BMC Health Serv Res 2023; 23:1175. [PMID: 37891574 PMCID: PMC10612159 DOI: 10.1186/s12913-023-10186-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Anxiety and depression are common among older adults and can intensify during perioperative periods, but few mental health interventions are designed for older surgical patients' unique needs. As part of the feasibility trial, we developed and adapted a perioperative mental health (PMH) bundle for older patients comprised of behavioral activation (BA) and medication optimization (MO) to ameliorate anxiety and depressive symptoms before, during, and after cardiac, orthopedic, and oncologic surgery. METHODS We used mixed-methods including workshop studios with patients, caregivers, clinicians, researchers, and interventionists; intervention refinement and reflection meetings; patient case review meetings; intervention session audio-recordings and documentation forms; and patient and caregiver semi-structured interviews. We used the results to refine our PMH bundle. We used multiple analytical approaches to report the nature of adaptations, including hybrid thematic analysis and content analysis informed by the Framework for Reporting Adaptations and Modifications - Expanded. RESULTS Adaptations were categorized by content (intervention components), context (how the intervention is delivered, based on the study, target population, intervention format, intervention delivery mode, study setting, study personnel), training, and evaluation. Of 51 adaptations, 43.1% involved content, 41.2% involved context, and 15.7% involved training and evaluation. Several key adaptations were noted: (1) Intervention content was tailored to patient preferences and needs (e.g., rewording elements to prevent stigmatization of mental health needs; adjusting BA techniques and documentation forms to improve patient buy-in and motivation). (2) Cohort-specific adaptations were recommended based on differing patient needs. (3) Compassion was identified by patients as the most important element. CONCLUSIONS We identified evidence-based mental health intervention components from other settings and adapted them to the perioperative setting for older adults. Informed by mixed-methods, we created an innovative and pragmatic patient-centered intervention bundle that is acceptable, feasible, and responsive to the needs of older surgical populations. This approach allowed us to identify implementation strategies to improve the reach, scalability, and sustainability of our bundle, and can guide future patient-centered intervention adaptations. CLINICAL TRIALS REGISTRATION NCT05110690 (11/08/2021).
Collapse
Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA.
- Institute for Informatics, Data Science and Biostatistics, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA.
- Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA.
| | - Alicia Meng
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Ana Baumann
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Katherine J Holzer
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Emily Lenard
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Kenneth E Freedland
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| |
Collapse
|
11
|
Bushroe KM, Crisp KD, Politi MC, Brennan SK, Housten AJ. Evaluating caregiver-clinician communication for tracheostomy placement in the neonatal intensive care unit: a qualitative inquiry. J Perinatol 2023:10.1038/s41372-023-01793-3. [PMID: 37833495 PMCID: PMC11014892 DOI: 10.1038/s41372-023-01793-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/07/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023]
Abstract
OBJECTIVE Identify stakeholders' tracheostomy decision-making information priorities in the Neonatal Intensive Care Unit (NICU). STUDY DESIGN English-speaking caregivers and clinicians who participated in NICU tracheostomy discussions between January 2017 and December 2021 were eligible. They reviewed a pediatric tracheostomy communication guide prior to meeting. Interviews focused on tracheostomy decision-making experiences, communication preferences, and guide perceptions. Interviews were recorded, transcribed, and analyzed using iterative inductive/deductive coding to inform thematic analysis. RESULTS Ten caregivers and nine clinicians were interviewed. Caregivers were surprised by the severity of their child's diagnosis and the intensive home care required, but proceeded with tracheostomy because it was the only chance for survival. All recommended that tracheostomy information be introduced early and in phases. Inadequate communication limited caregivers' understanding of post-surgical care and discharge requirements. All felt a guide could standardize communication. CONCLUSIONS Caregivers seek detailed information regarding expectations after tracheostomy placement in the NICU and at home.
Collapse
Affiliation(s)
- Kylie M Bushroe
- Department of Pediatrics, Division of Newborn Medicine, St. Louis Children's Hospital and Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
| | - Kelly D Crisp
- College of Health and Human Sciences, Northern Illinois University, DeKalb, IL, USA
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Mary C Politi
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Steven K Brennan
- Department of Pediatrics, Division of Allergy and Pulmonary Medicine, St. Louis Children's Hospital and Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Ashley J Housten
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| |
Collapse
|
12
|
Politi MC, Forcino RC, Parrish K, Durand M, O'Malley AJ, Moses R, Cooksey K, Elwyn G. The impact of adding cost information to a conversation aid to support shared decision making about low-risk prostate cancer treatment: Results of a stepped-wedge cluster randomised trial. Health Expect 2023; 26:2023-2039. [PMID: 37394739 PMCID: PMC10485319 DOI: 10.1111/hex.13810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND Decision aids help patients consider the benefits and drawbacks of care options but rarely include cost information. We assessed the impact of a conversation-based decision aid containing information about low-risk prostate cancer management options and their relative costs. METHODS We conducted a stepped-wedge cluster randomised trial in outpatient urology practices within a US-based academic medical center. We randomised five clinicians to four intervention sequences and enroled patients newly diagnosed with low-risk prostate cancer. Primary patient-reported outcomes collected postvisit included the frequency of cost conversations and referrals to address costs. Other patient-reported outcomes included: decisional conflict postvisit and at 3 months, decision regret at 3 months, shared decision-making postvisit, financial toxicity postvisit and at 3 months. Clinicians reported their attitudes about shared decision-making pre- and poststudy, and the intervention's feasibility and acceptability. We used hierarchical regression analysis to assess patient outcomes. The clinician was included as a random effect; fixed effects included education, employment, telehealth versus in-person visit, visit date, and enrolment period. RESULTS Between April 2020 and March 2022, we screened 513 patients, contacted 217 eligible patients, and enroled 117/217 (54%) (51 in usual care, 66 in the intervention group). In adjusted analyses, the intervention was not associated with cost conversations (β = .82, p = .27), referrals to cost-related resources (β = -0.36, p = .81), shared decision-making (β = -0.79, p = .32), decisional conflict postvisit (β = -0.34, p= .70), or at follow-up (β = -2.19, p = .16), decision regret at follow-up (β = -9.76, p = .11), or financial toxicity postvisit (β = -1.32, p = .63) or at follow-up (β = -2.41, p = .23). Most clinicians and patients had positive attitudes about the intervention and shared decision-making. In exploratory unadjusted analyses, patients in the intervention group experienced more transient indecision (p < .02) suggesting increased deliberation between visit and follow-up. DISCUSSION Despite enthusiasm from clinicians, the intervention was not significantly associated with hypothesised outcomes, though we were unable to robustly test outcomes due to recruitment challenges. Recruitment at the start of the COVID-19 pandemic impacted eligibility, sample size/power, study procedures, and increased telehealth visits and financial worry, independent of the intervention. Future work should explore ways to support shared decision-making, cost conversations, and choice deliberation with a larger sample. Such work could involve additional members of the care team, and consider the detail, quality, and timing of addressing these issues. PATIENT OR PUBLIC CONTRIBUTION Patients and clinicians were engaged as stakeholder advisors meeting monthly throughout the duration of the project to advise on the study design, measures selected, data interpretation, and dissemination of study findings.
Collapse
Affiliation(s)
- Mary C. Politi
- Department of Surgery, Division of Public Health SciencesWashington University School of MedicineSt. LouisMissouriUSA
| | - Rachel C. Forcino
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical PracticeDartmouth CollegeLebanonNew HampshireUSA
| | - Katelyn Parrish
- Department of Surgery, Division of Public Health SciencesWashington University School of MedicineSt. LouisMissouriUSA
| | - Marie‐Anne Durand
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical PracticeDartmouth CollegeLebanonNew HampshireUSA
- Université Toulouse III Paul SabatierToulouseFrance
| | - A. James O'Malley
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical PracticeDartmouth CollegeLebanonNew HampshireUSA
- Department of Biomedical Data ScienceGeisel School of Medicine at Dartmouth, Dartmouth CollegeLebanonNew HampshireUSA
| | - Rachel Moses
- Section of Urology, Department of SurgeryDartmouth‐Hitchcock Medical CenterLebanonNew HampshireUSA
| | - Krista Cooksey
- Department of Surgery, Division of Public Health SciencesWashington University School of MedicineSt. LouisMissouriUSA
| | - Glyn Elwyn
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical PracticeDartmouth CollegeLebanonNew HampshireUSA
| |
Collapse
|
13
|
King CR, Gregory S, Fritz BA, Budelier TP, Ben Abdallah A, Kronzer A, Helsten DL, Torres B, McKinnon S, Goswami S, Mehta D, Higo O, Kerby P, Henrichs B, Wildes TS, Politi MC, Abraham J, Avidan MS, Kannampallil T. An Intraoperative Telemedicine Program to Improve Perioperative Quality Measures: The ACTFAST-3 Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2332517. [PMID: 37738052 PMCID: PMC10517374 DOI: 10.1001/jamanetworkopen.2023.32517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/30/2023] [Indexed: 09/23/2023] Open
Abstract
Importance Telemedicine for clinical decision support has been adopted in many health care settings, but its utility in improving intraoperative care has not been assessed. Objective To pilot the implementation of a real-time intraoperative telemedicine decision support program and evaluate whether it reduces postoperative hypothermia and hyperglycemia as well as other quality of care measures. Design, Setting, and Participants This single-center pilot randomized clinical trial (Anesthesiology Control Tower-Feedback Alerts to Supplement Treatments [ACTFAST-3]) was conducted from April 3, 2017, to June 30, 2019, at a large academic medical center in the US. A total of 26 254 adult surgical patients were randomized to receive either usual intraoperative care (control group; n = 12 980) or usual care augmented by telemedicine decision support (intervention group; n = 13 274). Data were initially analyzed from April 22 to May 19, 2021, with updates in November 2022 and February 2023. Intervention Patients received either usual care (medical direction from the anesthesia care team) or intraoperative anesthesia care monitored and augmented by decision support from the Anesthesiology Control Tower (ACT), a real-time, live telemedicine intervention. The ACT incorporated remote monitoring of operating rooms by a team of anesthesia clinicians with customized analysis software. The ACT reviewed alerts and electronic health record data to inform recommendations to operating room clinicians. Main Outcomes and Measures The primary outcomes were avoidance of postoperative hypothermia (defined as the proportion of patients with a final recorded intraoperative core temperature >36 °C) and hyperglycemia (defined as the proportion of patients with diabetes who had a blood glucose level ≤180 mg/dL on arrival to the postanesthesia recovery area). Secondary outcomes included intraoperative hypotension, temperature monitoring, timely antibiotic redosing, intraoperative glucose evaluation and management, neuromuscular blockade documentation, ventilator management, and volatile anesthetic overuse. Results Among 26 254 participants, 13 393 (51.0%) were female and 20 169 (76.8%) were White, with a median (IQR) age of 60 (47-69) years. There was no treatment effect on avoidance of hyperglycemia (7445 of 8676 patients [85.8%] in the intervention group vs 7559 of 8815 [85.8%] in the control group; rate ratio [RR], 1.00; 95% CI, 0.99-1.01) or hypothermia (7602 of 11 447 patients [66.4%] in the intervention group vs 7783 of 11 672 [66.7.%] in the control group; RR, 1.00; 95% CI, 0.97-1.02). Intraoperative glucose measurement was more common among patients with diabetes in the intervention group (RR, 1.07; 95% CI, 1.01-1.15), but other secondary outcomes were not significantly different. Conclusions and Relevance In this randomized clinical trial, anesthesia care quality measures did not differ between groups, with high confidence in the findings. These results suggest that the intervention did not affect the targeted care practices. Further streamlining of clinical decision support and workflows may help the intraoperative telemedicine program achieve improvement in targeted clinical measures. Trial Registration ClinicalTrials.gov Identifier: NCT02830126.
Collapse
Affiliation(s)
- Christopher R. King
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Stephen Gregory
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Daniel L. Helsten
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Brian Torres
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Sherry McKinnon
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Shreya Goswami
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Divya Mehta
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Omokhaye Higo
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Paul Kerby
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Bernadette Henrichs
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Troy S. Wildes
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha
| | - Mary C. Politi
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, Missouri
| |
Collapse
|
14
|
Pennington BRT, Politi MC, Abdallah AB, Janda AM, Eshun-Wilsonova I, deBourbon NG, Siderowf L, Klosterman H, Kheterpal S, Avidan MS. A survey of surgical patients' perspectives and preferences towards general anesthesia techniques and shared-decision making. BMC Anesthesiol 2023; 23:277. [PMID: 37592215 PMCID: PMC10433576 DOI: 10.1186/s12871-023-02219-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/23/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The decision about which type of general anesthetic to administer is typically made by the clinical team without patient engagement. This study examined patients' preferences, experiences, attitudes, beliefs, perceptions, and perceived social norms about anesthesia and about engaging in the decision regarding general anesthetic choice with their clinician. METHODS We conducted a survey in the United States, sent to a panel of surgical patients through Qualtrics (Qualtrics, Provo, UT) from March 2022 through May 2022. Questions were developed based on the Theory of Planned Behavior and validated measures were used when available. A patient partner who had experienced both intravenous and inhaled anesthesia contributed to the development and refinement of the questions. RESULTS A total of 806 patients who received general anesthesia for an elective procedure in the last five years completed the survey. 43% of respondents preferred a patient-led decision making role and 28% preferred to share decision making with their clinical team, yet only 7.8% reported being engaged in full shared decision making about the anesthesia they received. Intraoperative awareness, pain, nausea, vomiting and quickly returning to work and usual household activities were important to respondents. Waking up in the middle of surgery was the most commonly reported concern, despite this experience being reported only 8% of the time. Most patients (65%) who searched for information about general anesthesia noted that it took a lot of effort to find the information, and 53% agreed to feeling frustrated during the search. CONCLUSIONS Most patients prefer a patient-led or shared decision making process when it comes to their anesthetic care and want to be engaged in the decision. However, only a small percentage of patients reported being fully engaged in the decision. Further studies should inform future shared decision-making tools, informed consent materials, educational materials and framing of anesthetic choices for patients so that they are able to make a choice regarding the anesthetic they receive.
Collapse
Affiliation(s)
| | - Mary C Politi
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Allison M Janda
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Lilly Siderowf
- College of Arts and Sciences, Washington University, St. Louis, MO, USA
| | | | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
15
|
Foraker R, Phommasathit C, Clevenger K, Lee C, Boateng J, Shareef N, Politi MC. Using the sociotechnical model to conduct a focused usability assessment of a breast reconstruction decision tool. BMC Med Inform Decis Mak 2023; 23:140. [PMID: 37507683 PMCID: PMC10375746 DOI: 10.1186/s12911-023-02236-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION BREASTChoice is a web-based breast reconstruction decision aid. The previous clinical trial-prior to the adaptation of this refined tool in which we explored usability-measured decision quality, quality of life, patient activation, shared decision making, and treatment choice. The current usability study was designed to elicit patients' and clinicians' perspectives on barriers and facilitators for implementing BREASTChoice into the clinical workflow. METHODS We conducted qualitative interviews with patients and clinicians from two Midwestern medical specialty centers from August 2020 to April 2021. Interviews were first double coded until coders achieved a kappa > 0.8 and percent agreement > 95%, then were coded independently. We used a sociotechnical framework to evaluate BREASTChoice's implementation and sustainability potential according to end-users, human-computer interaction, and contextual factors. RESULTS Twelve clinicians and ten patients completed interviews. Using the sociotechnical framework we determined the following. People Using the Tool: Patients and clinicians agreed that BREASTChoice could help patients make more informed decisions about their reconstruction and prepare better for their first plastic surgery appointment. Workflow and Communications: They felt that BREASTChoice could improve communication and process if the patient could view the tool at home and/or in the waiting room. Clinicians suggested the information from BREASTChoice about patients' risks and preferences be included in the patient's chart or the clinician electronic health record (EHR) inbox for accessibility during the consultation. Human Computer Interface: Patients and clinicians stated that the tool contains helpful information, does not require much time for the patient to use, and efficiently fills gaps in knowledge. Although patients found the risk profile information helpful, they reported needing time to read and digest. CONCLUSION BREASTChoice was perceived as highly usable by patients and clinicians and has the potential for sustainability. Future research will implement and test the tool after integrating the stakeholder-suggested changes to its delivery process and content. It is critical to conduct usability assessments such as these prior to decision aid implementation to ensure success of the tool to improve risk communication.
Collapse
Affiliation(s)
- Randi Foraker
- Division of General Medical Sciences, Department of Internal Medicine, Washington University in St. Louis School of Medicine, Saint Louis, MO, USA.
| | - Crystal Phommasathit
- Comprehensive Cancer Center, College of Health Sciences, The Ohio State University, Columbus, OH, USA
| | - Kaleigh Clevenger
- Comprehensive Cancer Center, College of Health Sciences, The Ohio State University, Columbus, OH, USA
| | - Clara Lee
- Department of Plastic and Reconstructive Surgery, College of Medicine, Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Jessica Boateng
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University in St Louis, Saint Louis, MO, USA
| | - Napiera Shareef
- College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University in St Louis, Saint Louis, MO, USA
| |
Collapse
|
16
|
Housten AJ, Rice HE, Chang SH, L'Hotta AJ, Kim EH, Drake BF, Wright-Jones R, Politi MC. Financial burden of men with localized prostate cancer: a process paper. Front Psychol 2023; 14:1176843. [PMID: 37476084 PMCID: PMC10354547 DOI: 10.3389/fpsyg.2023.1176843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/13/2023] [Indexed: 07/22/2023] Open
Abstract
Background Many individuals undergoing cancer treatment experience substantial financial hardship, often referred to as financial toxicity (FT). Those undergoing prostate cancer treatment may experience FT and its impact can exacerbate disparate health outcomes. Localized prostate cancer treatment options include: radiation, surgery, and/or active surveillance. Quality of life tradeoffs and costs differ between treatment options. In this project, our aim was to quantify direct healthcare costs to support patients and clinicians as they discuss prostate cancer treatment options. We provide the transparent steps to estimate healthcare costs associated with treatment for localized prostate cancer among the privately insured population using a large claims dataset. Methods To quantify the costs associated with their prostate cancer treatment, we used data from the Truven Health Analytics MarketScan Commercial Claims and Encounters, including MarketScan Medicaid, and peer reviewed literature. Strategies to estimate costs included: (1) identifying the problem, (2) engaging a multidisciplinary team, (3) reviewing the literature and identifying the database, (4) identifying outcomes, (5) defining the cohort, and (6) designing the analytic plan. The costs consist of patient, clinician, and system/facility costs, at 1-year, 3-years, and 5-years following diagnosis. Results We outline our specific strategies to estimate costs, including: defining complex research questions, defining the study population, defining initial prostate cancer treatment, linking facility and provider level related costs, and developing a shared understanding of definitions on our research team. Discussion and next steps Analyses are underway. We plan to include these costs in a prostate cancer patient decision aid alongside other clinical tradeoffs.
Collapse
Affiliation(s)
- Ashley J. Housten
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Hannah E. Rice
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Allison J. L'Hotta
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Eric H. Kim
- Division of Urology, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Bettina F. Drake
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | | | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| |
Collapse
|
17
|
Moritz W, Westman AM, Politi MC, DOD Working Group, Fox IK. Assessing an Online Patient Decision Aid about Upper Extremity Reconstructive Surgery for Cervical Spinal Cord Injury: Pilot Testing Knowledge, Decisional Conflict, and Acceptability. MDM Policy Pract 2023; 8:23814683231199721. [PMID: 37860721 PMCID: PMC10583528 DOI: 10.1177/23814683231199721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 07/30/2023] [Indexed: 10/21/2023] Open
Abstract
Background. While nerve and tendon transfer surgery can restore upper extremity function and independence after midcervical spinal cord injury, few individuals (∼14%) undergo surgery. There is limited information regarding these complex and time-sensitive treatment options. Patient decision aids (PtDAs) convey complex health information and help individuals make informed, preference-consistent choices. The purpose of this study is to evaluate a newly created PtDA for people with spinal cord injury who are considering options to optimize upper extremity function. Methods. The PtDA was developed by our multidisciplinary group based on clinical evidence and the Ottawa Decision Support Framework. A prospective pilot study enrolled adults with midcervical spinal cord injury to evaluate the PtDA. Participants completed surveys about knowledge and decisional conflict before and after viewing the PtDA. Acceptability measures and suggestions for further improvement were also solicited. Results. Forty-two individuals were enrolled and completed study procedures. Participants had a 20% increase in knowledge after using the PtDA (P < 0.001). The number of participants experiencing decisional conflict decreased after viewing the PtDA (33 v. 18, P = 0.001). Acceptability was high. To improve the PtDA, participants suggested adding details about specific surgeries and outcomes. Limitations. Due to the COVID-19 pandemic, we used an entirely virtual study methodology and recruited participants from national networks and organizations. Most participants were older than the general population with a new spinal cord injury and may have different injury causes than typical surgical candidates. Conclusions. A de novo PtDA improved knowledge of treatment options and reduced decisional conflict about reconstructive surgery among people with cervical spinal cord injury. Future work should explore PtDA use for improving knowledge and decisional conflict in the nonresearch, clinical setting. Highlights People with cervical spinal cord injury prioritize gaining upper extremity function after injury, but few individuals receive information about treatment options.A newly created patient decision aid (PtDA) provides information about recovery after spinal cord injury and the role of traditional tendon and newer nerve transfer surgery to improve upper extremity upper extremity function.The PtDA improved knowledge and decreased decisional conflict in this pilot study.Future work should focus on studying dissemination and implementation of the ptDA into clinical practice.
Collapse
Affiliation(s)
- William Moritz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Amanda M. Westman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Ida K. Fox
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
18
|
Tellor Pennington BR, Colquhoun DA, Neuman MD, Politi MC, Janda AM, Spino C, Thelen-Perry S, Wu Z, Kumar SS, Gregory SH, Avidan MS, Kheterpal S. Feasibility pilot trial for the Trajectories of Recovery after Intravenous propofol versus inhaled VolatilE anesthesia (THRIVE) pragmatic randomised controlled trial. BMJ Open 2023; 13:e070096. [PMID: 37068889 PMCID: PMC10111921 DOI: 10.1136/bmjopen-2022-070096] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION Millions of patients receive general anaesthesia for surgery annually. Crucial gaps in evidence exist regarding which technique, propofol total intravenous anaesthesia (TIVA) or inhaled volatile anaesthesia (INVA), yields superior patient experience, safety and outcomes. The aim of this pilot study is to assess the feasibility of conducting a large comparative effectiveness trial assessing patient experiences and outcomes after receiving propofol TIVA or INVA. METHODS AND ANALYSIS This protocol was cocreated by a diverse team, including patient partners with personal experience of TIVA or INVA. The design is a 300-patient, two-centre, randomised, feasibility pilot trial. Patients 18 years of age or older, undergoing elective non-cardiac surgery requiring general anaesthesia with a tracheal tube or laryngeal mask airway will be eligible. Patients will be randomised 1:1 to propofol TIVA or INVA, stratified by centre and procedural complexity. The feasibility endpoints include: (1) proportion of patients approached who agree to participate; (2) proportion of patients who receive their assigned randomised treatment; (3) completeness of outcomes data collection and (4) feasibility of data management procedures. Proportions and 95% CIs will be calculated to assess whether prespecified thresholds are met for the feasibility parameters. If the lower bounds of the 95% CI are above the thresholds of 10% for the proportion of patients agreeing to participate among those approached and 80% for compliance with treatment allocation for each randomised treatment group, this will suggest that our planned pragmatic 12 500-patient comparative effectiveness trial can likely be conducted successfully. Other feasibility outcomes and adverse events will be described. ETHICS AND DISSEMINATION This study is approved by the ethics board at Washington University (IRB# 202205053), serving as the single Institutional Review Board for both participating sites. Recruitment began in September 2022. Dissemination plans include presentations at scientific conferences, scientific publications, internet-based educational materials and mass media. TRIAL REGISTRATION NUMBER NCT05346588.
Collapse
Affiliation(s)
| | - Douglas A Colquhoun
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Mark D Neuman
- Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary C Politi
- Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Allison M Janda
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Cathie Spino
- Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Zhenke Wu
- Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Sathish S Kumar
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Stephen H Gregory
- Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael S Avidan
- Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sachin Kheterpal
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| |
Collapse
|
19
|
Housten AJ, Kozower BD, Engelhardt KE, Robinson C, Puri V, Samson P, Cooksey K, Politi MC. Developing an Educational and Decision Support Tool for Stage I Lung Cancer Using Decision Science. Ann Thorac Surg 2023; 115:299-308. [PMID: 35926640 DOI: 10.1016/j.athoracsur.2022.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/26/2022] [Accepted: 07/19/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Guidelines recommend shared decision-making about treatment options for high-risk, operable stage I lung cancer. Patient decision aids can facilitate shared decision-making; however, their development, implementation, and evaluation in routine clinical practice presents numerous challenges and opportunities. METHODS The purpose of this review is to reflect on the process of tool development; identify the challenges associated with meeting the needs of patients, clinicians from multiple disciplines, and institutional workflow during implementation; and propose recommendations for future clinicians who wish to develop, refine, or implement similar tools into routine care. RESULTS In this review, we: (1) discuss guidelines for decision aid development; (2) describe how we applied those to create an education and decision support tool for patients with clinical stage I lung cancer deciding between radiation therapy and surgical resection; and (3) highlight challenges in implementing and evaluating the tool. CONCLUSIONS We provide recommendations for those seeking to develop, refine, or implement similar tools into routine care.
Collapse
Affiliation(s)
- Ashley J Housten
- Division of Public Health Sciences, Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Kathryn E Engelhardt
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Pamela Samson
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Krista Cooksey
- Division of Public Health Sciences, Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St Louis, St Louis, Missouri.
| |
Collapse
|
20
|
Abraham J, Meng A, Baumann-Walker A, Holzer K, Lenard E, Freedland KE, Lenze EJ, Avidan MS, Politi MC. A Patient-Centered Perioperative Mental Health Intervention Bundle: A Multi- and Mixed-Method Adaptation Study. Res Sq 2023:rs.3.rs-2451723. [PMID: 36711989 PMCID: PMC9882664 DOI: 10.21203/rs.3.rs-2451723/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Anxiety and depression are common among older adults and can intensify during perioperative periods, but few mental health interventions are designed for older surgical patients' unique needs. We developed and adapted a perioperative mental health (PMH) bundle for older patients comprised of behavioral activation (BA) and medication optimization (MO) to ameliorate anxiety and depressive symptoms before, during, and after cardiac, orthopedic, and oncologic surgery. Methods We used mixed-methods including workshop studios with patients, caregivers, clinicians, researchers, and interventionists; intervention refinement and reflection meetings; patient case review meetings; intervention session audio-recordings and documentation forms; and patient and caregiver semi-structured interviews. We used the results to refine our PMH bundle. We used multiple analytical approaches to report the nature of adaptations, including hybrid thematic analysis and content analysis informed by the Framework for Reporting Adaptations and Modifications - Expanded. Results Adaptations were categorized by content (intervention components), context (how the intervention is delivered, based on the study, target population, intervention format, intervention delivery mode, study setting, study personnel), training, and evaluation. Of 51 adaptations, 43.1% involved content, 41.2% involved context, and 15.7% involved training and evaluation. Several key adaptations were noted: 1) Intervention content was tailored to patient preferences and needs (e.g., rewording elements to prevent stigmatization of mental health needs; adjusting BA techniques and documentation forms to improve patient buy-in and motivation). 2) Cohort-specific adaptations were recommended based on differing patient needs. 3) Compassion was identified by patients as the most important element. Conclusions We identified evidence-based mental health intervention components from other settings and adapted them to the perioperative setting for older adults. Informed by mixed-methods, we created an innovative and pragmatic patient-centered intervention bundle that is acceptable, feasible, and responsive to the needs of older surgical populations. This approach allowed us to identify implementation strategies to improve the reach, scalability, and sustainability of our bundle, and can guide future patient-centered intervention adaptations.
Collapse
|
21
|
Politi MC, Housten AJ, Forcino RC, Jansen J, Elwyn G. Discussing Cost and Value in Patient Decision Aids and Shared Decision Making: A Call to Action. MDM Policy Pract 2023; 8:23814683221148651. [PMID: 36643615 PMCID: PMC9834940 DOI: 10.1177/23814683221148651] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/05/2022] [Indexed: 01/12/2023] Open
Abstract
Direct and indirect costs of care influence patients' health choices and the ability to implement those choices. Despite the significant impact of care costs on patients' health and daily lives, patient decision aid (PtDA) and shared decision-making (SDM) guidelines almost never mention a discussion of costs of treatment options as part of minimum standards or quality criteria. Given the growing study of the impact of costs in health decisions and the rising costs of care more broadly, in fall 2021 we organized a symposium at the Society for Medical Decision Making's annual meeting. The focus was on the role of cost information in PtDAs and SDM. Panelists gave an overview of work in this space at this virtual meeting, and attendees engaged in rich discussion with the panelists about the state of the problem as well as ideas and challenges in incorporating cost-related issues into routine care. This article summarizes and extends our discussion based on the literature in this area and calls for action. We recommend that PtDA and SDM guidelines routinely include a discussion of direct and indirect care costs and that researchers measure the frequency, quality, and response to this information.
Collapse
Affiliation(s)
- Mary C. Politi
- Division of Public Health Sciences, Department
of Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Ashley J. Housten
- Division of Public Health Sciences, Department
of Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Rachel C. Forcino
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon,
NH, USA
| | - Jesse Jansen
- School for Public Health and Primary Care
CAPHRI, Maastricht University, Maastricht, the Netherlands
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon,
NH, USA
| |
Collapse
|
22
|
Lyons PG, Chen V, Sekhar TC, McEvoy CA, Kollef MH, Govindan R, Westervelt P, Vranas KC, Maddox TM, Geng EH, Payne PRO, Politi MC. Clinician Perspectives on Barriers and Enablers to Implementing an Inpatient Oncology Early Warning System: A Mixed-Methods Study. JCO Clin Cancer Inform 2023; 7:e2200104. [PMID: 36706345 DOI: 10.1200/cci.22.00104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To elicit end-user and stakeholder perceptions regarding design and implementation of an inpatient clinical deterioration early warning system (EWS) for oncology patients to better fit routine clinical practices and enhance clinical impact. METHODS In an explanatory-sequential mixed-methods study, we evaluated a stakeholder-informed oncology early warning system (OncEWS) using surveys and semistructured interviews. Stakeholders were physicians, advanced practice providers (APPs), and nurses. For qualitative data, we used grounded theory and thematic content analysis via the constant comparative method to identify determinants of OncEWS implementation. RESULTS Survey respondents generally agreed that an oncology-focused EWS could add value beyond clinical judgment, with nurses endorsing this notion significantly more strongly than other clinicians (nurse: median 5 on a 6-point scale [6 = strongly agree], interquartile range 4-5; doctors/advanced practice providers: 4 [4-5]; P = .005). However, some respondents would not trust an EWS to identify risk accurately (n = 36 [42%] somewhat or very concerned), while others were concerned that institutional culture would not embrace such an EWS (n = 17 [28%]).Interviews highlighted important aspects of the EWS and the local context that might facilitate implementation, including (1) a model tailored to the subtleties of oncology patients, (2) transparent model information, and (3) nursing-centric workflows. Interviewees raised the importance of sepsis as a common and high-risk deterioration syndrome. CONCLUSION Stakeholders prioritized maximizing the degree to which the OncEWS is understandable, informative, actionable, and workflow-complementary, and perceived these factors to be key for translation into clinical benefit.
Collapse
Affiliation(s)
- Patrick G Lyons
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St Louis, MO.,Healthcare Innovation Lab, BJC HealthCare, St Louis, MO.,Siteman Cancer Center, St Louis, MO
| | - Vanessa Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St Louis, MO
| | - Tejas C Sekhar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St Louis, MO
| | - Colleen A McEvoy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St Louis, MO
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St Louis, MO
| | - Ramaswamy Govindan
- Siteman Cancer Center, St Louis, MO.,Division of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO
| | - Peter Westervelt
- Siteman Cancer Center, St Louis, MO.,Division of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO
| | - Kelly C Vranas
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR.,Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR
| | - Thomas M Maddox
- Healthcare Innovation Lab, BJC HealthCare, St Louis, MO.,Division of Cardiology, Department of Medicine, Washington University School of Medicine, St Louis, MO
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, MO.,Center for Dissemination and Implementation in the Institute for Public Health, Washington University School of Medicine, St Louis, MO
| | - Philip R O Payne
- Institute for Informatics, Washington University School of Medicine, St Louis, MO
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO.,Center for Collaborative Care Decisions, Department of Surgery, Washington University School of Medicine, St Louis, MO
| |
Collapse
|
23
|
Parks RG, Thomas F, Morshed AB, Dodson EA, Tian R, Politi MC, Eyler AA, Thomas I, Brownson RC. Municipal officials' perspectives on policymaking for addressing obesity and health equity. Evid Policy 2023; 19:444-464. [PMID: 38650970 PMCID: PMC11034731 DOI: 10.1332/174426421x16793276974116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Background Obesity evidence-based policies (EBPs) can make a lasting, positive impact on community health; however, policy development and enactment is complex and dependent on multiple forces. Aims and objectives This study investigated key factors affecting municipal officials' policymaking for obesity and related health disparities. Methods Semi-structured interviews were conducted with 20 local officials from a selection of municipalities with high obesity or related health disparities across the United States between December 2020 and April 2021. Findings Policymakers follow a general decision-making process with limited distinction between health and other policy areas. Factors affecting policymaking included: being informed about other local, state, and federal policy, conducting their own research using trustworthy sources, and seeking constituent and stakeholder perspectives. Key facilitators included the need for timely, relevant local data, and seeing or hearing from those impacted. Key local policymaking barriers included constituent opposition, misinformation, controversial issues with contentious solutions, and limited understanding of the connection between issues and obesity/health. Policymakers had a range of understanding about causes of health disparities, including views of individual choices, environmental influences on behaviors, and structural factors impacting health. To address health disparities, municipal officials described: a variety of roles policymakers can take, limitations based on the scope of government, challenges with intergovernmental collaboration or across government levels, ability of policymakers and government employees to understand the problem, and the challenge of framing health disparities given the social-political context. Discussion and conclusion Understanding factors affecting the uptake of EBPs can inform local-level interventions that encourage EBP adoption.
Collapse
Affiliation(s)
- Renee G. Parks
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO
| | - Fanice Thomas
- Brown School, Washington University in St. Louis, St. Louis, MO
| | - Alexandra B. Morshed
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Elizabeth A. Dodson
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO
| | - Ruiyi Tian
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO
| | - Mary C. Politi
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Amy A. Eyler
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO
| | | | - Ross C. Brownson
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO
| |
Collapse
|
24
|
Affiliation(s)
- Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, USA.
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, USA
| |
Collapse
|
25
|
Simonovic N, Taber JM, Scherr CL, Dean M, Hua J, Howell JL, Chaudhry BM, Wain KE, Politi MC. Uncertainty in healthcare and health decision making: Five methodological and conceptual research recommendations from an interdisciplinary team. J Behav Med 2022. [DOI: 10.1007/s10865-022-00384-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
26
|
Zeal C, Paul R, Dorsey M, Politi MC, Madden T. Young women's preferences for contraceptive education & development of an online educational resource. PEC Innov 2022; 1:100046. [PMID: 37213738 PMCID: PMC10194227 DOI: 10.1016/j.pecinn.2022.100046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/21/2022] [Accepted: 04/27/2022] [Indexed: 05/23/2023]
Abstract
Objectives To explore young women's preferences for contraceptive education to inform the development of an educational resource and to pilot test the resource with patients and clinicians. Methods We performed a mixed-methods study to elicit preferences for contraceptive educational resources among patients, develop an online resource, and pilot test the resource with clinicians and patients to assess feasibility, systems usability, and contraceptive knowledge. Results Forty-one women aged 16-29 completed in-depth interviews: they preferred an online format which was recommended by a clinician, presented contraceptive methods in order of effectiveness, and contained information from experts and experiences from individual users. We adapted an existing website (bedsider.org) to create an online educational resource. Thirty clinicians and thirty patients completed surveys after use. System Usability Scale scores were high among patients (median [IQR]: 80 [72-86]) and clinicians (84 [75-90]). Patients answered more contraceptive knowledge questions correctly after interacting with the resource (9.9±2.7 vs 12.0±2.8, p<0.001). Conclusions We developed a contraceptive educational resource incorporating end-user feedback that was highly usable and increased patients' contraceptive knowledge. Future research should assess effectiveness and scalability among a larger sample of patients. Innovation This contraceptive educational resource can supplement clinician counseling to increase patient contraceptive knowledge.
Collapse
Affiliation(s)
- Carley Zeal
- Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
- Department of Obstetrics and Gynecology, Mercy Health – Beloit, Beloit, WI, USA
| | - Rachel Paul
- Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Megan Dorsey
- Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Mary C. Politi
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Tessa Madden
- Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
- Corresponding author at: Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, 4901 Forest Park Avenue, Mailstop: 8064-37-1005, St. Louis, MO 63108, USA.
| |
Collapse
|
27
|
Cooksey KE, Mozersky J, DuBois J, Kuroki L, Marx CM, Politi MC. Challenges and Possible Solutions to Adapting to Virtual Recruitment: Lessons Learned from a Survey Study during the Covid-19 Pandemic. Ethics Hum Res 2022; 44:23-31. [PMID: 36316973 PMCID: PMC9631333 DOI: 10.1002/eahr.500148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Covid-19 pandemic required rapid changes to research protocols, including immediate transitions to recruiting research participants and conducting the informed consent process virtually. This case study details the challenges our research team faced adapting an in-person, behavioral-intervention and survey study to virtual recruitment. We reflect on the impact of these rapid changes on recruitment and retention, discuss protocol changes we made to address these challenges and the needs of potential and enrolled participants, and propose recommendations for future work. Using computer technology to display professional return phone numbers, being flexible by contacting potential participants through various means, minimizing email communication due to added regulatory requirements, and partnering with the institutional review board to shorten and improve the consent document and process were critical to study success. This case study can offer insight to other researchers as they navigate similar processes. Virtual recruitment is likely to continue; it is important to ensure that it facilitates, rather than hinders, equitable and just recruitment practices.
Collapse
Affiliation(s)
- Krista E Cooksey
- Research coordinator in the Division of Public Health Sciences in the Department of Surgery at Washington University School of Medicine
| | - Jessica Mozersky
- Assistant professor in the Bioethics Research Center in the Department of Medicine at Washington University School of Medicine
| | - James DuBois
- Steven J. Bander Professor of Medical Ethics and Professionalism in the Department of Medicine and the executive director of the Bioethics Research Center at Washington University School of Medicine
| | - Lindsay Kuroki
- Associate professor in the Division of Gynecologic Oncology in the Department of Obstetrics & Gynecology at Washington University School of Medicine
| | - Christine M Marx
- Research coordinator in the Division of Public Health Sciences in the Department of Surgery at Washington University School of Medicine
| | - Mary C Politi
- Professor in the Division of Public Health Sciences in the Department of Surgery at Washington University School of Medicine
| |
Collapse
|
28
|
Lee CN, Sullivan J, Foraker R, Myckatyn TM, Olsen MA, Phommasathit C, Boateng J, Parrish KL, Rizer M, Huerta T, Politi MC. Integrating a Patient Decision Aid into the Electronic Health Record: A Case Report on the Implementation of BREASTChoice at 2 Sites. MDM Policy Pract 2022; 7:23814683221131317. [PMID: 36225966 PMCID: PMC9549192 DOI: 10.1177/23814683221131317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/06/2022] [Indexed: 11/17/2022] Open
Abstract
Patient decision aids can support shared decision making and improve decision quality. However, decision aids are not widely used in clinical practice due to multiple barriers. Integrating patient decision aids into the electronic health record (EHR) can increase their use by making them more clinically relevant, personalized, and actionable. In this article, we describe the procedures and considerations for integrating a patient decision aid into the EHR, based on the example of BREASTChoice, a decision aid for breast reconstruction after mastectomy. BREASTChoice's unique features include 1) personalized risk prediction using clinical data from the EHR, 2) clinician- and patient-facing components, and 3) an interactive format. Integrating a decision aid with patient- and clinician-facing components plus interactive sections presents unique deployment issues. Based on this experience, we outline 5 key implementation recommendations: 1) engage all relevant stakeholders, including patients, clinicians, and informatics experts; 2) explicitly and continually map all persons and processes; 3) actively seek out pertinent institutional policies and procedures; 4) plan for integration to take longer than development of a stand-alone decision aid or one with static components; and 5) transfer knowledge about the software programming from one institution to another but expect local and context-specific changes. Integration of patient decision aids into the EHR is feasible and scalable but requires preparation for specific challenges and a flexible mindset focused on implementation. Highlights Integrating an interactive decision aid with patient- and clinician-facing components into the electronic health record could advance shared decision making but presents unique implementation challenges.We successfully integrated a decision aid for breast reconstruction after mastectomy called BREASTChoice into the electronic health record.Based on this experience, we offer these implementation recommendations: 1) engage relevant stakeholders, 2) explicitly and continually map persons and processes, 3) seek out institutional policies and procedures, 4) plan for it to take longer than for a stand-alone decision aid, and 5) transfer software programming from one site to another but expect local changes.
Collapse
Affiliation(s)
- Clara N. Lee
- Clara N. Lee, Department of Plastic and
Reconstructive Surgery, College of Medicine, Division of Health Services
Management and Policy, College of Public Health, The Ohio State University, 915
Olentangy River Rd, Ste 2100, Columbus, OH 43212, USA.
| | - Janessa Sullivan
- Division of Plastic and Reconstructive Surgery,
Department of Surgery, Washington University School of Medicine, Saint
Louis, MO, USA
| | - Randi Foraker
- Division of General Medical Sciences,
Department of Medicine, Washington University School of Medicine, Saint
Louis, MO, USA
| | - Terence M. Myckatyn
- Division of Plastic and Reconstructive Surgery,
Department of Surgery, Washington University School of Medicine, Saint
Louis, MO, USA,Division of General Medical Sciences,
Department of Medicine, Washington University School of Medicine, Saint
Louis, MO, USA
| | - Margaret A. Olsen
- Division of Public Health Sciences, Department
of Surgery, Washington University School of Medicine, Saint Louis, MO,
USA,Department of Family and Community Medicine,
Department of Biomedical Informatics, College of Medicine, The Ohio State
University, Columbus, OH, USA
| | | | - Jessica Boateng
- Division of Public Health Sciences, Department
of Surgery, Washington University School of Medicine, Saint Louis, MO,
USA
| | - Katelyn L. Parrish
- Division of Public Health Sciences, Department
of Surgery, Washington University School of Medicine, Saint Louis, MO,
USA
| | - Milisa Rizer
- Division of Infectious Diseases, Department of
Medicine, Washington University School of Medicine, Saint Louis, MO,
USA
| | - Tim Huerta
- Department of Biomedical Informatics,
Washington University School of Medicine, Saint Louis, MO, USA
| | - Mary C. Politi
- Division of Public Health Sciences, Department
of Surgery, Washington University School of Medicine, Saint Louis, MO,
USA
| |
Collapse
|
29
|
Charles ME, Kuroki LM, Baumann AA, Tabak RG, James A, Cooksey K, Politi MC. A case study of adapting a health insurance decision intervention from trial into routine cancer care. BMC Res Notes 2022; 15:298. [PMID: 36088371 PMCID: PMC9463661 DOI: 10.1186/s13104-022-06189-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/27/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objective
This study adapted Improving Cancer Patients’ Insurance Choices (I Can PIC), an intervention to help cancer patients navigate health insurance decisions and care costs. The original intervention improved knowledge and confidence making insurance decisions, however, users felt limited by choices provided in insurance markets. Using decision trees and frameworks to guide adaptations, we modified I Can PIC to focus on using rather than choosing health insurance. The COVID-19 pandemic introduced unforeseen obstacles, prompting changes to study protocols. As a result, we allowed users outside of the study to use I Can PIC (> 1050 guest users) to optimize public benefit. This paper describes the steps took to conduct the study, evaluating both the effectiveness of I Can PIC and the implementation process to improve its impact.
Results
Although I Can PIC users had higher knowledge and health insurance literacy compared to the control group, results were not statistically significant. This outcome may be associated with systems-level challenges as well as the number and demographic characteristics of participants. The publicly available tool can be a resource for those navigating insurance and care costs, and researchers can use this flexible approach to intervention delivery and testing as future health emergencies arise.
Collapse
|
30
|
Aronson PL, Schaeffer P, A Ponce K, K Gainey T, Politi MC, Fraenkel L, Florin TA. Stakeholder Perspectives on Hospitalization Decisions and Shared Decision-Making in Bronchiolitis. Hosp Pediatr 2022; 12:473-482. [PMID: 35441213 PMCID: PMC9647631 DOI: 10.1542/hpeds.2021-006475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Our objective was to elicit clinicians' and parents' perspectives about decision-making related to hospitalization for children with bronchiolitis and the use of shared decision-making (SDM) to guide these decisions. METHODS We conducted individual, semistructured interviews with purposively sampled clinicians (pediatric emergency medicine physicians and nurses) at 2 children's hospitals and parents of children age <2 years with bronchiolitis evaluated in the emergency department at 1 hospital. Interviews elicited clinicians' and parents' perspectives on decision-making and SDM for bronchiolitis. We conducted an inductive analysis following the principles of grounded theory until data saturation was reached for both groups. RESULTS We interviewed 24 clinicians (17 physicians, 7 nurses) and 20 parents. Clinicians identified factors in 3 domains that contribute to hospitalization decision-making for children with bronchiolitis: demographics, clinical factors, and social-emotional factors. Although many clinicians supported using SDM for hospitalization decisions, most reported using a clinician-guided decision-making process in practice. Clinicians also identified several barriers to SDM, including the unpredictable course of bronchiolitis, perceptions of parents' preferences for engaging in SDM, and parents' emotions, health literacy, preferred language, and comfort with discharge. Parents wanted the opportunity to express their opinions during decision-making about hospitalization, although they often felt comfortable with the clinician's decision when adequately informed. CONCLUSIONS Although clinicians and parents of children with bronchiolitis are supportive of SDM, most hospitalization decision-making is clinician guided. Future investigation should evaluate how to address barriers and implement SDM in practice, including training clinicians in this SDM approach.
Collapse
Affiliation(s)
| | | | | | | | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University, St Louis, Missouri
| | - Liana Fraenkel
- Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Todd A Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
31
|
Oman K, Durand MA, Elwyn G, Yen RW, Marx C, Politi MC. Unexpected Outcomes of Measuring Decision Regret: Using a Breast Cancer Decision-Making Case Example. Patient 2022; 15:151-155. [PMID: 34337674 PMCID: PMC10599632 DOI: 10.1007/s40271-021-00543-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
Shared decision making can help patients feel supported and empowered when deciding between healthcare options. Decision regret can be a meaningful measure of the quality of that encounter. However, in a patient-engaged research study examining shared decision making for breast cancer surgery, decision regret was a difficult construct to assess, and asking questions about decision regret caused the patient to experience that emotion upon reflection. In this article, we consider the complexity of decision regret, and discuss the difficulty of measuring that emotion through existing instruments. We call for clarity in definitions of decision regret and offer suggestions for developing a set of questions that can capture regret in a more meaningful way.
Collapse
Affiliation(s)
- Kelly Oman
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, Saint Louis, MO, USA.
| | - Marie-Anne Durand
- Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, USA
- UM1295, CERPOP, Team EQUITY, Université Toulouse III Paul Sabatier, Toulouse, France
- Unisanté, Centre Universitaire de Médecine Générale et Santé Publique, Lausanne, Switzerland
| | - Glyn Elwyn
- Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, USA
| | - Renata West Yen
- Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, USA
| | - Christine Marx
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, Saint Louis, MO, USA
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, Saint Louis, MO, USA
| |
Collapse
|
32
|
Aronson PL, Fleischer E, Schaeffer P, Fraenkel L, Politi MC, White MA. Development of a Parent-Reported Outcome Measure for Febrile Infants ≤60 Days Old. Pediatr Emerg Care 2022; 38:e821-e827. [PMID: 35100782 PMCID: PMC8807943 DOI: 10.1097/pec.0000000000002378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We aimed to develop a parent-reported outcome measure for febrile infants 60 days or younger evaluated in the emergency department. METHODS We conducted a 3-part study: (1) individual, semistructured interviews with parents of febrile infants 60 days or younger to generate potential items for the measure; (2) expert review with pediatric emergency medicine physicians and member checking with parents, who rated each item's clarity and relevance using 4-point scales; and (3) cognitive interviews with a new sample of parents, who gave feedback and rated the measure's ease of use on a 4-point scale. The measure was iteratively revised during each part of the development process. RESULTS In part 1, we interviewed 24 parents of 21 infants. Interviews revealed several themes: parents' experiences with medical care, communication, and decision making; parents' emotions, particularly worry, fear, and stress; the infant's outcomes valued by parents; and the impact of the infant's illness on the family. From these themes, we identified 22 potential items for inclusion in the measure. In part 2, 10 items were revised for clarity based on feedback from physicians and parents, primarily under the domains of parents' emotions and the infant's outcomes. In part 3, we further revised the measure for clarity and added an item. The final measure included 23 items and was rated as excellent in its ease of use. CONCLUSIONS The 23-item parent-reported outcome measure includes the experiences and outcomes important to parents. Further studies are needed to evaluate the measure's psychometric properties.
Collapse
Affiliation(s)
- Paul L. Aronson
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eduardo Fleischer
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Paula Schaeffer
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Liana Fraenkel
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University, St. Louis, MO, USA
| | - Marney A. White
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| |
Collapse
|
33
|
Politi MC, Saunders CH, Grabinski VF, Yen RW, Cyr AE, Durand MA, Elwyn G. An absence of equipoise: Examining surgeons' decision talk during encounters with women considering breast cancer surgery. PLoS One 2021; 16:e0260704. [PMID: 34914705 PMCID: PMC8675712 DOI: 10.1371/journal.pone.0260704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 11/15/2021] [Indexed: 11/25/2022] Open
Abstract
Shared decision-making is recommended for decisions with multiple reasonable options, yet clinicians often subtly or explicitly guide choices. Using purposive sampling, we performed a secondary analysis of 142 audio-recorded encounters between 13 surgeons and women eligible for breast-conserving surgery with radiation or mastectomy. We trained 9 surgeons in shared decision-making and provided them one of two conversation aids; 4 surgeons practiced as usual. Based on a published taxonomy of treatment recommendations (pronouncements, suggestions, proposals, offers, assertions), we examined how surgeons framed choices with patients. Many surgeons made assertions providing information and advice (usual care 71% vs. intervention 66%; p = 0.54). Some made strong pronouncements (usual care 51% vs. intervention 36%; p = .09). Few made proposals and offers, leaving the door open for deliberation (proposals usual care 21% vs. intervention 26%; p = 0.51; offers usual care 40% vs. intervention 40%; p = 0.98). Surgeons were significantly more likely to describe options as comparable when using a conversation aid, mentioning this in all intervention group encounters (usual care 64% vs. intervention 100%; p<0.001). Conversation aids can facilitate offers of comparable options, but other conversational actions can inhibit aspects of shared decision-making.
Collapse
Affiliation(s)
- Mary C. Politi
- Department of Surgery, Division of Public Health Sciences, Washington University in St Louis School of Medicine, St Louis, MO, United States of America
- * E-mail:
| | - Catherine H. Saunders
- Dartmouth-Hitchcock Medical Center, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, United States of America
| | - Victoria F. Grabinski
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Renata W. Yen
- Dartmouth-Hitchcock Medical Center, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, United States of America
| | - Amy E. Cyr
- Department of Medicine, Division of Medical Oncology, Washington University in St Louis School of Medicine, St Louis, MO, United States of America
| | - Marie-Anne Durand
- Dartmouth-Hitchcock Medical Center, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, United States of America
- Centre d’Epidémiologie et de Recherche en santé des Populations, Université de Toulouse, INSERM UMR1295, Université Toulouse, Toulouse, France
- Unisanté, Centre universitaire de médecine générale et santé publique, Lausanne, Switzerland
| | - Glyn Elwyn
- Dartmouth-Hitchcock Medical Center, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, United States of America
| |
Collapse
|
34
|
Abraham J, Meng A, Holzer KJ, Brawer L, Casarella A, Avidan M, Politi MC. Exploring patient perspectives on telemedicine monitoring within the operating room. Int J Med Inform 2021; 156:104595. [PMID: 34627112 PMCID: PMC10627166 DOI: 10.1016/j.ijmedinf.2021.104595] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/10/2021] [Accepted: 09/24/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clinical decision support systems and telemedicine for remote monitoring can together support clinicians' intraoperative decision-making and management of surgical patients' care. However, there has been limited investigation on patient perspectives about advanced health information technology use in intraoperative settings, especially an electronic OR (eOR) for remote monitoring and management of surgical patients. PURPOSE Our study objectives were: (1) to identify participant-rated items contributing to patient attitudes, beliefs, and level of comfort with eOR monitoring; and (2) to highlight barriers and facilitators to eOR use. METHODS We surveyed 324 individuals representing surgical patients across the United States using Amazon Mechanical Turk, an online platform supporting internet-based work. The structured survey questions examined the level of agreement and comfort with eOR for remote patient monitoring. We calculated descriptive statistics for demographic variables and performed a Wilcoxon matched-pairs signed-rank test to assess whether participants were more comfortable with familiar clinicians from local hospitals or health systems monitoring their health and safety status during surgery than clinicians from hospitals or health systems in other regions or countries. We also analyzed open-ended survey responses using a thematic approach informed by an eight-dimensional socio-technical model. RESULTS Participants' average age was 34.07 (SD = 10.11). Most were white (80.9%), male (57.1%), and had a high school degree or more (88.3%). Participants reported a higher level of comfort with clinicians they knew monitoring their health and safety than clinicians they did not know, even within the same healthcare system (z = -4.012, p < .001). They reported significantly higher comfort levels with clinicians within the same hospital or health system in the United States than those in a different country (z = -10.230, p < .001). Facilitators and barriers to eOR remote monitoring were prevalent across four socio-technical dimensions: 1) organizational policies, procedures, environment, and culture; 2) people; 3) workflow and communication; and 4) hardware and software. Facilitators to eOR use included perceptions of improved patient safety through a safeguard system and perceptions of streamlined care. Barriers included fears of incorrect eOR patient assessments, decision-making conflicts between care teams, and technological malfunctions. CONCLUSIONS Participants expressed significant support for intraoperative telemedicine use and greater comfort with local telemedicine systems instead of long-distance telemedicine systems. Reservations centered on organizational policies, procedures, environment, culture; people; workflow and communication; and hardware and software. To improve the buy-in and acceptability of remote monitoring by an eOR team, we offer a few evidence-based guidelines applicable to telemedicine use within the context of OR workflow. Guidelines include backup plans for technical challenges, rigid care, and privacy standards, and patient education to increase understanding of telemedicine's potential to improve patient care.
Collapse
Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States; Institute for Informatics, Washington University School of Medicine, St Louis, MO, United States.
| | - Alicia Meng
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States
| | - Katherine J Holzer
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States
| | - Luke Brawer
- Wallace H. Coulter Department of Biomedical Engineering Georgia Institute of Technology and Emory University, Atlanta, GA, United States
| | - Aparna Casarella
- Brown School at Washington University in St. Louis, St. Louis, MO, United States
| | - Michael Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO, United States
| |
Collapse
|
35
|
Soltys FC, Spilo K, Politi MC. The Content and Quality of Publicly Available Information About Congenital Diaphragmatic Hernia: Descriptive Study. JMIR Pediatr Parent 2021; 4:e30695. [PMID: 34665147 PMCID: PMC8564656 DOI: 10.2196/30695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/23/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) diagnosis in an infant is distressing for parents. Parents often feel unable to absorb the complexities of CDH during prenatal consultations and use the internet to supplement their knowledge and decision making. OBJECTIVE We aimed to examine the content and quality of publicly available, internet-based CDH information. METHODS We conducted internet searches across 2 popular search engines (Google and Bing). Websites were included if they contained CDH information and were publicly available. We developed a coding instrument to evaluate websites. Two coders (FS and KS) were trained, achieved interrater reliability, and rated remaining websites independently. Descriptive statistics were performed. RESULTS Searches yielded 520 websites; 91 met inclusion criteria and were analyzed. Most websites provided basic CDH information including describing the defect (86/91, 95%), need for neonatal intensive care (77/91, 85%), and surgical correction (79/91, 87%). Few mentioned palliative care, decisions about pregnancy termination (13/91, 14%), or support resources (21/91, 23%). CONCLUSIONS Findings highlight the variability of information about CDH on the internet. Clinicians should work to develop or identify reliable, comprehensive information about CDH to support parents.
Collapse
Affiliation(s)
- Frank Coyle Soltys
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Kimi Spilo
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| |
Collapse
|
36
|
Boateng J, Lee CN, Foraker RE, Myckatyn TM, Spilo K, Goodwin C, Politi MC. Implementing an Electronic Clinical Decision Support Tool Into Routine Care: A Qualitative Study of Stakeholders' Perceptions of a Post-Mastectomy Breast Reconstruction Tool. MDM Policy Pract 2021; 6:23814683211042010. [PMID: 34553067 PMCID: PMC8450551 DOI: 10.1177/23814683211042010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 08/04/2021] [Indexed: 11/15/2022] Open
Abstract
Objective. To explore barriers and facilitators to implementing an evidence-based clinical decision support (CDS) tool (BREASTChoice) about post-mastectomy breast reconstruction into routine care. Materials and Methods. A stakeholder advisory group of cancer survivors, clinicians who discuss and/or perform breast reconstruction in women with cancer, and informatics professionals helped design and review the interview guide. Based on the Consolidated Framework for Implementation Research (CFIR), we conducted qualitative semistructured interviews with key stakeholders (patients, clinicians, informatics professionals) to explore intervention, setting characteristics, and process-level variables that can impact implementation. Interviews were transcribed, coded, and analyzed based on the CFIR framework using both inductive and deductive methods. Results. Fifty-seven potential participants were contacted; 49 (85.9%) were eligible, and 35 (71.4%) were enrolled, continuing until thematic saturation was reached. Participants consisted of 13 patients, 13 clinicians, and 9 informatics professionals. Stakeholders thought that BREASTChoice was useful and provided patients with an evidence-based source of information about post-mastectomy breast reconstruction, including their personalized risks. They felt that BREASTChoice could support shared decision making, improve workflow, and possibly save consultation time, but were uncertain about the best time to deliver BREASTChoice to patients. Some worried about cost, data availability, and security of integrating the tool into an electronic health record. Most acknowledged the importance of showing clinical utility to gain institutional buy-in and encourage routine adoption. Discussion and Conclusion. Stakeholders felt that BREASTChoice could support shared decision making, improve workflow, and reduce consultation time. Addressing key questions such as cost, data integration, and timing of delivering BREASTChoice could build institutional buy-in for CDS implementation. Results can guide future CDS implementation studies.
Collapse
Affiliation(s)
- Jessica Boateng
- Jessica Boateng, Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, 620 S Taylor Ave, St. Louis, MO 63110, USA; Telephone: (704) 858 6599 ()
| | - Clara N. Lee
- Washington University School of Medicine, Saint Louis, Missouri; Department of Plastic Surgery, Ohio State University, Wexner Medical Center, Columbus, Ohio
| | | | | | - Kimi Spilo
- Division of Public Health Sciences, Department of Surgery
| | | | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery
| |
Collapse
|
37
|
Affiliation(s)
- Carrie C Coughlin
- Division of Dermatology, Departments of Medicine and Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Mary C Politi
- Divison of Public Health Sciences, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri
| |
Collapse
|
38
|
Kozina Y, Politi MC, Coughlin CC. Shared decision making in pediatric dermatology: context, opportunities, and practical examples. Curr Opin Pediatr 2021; 33:402-409. [PMID: 34226425 DOI: 10.1097/mop.0000000000001039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Shared decision making (SDM) is an important part of patient-centered care. However, it is neither widely practiced nor researched in pediatric dermatology. In this article, we provide practical examples of how to engage in SDM in pediatric dermatology, and identify future areas of research. RECENT FINDINGS Children and parents/guardians desire SDM in clinical encounters. The process is applicable to discussions of medical as well as surgical care. Additionally, SDM can help prepare children for the transition from pediatric to adult/general providers. Clinicians often want more guidance on its implementation, and there is a dearth of research on SDM or decision tools specific to pediatric dermatology. SUMMARY SDM is underused and understudied in pediatric dermatology. This article highlights how to engage in SDM and presents opportunities for research and implementation in pediatric dermatology.
Collapse
Affiliation(s)
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St Louis School of Medicine
| | - Carrie C Coughlin
- Division of Dermatology, Departments of Medicine and Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| |
Collapse
|
39
|
Politi MC, Forcino RC, Parrish K, Durand MA, O'Malley AJ, Elwyn G. Cost talk: protocol for a stepped-wedge cluster randomized trial of an intervention helping patients and urologic surgeons discuss costs of care for slow-growing prostate cancer during shared decision-making. Trials 2021; 22:422. [PMID: 34187547 PMCID: PMC8240421 DOI: 10.1186/s13063-021-05369-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 06/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Costs of care are important to patients making cancer treatment decisions, but clinicians often do not feel prepared to discuss treatment costs. We aim to (1) assess the impact of a conversation-based decision aid (Option Grid) containing cost information about slow-growing prostate cancer management options, combined with urologic surgeon training, on the frequency and quality of patient-urologic surgeon cost conversations, and (2) examine the impact of the decision aid and surgeon training on decision quality. METHODS We will conduct a stepped-wedge cluster randomized trial in outpatient urology practices affiliated with a large academic medical center in the USA. We will randomize five urologic surgeons to four intervention sequences and enroll their patients with a first-time diagnosis of slow-growing prostate cancer independently at each period. Primary outcomes include frequency of cost conversations, initiator of cost conversations, and whether or not a referral is made to address costs. These outcomes will be collected by patient report (post-visit survey) and by observation (audio-recorded clinic visits) with consent. Other outcomes include the following: patient-reported decisional conflict post-visit and at 3-month follow-up, decision regret at 3-month follow-up, shared decision-making post-visit, communication post-visit, and financial toxicity post-visit and at 3-month follow-up; clinician-reported attitudes about shared decision-making before and after the study, and feasibility of sustained intervention use. We will use hierarchical regression analysis to assess patient-level outcomes, including urologic surgeon as a random effect to account for clustering of patient participants. DISCUSSION This study evaluates a two-part intervention to improve cost discussions between urologic surgeons and patients when deciding how to manage slow-growing prostate cancer. Establishing the effectiveness of the strategy under study will allow for its replication in other clinical decision contexts. TRIAL REGISTRATION ClinicalTrials.gov NCT04397016 . Registered on 21 May 2020.
Collapse
Affiliation(s)
- Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8100, St. Louis, MO, 63110, USA.
| | - Rachel C Forcino
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA
| | - Katelyn Parrish
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8100, St. Louis, MO, 63110, USA
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA.,Université Toulouse III Paul Sabatier, Toulouse, France
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA
| |
Collapse
|
40
|
Zeal C, Paul R, Dorsey M, Politi MC, Madden T. Young women's preferences for contraceptive education: The importance of the clinician. Contraception 2021; 104:553-555. [PMID: 34139152 DOI: 10.1016/j.contraception.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/28/2021] [Accepted: 06/09/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We explored women's preferences for contraceptive education and assess the role of the clinician in delivering this education. STUDY DESIGN We recruited women ages 16 to 29 presenting for gynecologic care at 3 clinical sites. Respondents completed a survey about preferences for receipt of contraceptive information and trustworthiness of information sources. RESULTS We included 270 respondents' surveys (77.6% of approached). Clinicians were the most preferred (87.0%) and trusted (83.5%) source of contraceptive information, and 69.0% said a clinician's recommendation made a source more trustworthy. CONCLUSIONS Clinicians are a trusted source of contraceptive information; their recommendations of other educational resources may improve acceptance by patients.
Collapse
Affiliation(s)
- Carley Zeal
- Divisions of Family Planning & Clinical Research, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States; Department of Obstetrics and Gynecology, Mercyhealth - Beloit. 2825 Prairie Ave Beloit, WI 53511, United States
| | - Rachel Paul
- Divisions of Family Planning & Clinical Research, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Megan Dorsey
- Divisions of Family Planning & Clinical Research, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Tessa Madden
- Divisions of Family Planning & Clinical Research, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States.
| |
Collapse
|
41
|
Schubbe D, Yen RW, Saunders CH, Elwyn G, Forcino RC, O'Malley AJ, Politi MC, Margenthaler J, Volk RJ, Sepucha K, Ozanne E, Percac-Lima S, Bradley A, Goodwin C, van den Muijsenbergh M, Aarts JWM, Scalia P, Durand MA. Implementation and sustainability factors of two early-stage breast cancer conversation aids in diverse practices. Implement Sci 2021; 16:51. [PMID: 33971913 PMCID: PMC8108365 DOI: 10.1186/s13012-021-01115-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Conversation aids can facilitate shared decision-making and improve patient-centered outcomes. However, few examples exist of sustained use of conversation aids in routine care due to numerous barriers at clinical and organizational levels. We explored factors that will promote the sustained use of two early-stage breast cancer conversation aids. We examined differences in opinions between the two conversation aids and across socioeconomic strata. METHODS We nested this study within a randomized controlled trial that demonstrated the effectiveness of two early-stage breast cancer surgery conversation aids, one text-based and one picture-based. These conversation aids facilitated more shared decision-making and improved the decision process, among other outcomes, across four health systems with socioeconomically diverse patient populations. We conducted semi-structured interviews with a purposive sample of patient participants across conversation aid assignment and socioeconomic status (SES) and collected observations and field notes. We interviewed trial surgeons and other stakeholders. Two independent coders conducted framework analysis using the NOrmalization MeAsure Development through Normalization Process Theory. We also conducted an inductive analysis. We conducted additional sub-analyses based on conversation aid assignment and patient SES. RESULTS We conducted 73 semi-structured interviews with 43 patients, 16 surgeons, and 14 stakeholders like nurses, cancer center directors, and electronic health record (EHR) experts. Patients and surgeons felt the conversation aids should be used in breast cancer care in the future and were open to various methods of giving and receiving the conversation aid (EHR, email, patient portal, before consultation). Patients of higher SES were more likely to note the conversation aids influenced their treatment discussion, while patients of lower SES noted more influence on their decision-making. Intervention surgeons reported using the conversation aids did not lengthen their typical consultation time. Most intervention surgeons felt using the conversation aids enhanced their usual care after using it a few times, and most patients felt it appeared part of their normal routine. CONCLUSIONS Key factors that will guide the future sustained implementation of the conversation aids include adapting to existing clinical workflows, flexibility of use, patient characteristics, and communication preferences. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03136367 , registered on May 2, 2017.
Collapse
Affiliation(s)
- Danielle Schubbe
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Renata W Yen
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Catherine H Saunders
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Rachel C Forcino
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Mary C Politi
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie Margenthaler
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Robert J Volk
- Division of Cancer Prevention & Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Sanja Percac-Lima
- Massachusetts General Hospital's Chelsea Healthcare Center, Chelsea, MA, USA
| | - Ann Bradley
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Courtney Goodwin
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Peter Scalia
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA.
- UMR 1295, CERPOP, Université de Toulouse, Inserm, Université Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000, Toulouse, France.
- Unisanté, Centre universitaire de médecine générale et santé publique, Rue du Bugnon 44, CH-1011, Lausanne, Switzerland.
| |
Collapse
|
42
|
Barnell EK, Newcomer KF, Skidmore ZL, Krysiak K, Anderson SR, Wartman LD, Oh ST, Welch JS, Stockerl-Goldstein KE, Vij R, Cashen AF, Pusic I, Westervelt P, Abboud CN, Ghobadi A, Uy GL, Schroeder MA, Dipersio JF, Politi MC, Spencer DH, Duncavage EJ, Ley TJ, Griffith M, Jacoby MA, Griffith OL. Impact of a 40-Gene Targeted Panel Test on Physician Decision Making for Patients With Acute Myeloid Leukemia. JCO Precis Oncol 2021; 5:PO.20.00182. [PMID: 34036230 PMCID: PMC8140802 DOI: 10.1200/po.20.00182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Physicians treating hematologic malignancies increasingly order targeted sequencing panels to interrogate recurrently mutated genes. The precise impact of these panels on clinical decision making is not well understood. METHODS Here, we report our institutional experience with a targeted 40-gene panel (MyeloSeq) that is used to generate a report for both genetic variants and variant allele frequencies for the treating physician (the limit of mutation detection is approximately one AML cell in 50). RESULTS In total, 346 sequencing reports were generated for 325 patients with suspected hematologic malignancies over an 8-month period (August 2018 to April 2019). To determine the influence of genomic data on clinical care for patients with acute myeloid leukemia (AML), we analyzed 122 consecutive reports from 109 patients diagnosed with AML and surveyed the treating physicians with a standardized questionnaire. The panel was ordered most commonly at diagnosis (61.5%), but was also used to assess response to therapy (22.9%) and to detect suspected relapse (15.6%). The panel was ordered at multiple timepoints during the disease course for 11% of patients. Physicians self-reported that 50 of 114 sequencing reports (44%) influenced clinical care decisions in 44 individual patients. Influences were often nuanced and extended beyond identifying actionable genetic variants with US Food and Drug Administration-approved drugs. CONCLUSION This study provides insights into how physicians are currently using multigene panels capable of detecting relatively rare AML cells. The most influential way to integrate these tools into clinical practice will be to perform prospective clinical trials that assess patient outcomes in response to genomically driven interventions.
Collapse
Affiliation(s)
- Erica K Barnell
- McDonnell Genome Institute, Washington University School of Medicine, St Louis, MO
| | - Kenneth F Newcomer
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Zachary L Skidmore
- McDonnell Genome Institute, Washington University School of Medicine, St Louis, MO
| | - Kilannin Krysiak
- McDonnell Genome Institute, Washington University School of Medicine, St Louis, MO
| | - Sydney R Anderson
- McDonnell Genome Institute, Washington University School of Medicine, St Louis, MO
| | - Lukas D Wartman
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Stephen T Oh
- Siteman Cancer Center, Washington University School of Medicine, St Louis, MO.,Department of Medicine, Division of Hematology, Washington University School of Medicine, St Louis, MO
| | - John S Welch
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Keith E Stockerl-Goldstein
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Ravi Vij
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Amanda F Cashen
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Iskra Pusic
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Peter Westervelt
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Camille N Abboud
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Armin Ghobadi
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Geoffrey L Uy
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO
| | - Mark A Schroeder
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - John F Dipersio
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Mary C Politi
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St Louis, MO
| | - David H Spencer
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Eric J Duncavage
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, MO
| | - Timothy J Ley
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Malachi Griffith
- McDonnell Genome Institute, Washington University School of Medicine, St Louis, MO.,Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO.,Department of Genetics, Washington University School of Medicine, St Louis, MO
| | - Meagan A Jacoby
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Obi L Griffith
- McDonnell Genome Institute, Washington University School of Medicine, St Louis, MO.,Department of Medicine, Division of Oncology, Washington University School of Medicine, St Louis, MO.,Siteman Cancer Center, Washington University School of Medicine, St Louis, MO.,Department of Genetics, Washington University School of Medicine, St Louis, MO
| |
Collapse
|
43
|
Barker AR, Joynt Maddox KE, Peters E, Huang K, Politi MC. Predicting Future Utilization Using Self-Reported Health and Health Conditions in a Longitudinal Cohort Study: Implications for Health Insurance Decision Support. INQUIRY 2021; 58:469580211064118. [PMID: 34919462 PMCID: PMC8695746 DOI: 10.1177/00469580211064118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Decision support techniques and online algorithms aim to help individuals predict costs
and facilitate their choice of health insurance coverage. Self-reported health status
(SHS), whereby patients rate their own health, could improve cost-prediction estimates
without requiring individuals to share personal health information or know about
undiagnosed conditions. We compared the predictive accuracy of several models: (1) SHS
only, (2) a “basic” model adding health-related variables, and (3) a “full” model adding
measures of healthcare access. The Medical Expenditure Panel Survey was used to predict
2015 health expenditures from 2014 data. Relative performance was assessed by comparing
adjusted-R2 values and by reporting the predictive accuracy of the models for
a new cohort (2015–2016 data). In the SHS-only model, those with better SHS were less
likely to incur expenditures. However, after accounting for health variables, those with
better SHS were more likely to incur expenses. In the full model, SHS was no longer
predictive of incurring expenses. Variables indicating better access to care were
associated with higher likelihood of spending and higher spending. The full model
(R2 = 0.290) performed slightly better than the basic model
(R2 = 0.240), but neither performed well at the upper tail
of the cost distribution. While our SHS-based models perform well in the aggregate,
predicting population-level risk well, they are not sufficiently accurate to guide
individuals’ insurance shopping decisions in all cases. Policies that rely heavily on
health insurance consumers making individually optimal choices cannot assume that decision
tools can accurately anticipate high costs.
Collapse
Affiliation(s)
- Abigail R. Barker
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St. Louis, St. Louis, MO, USA
| | - Karen E. Joynt Maddox
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St. Louis, St. Louis, MO, USA
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Ellen Peters
- Center for Science Communication Research, School of Journalism and Communication, University of Oregon, Eugene, OR, USA
| | - Kristine Huang
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
44
|
Politi MC, Yen RW, Elwyn G, O'Malley AJ, Saunders CH, Schubbe D, Forcino R, Durand M. Women Who Are Young, Non-White, and with Lower Socioeconomic Status Report Higher Financial Toxicity up to 1 Year After Breast Cancer Surgery: A Mixed-Effects Regression Analysis. Oncologist 2021; 26:e142-e152. [PMID: 33000504 PMCID: PMC7794185 DOI: 10.1002/onco.13544] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/04/2020] [Indexed: 01/07/2023] Open
Abstract
PURPOSE We examined self-reported financial toxicity and out-of-pocket expenses among adult women with breast cancer. METHODS Patients spoke English, Spanish, or Mandarin Chinese, were aged 18+ years, had stage I-IIIA breast cancer, and were eligible for breast-conserving and mastectomy surgery. Participants completed surveys about out-of-pocket costs and financial toxicity at 1 week, 12 weeks, and 1 year postsurgery. RESULTS Three hundred ninety-five of 448 eligible patients (88.2%) from the parent trial completed surveys. Excluding those reporting zero costs, crude mean ± SD out-of-pocket costs were $1,512 ± $2,074 at 1 week, $2,609 ± $6,369 at 12 weeks, and $3,308 ± $5,000 at 1 year postsurgery. Controlling for surgery, cancer stage, and demographics with surgeon and clinic as random effects, higher out-of-pocket costs were associated with higher financial toxicity 1 week and 12 weeks postsurgery (p < .001). Lower socioeconomic status (SES) was associated with lower out-of-pocket costs at each time point (p = .002-.013). One week postsurgery, participants with lower SES reported financial toxicity scores 1.02 points higher than participants with higher SES (95% confidence interval [CI], 0.08-1.95). Black and non-White/non-Black participants reported financial toxicity scores 1.91 (95% CI, 0.46-3.37) and 2.55 (95% CI, 1.11-3.99) points higher than White participants. Older (65+ years) participants reported financial toxicity scores 2.58 points lower than younger (<65 years) participants (95% CI, -3.41, -1.74). Younger participants reported significantly higher financial toxicity at each time point. DISCUSSION Younger age, non-White race, and lower SES were associated with higher financial toxicity regardless of costs. Out-of-pocket costs increased over time and were positively associated with financial toxicity. Future work should reduce the impact of cancer care costs among vulnerable groups. IMPLICATIONS FOR PRACTICE This study was one of the first to examine out-of-pocket costs and financial toxicity up to 1 year after breast cancer surgery. Younger age, Black race, race other than Black or White, and lower socioeconomic status were associated with higher financial toxicity. Findings highlight the importance of addressing patients' financial toxicity in several ways, particularly for groups vulnerable to its effects.
Collapse
Affiliation(s)
- Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of MedicineSt. LouisMissouriUSA
| | - Renata W. Yen
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth CollegeLebanonNew HampshireUSA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth CollegeLebanonNew HampshireUSA
| | - A. James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth CollegeLebanonNew HampshireUSA
- Department of Biomedical Data Science, Dartmouth CollegeLebanonNew HampshireUSA
| | - Catherine H. Saunders
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth CollegeLebanonNew HampshireUSA
| | - Danielle Schubbe
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth CollegeLebanonNew HampshireUSA
| | - Rachel Forcino
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth CollegeLebanonNew HampshireUSA
| | - Marie‐Anne Durand
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth CollegeLebanonNew HampshireUSA
| |
Collapse
|
45
|
Aronson PL, Politi MC, Schaeffer P, Fleischer E, Shapiro ED, Niccolai LM, Alpern ER, Bernstein SL, Fraenkel L. Development of an App to Facilitate Communication and Shared Decision-making With Parents of Febrile Infants ≤ 60 Days Old. Acad Emerg Med 2021; 28:46-59. [PMID: 32648270 DOI: 10.1111/acem.14082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/21/2020] [Accepted: 07/07/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES We aimed to develop and test a tool to engage parents of febrile infants ≤ 60 days of age evaluated in the emergency department (ED). The tool was designed to improve communication for all parents and to support shared decision-making (SDM) about whether to perform a lumbar puncture (LP) for infants 29 to 60 days of age. METHODS We conducted a multiphase development and testing process: 1) individual, semistructured interviews with parents and clinicians (pediatric and general emergency medicine [EM] physicians and pediatric EM nurses) to learn their preferences for a communication and SDM tool; 2) design of a "storyboard" of the tool with design impression testing; 3) development of a software application (i.e., app) prototype, called e-Care; and 4) usability testing of e-Care, using qualitative assessment and the system usability scale (SUS). RESULTS We interviewed 27 parents and 23 clinicians. Interviews revealed several themes, including that a communication tool should augment but not replace verbal communication; a Web-based format was preferred; and information about infections and testing, including the rationales for specific tests, would be valuable. We then developed separate versions of e-Care for infants ≤ 28 days and 29 to 60 days of age, in both English and Spanish. The e-Care app includes four sections: 1) homepage; 2) why testing is done; 3) what tests are done; and 4) what happens after testing, including a table for parents of infants 29 to 60 days of age to compare the risks/benefits of LP in preparation for an SDM conversation. Parents and clinicians reported that e-Care was understandable and helpful. The mean SUS score was 90.3 (95% confidence interval = 84 to 96.6), representing "excellent" usability. CONCLUSIONS The e-Care app is a useable and understandable tool to support communication and SDM with parents of febrile infants ≤ 60 days of age in the ED.
Collapse
Affiliation(s)
- Paul L. Aronson
- From the Department of PediatricsYale School of Medicine New HavenCTUSA
- the Department of Emergency Medicine Yale School of Medicine New Haven CTUSA
| | - Mary C. Politi
- the Department of Surgery Division of Public Health Sciences School of Medicine Washington University St. Louis MOUSA
| | - Paula Schaeffer
- From the Department of PediatricsYale School of Medicine New HavenCTUSA
| | - Eduardo Fleischer
- From the Department of PediatricsYale School of Medicine New HavenCTUSA
| | - Eugene D. Shapiro
- From the Department of PediatricsYale School of Medicine New HavenCTUSA
- the Department of Epidemiology of Microbial Diseases Yale School of Public Health Yale School of Public Health New Haven CTUSA
| | - Linda M. Niccolai
- the Department of Epidemiology of Microbial Diseases Yale School of Public Health Yale School of Public Health New Haven CTUSA
| | - Elizabeth R. Alpern
- the Department of Pediatrics, Division of Emergency Medicine Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago ILUSA
| | - Steven L. Bernstein
- the Department of Emergency Medicine Yale School of Medicine New Haven CTUSA
- and the Yale Center for Implementation Science Yale School of Medicine New Haven CTUSA
| | - Liana Fraenkel
- and the Department of Internal Medicine Yale School of Medicine New Haven CTUSA
| |
Collapse
|
46
|
Grant RL, Paul R, Zeal C, Madden T, Politi MC. Decisional conflict associated with clinicians discouraging particular contraceptive methods. J Eval Clin Pract 2020; 26:1612-1619. [PMID: 32026566 DOI: 10.1111/jep.13364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/10/2020] [Accepted: 01/16/2020] [Indexed: 01/07/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Approximately 45% of pregnancies in the United States are unintended. The use of contraception reduces the risk of unintended pregnancy. The initiation of several contraceptive methods requires seeing a clinician. This study explored how clinicians' expressed preferences against particular contraceptive methods impacted participants' confidence in their method choice and perception of shared contraceptive decision making. METHODS Eligible individuals were 18 to 45 years of age, assigned female sex at birth, English speaking, and either using or had previously used contraception. Participants completed an anonymous survey via web link on Amazon Mechanical Turk. Primary self-reported outcomes were (a) proportion of participants being discouraged from a particular contraceptive method, (b) decisional conflict, and (c) extent of shared decision making. Secondary self-reported outcomes were (a) importance of contraceptive attributes and (b) self-reported quality of care. RESULTS Six hundred sixty-nine participants completed the survey. Most were white (74.0%), non-Hispanic (84.5%), married or cohabitating (69.4%), and nulliparous (47.2%). A total of 33.8% reported that a clinician had discouraged them from using a particular contraceptive method, most commonly because of side effects, usability, and/or method effectiveness. Effectiveness, affordability, and side effects were the self-reported most important contraceptive features. Those who were discouraged from using a method (versus those who were not) were more likely to report decisional conflict (41.2% vs 30.0%, P = .004), yet reported a higher extent of shared decision making (median: 76 vs 71; P = .03). Adjusting for age and nulliparity did not impact results, except nulliparity made the relationship between being discouraged from using a method and shared decision making no longer significant (P = .06). CONCLUSIONS Decisional conflict might arise when clinicians discourage individuals using particular contraceptive methods. Clinicians' reasons for discouraging methods might not always align with patients' preferences. More research is needed to examine how to reduce decisional conflict and support contraceptive method selection.
Collapse
Affiliation(s)
- Rachel L Grant
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Rachel Paul
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Carley Zeal
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Tessa Madden
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| |
Collapse
|
47
|
Durand MA, Yen RW, O'Malley AJ, Schubbe D, Politi MC, Saunders CH, Dhage S, Rosenkranz K, Margenthaler J, Tosteson ANA, Crayton E, Jackson S, Bradley A, Walling L, Marx CM, Volk RJ, Sepucha K, Ozanne E, Percac-Lima S, Bergin E, Goodwin C, Miller C, Harris C, Barth RJ, Aft R, Feldman S, Cyr AE, Angeles CV, Jiang S, Elwyn G. What matters most: Randomized controlled trial of breast cancer surgery conversation aids across socioeconomic strata. Cancer 2020; 127:422-436. [PMID: 33170506 PMCID: PMC7983934 DOI: 10.1002/cncr.33248] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/02/2020] [Accepted: 08/18/2020] [Indexed: 01/17/2023]
Abstract
Background Women of lower socioeconomic status (SES) with early‐stage breast cancer are more likely to report poorer physician‐patient communication, lower satisfaction with surgery, lower involvement in decision making, and higher decision regret compared to women of higher SES. The objective of this study was to understand how to support women across socioeconomic strata in making breast cancer surgery choices. Methods We conducted a 3‐arm (Option Grid, Picture Option Grid, and usual care), multisite, randomized controlled superiority trial with surgeon‐level randomization. The Option Grid (text only) and Picture Option Grid (pictures plus text) conversation aids were evidence‐based summaries of available breast cancer surgery options on paper. Decision quality (primary outcome), treatment choice, treatment intention, shared decision making (SDM), anxiety, quality of life, decision regret, and coordination of care were measured from T0 (pre‐consultation) to T5 (1‐year after surgery. Results Sixteen surgeons saw 571 of 622 consented patients. Patients in the Picture Option Grid arm (n = 248) had higher knowledge (immediately after the visit [T2] and 1 week after surgery or within 2 weeks of the first postoperative visit [T3]), an improved decision process (T2 and T3), lower decision regret (T3), and more SDM (observed and self‐reported) compared to usual care (n = 257). Patients in the Option Grid arm (n = 66) had higher decision process scores (T2 and T3), better coordination of care (12 weeks after surgery or within 2 weeks of the second postoperative visit [T4]), and more observed SDM (during the surgical visit [T1]) compared to usual care arm. Subgroup analyses suggested that the Picture Option Grid had more impact among women of lower SES and health literacy. Neither intervention affected concordance, treatment choice, or anxiety. Conclusions Paper‐based conversation aids improved key outcomes over usual care. The Picture Option Grid had more impact among disadvantaged patients. Lay Summary The objective of this study was to understand how to help women with lower incomes or less formal education to make breast cancer surgery choices. Compared with usual care, a conversation aid with pictures and text led to higher knowledge. It improved the decision process and shared decision making (SDM) and lowered decision regret. A text‐only conversation aid led to an improved decision process, more coordinated care, and higher SDM compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education. Conversation aids with pictures and text helped women make better breast cancer surgery choices.
A paper‐based pictorial conversation aid (pictures plus text) is beneficial to all patients with early‐stage breast cancer and particularly to disadvantaged patients. Between‐surgeon variation suggests that the maximal impact of such interventions requires standardized physician training combined with these interventions.
Collapse
Affiliation(s)
- Marie-Anne Durand
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire.,UMR 1027 Team EQUITY, Paul Sabatier University, Toulouse, France
| | - Renata W Yen
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
| | - A James O'Malley
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Danielle Schubbe
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
| | - Mary C Politi
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Catherine H Saunders
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire.,Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Shubhada Dhage
- Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, New York, New York
| | | | - Julie Margenthaler
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Anna N A Tosteson
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire.,Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Eloise Crayton
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sherrill Jackson
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ann Bradley
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
| | - Linda Walling
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
| | - Christine M Marx
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Robert J Volk
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Karen Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Elissa Ozanne
- Department of Population Health Sciences, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Sanja Percac-Lima
- Massachusetts General Hospital Chelsea HealthCare Center, Chelsea, Massachusetts
| | | | - Courtney Goodwin
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Camille Harris
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
| | | | - Rebecca Aft
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Amy E Cyr
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Shuai Jiang
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Glyn Elwyn
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
| |
Collapse
|
48
|
Mangir C, Boehmer L, Kurtin SE, Wilfong LS, Kass R, Shockney LD, Politi MC, Jagsi R, LeBlanc TW, Sonet E, Studts JL, Hutton A, Plotkin E, Lucas L, Copeland A. Shared decision-making attitudes and practices in multidisciplinary cancer care teams. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
180 Background: Patients who engage in decision making are more likely to experience confidence in treatment decisions, satisfaction with treatment, and trust in clinicians. The Association of Community Cancer Centers (ACCC) conducted a survey to explore multidisciplinary team attitudes and practices around shared decision-making (SDM) and health literacy. Methods: ACCC convened a steering committee of multidisciplinary specialists and advocacy representatives to guide this research. The survey included 26 mostly closed-ended questions and was open to multidisciplinary cancer programs from 10/29/19 to 2/20/20. Exploratory analysis was performed on this data set of 305 complete responses. Results: While most respondents reported engaging patients in decision-making to some degree, only 50% reported that SDM is a top organizational priority. 33% reported organizational efforts to formally integrate SDM into the clinical workflow, with only 15% indicating staff opportunities for basic SDM training. The three most frequently cited perceived barriers to engaging in SDM were patients feeling overwhelmed (53%), wanting to defer decisions to clinicians (46%), and having limited health literacy (46%). Only 13% indicated that lack of time was a barrier. Less than half (41%) of respondents reported using patient decision aids to support SDM. Respondents represented a wide range of multidisciplinary team members, though surgical oncologists and general surgeons (20% and 16% respectively) are overrepresented in the results. Conclusions: SDM is commonly accepted as essential to patient engagement but clarity in terminology and prioritizing formal integration of SDM into practice is limited. Strategies to improve integration of SDM into oncology practice should include: 1) Educational initiatives and tools to overcome barriers to SDM, including patient decision aids and SDM training, 2) Initiatives to address health literacy as it relates to patient and caregiver engagement in decision making, 3) Psychosocial support for patients whose emotional upset is a barrier to SDM, 4) Healthcare policies that encourage and incentive providers to engage in SDM. Future analyses will require concurrent assessment of patient, caregiver, healthcare professional, and administrator perspectives.
Collapse
Affiliation(s)
| | - Leigh Boehmer
- Association of Community Cancer Centers, Rockville, MD
| | | | | | - Rena Kass
- Penn State Hershey Medical Center, Hershey, PA
| | | | | | | | | | | | | | - Andrea Hutton
- Metastatic Breast Cancer Alliance, Santa Barbara, CA
| | - Elana Plotkin
- Association of Community Cancer Centers, Rockville, MD
| | - Lorna Lucas
- Association of Community Cancer Centers, Rockville, MD
| | | |
Collapse
|
49
|
Abraham J, Meng A, Siraco S, Kannampallil T, Politi MC, Baumann AA, Lenze EJ, Avidan MS. A Qualitative Study of Perioperative Depression and Anxiety in Older Adults. Am J Geriatr Psychiatry 2020; 28:1107-1118. [PMID: 32234274 DOI: 10.1016/j.jagp.2020.02.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/19/2020] [Accepted: 02/19/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We had three aims 1) understand barriers to perioperative management of anxiety and depression in older surgical patients; 2) identify preferences and requirements for interventions to manage their anxiety and depression; and 3) explore the feasibility of implementing such interventions in perioperative care. DESIGN A qualitative study using semistructured interviews was conducted. SETTING Participants were recruited at a large academic medical center. PARTICIPANTS We interviewed older surgical patients and clinicians to characterize their perspectives on management of anxiety and depression symptoms, with emphasis on patient needs, barriers, and potential interventions to address these needs. MEASUREMENTS We used the Consolidated Framework for Intervention Research to guide the development of interview questions related to intervention implementation feasibility. Thematic analysis was used to analyze interview responses. RESULTS Forty semistructured interviews were conducted. Key barriers for perioperative management of depression and anxiety included fear of surgery, acute pain, postoperative neurocognitive disorders, limited understanding of what to expect regarding surgery and recovery, and overwhelmingly complex medication management. Patients and clinicians suggested that a bundled mental health management intervention targeted for older surgical patient population comprised of behavioral and pharmacologic strategies can help mitigate anxiety and depression symptoms during the perioperative period. Clinicians emphasized the need for a collaborative engagement strategy that includes multiple stakeholders in the design, planning, and implementation of such an intevention. CONCLUSION New care models need to be developed to integrate mental health care into the current perioperative care practice.
Collapse
Affiliation(s)
- Joanna Abraham
- Department Anesthesiology of (JA, AM, TK, MSA), School of Medicine, Washington University, St. Louis, MO; Institute for Informatics, School of Medicine, Washington University (JA, TK), St. Louis, MO.
| | - Alicia Meng
- Department Anesthesiology of (JA, AM, TK, MSA), School of Medicine, Washington University, St. Louis, MO
| | - Susan Siraco
- School of Medicine, St. Louis University (SS), St. Louis, MO
| | - Thomas Kannampallil
- Department Anesthesiology of (JA, AM, TK, MSA), School of Medicine, Washington University, St. Louis, MO; Institute for Informatics, School of Medicine, Washington University (JA, TK), St. Louis, MO
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery (MCP), School of Medicine, Washington University, St. Louis, MO
| | - Ana A Baumann
- George Warren Brown School of Social Work, Washington University (AAB), St. Louis, MO
| | - Eric J Lenze
- Department of Psychiatry (EJL), School of Medicine, Washington University, St. Louis, MO
| | - Michael S Avidan
- Department Anesthesiology of (JA, AM, TK, MSA), School of Medicine, Washington University, St. Louis, MO
| |
Collapse
|
50
|
George N, Liapakis A, Korenblat KM, Li T, Roth D, Yee J, Fowler KJ, Howard L, Liu J, Politi MC. A Patient Decision Support Tool for Hepatitis C Virus and CKD Treatment. Kidney Med 2020; 1:200-206. [PMID: 32734200 PMCID: PMC7380397 DOI: 10.1016/j.xkme.2019.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Rationale & Objective Patient education and decision support tools could facilitate decisions around the timing of antiviral therapy in patients living with both hepatitis C virus (HCV) infection and chronic kidney disease (CKD). We previously developed a tool through the HELP (Helping Empower Liver and Kidney Patients) study. This article evaluates the preliminary efficacy and usability of the tool among participants with both HCV infection and CKD. Study Design Pre-post study pilot evaluation. Setting & Participants Participants were at least 18 years old, were English speaking, and had a diagnosis of chronic HCV infection and CKD; they were seen in CKD clinics, dialysis units, and/or hepatology and liver transplantation clinics. Intervention Electronic patient decision support tool. Outcomes Participants' change in knowledge, certainty about choice, decision self-efficacy, patients' treatment preferences, and tool usability. Results 70 participants were recruited; 56 of 70 (80.0%) completed study procedures. Nearly all (51/56; 91.1%) requested paper-based study procedures despite the electronic design of the tool. Participants reported that they were most worried about the following treatment factors: (1) cost of drugs to treat HCV infection, (2) how their HCV infection affected their CKD, and (3) wait times for a kidney transplant. After using the decision tool, participants had significantly higher HCV infection and CKD knowledge (mean posttest percent of questions answered correctly = 65.74% vs pretest percent of questions answered correctly = 53.44%; P < 0.001) and more certainty about choice (mean posttest = 3.13 vs pretest = 2.65; P = 0.05). There were no significant changes in decision self-efficacy (mean posttest = 86.62 vs pretest = 84.68; P = 0.48). Limitations Single-site pilot study to explore preliminary tool efficacy and usability. Conclusions This study suggests that a decision tool may support informed patient-centered choices among patients with HCV infection and CKD. Future studies should evaluate ways to improve care decisions in a larger sample using both paper-based and electronic materials. Funding Merck & Co, Inc, Kenilworth, NJ. Trial Registration Registered at clinicaltrials.gov with study number NCT03426787.
Collapse
Affiliation(s)
- Nerissa George
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - AnnMarie Liapakis
- Section of Digestive Disease, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Kevin M Korenblat
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | - Tingting Li
- Division of Nephrology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | - David Roth
- Katz Family Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, FL
| | - Jerry Yee
- Division of Nephrology, Hypertension & Transplant, Henry Ford Hospital and Medical Center, Detroit, MI
| | | | | | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO
| |
Collapse
|