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Smith CL, Stark BC, Kobalter M, Barks MC, Nakano-Okuno M, Romesburg EW, Limdi N, May T. Key Contextual Factors Involved with Participation in Medical and Genomic Screening and Research for African American and Caucasian Americans: A Qualitative Inquiry American Journal of Community Genetics. Res Sq 2024:rs.3.rs-4132207. [PMID: 38585843 PMCID: PMC10996799 DOI: 10.21203/rs.3.rs-4132207/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] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Tremendous progress has been made promoting diversity in recruitment for genomic research, yet challenges remain for several racial demographics. Research has cited intertwined fears of racial discrimination and medical mistrust as contributing factors. This study aimed to identify key factors to establishing trust in medical and genomic screening and research among African Americans and White Americans. Participants completed online focus groups and resulting transcripts were analyzed using a qualitative descriptive approach, with content analysis methods based on recommendations by Schreier. Fifteen African Americans and 23 Caucasian Americans participated in the study, 63% of which were female. The mean age of participants was 38.53 (SD = 16.6). The Overarching Theme of Trust is Context Dependent was identified, along with the following five themes describing elements influencing trustworthiness for our participants: 1) Professional Experience, Education, and Training Bolster Trust; 2) Trust Depends on Relationships; 3) Cross-checking Provided Information is Influential in Establishing Trust; 4) Trust is Undermined by Lack of Objectivity and Bias; and 5) Racism is an Embedded Concern and a Medical Trust Limiting Component for African Americans. To effectively address mistrust and promote recruitment of diverse participants, genomic research initiatives must be communicated in a manner that resonates with the specific diverse communities targeted. Our results suggest key factors influencing trust that should be attended to if we are to promote equity appropriately and respectfully by engaging diverse populations in genomic research.
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Affiliation(s)
| | | | | | | | | | | | - Nita Limdi
- The University of Alabama at Birmingham Heersink School of Medicine
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Rao BR, Akrobetu DJ, Dickert NW, Nguyen T, Davis JK, Campagna A, Mitchell AR, Sharma A, Speight CD, Barks MC, Farley S, Gutterman S, Santanam T, Ubel PA. Deciding Whether to Take Sacubitril/Valsartan: How Cardiologists and Patients Discuss Out-of-Pocket Costs. J Am Heart Assoc 2023; 12:e028278. [PMID: 36974764 PMCID: PMC10122884 DOI: 10.1161/jaha.122.028278] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/23/2023] [Indexed: 03/29/2023]
Abstract
Background Out-of-pocket costs have significant implications for patients with heart failure and should ideally be incorporated into shared decision-making for clinical care. High out-of-pocket cost is one potential reason for the slow uptake of newer guideline-directed medical therapies for heart failure with reduced ejection fraction. This study aims to characterize patient-cardiologist discussions involving out-of-pocket costs associated with sacubitril/valsartan during the early postapproval period. Methods and Results We conducted content analysis on 222 deidentified transcripts of audio-recorded outpatient encounters taking place between 2015 and 2018 in which cardiologists (n=16) and their patients discussed whether to initiate, continue, or discontinue sacubitril/valsartan. In the 222 included encounters, 100 (45%) contained discussions about cost. Cost was discussed in a variety of contexts: when sacubitril/valsartan was initiated, not initiated, continued, and discontinued. Of the 97 cost conversations analyzed, the majority involved isolated discussions about insurance coverage (64/97 encounters; 66%) and few addressed specific out-of-pocket costs or affordability (28/97 encounters; 29%). Discussion of free samples of sacubitril/valsartan was common (52/97 encounters; 54%), often with no discussion of a longer-term plan for addressing cost. Conclusions Although cost conversations were somewhat common in patient-cardiologist encounters in which sacubitril/valsartan was discussed, these conversations were generally superficial, rarely addressing affordability or cost-value judgments. Cardiologists frequently provided patients with a course of free sacubitril/valsartan samples without a plan to address the cost after the samples ran out.
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Affiliation(s)
- Birju R. Rao
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
| | | | - Neal W. Dickert
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
- Department of EpidemiologyEmory University Rollins School of Public HealthAtlantaGAUSA
| | | | | | - Ada Campagna
- Duke‐Margolis Center for Health PolicyDurhamNCUSA
| | - Andrea R. Mitchell
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
| | - Anu Sharma
- Duke‐Margolis Center for Health PolicyDurhamNCUSA
| | - Candace D. Speight
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
| | | | | | | | | | - Peter A. Ubel
- Duke University School of MedicineDurhamNCUSA
- Duke‐Margolis Center for Health PolicyDurhamNCUSA
- Duke University’s Fuqua School of BusinessDurhamNCUSA
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Sloan CE, Gutterman S, Davis JK, Campagna A, Pollak KI, Barks MC, Santanam T, Sharma M, Grande DT, Zafar SY, Ubel PA. How can healthcare organizations improve cost-of-care conversations? A qualitative exploration of clinicians' perspectives. Patient Educ Couns 2022; 105:2708-2714. [PMID: 35440376 DOI: 10.1016/j.pec.2022.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Clinicians increasingly believe they should discuss costs with their patients. We aimed to learn what strategies clinicians, clinic leaders, and health systems can use to facilitate vital cost-of-care conversations. METHODS We conducted focus groups and semi-structured interviews with outpatient clinicians at two US academic medical centers. Clinicians recalled previous cost conversations and described strategies that they, their clinic, or their health system could use to facilitate cost conversations. Independent coders recorded, transcribed, and coded focus groups and interviews. RESULTS Twenty-six clinicians participated between December 2019 and July 2020: general internists (23%), neurologists (27%), oncologists (15%), and rheumatologists (35%). Clinicians proposed the following strategies: teach clinicians to initiate cost conversations; systematically collect financial distress information; partner with patients to identify costs; provide accurate insurance coverage and/or out-of-pocket cost information via the electronic health record; develop local lists of lowest-cost pharmacies, laboratories, and subspecialists; hire financial counselors; and reduce indirect costs (e.g., parking). CONCLUSIONS Despite considerable barriers to discussing, identifying, and reducing patient costs, clinicians described a variety of strategies for improving cost communication in the clinic. PRACTICE IMPLICATIONS Health systems and clinic leadership can and should implement these strategies to improve the financial health of the patients they serve.
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Affiliation(s)
- Caroline E Sloan
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Sophia Gutterman
- University of Michigan School of Medicine, Ann Arbor, MI, USA; Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - J Kelly Davis
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA
| | - Ada Campagna
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University, Durham, NC, USA; Duke Cancer Institute, Duke University Health System, Durham, NC, USA
| | - Mary Carol Barks
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA
| | - Taruni Santanam
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Meghana Sharma
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David T Grande
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - S Yousuf Zafar
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University, Durham, NC, USA; Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Peter A Ubel
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University, Durham, NC, USA; Sanford School of Public Policy, Duke University, Durham, NC, USA
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Farley S, Bansal S, Barks MC, Pollak KI, Kaye EC, Quarles A, Briglia K, Johnson E, Lakis K, Lemmon ME. Role of Social Workers in Family Conferences for Critically Ill Infants. J Palliat Med 2022; 25:1236-1242. [PMID: 35285675 PMCID: PMC9347387 DOI: 10.1089/jpm.2021.0574] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Communication challenges in the neonatal intensive care unit include fragmented communication, challenges managing expectations amidst uncertainty, and navigating complex medical information. Social workers are well suited to mitigate these challenges. Objective: In this study, we aimed to characterize the extent and nature of social worker participation in family conferences for critically ill infants. Design: We used a longitudinal observational mixed-methods design, enrolling infants with a neurological condition, their parent(s), and their clinicians. All audio-recorded conferences were transcribed and de-identified. Emergent themes and subthemes were identified using conventional content analysis. Results: We enrolled 40 infants and 61 parents. Sixty-eight conferences were held and audio recorded for 24 infants. Social workers were present for 51 of these conferences (n = 51/68, 75%) across 18 cases (n = 18/24, 75%). We identified four themes, conceptualized as distinct roles played by social workers in family conferences: (1) Translator: social workers served as a communicative bridge between parents and the medical team; (2) Coordinator: social workers simplified logistics and connected parents to community resources, including home health agencies and financial assistance; (3) Expectation manager: social workers provided anticipatory guidance and helped parents conceptualize the remainder of the hospital stay, discharge, and life at home; and (4) Advocate: social workers validated parental values and concerns and provided immediate emotional support. Conclusions: Social workers participated in three-quarters of family conferences for critically ill infants. When they participated, they facilitated communication, coordinated care, managed expectations, and advocated for families. These findings underscore the important, varied, and concurrent roles social workers play in the care of critically ill infants. Future communication and family support interventions should leverage these distinct roles.
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Affiliation(s)
- Sam Farley
- Duke University, Durham, North Carolina, USA
| | | | - Mary Carol Barks
- Duke University, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kathryn I. Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Erica C. Kaye
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Anna Quarles
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kathleen Briglia
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Erika Johnson
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kristen Lakis
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Palliative Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Monica E. Lemmon
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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5
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Anderson DI, Balog V, Bansal S, Barbu-Roth M, Barks MC, Barlet M, Barrera Resendiz JE, Bernstein S, Biran V, Blennow M, Brandon D, Canfora M, Craig A, Cutler A, Deerwester K, Dumuids MV, El-Dib M, Erdei C, Eriksson Westblad M, Forde M, Forma V, Fox L, Glass H, Harmony T, Inder T, Jermendy Á, Kaneko-Tarui T, Kapadia J, Kátai LK, Kumar A, Lemmon M, Lindström K, Maron J, Pilon B, Pollak K, Provasi J, Grossmann KR, Sunwoo J, Szabó M, Ubel P, Vakharia B, Vatai B, Vatsavai S, Weinfurt K. Proceedings of the 13th International Newborn Brain Conference: Long-term outcome studies, Developmental care, Palliative care, Ethical dilemmas, and Challenging clinical scenarios. J Neonatal Perinatal Med 2022; 15:441-452. [PMID: 35431187 DOI: 10.3233/npm-229004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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Lemmon ME, Glass HC, Shellhaas RA, Barks MC, Bansal S, Annis D, Guerriero JL, Pilon B, Wusthoff CJ, Chang T, Soul JS, Chu CJ, Thomas C, Massey SL, Abend NS, Rau S, Rogers EE, Franck LS. Family-Centered Care for Children and Families Impacted by Neonatal Seizures: Advice From Parents. Pediatr Neurol 2021; 124:26-32. [PMID: 34509000 PMCID: PMC8523194 DOI: 10.1016/j.pediatrneurol.2021.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 05/19/2021] [Revised: 07/21/2021] [Accepted: 07/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Parents of neonates with seizures are at risk of mental health symptoms due to the impact of illness on family life, prognostic uncertainty, and the emotional toll of hospitalization. A family-centered approach is the preferred model to mitigate these challenges. We aimed to identify strategies to promote family-centered care through an analysis of parent-offered advice to clinicians caring for neonates with seizures. METHODS This prospective, observational, and multicenter (Neonatal Seizure Registry) study enrolled parents of neonates with acute symptomatic seizures. Parents completed surveys about family well-being at 12, 18, and 24 months corrected gestational age. Parents were asked open-ended questions eliciting their advice to clinicians caring for neonates with seizures. Responses were analyzed using a conventional content analysis approach. RESULTS Among the 310 parents who completed surveys, 118 (38%) shared advice for clinicians. These parents were predominantly mothers (n = 103, 87%). Three overarching themes were identified. (1) Communicate information effectively: parents appreciate when clinicians offer transparent and balanced information in an accessible way. (2) Understand and validate parent experience: parents value clinicians who display empathy, compassion, and a commitment to parent-partnered clinical care. (3) Providesupportand resources: parents benefit from emotional support, education, connection with peers, and help navigating the health care system. CONCLUSIONS Parents caring for neonates with seizures appreciate a family-centered approach in health care encounters, including skilled communication, understanding and validation of the parent experience, and provision of support and resources. Future interventions should focus on building structures to reinforce these priorities.
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Affiliation(s)
- Monica E. Lemmon
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA,Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Hannah C. Glass
- Departments of Neurology and Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, California, USA,Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Renée A. Shellhaas
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Mary Carol Barks
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Simran Bansal
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Dana Annis
- NSR Parent Partner, Children’s National Hospital, Washington, DC, USA
| | - Jennifer L. Guerriero
- NSR Parent Partner, Children’s Hospital Boston, Boston, MA, USA,Dana Farber Cancer Institute
| | | | | | - Taeun Chang
- Department of Neurology, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Janet S. Soul
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine J. Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA,Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Shavonne L. Massey
- Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicholas S. Abend
- Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Anesthesia and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Rau
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth E. Rogers
- Departments of Neurology and Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, California, USA
| | - Linda S. Franck
- Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, California, USA
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7
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Lemmon M, Glass H, Shellhaas RA, Barks MC, Bailey B, Grant K, Grossbauer L, Pawlowski K, Wusthoff CJ, Chang T, Soul J, Chu CJ, Thomas C, Massey SL, Abend NS, Rogers EE, Franck LS. Parent experience of caring for neonates with seizures. Arch Dis Child Fetal Neonatal Ed 2020; 105:634-639. [PMID: 32503792 PMCID: PMC7581607 DOI: 10.1136/archdischild-2019-318612] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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] [Received: 11/27/2019] [Revised: 03/10/2020] [Accepted: 03/19/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Neonates with seizures have a high risk of mortality and neurological morbidity. We aimed to describe the experience of parents caring for neonates with seizures. DESIGN This prospective, observational and multicentre (Neonatal Seizure Registry) study enrolled parents of neonates with acute symptomatic seizures. At the time of hospital discharge, parents answered six open-ended response questions that targeted their experience. Responses were analysed using a conventional content analysis approach. RESULTS 144 parents completed the open-ended questions (732 total comments). Four themes were identified. Sources of strength: families valued medical team consensus, opportunities to contribute to their child's care and bonding with their infant. Uncertainty: parents reported three primary types of uncertainty, all of which caused distress: (1) the daily uncertainty of the intensive care experience; (2) concerns about their child's uncertain future and (3) lack of consensus between members of the medical team. Adapting family life: parents described the many ways in which they anticipated their infant's condition would lead to adaptations in their family life, including adjusting their family's lifestyle, parenting approach and routine. Many parents described financial and work challenges due to caring for a child with medical needs. Emotional and physical toll: parents reported experiencing anxiety, fear, stress, helplessness and loss of sleep. CONCLUSIONS Parents of neonates with seizures face challenges as they adapt to and find meaning in their role as a parent of a child with medical needs. Future interventions should target facilitating parent involvement in clinical and developmental care, improving team consensus and reducing the burden associated with prognostic uncertainty.
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Affiliation(s)
- Monica Lemmon
- Pediatrics and Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hannah Glass
- Neurology and Pediatrics, University of California San Francisco, San Francisco, California, USA,Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Renee A Shellhaas
- Pediatrics (Neurology Division), University of Michigan, Ann Arbor, Michigan, USA
| | - Mary Carol Barks
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Bria Bailey
- Neurology and Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Katie Grant
- Parent Partner, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lisa Grossbauer
- Parent Partner, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kamil Pawlowski
- Parent Partner, UCSF Benioff Children’s Hospital Oakland, Oakland, California, USA
| | | | - Taeun Chang
- Neurology, Children’s National Medical Center, Washington, District of Columbia, USA
| | - Janet Soul
- Neurology, Children’s Hospital, Boston, Massachusetts, USA
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cameron Thomas
- Pediatrics, Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nicholas S Abend
- Neurology, Pediatrics, Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Linda S Franck
- Family Health Care Nursing, University of California San Francisco School of Nursing, San Francisco, California, USA
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Williamson T, Ryser MD, Abdelgadir J, Lemmon M, Barks MC, Zakare R, Ubel PA. Surgical decision making in the setting of severe traumatic brain injury: A survey of neurosurgeons. PLoS One 2020; 15:e0228947. [PMID: 32119677 PMCID: PMC7051065 DOI: 10.1371/journal.pone.0228947] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/26/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Surgical decision-making in severe traumatic brain injury (TBI) is complex. Neurosurgeons weigh risks and benefits of interventions that have the potential to both maximize the chance of recovery and prolong suffering. Inaccurate prognostication can lead to over- or under-estimation of outcomes and influence treatment recommendations. OBJECTIVE To evaluate the impact of evidence-based risk estimates on neurosurgeon treatment recommendations and prognostic beliefs in severe TBI. METHODS In a survey-based randomized experiment, a total of 139 neurosurgeons were presented with two hypothetical patient with severe TBI and subdural hematoma; the intervention group received additional evidence-based risk estimates for each patient. The main outcome was neurosurgeon treatment recommendation of non-surgical management. Secondary outcomes included prediction of functional recovery at six months. RESULTS In the first patient scenario, 22% of neurosurgeons recommended non-surgical management and provision of evidence-based risk estimates increased the propensity to recommend non-surgical treatment (odds ratio [OR]: 2.81, 95% CI: 1.21-6.98; p = 0.02). Neurosurgeon prognostic beliefs of 6-month functional recovery were variable in both control (median 20%, IQR: 10%-40%) and intervention (30% IQR: 10%-50%) groups and neurosurgeons were less likely to recommend non-surgical management when they believed prognosis was favorable (odds ratio [OR] per percentage point increase in 6-month functional recovery: 0.97, 95% confidence interval [CI]: 0.95-0.99). The results for the second patient scenario were qualitatively similar. CONCLUSIONS Our findings show that the provision of evidence-based risk predictions can influence neurosurgeon treatment recommendations and prognostication, but the effect is modest and there remains large variability in neurosurgeon prognostication.
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Affiliation(s)
- Theresa Williamson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Marc D. Ryser
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke School of Medicine, Duke University, Durham, North Carolina, United States of America
- Department of Mathematics, Duke University, Durham, North Carolina, United States of America
| | - Jihad Abdelgadir
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Monica Lemmon
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke-Margolis Center for Health Policy, Durham, North Carolina, United States of America
| | - Mary Carol Barks
- The Fuqua School of Business, Duke University, Durham, North Carolina, United States of America
| | - Rasheedat Zakare
- Duke School of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Peter A. Ubel
- Duke School of Medicine, Duke University, Durham, North Carolina, United States of America
- The Fuqua School of Business, Duke University, Durham, North Carolina, United States of America
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9
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Lemmon ME, Huffstetler H, Barks MC, Kirby C, Katz M, Ubel PA, Docherty SL, Brandon D. Neurologic Outcome After Prematurity: Perspectives of Parents and Clinicians. Pediatrics 2019; 144:peds.2018-3819. [PMID: 31248939 PMCID: PMC6615517 DOI: 10.1542/peds.2018-3819] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [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] [Accepted: 04/01/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Parents and clinicians caring for premature infants face high-stakes and time-sensitive decisions about care. We aimed to characterize how parents and clinicians discuss outcome in the context of decision-making for premature infants. METHODS In this qualitative descriptive study, we used a case-based, prospective design. Cases of extreme prematurity were targeted. Parents and clinicians completed semistructured interviews about care decisions longitudinally in the first year of life. Interview data were analyzed by using directed content analysis. RESULTS Sixteen parents and 53 clinicians of 10 infants completed 178 interviews (n = 115 parent; n = 63 clinician). Two primary themes emerged. First, parents and clinicians discussed prognostic information differently from each other. Parents focused on whether their infant would survive, whereas clinicians concentrated on neurologic outcome and the potential for life with disability. Parent discussion of the future was broad and rooted in hope and spirituality. Clinician prognostic language was narrowly focused and probabilistic. Second, we identified barriers and facilitators to a shared understanding of infant outcome. Clinicians perceived that parents were unaware of or unable to process important information about the big picture. Parents valued consistent therapeutic relationships; transitions of care and underused roles of the care team undermined this consistency. Clinical uncertainty forced parents and clinicians to "wait and see" about the future. CONCLUSIONS Parents and clinicians discuss and weigh information about the future differently from each other as they consider choices for extremely premature infants. Future work should characterize the impact of these differences on prognostic communication and decision-making.
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Affiliation(s)
- Monica E. Lemmon
- Department of Pediatrics, School of Medicine,,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Hanna Huffstetler
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Mary Carol Barks
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Christine Kirby
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Madelaine Katz
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Peter A. Ubel
- Fuqua School of Business, Sanford School of Public Policy, School of Medicine
| | | | - Debra Brandon
- Department of Pediatrics, School of Medicine,,School of Nursing, and
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