The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder

PURPOSE

The purpose of this guideline is to provide evidence-based guidance to clinicians of all specialties on the evaluation, management, and treatment of idiopathic overactive bladder (OAB). The guideline informs the reader on valid diagnostic processes and provides an approach to selecting treatment options for patients with OAB through the shared decision-making process that will maximize symptom control and quality of life, while minimizing adverse events and burden of disease.

METHODS

An electronic search employing OVID was used to systematically search the MEDLINE and EMBASE databases, as well as the Cochrane Library, for systematic reviews and primary studies evaluating diagnosis and treatment of OAB from January 2013 to November 2023. Criteria for inclusion and exclusion of studies were based on the Key Questions and the populations, interventions, comparators, outcomes, timing, types of studies and settings (PICOTS) of interest. Following the study selection process, 159 studies were included and were used to inform evidence-based recommendation statements.

RESULTS

This guideline produced 33 statements that cover the evaluation and diagnosis of the patient with symptoms suggestive of OAB; the treatment options for patients with OAB, including non-invasive therapies, pharmacotherapy, minimally invasive therapies, invasive therapies, and indwelling catheters; and the management of patients with BPH and OAB.

CONCLUSION

Once the diagnosis of OAB is made, the clinician and the patient with OAB have a variety of treatment options to choose from and should, through shared decision-making, formulate a personalized treatment approach taking into account evidence-based recommendations as well as patient values and preferences.

Outcome prioritization and preferences among older adults with cancer starting chemotherapy in a randomized clinical trial

INTRODUCTION

Older adults with cancer facing competing treatments must prioritize between various outcomes. This study assessed health outcome prioritization among older adults with cancer starting chemotherapy.

METHODS

Secondary analysis of a randomized trial addressing vulnerabilities in older adults with cancer. Patients completed three validated outcome prioritization tools: 1) Health Outcomes Tool: prioritizes outcomes (survival, independence, symptoms) using a visual analog scale; 2) Now vs. Later Tool: rates the importance of quality of life at three times-today versus 1 or 5 years in the future; and 3) Attitude Scale: rates agreement with outcome-related statements. The authors measured the proportion of patients prioritizing various outcomes and evaluated their characteristics.

RESULTS

A total of 219 patients (median [range] age 71 [65-88], 68% with metastatic disease) were included. On the Health Outcomes Tool, 60.7% prioritized survival over other outcomes. Having localized disease was associated with choosing survival as top priority. On the Now vs. Later Tool, 50% gave equal importance to current versus future quality of life. On the Attitude Scale, 53.4% disagreed with the statement "the most important thing to me is living as long as I can, no matter what my quality of life is"; and 82.2% agreed with the statement "it is more important to me to maintain my thinking ability than to live as long as possible".

CONCLUSION

Although survival was the top priority for most participants, some older individuals with cancer prioritize other outcomes, such as cognition and function. Clinicians should elicit patient-defined priorities and include them in decision-making.

The experience of shared decision-making for people with asthma: A systematic review and metasynthesis of qualitative studies

OBJECTIVES

To identify, describe and synthesise the views and experiences of adults living with asthma regarding shared decision-making (SDM) in the existing qualitative literature METHODS: We conducted a comprehensive search of 10 databases (list databases) from inception until September 2023. Screening was performed according to inclusion criteria. Tools from the Joanna Briggs lnstitute were utilised for the purposes of data extraction and synthesis in this study. The data extraction process in this study employed the Capability, Opportunity and Motivation Model of Behaviour (COM-B model) as a framework, and a pragmatic meta-aggregative approach was employed to synthesise the collected results.

RESULTS

Nineteen studies were included in the metasynthesis. Three synthesised themes were identified: the capability of people living with asthma, the opportunities of people living with asthma in SDM, and the motivation of the people living with asthma in SDM.

CONCLUSIONS

We have identified specific factors influencing people living with asthma engaging in SDM. The findings of this study can serve as a basis for the implementation of SDM in people living with asthma and provide insights for the development of their SDM training programs. The ConQual score for the synthesised findings was rated as low. To enhance confidence, future studies should address dependability and credibility factors.

PRACTICE IMPLICATIONS

This review contemplates the implementation of SDM from the perspective of people living with asthma, with the aim of providing patient-centred services for them. The results of this review can benefit the implementation of SDM and facilitate information sharing. It offers guidance for SDM skills training among adults living with asthma, fosters a better doctor-patient relationship and facilitates consensus in treatment decisions, thereby enabling personalised and tailored medical care.

PATIENT OR PUBLIC CONTRIBUTION

Three nursing graduate students participated in the data extraction and integration process, with two students having extensive clinical experience that provided valuable insights for the integration.

Shared decision-making performance of general practice residents: an observational study combining observer, resident, and patient perspectives

BACKGROUND

Shared decision making (SDM) is considered fundamental to person-centred care. However, applying SDM may be a challenge for residents in general practice, since it is a complex competence that requires the integration of knowledge and skills from several competency domains.

OBJECTIVE

To support learning of SDM during medical residency, we aimed to gain insight in Dutch residents' observed and perceived SDM performance in general practice.

METHODS

We evaluated residents' SDM performance from an observer, resident, and patient perspective. Consultations of first- and third-year residents were recorded. Trained observers used the validated Observing Patient Involvement (OPTION5) scale to assess observed SDM performance of residents in 98 actual recorded consultations. Perceived SDM performance was evaluated by residents and patients completing validated SDM questionnaires, supplemented with questions about (the context of) the consultation and perceived relevance of SDM immediately after the consultation. The data were analysed using descriptive statistics (mean, SD, minimums, and maximums) and explorative bivariate analyses.

RESULTS

The residents' observed mean SDM performance was 19.1 (range, 0-100, SD = 10.9), mean resident self-reported SDM performance was 56.9 (range, 0-100, SD = 18.5), and mean patient-reported SDM performance was 73.3 (range, 0-100, SD = 26.8). We found a significant and positive correlation between observed SDM performance and residents' perceived relevance of SDM for the consultation (t = 4.571, P ≤ 0.001) and the duration of the consultation (r = 0.390, P ≤ 0.001).

CONCLUSIONS

This study showed that there is room for increasing awareness of the potential incongruence between observed and perceived SDM performance during medical residency, in order to facilitate the implementation of SDM in clinical practice.

Shared Decision-Making in the Treatment of Multiple Sclerosis: Results of a Cross-Sectional, Real-World Survey in Europe and the United States

Introduction

Multiple sclerosis (MS) is a neurodegenerative disease characterized by progressive deterioration of cognitive and physical functioning, reducing activities of daily living and quality of life (QoL). Several treatments are available that modify the course of the disease and reduce the frequency of relapses. Although effective, all treatment options are accompanied by adverse events, and this study aimed to assess the extent to which patients were involved in the choice of treatment.

Methods

Data were drawn from the Adelphi Multiple Sclerosis Disease Specific Program (DSP)™, a cross-sectional survey of healthcare practitioners (HCP) and their patients with MS in real-world clinical settings in Europe and the United States (US) between December 2020 and July 2021. HCPs reported patient demographics, clinical characteristics, current and previous treatment, and treatment outcomes. Patients voluntarily completed questionnaires reporting the physical and psychological impact of their MS and its treatment. Regression analysis with inverse probability of treatment weighting was used to compare treatment outcomes in patients actively involved in their current treatment choice with those who were not.

Results

Of a total of 692 patients, median age 40 years and 64% female, mostly diagnosed with relapsing-remitting MS, those who were involved in shared decision-making tended to choose oral therapies such as dimethyl fumarate more often than HCPs. MS had greater impact on physical and psychological functioning in patients whose HCP made treatment decisions solely. Patients involved in decision-making reported greater satisfaction with their treatment and a better QoL.

Discussion

Because no single optimal therapy exists for patients with MS, treatments should be individualized with consideration of patients' preferences. Our study shows that shared decision-making is under-utilized in the management of MS and supports the benefits of patient involvement.

Conclusion

Patients who have an active role in treatment decision-making show improved wellbeing and QoL, and overall treatment satisfaction.

Preclinical support for tumor protein D52 as a cancer vaccine antigen

Overexpressed tumor-associated antigens (TAAs) are a large group that includes proteins found at increased levels in tumors compared to healthy cells. Universal tumor expression can be defined as overexpression in all cancers examined as has been shown for Tumor Protein D52. TPD52 is an over expressed TAA actively involved in transformation, leading to increased proliferation and metastasis. TPD52 overexpression has been demonstrated in many human adult and pediatric malignancies. The murine orthologue of TPD52 (mD52) parallels normal tissue expression patterns and known functions of human TPD52 (hD52). Here in we present our preclinical studies over the past 15 years which have demonstrated that vaccine induced immunity against mD52 is effective against multiple cancers in murine models, without inducing autoimmunity against healthy tissues and cells.

Integrative Review of Black Birthing People's Interactions With Clinicians During the Perinatal Period

Maternal morbidity and mortality disproportionately affect Black birthing people. Multiple factors contribute to these disparities, including variations in quality health care, structural racism, and implicit bias. Interactions between Black patients and perinatal clinicians could further affect perinatal care use and subsequent perinatal outcomes. This integrative review aims to synthesize quantitative and qualitative literature published in peer-reviewed journals in English within the past 10 years that address patient-clinician interactions during the perinatal period for Black birthing people in the United States. A systematic search of CINAHL, PubMed, PsycINFO, MEDLINE, and Embase recovered 24 articles that met the eligibility criteria for inclusion in this review. The following themes emerged from synthesizing Black patients' interactions with perinatal clinicians: Care Quality, Communication, Power Dynamic, and Established Relationships. Mutual respect, effective communication, and shared decision-making may be key modifiable factors to address through clinician education to improve perinatal care for many Black persons.

Validation of a Process for Shared Decision-Making in Pediatrics

OBJECTIVE

We sought to confirm, refute, or modify a 4-step process for implementing shared decision-making (SDM) in pediatrics that involves determining 1) if the decision includes >1 medically reasonable option; 2) if one option has a favorable medical benefit-burden ratio compared to other options; and 3) parents' preferences regarding the options; then 4) calibrating the SDM approach based on other relevant decision characteristics.

METHODS

We videotaped a purposive sample of pediatric inpatient and outpatient encounters at a single US children's hospital. Clinicians from 7 clinical services (craniofacial, neonatology, oncology, pulmonary, pediatric intensive care, hospital medicine, and sports medicine) were eligible. English-speaking parents of children who participated in inpatient family care conferences or outpatient problem-oriented encounters with participating clinicians were eligible. We conducted individual postencounter interviews with clinician and parent participants utilizing video-stimulated recall to facilitate reflection of decision-making that occurred during the encounter. We utilized direct content analysis with open coding of interview transcripts to determine the salience of the 4-step SDM process and identify themes that confirmed, refuted, or modified this process.

RESULTS

We videotaped 30 encounters and conducted 53 interviews. We found that clinicians' and parents' experiences of decision-making confirmed each SDM step. However, there was variation in the interpretation of each step and a need for flexibility in implementing the process depending on specific decisional contexts.

CONCLUSIONS

The 4-step SDM process for pediatrics appears to be salient and may benefit from further guidance about the interpretation of each step and contextual factors that support a modified approach.

Nurse-led shared decision-making on complementary therapy use by patients with diabetes: An participatory action research

AIMS

The aim of this study was to develop, implement and evaluate a nurse-led shared decision-making model of care for discussing the use of complementary and alternative medicine with diabetic patients and to explore to what extent the risk-benefit assessment of using complementary and alternative medicine can provide a framework for facilitating nurse-patient dialogue and strengthening patient involvement in their disease management.

DESIGN

Participatory action research with pre-post intervention.

METHODS

A two-run cycle of action and spirals from participatory action research was undertaken using a purposive sampling method to involve healthcare professionals and diabetic patients from September 2021 to June 2022. The nurse-led shared decision-making model of care was designed and implemented congruent with participatory action research principles. Quantitative measures were collected about patients' perceived involvement in shared decision-making and their understanding of the risks and benefits of using complementary and alternative medicine. Patients' outcomes of disease control (fasting plasma glucose and HbA1c) were also collected. Data were analysed using IBM SPSS software (version 28). Interviews were summarized using thematic analysis. An EQUATOR Network guideline for participatory action research supported the preparation of this paper.

RESULTS

Comparison of pre-post intervention outcomes showed that patients' scale scores on shared decision-making involvement and understanding of the risk-benefit of using complementary and alternative medicine improved significantly after implementing the model. Fasting plasma glucose improved only slightly after a 3-month follow-up.

CONCLUSIONS

The care model strengthens patient involvement in their disease management and makes appropriate decisions about CAM use that should reduce potentially harmful side effects or interactions between CAM and conventional medicine.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The shared decision-making model of care incorporates evidence-based CAM research into practice, facilitates the standardization of CAM management in diabetes, improves care options for patients and educates nurses about CAM use in managing diabetes.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Shared decision making: a personal view from two kidney doctors and a patient

Shared decision making (SDM) combines the clinician's expertise in the treatment of disease with the patient's expertise in their lived experience and what is important to them. All decisions made in the care of patients with kidney disease can potentially be explored through SDM. Adoption of SDM in routine kidney care faces numerous institutional and practical barriers. Patients with chronic disease who have become accustomed to paternalistic care may need support to engage in SDM-even though most patients actively want more involvement in decisions about their care. Nephrologists often underestimate the risks and overestimate the benefits of investigations and treatments and often default to recommending burdensome treatments rather than discussing prognosis openly. Guideline bodies continue to issue recommendations written for healthcare professionals without providing patient decision aids. To mitigate health inequalities, care needs to be taken to provide SDM to all patients, not just the highly health-literate patients least likely to need additional support in decision making. Kidney doctors spend much of their time in the consulting room, and it is unjustifiable that so little attention is paid to the teaching, audit and maintenance of consultation skills. Writing letters to the patient to summarise the consultation rather than sending them a copy of a letter between health professionals sets the tone for a consultation in which the patient is an active partner. Adoption of SDM will require nephrologists to relinquish long-established paternalistic models of care and restructure care around the values and preferences of patients.

Management reasoning and patient-clinician interactions: Insights from shared decision-making and simulated outpatient encounters

PURPOSE

To expand understanding of patient-clinician interactions in management reasoning.

METHODS

We reviewed 10 videos of simulated patient-clinician encounters to identify instances of problematic and successful communication, then reviewed the videos again through the lens of two models of shared decision-making (SDM): an 'involvement-focused' model and a 'problem-focused' model. Using constant comparative qualitative analysis we explored the connections between these patient-clinician interactions and management reasoning.

RESULTS

Problems in patient-clinician interactions included failures to: encourage patient autonomy; invite the patient's involvement in decision-making; convey the health impact of the problem; explore and address concerns and questions; explore the context of decision-making (including patient preferences); meet the patient where they are; integrate situational preferences and priorities; offer >1 viable option; work with the patient to solve a problem of mutual concern; explicitly agree to a final care plan; and build the patient-clinician relationship. Clinicians' 'management scripts' varied along a continuum of prioritizing clinician vs patient needs. Patients also have their own cognitive scripts that guide their interactions with clinicians. The involvement-focused and problem-focused SDM models illuminated distinct, complementary issues.

CONCLUSIONS

Management reasoning is a deliberative interaction occurring in the space between individuals. Juxtaposing management reasoning alongside SDM generated numerous insights.

Impact of the COVID-19 Pandemic on Providing Recommendations During Goals-of-Care Conversations: A Multisite Survey

Background: Goals-of-care conversations (GoCCs) are essential for individualized end-of-life care. Shared decision-making (SDM) that elicits patients' goals and values to collaboratively make life sustaining treatment (LST) decisions is best practice. However, it is unknown how the COVID-19 pandemic onset and associated changes to care delivery, stress on providers, and clinical uncertainty affected SDM and recommendation-making during GoCCs. Aim: To assess providers' attitudes and behaviors related to GoCCs during the COVID-19 pandemic and identify factors associated with provision of LST recommendations. Design: Survey of United States Veterans Health Administration (VA) health care providers. Setting/Participants: Health care providers from 20 VA facilities with high COVID-19 caseloads early in the pandemic who had authority to place LST orders and practiced in select specialties (n = 3398). Results: We had 323 respondents (9.5% adjusted response rate). Most were age ≥50 years (51%), female (63%), non-Hispanic white (64%), and had ≥1 GoCC per week during peak-COVID-19 (78%). Compared with pre-COVID-19, providers believed it was less appropriate and felt less comfortable giving an LST recommendation during peak-COVID-19 (p < 0.001). One-third (32%) reported either "never" or "rarely" giving an LST recommendation during GoCCs at peak-COVID-19. In adjusted regression models, being a physician and discussing patients' goals and values were positively associated with giving an LST recommendation (B = 0.380, p = 0.031 and B = 0.400, p < 0.001, respectively) at peak-COVID-19. Conclusion: Providers who discuss patients' preferences and values are more likely to report giving a recommendation; both behaviors are markers of SDM during GoCCs. Our findings suggest potential areas for training in conducting patient-centered GoCCs.

The systematic and participatory development of a patient decision aid about terminal devices for people with upper limb absence: The PDA-TULA

Selecting an upper limb prosthesis seems to be a challenge considering the high rejection rates. A patient decision aid (PDA) could support the decision-making process by providing information about available options and clarifying the patients' values related to those options. This study aims to describe the developmental process of a PDA about terminal devices (TDs) for people with upper limb absence: PDA-TULA. The developmental process was based on The International Patient Decision Aid Standards. We aimed at adults with major unilateral upper limb absence. A steering group including patients, clinicians, researchers, software and implementation experts was composed. The content and design of the PDA were based on a qualitative literature meta-synthesis, focus groups with patients and clinicians, surveys among patients and prosthetists, a nationwide digital meeting with clinicians and prosthetists, and information from manufacturers. Information on features of TDs was systematically collected, ordered, and refined. Subsequently, drafts of the PDA-TULA were made, improved, integrated into the software, and alpha tested. The digital PDA-TULA consists of three parts: (1) information about TDs; (2) consideration of personal values regarding the TDs; (3) comparison of TD profiles with a personal profile based on indicated preferences. A summarizing overview is offered to patients and clinicians. To conclude, a digital PDA, which was integrated into the national working process of clinicians, was developed in a systematic co-creation process. The PDA enables patients and their significant others to consider and formulate their preferences about TDs during the prosthesis selection process.

1-year functional outcomes after cardiopulmonary resuscitation for older adults with pre-existing long-term care needs

OBJECTIVE

To investigate the 1-year functional outcomes after cardiopulmonary resuscitation (CPR) in adults aged ≥65 years with pre-existing long-term care needs.

METHODS

This population-based cohort study was conducted in Tochigi Prefecture, one of 47 prefectures in Japan. We used medical and long-term care administrative databases, which included data on functional and cognitive impairment that were assessed with the nationally standardised care-needs certification system. Among individuals aged ≥65 years registered between June 2014 and February 2018, patients who underwent CPR were identified. The primary outcome was mortality and care needs at 1 year after CPR. The outcome was stratified by pre-existing care needs before CPR based on the total daily estimated care minutes: no care needs, support levels 1 and 2 and care-needs level 1 (estimated care time 25-49 min), care-needs levels 2 and 3 (50-89 min) and care-needs levels 4 and 5 (≥90 min).

RESULTS

Among 594,092 eligible individuals, 5,086 (0.9%) underwent CPR. The 1-year mortalities after CPR in patients with no care needs, support levels 1 and 2 and care-needs level 1, care-needs levels 2 and 3 and care-needs levels 4 and 5 were 94.6% (n = 2,207/2,332), 96.1% (n = 736/766), 94.5% (n = 930/984) and 95.9% (n = 963/1,004), respectively. Among survivors, most patients had no change in care needs before and at 1 year after CPR. There was no significant association between pre-existing functional and cognitive impairment and 1-year mortality and care needs after adjusting for potential confounders.

CONCLUSION

Healthcare providers need to discuss poor survival outcomes after CPR with all older adults and their families in shared decision making.

Cancer treatments touch a wide range of values that count for patients and other stakeholders: What are the implications for decision-making?

BACKGROUND

Cancer rates and expenditures are increasing, resulting in debates on the exact value of this care. Perspectives on what exactly constitutes worthwhile values differ. This study aims to explore all values-elements regarding new oncological treatments for patients with cancer and all stakeholders involved and to assess their implications in different decision-making procedures.

METHOD

Thirty-one individual in-depth interviews were conducted with different stakeholders to identify values within oncology. A focus group with seven experts was performed to explore its possible implications in decision-making procedures.

RESULTS

The overarching themes of values identified were impact on daily life and future, costs for patients and loved ones, quality of life, impact on loved ones, societal impact and quality of treatments. The expert panel revealed that the extended exploration of values that matter to patients is deemed useful in patient-level decision-making, information provision, patient empowerment and support during and after treatment. For national reimbursement decisions, implications for the broad range of values seems less clear.

CONCLUSION

Clinical values are not the only ones that matter to oncological patients and the stakeholders in the field. We found a much broader range of values. Proper recognition of values that count might add to patient-level decision-making, but implications for reimbursement decisions are less clear. The results could be useful to guide clinicians and policymakers when it comes to decision-making in oncology. Making more explicit which values counts for whom guarantees a more systematic approach to decision-making on all levels.

Cultural influences on shared decision-making among Asian Americans: A systematic review and meta-synthesis of qualitative studies

OBJECTIVE

To summarize how Asian Americans negotiate involvement in shared decision-making (SDM) with their providers, the cultural influences on SDM, and perceived barriers and facilitators to SDM.

METHODS

This is a systematic review of qualitative studies. We searched six electronic databases and sources of gray literature until March 2021. Two reviewers independently screened studies, performed quality appraisal, and data extraction. Meta-synthesis was performed to summarize themes using a three-step approach.

RESULTS

Twenty studies with 675 participants were included. We abstracted 275 initial codes and grouped these into 19 subthemes and 4 major themes: (1) negotiating power and differing expectations in SDM; (2) cultural influences on SDM; (3) importance of social support in SDM; and (4) supportive factors for facilitating SDM.

CONCLUSIONS

Asian Americans have important perspectives, needs, and preferences regarding SDM that impacts how they engage with the provider on medical decisions and their perception of the quality of their care.

PRACTICE IMPLICATIONS

Asian American patients valued good communication and sufficient time with their provider, and that it is important for health professionals to understand patients' desired level of involvement in the SDM process and in the final decision, and who should be involved in SDM beyond the patient.

OTHER

This systematic review was registered on PROSPERO (CRD42021241665).

Take on transplant: human-centered design of a patient education tool to facilitate informed discussions about lung transplant among people with cystic fibrosis

OBJECTIVE

Lung transplant (LTx) saves lives in cystic fibrosis (CF). However, many potential candidates express uncertainty about LTx and die before receiving this treatment. CF guidelines recommend LTx education and clinical discussions well before the need for LTx arises, but limited patient resources exist.

MATERIALS AND METHODS

We engaged people with CF and CF physicians in human-centered design of "Take On Transplant" (TOT), a web-based education tool to prepare patients for LTx discussions. Across 3 phases, needs assessment, design groups, and iterative user testing of TOT, we refined TOT from wireframe prototypes, to an interactive website, to a fully functional intervention ready for clinical trials.

RESULTS

Fifty-five people with CF and 105 physicians identified information needs to prepare for LTx discussions. Design groups (n = 14 participants) then established core requirements: didactic education ("Resource Library"), patient narratives ("CF Stories"), frequently asked questions ("FAQ"), and self-assessment to tailor content ("My CF Stage"). Iterative usability testing (n = 39) optimized the design of CF Stories and prototype layout. We then developed the TOT website and demonstrated feasibility and preliminary efficacy of use through 2-week field testing (n = 9).

DISCUSSION

Our human-centered design process provided guidance for educational tools to serve the evolving needs of potential LTx candidates. Our findings support the process of patient deliberation as a foundation for shared decision-making in CF, and inform educational tools that could potentially translate beyond LTx.

CONCLUSION

TOT fills a critical gap in preparing people with CF for shared decision-making about LTx and may serve as a model for educational tools for other preference-sensitive decisions.

Considerations for transferability of health technology assessments: a scoping review of tools, methods, and practices

Health technology assessment (HTA) is commonly used to guide evidence-informed decisions to optimize resource use, prioritize policies, and support countries to achieve universal health coverage. Producing HTAs requires time, scientific expertise, and political commitment, but these are not available in all settings - especially in low- and middle-income countries (LMIC) where HTA processes may be less institutionalized. Transferring and adapting existing HTAs to local settings may offer a solution while reducing duplication efforts. This scoping review aims to provide an overview of tools, methods, approaches, and considerations which can aid HTA transfers. We systematically searched (from 2005 to 2020) six databases and, using predefined inclusion criteria, included twenty-two studies. Data extraction followed a structured process, while synthesis was more iterative. We identified a common approach for HTA transfers. It follows the de novo process of undertaking original HTAs, but with additional steps to assess relevance (applicability), quality, and transferability, as well as steps to adapt parameters where necessary. The EUnetHTA Adaptation Toolkit was the only tool that provided guidance for adapting multiple HTA domains. Other tools were specific to systematic reviews (n = 1) or economic evaluations (n = 12), where one provided guidance for systematic reviews of economic evaluations. Eight papers reported transferring an HTA, with only one transferring to an LMIC. Finally, we reported issues that may facilitate or hinder transferability. In conclusion, we identified fourteen transfer approaches in the form of guidance or checklists, but harmonized and pragmatic guidance for HTA transfers to suit settings with limited HTA capacity seems warranted.

Health care professional perspectives on discharging hospitalized patients with injection drug use-associated infections

Background:

Patients with injection drug use (IDU)-associated infections traditionally experience prolonged hospitalizations, which often result in negative experiences and bad outcomes. Harm reduction approaches that value patient autonomy and shared decision-making regarding outpatient treatment options may improve outcomes. We sought to identify health care professionals (HCPs) perspectives on the barriers to offering four different options to hospitalized people who use drugs (PWUD): long-term hospitalization, oral antibiotics, long-acting antibiotics at an infusion center, and outpatient parenteral antibiotics.

Methods:

We recruited HCPs (n = 19) from a single tertiary care center in Portland, Maine. We interviewed HCPs involved with discharge decision-making and other HCPs involved in the specialized care of PWUD. Semi-structured interviews elicited lead HCP values, preferences, and concerns about presenting outpatient antimicrobial treatment options to PWUD, while support HCPs provided contextual information. We used the iterative categorization approach to code and thematically analyze transcripts.

Results:

HCPs were willing to present outpatient treatment options for patients with IDU-associated infections, yet several factors contributed to reluctance. First, insufficient resources, such as transportation, may make these options impractical. However, HCPs may be unaware of existing community resources or viable treatment options. They also may believe the hospital protects patients, and that discharging patients into the community exposes them to structural harms. Some HCPs are concerned that patients with substance use disorder will not make ‘good’ decisions regarding outpatient antimicrobial options. Finally, there is uncertainty about how responsibility for offering outpatient treatment is shared across changing care teams.

Conclusion:

HCPs perceive many barriers to offering outpatient care for people with IDU-associated infections, but with appropriate interventions to address their concerns, may be open to considering more options. This study provides important insights and contextual information that can help inform specific harm reduction interventions aimed at improving care of people with IDU-associated infections.

Decision Support Tools for Coronary Artery Calcium Scoring in the Primary Prevention of Cardiovascular Disease Do Not Meet Health Literacy Needs: A Systematic Environmental Scan and Evaluation

A shared decision-making approach is considered optimal in primary cardiovascular disease (CVD) prevention. Evidence-based patient decision aids can facilitate this but do not always meet patients' health literacy needs. Coronary artery calcium (CAC) scans are increasingly used in addition to traditional cardiovascular risk scores, but the availability of high-quality decision aids to support shared decision-making is unknown. We used an environmental scan methodology to review decision support for CAC scans and assess their suitability for patients with varying health literacy. We systematically searched for freely available web-based decision support tools that included information about CAC scans for primary CVD prevention and were aimed at the public. Eligible materials were independently evaluated using validated tools to assess qualification as a decision aid, understandability, actionability, and readability. We identified 13 eligible materials. Of those, only one qualified as a decision aid, and one item presented quantitative information about the potential harms of CAC scans. None presented quantitative information about both benefits and harms of CAC scans. Mean understandability was 68%, and actionability was 48%. Mean readability (12.8) was much higher than the recommended grade 8 level. Terms used for CAC scans were highly variable. Current materials available to people considering a CAC scan do not meet the criteria to enable informed decision-making, nor do they meet the health literacy needs of the general population. Clinical guidelines, including CAC scans for primary prevention, must be supported by best practice decision aids to support decision-making.

Interventions, Participative Role, Barriers, and Facilitators for Involvement in eHealth Communication for People Undergoing Hemodialysis: Protocol for a Scoping Review

Background

eHealth interventions have been shown to offer people living with chronic kidney disease the opportunity of embracing dialysis therapies with greater confidence, the potential to obtain better clinical outcomes and increased quality of life, and diverse and flexible designs and delivery options. eHealth interventions or solutions can offer one-way information without the possibility for dialogue, as with most mobile apps. eHealth interventions intending to enable two-way communication between patients undergoing hemodialysis and health professionals are the focus of this review. eHealth communication interventions that enable two-way communication between patients undergoing hemodialysis and health professionals is an emerging field, but issues relating to participation in eHealth communication for patients undergoing hemodialysis are scarcely described. The current conceptualization of this issue is too scattered to inform the development of future interventions. In this scoping review, we want to assemble and examine this scattered knowledge on participation in two-way eHealth communication for patients undergoing hemodialysis.

Objective

We want to understand the participative role of people living with chronic kidney disease undergoing hemodialysis in available communicative eHealth interventions and to understand which barriers and facilitators exist for patient involvement in eHealth communication with health professionals.

Methods

A scoping review methodology is guiding this study. Peer-reviewed primary studies, including quantitative, qualitative, and mixed methods study designs will be included. A systematic search for published studies, dissertations, and theses at the doctoral level in the English language will be conducted in five databases (MEDLINE, Embase, CINAHL, Scopus, and ProQuest Dissertations and Theses). The included literature will focus on adult (18 years or older) patients undergoing hemodialysis who are involved in eHealth communication with health professionals. Data on the type of eHealth communication interventions, the participative role, and barriers and facilitators for the involvement in eHealth communication for people undergoing hemodialysis will be extracted independently by two reviewers. The extracted data will be collected in a draft charting table prepared for the study. Any discrepancies between the reviewers will be solved through discussion or with a third reviewer.

Results

Results are anticipated by the spring of 2023 and will be presented in tabular format along with a narrative summary. The anticipated results will be presented in alignment with the objectives of the study, presenting findings on the participative role of patients undergoing hemodialysis in eHealth communication interventions.

Conclusions

We anticipate that this study will inform on eHealth communication interventions and the level of patient participation in eHealth communication for patients undergoing hemodialysis. The systematized overview will possibly identify research gaps and motivate further development of eHealth communication to ensure patient participation. The findings will be of interest to key stakeholders in clinical care, research, development, policy, and patient advocacy.

International Registered Report Identifier (IRRID)

PRR1-10.2196/38615

Focus group study of factors relevant to treatment decisions and experiences among patients with symptomatic peripheral artery disease

BACKGROUND

Clinical guidelines recommend shared decision-making for treatment of peripheral artery disease (PAD), which requires understanding of patient perspectives and preferences. We conducted a focus group study of patients with symptomatic PAD to identify factors important and relevant to treatment choices, and to characterize aspects of the healthcare process that contribute to positive versus negative experiences apart from the specific treatment(s) received.

METHODS

Participants were recruited from an academic medical center over two years using a purposeful sampling approach based on a clinical diagnosis of symptomatic PAD (either claudication or chronic limb threatening ischemia [CLTI]) confirmed by abnormal ankle or toe brachial index. Focus groups were led by a non-physician moderator, consisted of 5-12 participants, and were conducted separately for patients with CLTI and claudication. Audio recordings converted to verbatim transcripts were used for qualitative analysis.

RESULTS

51 patients (26 with CLTI and 25 with claudication) were enrolled and participated in focus groups. Major themes related to the process of care included: decision-making input, provider communication and trust, the timeline from diagnosis to definitive treatment, and compartmentalized care (including different venues of care). Major themes related to the process of care included: decision-making input, provider communication and trust, the timeline from diagnosis to definitive treatment, and compartmentalized care (including different venues of care).

CONCLUSIONS

The results provide insights into patient preferences, perspectives, and experiences related to PAD treatment. These observations can be used to inform patient-centered approaches to shared decision making, communication, and assessment of PAD treatment outcomes.

Assessing the Impact of Decision Aid Use on Post Prostatectomy Patient Reported Outcomes

OBJECTIVE

To evaluate whether completing a decision aid, Personal Patient Profile - Prostate (P3P), prior to prostatectomy, affects self-reported bother from post-prostatectomy urinary incontinence and erectile dysfunction.

MATERIALS AND METHODS

This retrospective analysis included data from men with newly diagnosed clinically localized, very low to intermediate risk prostate cancer who elected for prostatectomy within the Michigan Urological Surgery Improvement Collaborative between 2018-2021. Multivariable logistic regression models were used to estimate the association between P3P use and bother from post prostatectomy erectile dysfunction and urinary incontinence as measured by the Expanded Prostate Cancer Index Composite (EPIC-26).

RESULTS

Among the 3987 patients included, 7% used P3P (n = 266). Men who used P3P reported significantly less bother from erectile dysfunction at 6 months vs non-users (aOR 0.42 [95% CI 0.27-0.66]). At 12 months, the effect of P3P on bother from erectile dysfunction was not statistically significant (aOR 0.62 [95% CI 0.37-1.03]). Men who used P3P did not have a statistically significant difference in bother from urinary incontinence (3-month: aOR 0.56 [95% CI 0.30-1.06]; 6-month; aOR 0.79 [95% CI 0.31-1.97]).

CONCLUSION

Within the stated limitations of this study, we find that use of a decision aid for localized prostate cancer was associated with decreased odds of men being bothered from sexual dysfunction but not urinary incontinence at 6 months post prostatectomy.

Medical communication and decision-making about assisted hydration in the last days of life: A qualitative study of doctors experienced with end of life care

BACKGROUND

The impact of assisted hydration on symptoms and survival at the end of life is unclear. Little is known about optimal strategies for communicating and decision-making about this ethically complex topic. Hydration near end of life is known to be an important topic for family members, but conversations about assisted hydration occur infrequently despite guidance suggesting these should occur with all dying people.

AIM

To explore the views and experiences of doctors experienced in end-of-life care regarding communicating with patients and families and making decisions about assisted hydration at the end of life.

DESIGN

Qualitative study involving framework analysis of data from semi-structured interviews.

SETTING/PARTICIPANTS

Sixteen UK-based Geriatrics and Palliative Medicine doctors were recruited from hospitals, hospices and community services from October 2019 to October 2020.

RESULTS

Participants reported clinical, practical and ethical challenges associated with this topic. The hospital setting provides barriers to high-quality communication with dying patients and their families about assisted hydration, which may contribute to the low incidence of documented assisted hydration-related conversations. Workplace culture in some hospices may make truly individualised decision-making about this topic more difficult. Lack of inclusion of patients in decision-making about assisted hydration appears to be common practice.

CONCLUSIONS

Proactive, routine discussion with dying people about hydration-related issues is indicated in all cases. There is room for debate regarding the limits of shared decision-making and the benefits of routine discussion of assisted hydration with all dying people. Clinicians have to navigate multiple barriers as they strive to provide individualised care.

Leveraging the timing and frequency of patient decision aids in longitudinal shared decision-making: A narrative review and applied model

Introduction

Shared decision‐making (SDM) is intended to increase patient‐centredness of medical decision‐making for patients with acute and chronic conditions. Concurrently, patient decision aids (PtDAs) can supplement SDM by providing information to guide communication between patients and healthcare providers. Because of the prevalence of chronic conditions, where decisions may be extended or recurring, we sought to explore how effectively these tools have been leveraged in this context.

Methods

We conducted a narrative review of the literature on both SDM and PtDAs, searching PubMed and Boston University's library database search tool for English‐language articles published from January 2005 until March 2021. Additional search terms focused on temporality. Drawing from our findings, we developed a combined framework to highlight areas for future research using the discussion of end‐of‐life decisions as an exemplar to illustrate its relevance to chronic care contexts.

Results

After screening 57 articles, we identified 25 articles that fulfilled the inclusion criteria on SDM, PtDA use and temporality for chronic care. The literature on SDM highlighted time outside of the medical visit and opportunity to include outside decision partners as important elements of the process. PtDAs were commonly evaluated for process‐related and proximal outcomes, but less often for distal outcomes. Early evidence points to the value of comparative outcome evaluation based on the timing of PtDA distribution.

Conclusion

Our review of the literature on SDM and PtDAs reveals less attention to the timing of PtDAs relative to that of SDM. We highlight the need for further study of timing in PtDA use to improve longitudinal SDM for chronic care. The model that we propose in our discussion provides a starting point for future research on PtDA efficacy.

Patient or Public Contribution

Five patient consultants provided input and feedback on the development and utility of our model.

Treatment Decision-making in Chinese Inflammatory Bowel Disease Patients

BACKGROUND

Inflammatory bowel disease (IBD) is rising in China, and the tendency for lifelong recurrence decreases patients' quality of life. However, no studies on treatment decision-making in Chinese patients with IBD exist. Thus, this study aimed to determine the actual and ideal decision-making, as well as factors affecting decision-making in Chinese IBD patients.

METHODS

A multicenter online questionnaire was distributed among patients diagnosed with IBD. To assess factors that influence treatment decision-making, univariate and multivariate logistic regression analyses were performed.

RESULTS

From March 20, 2018, to May 20, 2018, a total of 866 patients completed the questionnaires, including 222 patients with ulcerative colitis, 588 patients with Crohn's disease, and 56 patients with unclassified IBD. There was a significant difference between ideal and actual decision-making in Chinese IBD patients (P < .005). The factors affecting ideal decision-making included income, education, illness severity, religiosity, the importance of the treatment decision, the employment situation, and occupation area. The factors affecting actual decision-making included age, illness severity, religiosity, the employment situation, economic anxiety, concern about the side effects, and the importance of the treatment decision.

CONCLUSIONS

There is a significant difference between ideal and actual decision-making in IBD patients in China. That is, the economy, religiosity, illness severity, and concern about the side effects of treatment are the most important factors affecting treatment decisions in Chinese IBD patients.

Guideline No. 425b: Cannabis Use Throughout Women's Lifespans - Part 2: Pregnancy, the Postnatal Period, and Breastfeeding

OBJECTIVE

To provide health care providers with the best evidence on cannabis use and women's health. Areas of focus include screening, dependence, and withdrawal; communication and documentation; pregnancy (including maternal and fetal outcomes); maternal pain control; postpartum care (including second-hand smoking and parenting); and breastfeeding.

TARGET POPULATION

The target population includes women who are planning a pregnancy, pregnant, or breastfeeding.

BENEFITS, HARMS, AND COSTS

Discussing cannabis use with women who are planning a pregnancy, pregnant, or breastfeeding allows them to make informed choices about their cannabis use. Based on the limited evidence, cannabis use in pregnancy or while breastfeeding should be avoided, or reduced as much as possible if abstaining is not feasible, given the absence of safety and long-term follow up data on cannabis-exposed pregnancies and infants.

EVIDENCE

PubMed and Cochrane Library databases were searched for articles relevant to cannabis use during pregnancy and breastfeeding published between January 1, 2018, and February 5, 2021. The search terms were developed using the MeSH terms and keywords and their variants, including cannabis, cannabinoids, cannabidiol, CBD, THC, marijuana, edible, pregnancy, pregnant, prenatal, perinatal, postnatal, breastfeed, breastfed, lactation, nursing, fetus, fetal, neonatal, newborn, and child. In terms of publication type, all clinical trials, observational studies, reviews (including systematic reviews and meta-analyses), guidelines, and conference consensus statements were included. The main inclusion criteria were pregnant and breastfeeding women as the target population, and exposure to cannabis as the intervention of interest.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All health care providers who care for women of reproductive age.

SUMMARY STATEMENTS

RECOMMENDATIONS.

A multidisciplinary perioperative medicine clinic to improve high-risk patient outcomes: A service evaluation audit

Various perioperative interventions have been demonstrated to improve outcomes for high-risk patients undergoing surgery. This audit assessed the impact of introducing a multidisciplinary perioperative medicine clinic on postoperative outcomes and resource usage amongst high-risk patients.

Between January 2019 and March 2020, our institution piloted a Comprehensive High-Risk Surgical Patient Clinic. Surgical patients were eligible for referral when exhibiting criteria known to increase perioperative risk. The patient's decision whether to proceed with surgery was recorded; for those proceeding with surgery, perioperative outcomes and bed occupancy were recorded and compared against a similar surgical population identified as high-risk at our institution in 2017.

Of 23 Comprehensive High-Risk Surgical Patient Clinic referrals, 11 did not proceed with the original planned surgery. Comprehensive High-Risk Surgical patients undergoing original planned surgery, as compared to high-risk patients from 2017, experienced reduced unplanned intensive care unit admission (8% versus 19%, respectively), 30-day mortality (0% versus 13%) and 30-day re-admission to hospital (0% versus 20%); had shorter postoperative lengths of stay (median (range) 8 (7-14) days versus 10.5 (5-28)) and spent more days alive outside of hospital at 30 days (median (range) 18 (0-25) versus 21 (16-23)). Cumulatively, the Comprehensive High-Risk Surgical patient cohort compared to the 2017 cohort (both n=23) occupied fewer postoperative intensive care (total 13 versus 24) and hospital bed-days (total 106 versus 212).

The results of our Comprehensive High-Risk Surgical Patient pilot project audit suggest improved individual outcomes for high-risk patients proceeding with surgery. In addition, the results support potential resource savings through more appropriate patient selection.

Co-Developing an Antibiotic Stewardship Tool for Dentistry: Shared Decision-Making for Adults with Toothache or Infection

Dentistry is responsible for around 10% of antibiotic prescribing across global healthcare, with up to 80% representing inappropriate use. Facilitating shared decision-making has been shown to optimise antibiotic prescribing (antibiotic stewardship) in primary medical care. Our aim was to co-develop a shared decision-making antibiotic stewardship tool for dentistry. Dentists, patients and other stakeholders prioritised factors to include in the new tool, based on previous research (a systematic review and ethnographic study) about dentists’ decision-making during urgent appointments. Candidate behaviour-change techniques were identified using the Behaviour Change Wheel and selected based on suitability for a shared decision-making approach. A ‘think aloud’ study helped fine-tune the tool design and Crystal Marking ensured clarity of messaging. The resulting paper-based worksheet for use at point-of-care incorporated various behaviour change techniques, such as: ’information about (and salience of) health consequences’, ‘prompts and cues’, ‘restructuring the physical (and social) environment’ and ‘credible sources’. The think aloud study confirmed the tool’s acceptability to dentists and patients, and resulted in the title: ‘Step-by-step guide to fixing your toothache.’ Further testing will be necessary to evaluate its efficacy at safely reducing dental antibiotic prescribing during urgent dental appointments in England and, with translation, to other dental contexts globally.

Differences in baseline risk estimated by physicians and patients with early breast cancer

BACKGROUND

Physicians recommend adjuvant therapy to patients based on baseline risk. A common recognition for baseline risk between patients and physicians is critical for successful adjuvant therapy. We prospectively investigated the differences in estimated baseline risk between physicians and patients with early breast cancer.

METHODS

This analysis was performed at a single institution in Japan. Early breast cancer patients over 18 years old were enrolled after surgery. After explaining the pathological results, physicians asked each patient about an estimated baseline risk. Differences in estimated baseline risk were defined as the baseline risk estimated by patients minus the baseline risk estimated by physicians. The primary endpoint was that the number of patients who estimate baseline risk higher than physicians was higher than those who estimate a lower baseline risk. The secondary endpoints were differences in estimated baseline risk by stage, subtype and the influence of patient factors to differences in estimated baseline risk.

RESULTS

From July 2017 to December 2018, 262 patients were enrolled. Among the 262 patients, 190 estimated a higher baseline risk than physicians, 53 estimated a lower baseline risk and 19 estimated the same. Overall, patients estimated a significantly higher baseline risk than physicians (P < 0.001). Differences in estimated baseline risk was significantly smaller in patients who knew the term 'baseline risk' than patients who did not (P = 0.0037). Differences in estimated baseline risk were also significantly smaller in patients with stage II breast cancer than patients with stage I (P = 0.0239). However, there were no statistically significant differences of differences in estimated baseline risk according to other factors.

CONCLUSIONS

Patients with early breast cancer estimated a significantly higher baseline risk than physicians. Physicians should accurately explain baseline risk to patients for shared decision making.

Decision aid and preference assessment of topical anesthesia for otolaryngology procedures

OBJECTIVES

To determine preference patterns for topical anesthesia in patients undergoing endoscopy pre-coronavirus (2019 coronavirus disease [COVID-19]) pandemic and analyze outcomes based on preference, using a decision aid format.

METHODS

A decision aid was developed with expert and patient input. New patients presenting to subspecialty clinics over a 2-month pre-COVID-19 period completed a pre-procedure survey about their priorities, then were asked to choose between topical oxymetazoline/lidocaine spray or none. A post-procedure outcome survey followed.

RESULTS

Of 151 patients, 90.1% patients elected to have topical anesthesia. Top patient priorities were "I want the scope to be easy for the doctor" and "I want to be as comfortable as possible." Patients who strongly wanted to avoid medication (P = .002) and bad taste (P = .003) were more likely to select no spray, whereas those who wanted to avoid pain received anesthetic (P = .011). According to the post-procedure assessment, 95.4% of patients were satisfied or strongly satisfied their choice, and this did not correlate with anesthetic vs none.

CONCLUSIONS

Patient preferences are easily elicited and correlate with treatment choices. Most patients chose to have topical anesthetic and were willing to tolerate side effects; however, both patients with and without topical anesthetic were satisfied with their choices. This decision aid can be used to optimize shared decision making in the otolaryngology clinic. Given the aerosolizing potential of both spray and no spray conditions, this insight may be consequential when devising office protocols for post-COVID-19 practice.

LEVEL OF EVIDENCE

II.

Displaying emergency patient estimated wait times: A multi-centre, qualitative study of patient, community, paramedic and health administrator perspectives

OBJECTIVE

EDs have the potential ability to predict patient wait times and to display this to patients and other stakeholders. Little is known about whether consumers and stakeholders would want this information and how wait time predictions might be used. The aim of the present study was to gain perspectives from consumers and health services personnel regarding the concept of emergency wait time visibility.

METHODS

We conducted a qualitative interview and focus group study in 2019. Participants included emergency medicine patients, families, paramedics, well community members, and hospital/paramedic administrators from multiple EDs and organisations in Victoria, Australia. Transcripts were coded and themes presented.

RESULTS

One focus group and 103 semi-structured interviews were conducted in 2019 including 32 patients, 22 carers/advocates and 21 paramedics in the ED; 20 health service administrators (paramedic and hospital) and 15 community members. Consumers and paramedics face physical and psychological difficulties when wait times are not visible. Consumers believe about a 2-h wait is tolerable, beyond this most begin to consider alternative strategies for seeking care. Consumers want to see triage to doctor times; paramedics want door-to-off stretcher times (for all possible transport destinations); with 47 of 50 consumers and 30 of 31 paramedics potentially using this information. About 28 of 50 consumers would use times to inform facility or provider choice, another 19 of 50 want information once in the waiting room. During prolonged waits, 51 of 52 consumers would continue to seek care.

CONCLUSIONS

Consumers and paramedics want wait time information visibility. They would use the information in a variety of ways, both pre-hospital and while waiting for care.

Engagement With the Plan of Care Among Older Adults With Multiple Cardiac Diagnoses

Aging adults depend on complex treatment plans to manage chronic conditions, yet little is known about their ability to perform the sophisticated behaviors required of technologically engaged patients. This qualitative descriptive study describes engagement with the plan of care. Forty chronically ill adults participated in this study, which involved an observation of the clinical encounter and an interview. Data were collected and analyzed simultaneously in keeping with principles of qualitative research. Multiple techniques were used to test conclusions and findings were constructed as thematic sentences, including the following: I act in ways that support my health, I manage my health-related information, I make visits with my doctor part of my routine, I participate in treatment planning. Older adults work to achieve self-management to the best of their ability, shunning the use of health information technology (HIT) and demonstrating a preference for provider-created treatment plans.

Decision aids for prenatal testing: A systematic review and meta-analysis

AIMS

To analyse the effect of decision aids (DAs) used by pregnant women on prenatal testing decisions.

DESIGN

Systematic review and meta-analysis.

DATA RESOURCES

We searched Embase, PubMed, Web of Science and the Cochrane Central Library ending October 2020.

REVIEW METHODS

Papers were selected for analysis in accordance with the PRISMA guidelines. The meta-analysis was carried out using Review Manager 5.3 software. The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane Handbook. The result is knowledge, decision conflict, anxiety and other secondary outcomes.

RESULTS

A total of 18 studies were included in the systematic review and meta-analysis. Comprehensive analysis showed that DAs could significantly improve knowledge and decision-making satisfaction, reduce decision conflict, increase the proportion of women who make informed choice and had no influence on anxiety and decision regret.

CONCLUSIONS

This article systematically reviewed the positive effect of DAs on the decision-making of pregnant women facing prenatal testing. In the future, nurses should be encouraged to develop DAs in accordance with strict standards and apply them to pregnant women of different backgrounds.

IMPACT

There is a growing consensus that health care should be patient-centred, and the values and preferences of pregnant women who undergo prenatal testing need to be incorporated into the clinical decision-making process. This review reports that the use of DAs can increase pregnant women's chances of participating in prenatal testing decisions and may improve the quality of their decision-making. It also provides information on the role and practice of nurses in promoting evidence-based prenatal testing for DAs.

Development of an electronic conversation aid to support shared decision making for children with acute otitis media

Objective

The overuse of antibiotics for acute otitis media (AOM) in children is a healthcare quality issue in part arising from conflicting parent and physician understanding of the risks and benefits of antibiotics for AOM. Our objective was to develop a conversation aid that supports shared decision making (SDM) with parents of children who are diagnosed with non-severe AOM in the acute care setting.

Materials and Methods

We developed a web-based encounter tool following a human-centered design approach that includes active collaboration with parents, clinicians, and designers using literature review, observations of clinical encounters, parental and clinician surveys, and interviews. Insights from these processes informed the iterative creation of prototypes that were reviewed and field-tested in patient encounters.

Results

The ear pain conversation aid includes five sections: (1) A home page that opens the discussion on the etiologies of AOM; (2) the various options available for AOM management; (3) a pictograph of the impact of antibiotic therapy on pain control; (4) a pictograph of complication rates with and without antibiotics; and (5) a summary page on management choices. This open-access, web-based tool is located at www.earpaindecisionaid.org.

Conclusions

We collaboratively developed an evidence-based conversation aid to facilitate SDM for AOM. This decision aid has the potential to improve parental medical knowledge of AOM, physician/parent communication, and possibly decrease the overuse of antibiotics for this condition.

Shared decision making in consultations for hypertension: Qualitative study in general practice

Background

Hypertension is mainly managed in primary care. Shared decision making is widely recommended as an approach to treatment decision making. However, no studies have investigated; in detail, what happens during primary care consultations for hypertension.

Aim

To understand patients’ and clinicians’ experience of shared decision making for hypertension in primary care, in order to propose how it might be better supported.

Design

Longitudinal qualitative study.

Setting

Five general practices in south‐west England.

Method

Interviews with a purposive sample of patients with hypertension, and with the health‐care practitioners they consulted, along with observations of clinical consultations, for up to 6 appointments. Interviews and consultations were audio‐recorded and observational field notes taken. Data were analysed thematically.

Results

Forty‐six interviews and 18 consultations were observed, with 11 patients and nine health‐care practitioners (five GPs, one pharmacist and three nurses). Little shared decision making was described by participants or observed. Often patients’ understanding of their hypertension was limited, and they were not aware there were treatment choices. Consultations provided few opportunities for patients and clinicians to reach a shared understanding of their treatment choices. Opportunities for patients to engage in choices were limited by structured consultations and the distribution of decisions across consultations.

Conclusion

For shared decision making to be better supported, consultations need to provide opportunities for patients to learn about their condition, to understand that there are treatment choices, and to discuss these choices with clinicians.

Patient or Public Contribution

A patient group contributed to the design of this study.

Improving long-term adherence to sublingual immunotherapy. Results of a proactive patients-centered management planning

Summary

Background. Long-term adherence to sublingual immunotherapy (SLIT) results very poor in real-life studies. Effective actions are needed. Key point of any policy aimed to overcoming non-cost related barriers to medication long-term adherence is to actively support patients' needs and preferences starting from shared decisions making. Objective. To explore SLIT related viewpoints, needs and preferences of a homogeneous group of patients. To assess their priority order and to what extent each of them could affect SLIT adherence. To find a rational basis for a proactive action-plan to support patients' needs and preferences and assess results on SLIT long-term adherence. Patients and methods. Preferences and viewpoint of patients in treatment-related decisions and their health-related needs have been explored by structured, direct interview of 65 adult patient. The activities of the hospital outpatient clinic were rearranged to support needs and requests shared by all patients, and to allow tailored interventions integrating them into routine practice. Adherence to SLIT was studied on a different group of 129 patients aged 14 to 42 years and defined as number of patients who completed three years of therapy. Results. SLIT was completed by 98 patients (76%). Main cause of discontinuation for 31 remaining patients have been pregnancy (16%), change of work residence (19%), side-effects (10%), perceived inefficacy (26%), and non-compliance (29%). Conclusions. To improve adherence, it is necessary to investigate patient-related factors to find a common ground to take actions aimed to remove barriers to long-term SLIT-adherence that virtually can work for all patients, but flexible enough to allow patient-tailored interventions. The substantial differences on disease's perception between patients with only allergic rhinitis and those with asthma entail the necessity of differentiated approaches. Management strategy based on shared decision making followed by proactive and ongoing interventions to support patients' needs and preferences proves effective to ensure a good long-term adherence to SLIT in real-life.

Assessing Patient Preferences for Treatment Options for Pediatric Sickle Cell Disease: A Critical Review of Quantitative and Qualitative Studies

Sickle cell disease (SCD) resulting from a mutation of the β-globin gene results in sickle deformation of the red blood cell with consequent vaso-occlusion and intravascular hemolysis. SCD results in substantial morbidity, with impaired quality of life and premature mortality. Comprehensive and supportive care, disease modifying therapies and treatments with curative intent are each associated with asymmetrical costs, burden of care, and impact on survival and quality of life. There is thus a considerable decisional dilemma regarding treatment among patients and caregivers. The objective of this review is to evaluate the literature regarding quantitative and qualitative studies of patient preferences in therapy for SCD. Numerous survey-based studies have been performed evaluating SCD patients' treatment preferences. These studies are limited, however, as they are purely descriptive in nature with limited quantitative information on the relative value of treatment alternatives. Time trade-off and standard gamble studies and health state utility studies have also been utilized to quantify patient utility especially for curative hematopoietic cell transplant. However, these studies suffer from inaccurate assumptions regarding patient preferences. Qualitative studies have garnered the patient and caregiver perspective. Qualitative studies may be limited by selective and purposive sampling, and lack of representativeness due to sample size.

"Let's Get the Consent Together": Rethinking How Surgeons Become Competent to Discuss Informed Consent

OBJECTIVE

Eliciting informed consent is a clinical skill that many residents are tasked to conduct without sufficient training and before they are competent to do so. Even senior residents and often attending physicians fall short of following best practices when conducting consent conversations.

DESIGN

This is a perspective on strategies to improve how residents learn to collect informed consent based on current literature.

CONCLUSIONS

We advocate that surgical educators approach teaching informed consent with a similar framework as is used for other surgical skills. Informed consent should be defined as a core clinical skill for which attendings themselves should be sufficiently competent and residents should be assessed through direct observation prior to entrustment.

Shared Decision-making in Urologic Practice: Results From the 2019 AUA Census

OBJECTIVE

To establish the rates of self-reported shared decision-making (SDM) and decision aid use among practicing urologists. Additionally, we aim to determine the practice factors that influence SDM use.

MATERIALS AND METHODS

This study uses data from the 2019 American Urological Association Annual Census SDM module. Urologists were presented with a rubric of 7 preference sensitive clinical situations and asked to choose the elements of SDM that they regularly use for the diagnosis. Multivariable logistic regression models were fit to evaluate factors contributing to the use of SDM.

RESULTS

Two thousand two hundred and nineteen urologists responded. Of these, 77% reported that they regularly use SDM in at least 1 preference sensitive clinical scenario. Between 40% and 58% regularly gave patients decision aids. Urologists who reported barriers to SDM had a decreased odds of reporting SDM (adjusted odds ratio OR [aOR] 0.80 [95% confidence interval [CI] 0.71-0.91]). Those practicing in academic settings (aOR 0.78 [95% CI 0.69-0.88]) were less likely than those in private practice to report SDM use. The number of patient visits per week was inversely associated with SDM use, with greater than 76 visits per week having decreased odds (aOR 0.65 [95% CI 0.57-0.74]).

CONCLUSION

In this sample of practicing urologists in the United States, the majority report regularly using SDM. However, rates of SDM varied by training, practice setting and clinical volume. Our findings highlight specific opportunities to improve in SDM in urology.

The value of values: shared decision-making in person-centered, value-based oral health care

In order to provide care that is truly person-centered, dental practitioners must incorporate the informed preferences of our patients into clinical treatment decisions. Shared decision making provides the necessary framework to accomplish this goal, especially in an era of value-based care.

Clinician and Patient Factors Influencing Treatment Decisions: Ethnographic Study of Antibiotic Prescribing and Operative Procedures in Out-of-Hours and General Dental Practices

Operative treatment is indicated for most toothache/dental abscesses, yet antibiotics instead of procedures are often prescribed. This ethnographic study aimed to identify clinician and patient factors influencing urgent dental care for adults during actual appointments; and to identify elements sensitive to context. Appointments were observed in out-of-hours and general dental practices. Follow-up interviews took place with dentists, dental nurses, and patients. Dentist and patient factors were identified through thematic analysis of observation records and appointment/interview transcripts. Dentist factors were based on a published list of factors influencing antibiotic prescribing for adults with acute conditions across primary health care and presented within the Capability-Opportunity-Motivation-Behaviour model. Contextually sensitive elements were revealed by comparing the factors between settings. In total, thirty-one dentist factors and nineteen patient factors were identified. Beliefs about antibiotics, goals for the appointment and access to dental services were important for both dentists and patients. Dentist factors included beliefs about the lifetime impact of urgent dental procedures on patients. Patient factors included their communication and negotiation skills. Contextual elements included dentists’ concerns about inflicting pain on regular patients in general dental practice; and patients’ difficulties accessing care to complete temporary treatment provided out of hours. This improved understanding of factors influencing shared decisions about treatments presents significant opportunity for new, evidence-based, contextually sensitive antibiotic stewardship interventions.

Understanding shared decision-making experience among vulnerable population: Focus group with food bank clients

Introduction

Shared decision-making (SDM) is a critical component of delivering patient-centered care. Members of vulnerable populations may play a passive role in clinical decision-making; therefore, understanding their prior decision-making experiences is a key step to engaging them in SDM.

Objective

To understand the previous healthcare experiences and current expectations of vulnerable populations on clinical decision-making regarding therapeutic options.

Methods

Clients of a local food bank were recruited to participate in focus groups. Participants were asked to share prior health decision experiences, explain difficulties they faced when making a therapeutic decision, describe features of previous satisfactory decision-making processes, share factors under consideration when choosing between treatment options, and suggest tools that would help them to communicate with healthcare providers. We used the inductive content analysis to interpret data gathered from the focus groups.

Results

Twenty-six food bank clients participated in four focus groups. All participants lived in areas of socioeconomic disadvantage. Four themes emerged: prior negative clinical decision-making experience with providers, patients preparing to engage in SDM, challenges encountered during the decision-making process, and patients' expectations of decision aids. Participants also reported they were unable to discuss therapeutic options at the time of decision-making. They also expressed financial concerns and the need for sufficiently detailed information to evaluate risks.

Conclusion

Our findings suggest the necessity of developing decision aids that would improve the engagement of vulnerable populations in the SDM process, including consideration of affordability, use of patient-friendly language, and incorporation of drug-drug and drug-food interactions information.

Shared governance: a children's hospital journey to clinical nursing excellence

BACKGROUND

Shared governance is examined through a framework for developing independent decision making in professional nursing practice and improving patient care outcomes.

AIMS

This study is designed to obtain a baseline measurement of the degree of shared governance in a selected children's hospital in Saudi Arabia.

METHODS

The study was guided by the Donabedian model. The Professional Nursing Governance Index was used. A total of 400 questionnaires were distributed to nurses working at the hospital, with a response rate of 77% (n = 307). Descriptive and inferential statistics were used for analysis.

RESULTS

The results corresponded with those from nurses and managers in most subscales of the Index of Professional Nursing Governance (information, goals, resources, participation and practice). However, nurses working in the operating theatre and surgical unit have a perceived higher level of shared governance than those in critical care units and medical wards.

CONCLUSIONS

The results could encourage shareholders and leaders in the nursing field to develop the perception of shared governance by adopting a shared governance model, which in turn might improve the quality of nursing care.

Turn analysis and patient-centredness in paediatric otolaryngology surgical consultations

OBJECTIVES

Physician and patient/parent communication is of utmost importance in consultations to improve the shared decision-making (SDM) processes. This study investigated SDM-related outcomes through turn analysis and an assessment of patient-centred dialogue.

DESIGN

Multi-centre prospective cohort study analysing audio- and video-recorded patient/parent-physician interactions.

SETTING

Two tertiary paediatric hospitals in Halifax, Nova Scotia and Salt Lake City, Utah.

PARTICIPANTS

Paediatric otolaryngologists, patients and parents during consultation for adenotonsillectomy.

MAIN OUTCOME MEASURES

Medical dialogue measures (turn analysis, patient-centredness scores via the Roter Interaction Analysis System) and SDM questionnaires (SDM-Q-9).

RESULTS

Turn density was significantly higher for physicians than patients/parents (P < .001), as were total statements (P < .001), and total time talking (P < .001). The opening statement was completed by the physician in 91.5% of interactions and was significantly longer than family opening statements (P = .003). The mean number of informed consent elements addressed per interaction was 4.5 out of 6. The mean patient-centredness score was 0.2 (range 0-0.56). Significant negative correlations between patient-centredness score and physician turn density (r = -.390, P = .002), physician mean turn time (r = -.406, P = .001), total physician statements (r = -.426, P = .001) and total physician speaking time (r = -.313, P = .016) were noted. There were no correlations in SDM questionnaire scores with turn analysis variables, informed consent elements or patient-centredness scores.

CONCLUSIONS

Surgeons dominated the consultation in terms of talking, mostly in a unidirectional manner. Neither patient-centredness nor turn analysis correlated with perceptions of SDM from the parents' perspective.

Survival, Outcomes, and Use of Acuity Scoring Systems Following Tracheotomy in Veteran Patients

OBJECTIVES

To determine whether established prognosis tools used in the general population of critically ill patients will accurately predict tracheotomy-related outcomes and survival outcomes in critically ill patients undergoing tracheotomy.

METHODS

Retrospective chart review of 94 consecutive critically ill patients undergoing isolated tracheotomy.

RESULTS

Logistic Organ Dysfunction System (LODS) and sepsis-related organ failure assessment (SOFA) scores, 2 validated measures of acuity in critically ill patients, were calculated for all patients. The only tracheotomy-related outcome of significance was the finding that patients with an LODS score ≤6 were more likely to become ventilator independent (P < .015). Higher LODS or SOFA scores were associated with in-house death (LODS, P = .001, SOFA, P = .008) and death within 90 days (LODS, P = .009, SOFA, P = .031), while death within 180 days was associated only with a higher LODS score (LODS, P = .018). When controlling for age, there was an association between both LODS (P = .015) and SOFA (P = .019) scores and death within 90 days of tracheotomy.

CONCLUSIONS

The survival outcome for critically ill patients undergoing tracheotomy seems accurately predicted based on scoring systems designed for use in the general population of critically ill patients. Logistic Organ Dysfunction System may also be useful to predict the likelihood of the tracheotomy-related outcome of ventilator independence. This suggests that LODS scores may be helpful to palliative care clinicians as part of a shared decision-making aid in critically ill, ventilated patients for whom tracheotomy is being considered.