Patient and clinician priorities for information on treatment outcomes for advanced ovarian cancer: a Delphi exercise

OBJECTIVE

Patients with advanced ovarian cancer face a range of treatment options, and there is unwarranted variation in treatment decision-making between UK providers. Decision support tools that produce data on treatment outcomes as a function of individual patient characteristics, would help both patients and clinicians to make informed, preference- and values-based choices. However, data on treatment outcomes to include in such tools are lacking.

METHODS

Following a literature review, a questionnaire was designed for use in a Delphi process to establish which treatment outcomes are important to both patients and clinicians in decision-making for treatment for advanced ovarian cancer. Patient and clinician panels were established.

RESULTS

Following 2 Delphi rounds, consensus was achieved for 7/11 items in the patient panel and 8/11 items in the clinician panel. Consensus across both panels was achieved for inclusion of both overall survival and progression free survival as important items in the decision-making process, although there remained differences of opinion as to whether these should be presented as relative or absolute values.

CONCLUSION

Information needs for treatment decision-making in ovarian cancer differ between and within patient and clinician groups. Whilst overall survival and progression free survival are universally accepted as important data items, decision support tools will need to be nuanced to allow presentation of a range of outcomes and associated probabilities, and in a range of formats, that can be tailored to the preferences of clinician and patients.

Patient experiences of undergoing abortion with and without an ultrasound scan in Britain

BACKGROUND

Routine ultrasound scanning to determine gestational age and pregnancy location has long been part of pre-abortion assessment in Britain, despite not being legally required or recommended in national clinical guidelines. To support implementation of fully telemedical abortion care (implemented in Britain in April 2020), the Royal College of Obstetricians and Gynaecologists (RCOG) issued clinical guidance for an 'as-indicated' approach to pre-abortion ultrasound, removing the need for a clinic visit. We aimed to understand patient experiences of ultrasound in abortion care by conducting a qualitative study with individuals who had abortions with and without an ultrasound scan.

METHODS

Between November 2021 and July 2022, we recruited patients who had a medical abortion at home without a pre-procedure ultrasound at 69 days' gestation or less at British Pregnancy Advisory Service (BPAS), and also had at least one other abortion with an ultrasound from any provider in Britain. We conducted interviews using a semi-structured interview guide to explore our participants' experiences and conducted reflexive thematic analysis.

RESULTS

We recruited 24 participants and included 19 interviews in our analysis. We developed three themes from our data. These were 'Ultrasound scans and their relationship with autonomy and decision-making', 'Intrusive and out of place: the ultrasound as an inappropriate technology' and 'Towards preference-centred, quality care'.

CONCLUSIONS

Further research and user-testing of strategies to improve the scan experience should be undertaken. Patient testimonies on the negative impact of ultrasound scans in abortion care should reassure providers that omitting them according to patient preference is a positive step towards providing patient-centred care.

Mixed methods study of attitudes on location of gynaecological oncology outpatient care: a patient and healthcare professional questionnaire

OBJECTIVE

Gynaecological oncology place of care is often based on evolution of services, along historical professional boundaries, rather than user needs or preferences. We aimed to assess existing evidence, gather views of patients in the UK on their preferred place of outpatient care for gynaecological malignancies and evaluate alignment with preferences of healthcare professionals (HCP).

METHODS

We performed a mixed methods study, including a scoping review, a patient survey and a healthcare practitioner questionnaire. We collected quantitative and qualitative data, performing content analysis to determine current practice and impact on patients.

RESULTS

No studies were identified in our scoping review. We received responses from 159 patients and 54 gynaecological oncology HCPs. There was a strong preference for a dedicated gynaecological oncology setting (89% somewhat or very happy) (p<0.0001). Fifty-three percent of patients were somewhat or very unhappy to have care colocated with general obstetrics and gynaecology services. Specifically, two key themes were identified through content analysis of qualitative data from patients: 'environment and getting this right is vital'; and 'our cancer should be the priority'. HCPs underestimated the strong patient preference to be seen in dedicated units. Of those who see patients within general obstetrics and gynaecology, only 50% said patients were seen at separate times/locations from obstetric patients.

CONCLUSION

This study demonstrates the significant impact of place of care on gynaecological oncology patients, which may be underestimated by HCPs.

Patterns in the provision of government-subsidised hormonal postpartum contraception in Queensland, Australia between 2012 and 2018: a population-based cohort study

BACKGROUND

Short birth intervals and unintended pregnancy are associated with poorer maternal and infant outcomes. There is a risk of pregnancy during the immediate postpartum period unless contraception is initiated. This retrospective cohort study aimed to capture the current patterns of hormonal contraceptive provision within 12 months postpartum in a high-income country.

METHODS

We used a linked administrative dataset comprising all women who gave birth in Queensland, Australia between 1 July 2012 and 30 June 2018 (n=339 265 pregnancies). We described our cohort by whether they were provided with government-subsidised hormonal contraception within 12 months postpartum. The associations between hormonal postpartum contraceptive provision and demographic and clinical characteristics were examined using univariate and multivariate logistic regression and presented in terms of crude and adjusted odds ratios with 95% confidence intervals.

RESULTS

A majority of women (60.2%) were not provided with government-subsidised hormonal postpartum contraception within 12 months postpartum. Women who were younger (<25 years), were overweight or obese, smoked, were born in Australia, were non-Indigenous, gave birth in a public hospital, or were in the lowest socioeconomic status group were more likely to be provided with postpartum contraception after adjusting for other covariates, compared with their counterparts.

CONCLUSIONS

Strategies to increase the provision and uptake of contraception in the immediate postpartum period are needed to prevent short birth intervals and unintended pregnancy and ensure women's fertility intentions are enacted. Ongoing research is needed to examine the factors influencing women's access to contraceptive services and, further, the types of contraception provided.

Optimizing the Management Algorithm for Heartburn in General Gastroenterology: Cost-Effectiveness and Cost-Minimization Analysis

BACKGROUND AND AIMS

Heartburn is the most common symptom seen in gastroenterology practice. We aimed to optimize cost-effective evaluation and management of heartburn.

METHODS

We developed a decision analytic model from insurer and patient perspectives comparing 4 strategies for patients failing empiric proton pump inhibitors (PPIs): (1) PPI optimization without testing, (2) endoscopy with PPI optimization for all patients, (3) endoscopy with PPI discontinuation when erosive findings are absent, and (4) endoscopy/ambulatory reflux monitoring with PPI discontinuation as appropriate for phenotypic management. Health outcomes were respectively defined on systematic reviews of clinical trials. Cost outcomes were defined on Centers for Medicare and Medicaid Services databases and commercial multipliers for direct healthcare costs, and national observational studies evaluating healthcare utilization. The time horizon was 1 year. All testing was performed off PPI.

RESULTS

PPI optimization without testing cost $3784/y to insurers and $3128 to patients due to lower work productivity and suboptimal symptom relief. Endoscopy with PPI optimization lowered insurer costs by $1020/y and added 11 healthy days/y by identifying erosive reflux disease. Endoscopy with PPI discontinuation added 11 additional healthy days/y by identifying patients without erosive reflux disease that did not need PPI. By optimizing phenotype-guided treatment, endoscopy/ambulatory reflux monitoring with a trial of PPI discontinuation was the most effective of all strategies (gaining 22 healthy days/y) and saved $2183 to insurers and $2396 to patients.

CONCLUSIONS

Among patients with heartburn, endoscopy with ambulatory reflux monitoring (off PPI) optimizes cost-effective management by matching treatment to phenotype. When erosive findings are absent, trialing PPI discontinuation is more cost-effective than optimizing PPI.

Patient perceptions and experiences with medication-related activities in the emergency department: a qualitative study

BACKGROUND

Emergency department (ED) pharmacists reduce medication errors and improve quality of medication use. Patient perceptions and experiences with ED pharmacists have not been studied. The aim of this study was to explore patients' perceptions of and experiences with medication-related activities in the ED, with and without an ED pharmacist present.

METHODS

We conducted 24 semistructured individual interviews with patients admitted to one ED in Norway, 12 before and 12 during an intervention, where pharmacists performed medication-related tasks close to patients and in collaboration with ED staff. Interviews were transcribed and analysed applying thematic analysis.

RESULTS

From our five developed themes, we identified that: (1) Our informants had low awareness and few expectations of the ED pharmacist, both with and without the pharmacist present. However, they were positive to the ED pharmacist. (2) Our informants expressed a variation of trust in the healthcare system, healthcare professionals and electronic systems, though the majority expressed a high level of trust. They believed that their medication list was automatically updated and assumed to get the correct medication. (3) Some informants felt responsible to have an overview of their medication use, while others expressed low interest in taking responsibility regarding their medication. (4) Some informants did not want involvement from healthcare professionals in medication administration, while others expressed no problems with giving up control. (5) Medication information was important for all informants to feel confident in medication use, but the need for information differed.

CONCLUSION

Despite being positive to pharmacists, it did not seem important to our informants who performed the medication-related tasks, as long as they received the help they needed. The degree of trust, responsibility, control and information varied among ED patients. These dimensions can be applied by healthcare professionals to tailor medication-related activities to patients' individual needs.

Eliciting Low-Risk Thyroid Cancer Treatment Preferences using Clinical Vignettes: A Pilot Study

OBJECTIVE

While surgical resection has been the traditional standard treatment for small (≤1 cm), differentiated thyroid cancers, active surveillance and radiofrequency ablation are increasingly considered. The aim of this study was to explore patient preferences in thyroid cancer treatment using a series of clinical vignettes.

METHODS

Thyroid cancer survivors and general population volunteers were recruited to rank experience-driven clinical vignettes in order of preference. Rankings were compared using Wilcoxon signed rank. Formative qualitative methods were used to develop and refine clinical vignettes that captured four treatments-thyroid lobectomy (TL), total thyroidectomy (TT), active surveillance (AS), and radiofrequency ablation (RFA)-along with six treatment complications. Content was validated via interviews with five academic subspecialists.

RESULTS

Nineteen volunteers participated (10 survivors, 9 general population). Treatment complications were ranked lower than uncomplicated counterparts in 99.0% of cases, indicating excellent comprehension. Counter to our hypothesis, among uncomplicated vignettes, median rankings were 1 for AS, 2 for RFA, 3.5 for TL, and 5 for TT. Trends were consistent between thyroid cancer survivors and the general population. Active surveillance was significantly preferred over RFA (p = 0.02) and TT (p <0.01). Among surgical options, TL was significantly preferred over TT (p <0.01).

CONCLUSION

When treatments for low-risk thyroid cancer are described clearly and accurately through clinical vignettes, patients may be more likely to choose less invasive treatment options over traditional surgical resection.

Analysis of Barriers to Public and Private Cardiac Rehabilitation Programs in Patients with Low and High Adherence

INTRODUCTION

Participants in cardiac rehabilitation programs have low adherence to their sessions, which makes extremely important to recognize the barriers that cause non-adherence, identifying whether the type of service and level of adherence influence these barriers.

METHODS

This is a cross-sectional observational study, in which 220 individuals (66.80±11.59 years) of both genders who are members of public and private exercise-based cardiac rehabilitation programs participated. The volunteers were divided according to the level of adherence, considering patients with low adherence (PLA) those with < 70% of attendance and high adherence (PHA) those with > 70%. Then, initial evaluation, Cardiac Rehabilitation Barriers Scale, analysis of socioeconomic level, Hospital Anxiety and Depression Scale, and Mini-Mental State Examination were applied.

RESULTS

Higher total barriers were found in PLA in the public service compared to PHA in the private service (P=0.023). In the subscale "perceived need", PHA in the public service showed higher values than PLA and PHA in the private service (P≤0.001). The "access" barrier was higher for PHA in the public service when compared to PHA in the private service (P=0.024). PHA in the public service exhibited a higher barrier regarding questions about distance, transportation problems, cost, and time constraints.

CONCLUSION

The public program presents higher barriers in the questions and categories compared to the private program, mainly the PHA. Furthermore, there are differences in the profile of the participants regarding socioeconomic and anxiety levels, treatment time, ethnicity, and city where they live.

Interest in advance provision of abortion pills: a national survey of potential users in the USA

OBJECTIVE

To assess interest in clinician-administered advance provision of abortion pills among potential users in the USA.

METHODS

Using social media advertisements, we recruited people living in the USA who were aged 18-45 years and assigned female at birth, who were not pregnant or planning pregnancy, for an online survey on reproductive health experiences and attitudes. We explored interest in advance provision of abortion pills, participant characteristics, including demographics and pregnancy history, contraceptive use, abortion knowledge and comfort, and healthcare system distrust. We used descriptive statistics to assess interest in advance provision, and ordinal regression modelling to evaluate differences in interest controlling for age, pregnancy history, contraceptive use, familiarity and comfort with medication abortion, and healthcare system distrust, reporting adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs).

RESULTS

From January-February 2022, we recruited 634 diverse respondents from 48 states, among whom 65% were interested, 12% neutral, and 23% disinterested in advance provision. There were no differences among interest groups by US region, race/ethnicity, or income. In the model, variables associated with interest included being aged 18-24 years (aOR 1.9, 95% CI 1.0 to 3.4) versus 35-45 years, using a tier 1 (permanent or long-acting reversible) or tier 2 (short-acting hormonal) contraceptive method (aOR 2.3, 95% CI 1.2 to 4.1, and aOR 2.2, 95% CI 1.2 to 3.9, respectively) versus no contraception, being familiar or comfortable with the medication abortion process (aOR 4.2, 95% CI 2.8 to 6.2, and aOR 17.1, 95% CI 10.0 to 29.0, respectively), and having high healthcare system distrust (aOR 2.2, 95% CI 1.0 to 4.4) versus low distrust.

CONCLUSION

As abortion access becomes more constrained, strategies are needed to ensure timely access. Advance provision is of interest to the majority of those surveyed and warrants further policy and logistical exploration.

Exploring Patients' Needs and Desires for Quality Prenatal Care in Florida, United States

Background and Objective

High-quality prenatal care promotes adequate care throughout pregnancy by increasing patients' desires to return for follow-up visits. Almost 15% of women in the United States receive inadequate prenatal care, with 6% receiving late or no prenatal care. Only 63% of pregnant women in Florida receive adequate prenatal care, and little is known about their perceptions of high-quality prenatal care. Therefore, the objective of this study was to assess women's perceptions of the quality of their prenatal care and to describe their preferences for seeking prenatal care that meets their needs.

Methods

From April to December 2019, a qualitative study was conducted with postpartum women (n = 55) who received no or late prenatal care and delivered in Tampa, Florida, USA. Eligible women completed an open-ended qualitative survey and a semi-structured in-depth interview. The interview contextualized the factors influencing prenatal care quality perceptions. The qualitative data analysis was based on Donabedian's quality of care model.

Results

The qualitative data analysis revealed three key themes about women's perceptions and preferences for prenatal care that meets their needs. First, clinical care processes included provision of health education and medical assessments. Second, structural conditions included language preferences, clinic availability, and the presence of ancillary staff. Finally, interpersonal communication encompassed interactions with providers and continuity of care. Overall, participants desired patient-centered care and care that was informative, tailored to their needs, and worked within the constraints of their daily lives.

Conclusion and Global Health Implications

Women seeking and receiving prenatal care prefer a welcoming, patient-centered health care environment. These findings should prompt health care providers and organizations to improve existing prenatal care models and develop new prenatal care models that provide early, accessible, and high-quality prenatal care to a diverse population of maternity patients.

Characteristics of patients with advanced cancer preferring not to know prognosis: a multicenter survey study

Background

For some patients with advanced cancer not knowing prognosis is essential. Yet, in an era of informed decision-making, the potential protective function of unawareness is easily overlooked. We aimed to investigate 1) the proportion of advanced cancer patients preferring not to know prognosis; 2) the reasons underlying patients’ prognostic information preference; 3) the characteristics associated with patients’ prognostic information preference; and 4) the concordance between physicians’ perceived and patients’ actual prognostic information preference.

Methods

This is a cross-sectional study with structured surveys (PROSPECT). Medical and thoracic oncologists included patients (n = 524), from seven Dutch hospitals, with metastatic/inoperable cancer and an expected median overall survival of ≤ 12 months. For analysis, descriptive statistics and logistic regression models were used.

Results

Twenty-five to 31% of patients preferred not to know a general life expectancy estimate or the 5/2/1-year mortality risk. Compared to patients preferring to know prognosis, patients preferring unawareness more often reported optimism, avoidance and inability to comprehend information as reasons for wanting limited information; and less often reported expectations of others, anxiety, autonomy and a sense of control as reasons for wanting complete information. Females (p < .05), patients receiving a further line of systemic treatment (p < .01) and patients with strong fighting spirit (p < .001) were more likely to prefer not to know prognosis. Concordance between physicians’ perceived and patients’ actual prognostic information preference was poor (kappa = 0.07).

Conclusions

We encourage physicians to explore patients’ prognostic information preferences and the underlying reasons explicitly, enabling individually tailored communication. Future studies may investigate changes in patients’ prognostic information preferences over time and examine the impact of prognostic disclosure on patients who prefer unawareness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09911-8.

The perspective of Iranian patients with multiple sclerosis on the third dose of COVID-19 vaccine

Background: Now that the majority of the population has been immunized with two-dose vaccines, debates over the third booster dose have been raised. We studied the viewpoint of cases with multiple sclerosis (MS) on this matter. Methods: In a cross-sectional study, a google form containing questions about participants' characteristics, the history of coronavirus disease 2019 (COVID-19) infection and vaccination, and opinions on the third dose was designed. Results: Of 1067 responders, only 16 (1.5%) were not vaccinated at all. The most used vaccine type was Sinopharm BBIBP COVID-19 vaccine (BBIBP-CorV) (n = 1002, 93.9%). Generally, 58 (5.4%) cases were hospitalized due to COVID-19. Of those with full vaccination, 134 (13.3%) got COVID-19 infection after the second dose. Only 13 participants (1%) did not agree with the third dose, while 564 (53.0%) believed that a booster dose was needed. Of all, 488 (45.7%) declared that they did not have a final idea and would follow the instructions by the experts. A significant association was found between not receiving the first two doses and not believing in the third dose (P = 0.001). 692 patients declared their reasoning for the importance of the third dose. All the cases who thought the administered vaccine was not efficient enough had received Sinopharm BBIBP-CorV. Those who got infected after full vaccination were more uncertain about the efficacy of the vaccine [odds ratio (OR): 2.6, 95% confidence interval (CI): 1.6-4.2]. Conclusion: It seems that the majority of the Iranian patients with MS expect the authorities to administer a third booster dose, especially if scientifically validated.

Acceptability of different mechanisms of action of contraception in women: a questionnaire survey

BACKGROUND

The mechanism of action of a contraceptive method is an importantg consideration in a woman's choice of contraception. For the development of new methods of contraception it is important to understand the acceptability of different contraceptive mechanisms within a population.

METHODS

We recruited women attending contraceptive, termination of pregnancy or postnatal care services in Hong Kong for a questionnaire survey on their acceptability of the different ways in which contraceptive methods prevent pregnancy. Univariable and multivariable analyses were used to establish factors which may predict acceptability of the mechanism of action.

RESULTS

A total of 1448 women completed the survey. The acceptability of contraceptive methods that act by preventing fertilisation ranked highest (78%), followed by those that inhibit ovulation (52%), disrupt implantation (43%) and dislodge an implanted embryo (30%). A history of termination of pregnancy was associated with greater acceptance of all posited contraceptive mechanisms. There was a very low degree of agreement between the declared acceptance of the various contraceptive mechanisms and the ever use of a method with the respective mechanism of action (Cohen's kappa coefficient range 0.017-0.162).

CONCLUSIONS

In this population the acceptability of contraceptive methods that act by preventing fertilisation ranked highest, followed by those that inhibit ovulation, disrupt implantation and dislodge an implanted embryo. Women who had ever had a termination of pregnancy were more likely to accept all the posited contraceptive mechanisms.

Patient preferences using telehealth during COVID-19 pandemic in four Victorian tertiary hospital services

INTRODUCTION

To measure patients' evaluation of telehealth, preferences for telehealth versus in-person appointments, and potential cost savings by patient characteristics.

METHODS

A cross-sectional online survey (including patient and appointment characteristics, telehealth evaluation, preferences for care and costs) of adult patients using video telehealth in four metropolitan tertiary hospital services in Melbourne, Victoria.

RESULTS AND DISCUSSIONS

A total of 1045 patients (44 years - IQR 29-59) participated with an overall response rate of 9.2%. For 98.7% patients telehealth was convenient, 96.4% stated that it saved time, 95.9% found telehealth acceptable to receive care and 97.0% found that telehealth improved their access to care. Most (62.6%) preferred in-person consultations, although 86.9% agreed that telehealth was equivalent to an in-person consultation. Those in regional and rural areas were less likely to prefer in-person consultations. Patients attending for medical reasons were less likely to prefer in-person consultation compared to patients with surgical reasons. Patient preference to telehealth were independent of level of education, appointment type, self-rated health status and socio-economic status. Patients saved an average of $120.9 (SD $93.0) per appointment, with greater cost savings for patients from low and middle socioeconomic areas and regional or rural areas. Telehealth video consultations were largely evaluated positively with most patients considering the service to be as good as in-person. Understanding patient preference is critical to consider when implementing telehealth as mainstream across hospital health services. This article is protected by copyright. All rights reserved.

"Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?"

BACKGROUND

The limitations of metoidioplasty and phalloplasty have been reported as deterrents for transgender and other gender expansive individuals (T/GE) desiring gender affirming surgery, and thus penile transplantation, epithesis, and composite tissue engineering (CTE) are being explored as alternative interventions.

AIM

We aim to understand the acceptability of novel techniques and factors that may influence patient preferences in surgery to best treat this diverse population.

METHODS

Descriptions of metoidioplasty, phalloplasty, epithesis, CTE, and penile transplant were delivered via online survey from January 2020 to May 2020. Respondents provided ordinal ranking of interest in each intervention from 1 to 5, with 1 representing greatest personal interest. Demographics found to be significant on univariable analysis underwent multivariable ordinal logistic regression to determine independent predictors of interest.

OUTCOMES

Sexual orientation, gender, and age were independent predictors of interest in interventions.

RESULTS

There were 965 qualifying respondents. Gay respondents were less likely to be interested in epithesis (OR: 2.282; P = .001) compared to other sexual orientations. Straight individuals were the least likely to be interested in metoidioplasty (OR 3.251; P = .001), and most interested in penile transplantation (OR 0.382; P = .005) and phalloplasty (OR 0.288, P < .001) as potential interventions. Gay and queer respondents showed a significant interest in phalloplasty (Gay: OR 0.472; P = .004; Queer: OR 0.594; P = .017). Those who identify as men were more interested in phalloplasty (OR 0.552; P < .001) than those with differing gender identities. Older age was the only variable associated with a decreased interest in phalloplasty (OR 1.033; P = .001). No demographic analyzed was an independent predictor of interest in CTE.

CLINICAL IMPLICATIONS

A thorough understanding of patient gender identity, sexual orientation, and sexual behavior should be obtained during consultation for gender affirming penile reconstruction, as these factors influence patient preferences for surgical interventions.

STRENGTHS AND LIMITATIONS

This study used an anonymous online survey that was distributed through community channels and allowed for the collection of a high quantity of responses throughout the T/GE population that would otherwise be impossible through single-center or in-person means. The community-based methodology minimized barriers to honesty, such as courtesy bias. The survey was only available in English and respondents skewed young and White.

CONCLUSION

Despite previously reported concerns about the limitations of metoidioplasty, participants ranked it highly, along with CTE, in terms of personal interest, with sexual orientation, gender, and age independently influencing patient preferences, emphasizing their relevance in patient-surgeon consultations. A. Parker, G. Blasdel, C. Kloer et al. "Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?". J Sex Med 2022;19:385-393.

How do we and how should we deal with uncertainty in Endodontics?

In many clinical cases a dentist may feel certain when for example diagnosing, deciding on treatment, or assessing the prognosis—in other cases many dentists may feel a degree of doubt or uncertainty. This paper aims to explore the philosophical concept of uncertainty and its different dimensions, using the condition “persistent apical periodontitis associated with a previously root filled tooth” as an example. Acknowledging that uncertainty exists in any clinical situation can be perceived as uncomfortable, as some might regard it as a weakness. Whilst some types of uncertainty met in dental practice can be addressed and reduced, there are other types which are inevitable and must be accepted. To make sound decisions, it is pertinent that the dentist reflects on and values the consequences of uncertainty. In this paper, a conceptual model is presented by which the dentist can identify the type of uncertainty in a clinical case, making it possible to decide on a strategy on how to manage the uncertainty and its possible consequences, with the aim to support the dentist's care for their patients. The understanding that uncertainty exists and the ability to acknowledge and be comfortable with it when making decisions should be addressed throughout our professional career, and thus ought to be developed during undergraduate education. Some suggestions on how teachers could target this are given in the paper.

Preferences based interventions to address the use of antibiotics without prescription: A discrete choice experiment

Background

In many countries, concerns have arisen over the population using antibiotics without consulting a physician. This practice can place patients at risk and increase antibiotic resistance in the community.

Objective

To evaluate individuals' preferences regarding the use of antibiotics. The study also assessed the likely effectiveness of interventions aimed at reducing inappropriate use of antibiotics.

Methods

A discrete choice experiment (DCE) was conducted in Bogotá, Colombia. The attributes were determined by a systematic literature review and four focus group sessions. The DCE included nine factors - cost, time to get attention, level of symptoms, efficacy, safety, among others- and one label -using or not antibiotics. Data analysis was carried out using a generalized multinomial logit (GMNL) model. Marginal probabilities of different sets of attributes' levels were compared to estimate the likely effectiveness of interventions.

Results

The survey was administered to 222 participants from diverse socioeconomic backgrounds. The results suggest that participants preferred not taking antibiotics and having a physician as an advisor, but the probability of inappropriate antibiotic use increased as the waiting time or the cost of receiving advice rose. The pharmacy was the preferred source of antibiotics, and participants chose the pharmacy worker (nonprofessional) as an advisor over the nurse on the phone. In the absence of any interventions aimed at reducing the use of antibiotics, approximately 47.3% of people would misuse antibiotics. This reduces to 26.5% when people perceive the efficacy of the antibiotics as low and the potential risks of self-medicating as high. An alternative model using a nursing service would likely lower inappropriate use of antibiotics.

Conclusions

Even though people prefer not using antibiotics or visiting a physician in case of disease rather than self-medicating, current access conditions might discourage them from appropriately use antibiotics. The results suggest that interventions that informing people about the risks of self-medication and the low efficacy might significantly reduce inappropriate use of antibiotics. Our results also suggest that programs that empower other health professionals to provide access to antibiotics would likely further lower inappropriate use.

Short-Term Concerns Primarily Determine Patient Preference for Abdominal Aortic Aneurysm Repair

INTRODUCTION

Abdominal aortic aneurysm (AAA) repair may be performed through open or endovascular approaches, but the factors influencing a patient's repair-type preference are not well characterized. Here we performed a qualitative analysis to better understand factors influencing patient preference within the Preference for Open Versus Endovascular Repair of AAA Trial.

METHODS

Open-ended responses regarding primary (n = 21) and secondary (n = 47) factors influencing patient preference underwent qualitative analysis using the constant comparative method with iterative reviews. Codes were used to generate themes and themes grouped into categories, with each step conducted via consensus agreement between three researchers. Relative prevalence of themes were compared to ascertain trends in patient preference.

RESULTS

Patient responses regarding both primary and secondary factors fell into four categories: Short-term concerns, long-term concerns, advice & experience, and other. Patients most frequently described short-term concerns (23) as their primary influence, with themes including post-op complications, hospitalization & recovery, and intraoperative concerns. Long-term concerns were more prevalent (20) as secondary factors, which included themes such as survival, and chronic management. The average age of patients voicing only long-term concerns as a primary factor was 11 years younger than those listing only short-term concerns.

CONCLUSION

Short-term concerns relating to the procedure and recovery are more often the primary factor influencing patient preference, while long term concerns play a more secondary role. Long-term concerns are more often a primary factor in younger patients. Vascular surgeons should consider this information in shared decision making to reach an optimal outcome.

Patient Perspectives and Preferences Regarding Gout and Gout Management: Impact on Adherence

BACKGROUND

Patient-centered management is becoming increasingly important in gout, but there are limited studies exploring patients' perspectives and preferences. We aimed to investigate patients' perspectives and preferences regarding gout and gout management, and their impacts on adherence to urate lowering therapy (ULT).

METHODS

A paper-based survey was performed in patients with gout seen at the rheumatology outpatient clinics of 16 tertiary hospitals. The survey included questions regarding demographics, comorbidities, gout attacks, current treatment and adherence, and patients' perspectives and preferences regarding gout and gout management. Multivariate regression analysis was performed to determine the factors associated with ULT adherence.

RESULTS

Of 809 surveyed patients with gout, 755 (94.5%) were using ULT. Among those using ULT, 89.1% had ≥ 80% adherence to ULT. Majority of the patients knew management strategies to some extent (94.8%), perceived gout as a life-long disease (91.2%), and were making efforts toward practicing at least one lifestyle modification (89.2%). Most patients (71.9%) obtained information about gout management during their clinic visits. Approximately half of the patients (53.6%) preferred managing their disease with both ULT and lifestyle modification, 28.4% preferred ULT only, and 17.4% preferred lifestyle modification only. Adherence was better in patients with older age (odds ratio [OR], 1.03), those with better knowledge of gout management strategies (OR, 3.56), and those who had preference for ULT (OR, 2.07).

CONCLUSION

Patients' perspectives and management preferences had high impacts on adherence to ULT in gout. Consideration of patients' perspectives and preferences is important for achieving the desired clinical outcome in gout.

The provision of undergraduate clinical placements in ENT during the coronavirus disease 2019 pandemic - exploring patient perspectives on a variety of approaches

Background

The coronavirus disease 2019 pandemic has greatly disrupted routine ENT services. Subsequently, universities have chosen to either augment or suspend clinical placements.

Objective

This study aimed to elicit patients’ perspectives toward various approaches to clinical placements in ENT during the coronavirus disease 2019 pandemic.

Methods

Cross-sectional questionnaires were given to patients attending the ENT department for routine out-patient care. Responses were measured using a five-point Likert scale. Seventy-nine patients completed the survey.

Results

Ninety-five per cent of respondents felt the coronavirus disease 2019 pandemic had not reduced their comfort in interacting with medical students. Most participants reported being comfortable with students participating directly or remotely in their care, and with students having access to their anonymised data. Twenty-five per cent of participants stated that they are uncomfortable with consultations being recorded and shared for medical education purposes.

Conclusion

A number of approaches to clinical placements remain acceptable to patients. Educational leads should continue to offer placements in ENT that can incorporate direct or remote observation of consultations.

Prioritizing the worries of AML patients: Quantifying patient experience using best-worst scaling

CONTEXT

Although patients with acute myeloid leukemia (AML) experience significant toxicities and poor outcomes, few studies have quantified patients' experience.

METHODS

A community-centered approach was used to develop an AML-specific best-worst scaling (BWS) instrument involving 13 items in four domains (psychological, physical, decision-making, and treatment delivery) to quantify patient worry. A survey of patients and caregivers was conducted using the instrument. Data were analyzed using conditional logistic regression.

RESULTS

The survey was completed by 832 patients and 237 caregivers. Patients were predominantly white (88%), married/partnered (72%), and in remission (95%). The median age was 55 years (range: 19-87). Median time since diagnosis was 8 years (range: 1-40). Patients worried most about "the possibility of dying from AML" (BWS score = 15.5, confidence interval [CI] [14.2-16.7]) and "long-term side effects of treatments" (14.0, CI [12.9-15.2]). Patients found these items more than twice as worrisome as all items within the domains of care delivery and decision-making. Patients were least worried about "communicating openly with doctors" (2.50, CI [1.97-3.04]) and "having access to the best medical care" (3.90, CI [3.28-4.61]). Caregiver reports were highly correlated to patients' (Spearman's ρ = 0.89) though noted significantly more worry about the possibility of dying and spending time in the hospital.

CONCLUSION

This large convenience sample demonstrates that AML patients have two principal worries: dying from their disease and suffering long-term side effects from treatment. To better foster patient-centered care, therapeutic decision-making and drug development should reflect the importance of both potential outcomes. Further work should explore interventions to address these worries.

Educating Patients on Unnecessary Antibiotics: Personalizing Potential Harm Aids Patient Understanding

INTRODUCTION

Antibiotic resistance is a public health emergency fueled by inappropriate antibiotic use. Public education campaigns often focus on global antibiotic resistance or societal harm of antibiotic misuse. There has been little research into what messages have the greatest impact on patient preferences for nonindicated antibiotics in ambulatory clinics.

METHODS

We administered a survey at a primary care clinic in Baltimore, MD. A total of 250 participants rated 18 statements about potential harm from antibiotics on how each statement changed their likelihood to request antibiotics for an upper respiratory tract infection. Statements focused on potential harm either to the individual, to contacts of the individual, to society, and related or not to antibiotic resistance. Initial and final likelihood of requesting antibiotics was measured, and the impact of the statements in each category were compared using general linear models and Wilcoxon rank sum or Kruskal-Wallis tests.

RESULTS

All statements decreased patient likelihood to request antibiotics. Statements about harm to the individual or contacts of the individual decreased participant likelihood to request antibiotics significantly more than statements about societal harm of antibiotic misuse. Statements not discussing antibiotic resistance decreased participant likelihood of requesting antibiotics significantly more than statements discussing antibiotic resistance. Overall likelihood to request antibiotics decreased after the survey by 2.2 points on an 11-point Likert scale (P < .001).

CONCLUSION

When dissuading patients from requesting nonindicated antibiotics, providers and public health campaigns should focus on potential harm of nonindicated antibiotics to the individual rather than societal harm or antibiotic resistance.

Mandatory pharmacist-led education session for patients seeking medical cannabis

Objective:

The primary objectives of this pre-post session study, was to evaluate the impact of a pharmacist-led education session on the perceived benefits and safety of cannabis among patients with chronic pain, as well as determine the influence of pharmacist education on the selection of safer cannabis products and dosage forms for medical use among patients.

Methods:

A retrospective analysis of completed pre-post session questionnaires was conducted among chronic pain patients attending a mandatory education session led by a pharmacist, prior to being authorized cannabis in clinic. All questionnaire data was analyzed using SPSS v. 25. Demographic and sample characteristics were reviewed using univariate analyses. Chi-Square tests were employed to determine if the group-based education significantly affected knowledge, perception of efficacy and safety of cannabis.

Results:

Of the 260 session participants, 203 completed pre-post session questionnaires. After the session, a majority of current cannabis users (33.8%) and cannabis naïve/past users (56.9%) reported they would use a low THC product in the future, and a majority of current users (54.5%) would use a high CBD product in the future. After education, participants were more likely to report cannabis as having the potential for addiction (chi-square =42.6, p <0.0001) and harm (chi-square =34.0, p <0.0001).

Conclusions:

Pharmacist counselling and education has the potential to influence patient selection and use of cannabis, from more harmful to safer products, as well as moderate the potential perceived benefits of use.

Priorities and Preferences of Patients With Head and Neck Cancer for Discussing and Receiving Information About Sexuality and Perception of Self-Report Measures

BACKGROUND

Head and neck cancer and its treatment can cause impairment in survivors' sexuality. Previous studies show a need for education and psychological support.

AIM

To examine patients' priorities and preferences for discussing and receiving information about sexuality and to examine patient perceptions of existing self-report measures used in research.

METHODS

This descriptive, cross-sectional, Web-based study recruited adults with a current or previous diagnosis of head and neck cancer. Participants answered questions about their priority and preference for receiving information about sexuality and reviewed 4 self-report measures commonly used in the research of this population.

RESULTS

More than 80% (n = 61) of participants reported that it was important to receive information about sexual issues. Participants chose "at the time of diagnosis" as the most frequent answer for preferred time to receive this information. Half of the participants (n = 35) indicated that they prefer discussing sexual issues with a health-care provider. The most frequent answer for the method of receiving information was through discussions. Participants endorsed 4 themes not addressed by self-report surveys: (i) elicitation of important information, (ii) symptom burden issues, (iii) psychological issues, and (iv) physical barriers.

CLINICAL IMPLICATIONS

Providers, regardless of specialty, must attempt or facilitate discussions around these issues at various times within the treatment and recovery phases.

STRENGTHS & LIMITATIONS

Although limited by sample representation and cross-sectional design, this study addresses an important patient-centered issue that is a critical aspect of quality of life.

CONCLUSIONS

Patients prefer to discuss sexual issues in person with their health-care providers at the time of diagnosis. Participants reacted positively to the self-report measures, but they felt that important issues faced by patients with head and neck cancer were not fully addressed. Rhoten BA, Davis AJ, Baraff BN, et al. Priorities and Preferences of Patients With Head and Neck Cancer for Discussing and Receiving Information About Sexuality and Perception of Self-Report Measures. J Sex Med 2020;17:1529-1537.

Relational autonomy in end-of-life care ethics: a contextualized approach to real-life complexities

Background

Respect for autonomy is a paramount principle in end-of-life ethics. Nevertheless, empirical studies show that decision-making, exclusively focused on the individual exercise of autonomy fails to align well with patients’ preferences at the end of life. The need for a more contextualized approach that meets real-life complexities experienced in end-of-life practices has been repeatedly advocated. In this regard, the notion of ‘relational autonomy’ may be a suitable alternative approach. Relational autonomy has even been advanced as a foundational notion of palliative care, shared decision-making, and advance-care planning. However, relational autonomy in end-of-life care is far from being clearly conceptualized or practically operationalized.

Main body

Here, we develop a relational account of autonomy in end-of-life care, one based on a dialogue between lived reality and conceptual thinking. We first show that the complexities of autonomy as experienced by patients and caregivers in end-of-life practices are inadequately acknowledged. Second, we critically reflect on how engaging a notion of relational autonomy can be an adequate answer to addressing these complexities. Our proposal brings into dialogue different ethical perspectives and incorporates multidimensional, socially embedded, scalar, and temporal aspects of relational theories of autonomy. We start our reflection with a case in end-of-life care, which we use as an illustration throughout our analysis.

Conclusion

This article develops a relational account of autonomy, which responds to major shortcomings uncovered in the mainstream interpretation of this principle and which can be applied to end-of-life care practices.

Do Patients Want Help Addressing Social Risks?

Evaluations of health care-based screening programs for social risks often report that a relatively small proportion of patients screening positive for social risk factors are interested in receiving assistance from their health care teams to address them. The relatively low number of patients who desire assistance is relevant to the growing number of initiatives in US health care settings designed to collect data on and address patients' social risks. We highlight multiple studies that have found differences between positive risks screens and desire for assistance. We explore possible explanations for those differences-focusing on the fallibility of screening tools as well as patient preferences, priorities, and lived experiences-and the potential implications for health equity.

National Survey of Decision-Making for Antidepressants and Educational Level

BACKGROUND

Despite recommendations to screen adults for depression in primary care, little is known about how people across education levels decide to treat their depression and factors that influence their decision.

METHODS

We conducted a secondary analysis of a national, probability-based web survey in English-speaking adults aged 40 or older living in the United States who reported they discussed starting or continuing an antidepressant with their clinician in the past 2 years. Respondents answered questions about knowledge, decision-making process, and demographics. Education level was analyzed using 5 ordered categories. The Shared Decision Making (SDM) Process score was used to assess patient involvement. Descriptive statistics, χ² tests, analysis of variance, and regression models were used to describe the data and test associations.

RESULTS

Of the 5682 people invited, 3396 answered questions about health decisions (59.8% response rate) and 385 reported discussing antidepressants. The mean percentage of knowledge questions answered correctly increased as education level increased (P = .008). The mean SDM Process score also increased with education (P = .001). There was an association between education and who made the treatment decision, suggesting that for respondents with less education, the clinician was more likely to decide (P = .001). Respondents with less education were less likely to report they would definitely make the same decision again (P = .000).

CONCLUSIONS

Those with less education were even less informed, had lower SDM Process scores and were less likely to think they made the right decision about antidepressants. There is a need to ensure patients are better informed about and involved in treatment for depression.

Selection and Receipt of Kidney Replacement in Critically Ill Older Patients with AKI

BACKGROUND AND OBJECTIVES

Older patients in the intensive care unit are at greater risk of AKI; however, use of kidney replacement therapy in this population is poorly characterized. We describe the triggers and outcomes associated with kidney replacement therapy in older patients with AKI in the intensive care unit.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Our study was a prospective cohort study in 16 Canadian hospitals from September 2013 to November 2015. Patients were ≥65 years old, were critically ill, and had severe AKI; exclusion criteria were urgent kidney replacement therapy for a toxin and ESKD. We recorded triggers for kidney replacement therapy (primary exposure), reasons for not receiving kidney replacement therapy, 90-day mortality (primary outcome), and kidney recovery.

RESULTS

Of 499 patients, mean (SD) age was 75 (7) years old, Charlson comorbidity score was 3.0 (2.3), and median (interquartile range) Clinical Frailty Scale score was 4 (3-5). Most were receiving mechanical ventilation (64%; n=319) and vasoactive support (63%; n=314). Clinicians were willing to offer kidney replacement therapy to 361 (72%) patients, and 229 (46%) received kidney replacement therapy. Main triggers for kidney replacement therapy were oligoanuria, fluid overload, and acidemia, whereas main reasons for not receiving therapy were anticipated recovery (67%; n=181) and therapy not consistent with patient preferences for care (24%; n=66). Ninety-day mortality was similar in patients who did and did not receive kidney replacement therapy (50% versus 51%; adjusted hazard ratio, 0.78; 95% confidence interval, 0.58 to 1.06); however, decisions to offer kidney replacement therapy varied significantly by patient mix, acuity, and perceived benefit. There were no differences in health-related quality of life or rehospitalization among survivors.

CONCLUSIONS

Most older, critically ill patients with severe AKI were perceived as candidates for kidney replacement therapy, and approximately one half received therapy. Both willingness to offer kidney replacement therapy and reasons for not starting showed heterogeneity due to a range in patient-specific factors and clinician perceptions of benefit.

Improving the Adoption of Advance Directives in Primary Care Practices

BACKGROUND

Oklahoma's Advance Directive completion rate is less than 10%. We compared the implementation performance of 2 advance directive forms to determine which form could be more successfully disseminated.

METHODS

The implementation of the Oklahoma Advance Directive (OKAD) and the Five Wishes form were compared in an 8-month pair-matched cluster randomized study in 6 primary care practices. The outcomes measured during the 22-week implementation included form offering rate, acceptance/completion rate by patients, and documentation in the chart. Twenty semistructured interviews with patients and clinicians were conducted to assess intervention experience.

RESULTS

A total of 2748 patient encounters were evaluated. OKAD was offered in 33% of eligible patient visits (493/1494) and accepted 54% of the time (266/493). Five Wishes was offered in 36% of eligible patient visits (450/1254) and accepted 82% of the time (369/450). Unadjusted analyses found no significant difference in offering of advance directive forms between groups. However, the odds of accepting Five Wishes were 3.89 times that of OKAD (95% CI, 2.88 to 5.24; P < .0001). Logistic regression models controlling for several confounders indicated that the acceptance of Five Wishes was favored significantly over OKAD (OR = 1.52; 95% CI, 1.27 to 1.81; P < .0001). Qualitative analyses indicated a clear clinician and patient preference for Five Wishes.

CONCLUSIONS

Results suggest that Five Wishes was more readable, understandable, appealing, and usable. It seemed to capture patient preferences for end-of-life care more effectively and it more readily facilitated patient-clinician conversations.

Swedish patients' trust in the bioequivalence of interchangeable generics. What factors are important for low trust?

Background:

Generic substitution (GS), is a cost-containment strategy meant to contain pharmaceutical expenditure without compromising health objectives. In order to shape GS into a policy that is both efficient and safe it is crucial to understand which factors are most important for patients’ trust in GS.

Objective:

To assess Swedish patients’ level of trust in the bioequivalence of cheap and expensive generic medicines, and the association between trust and various factors.

Methods:

A cross-sectional study was conducted. Questionnaires were handed out at 12 community pharmacies in Sweden, selected through stratified sampling, between March and April 2015. The questionnaire included seven socio-demographic questions in addition to 18 items divided into three sections: the ‘views on generic medicine’-scale, information on and prior experiences of GS, financial aspects and change of color/name. Odds Ratios (ORs) were estimated applying adjusted logistic regression analyses with trust in the bioequivalence of generic medicines used as outcome variable and various factors as predictors.

Results:

A total of 719 patients participated (response rate 85.7%). The results show that 70.7% of the respondents’ trust that cheap and expensive interchangeable generic medicines are equal. Of the respondents 36.0% considered the change in appearance and 40.8% the change in names to complicate adherence. Lower trust in the bioequivalence of generic medicines were associated with being female (aOR=1.82, 95%CI 1.20:2.75, p<0.01), patients perceiving that changes in product name and appearance make adherence more complicated (aOR=2.18, 95%CI 1.48:3.19, p<0.001), disagreeing in that GS saves money for me (the customer) (aOR=2.68, 95%CI 1.58:4.55, p<0.001) or that GS saves money for society (aOR=3.21, 95%CI 1.46:7.08, p<0.01).

Conclusions:

Seven out of ten respondents had trust in the bioequivalence of generic medicines, and one in three considered GS to complicate adherence. Four factors were associated with lower trust in GS, i.e. female gender, agreeing that changes in product name and appearance complicates adherence, disagreeing in that GS saves money for me or disagreeing in that GS saves money for the society. Low trust in GS needs to be addressed, not least in the communication between health professionals and patients.

Medication Adherence Improvement Similar for Shared Decision-Making Preference or Longer Patient-Provider Relationship

BACKGROUND

While increasing evidence supports the beneficial effects of shared decision making (SDM) on patient outcomes, the mechanisms underlying this relationship is unclear. This study evaluated length of the patient-provider relationship as one potential factor that may explain how SDM affects medication adherence in patients with hypertension.

METHODS

An observational study of 75 hypertensive patients and 27 providers in 3 primary care practices in New York City. A single-item measure assessed patients' preferences for decision-making style at baseline; medication adherence was collected over the 3-month study with an electronic monitoring device. Length of the relationship was measured as the number of years with the provider, and dichotomized as less than or greater than 1 year with the provider. Two generalized linear mixed models were conducted to determine whether the SDM-adherence association was modified by length of the relationship.

RESULTS

Most patients were Black and women, and 64% were seeing the same provider >1 year. Providers were mostly White women and have been at the clinic for 6 years. In the main-effects model, patients were more likely to exhibit better adherence when they preferred shared and active decision-making styles as compared with those who preferred a passive style (B = 15.87 [Standard Error [SE]: 6.62], P = .02; and B = 22.58 [SE:7.62], P = .004, respectively). In Model 2, the relative importance of SDM on adherence decreased as years with the provider increased (t₍₄₈₎ = 2.13; P = .04).

CONCLUSION

The benefits of SDM over passive decision making on medication adherence were reduced with increasing years of the patient-provider relationship. Having an established relationship with the provider may have a positive impact on medication adherence that is comparable to relationships high in SDM.

Atrial fibrillation patient preferences for oral anticoagulation and stroke knowledge: Results of a conjoint analysis

Background

Guidelines recommend that patients with atrial fibrillation (AF) are involved in oral anticoagulant (OAC) treatment decisions. Understanding which OAC attributes AF patients value most could help optimize treatment.

Objective

To assess the relationship between patient's stroke knowledge and their preferences for specific OAC attributes.

Methods

A cross‐sectional online survey was conducted in patients with nonvalvular AF taking an OAC for stroke prevention in the United States, Canada, Germany, France, and Japan. Patients were asked about their stroke knowledge, perception of the seriousness of AF and concern about stroke, and to rank 7 OAC attributes in order of importance. A conjoint analysis was performed to determine the inherent value of 4 attributes.

Results

In total, 937 patients (mean age [standard deviation] 54.3 [16.6] years; 37.1% female) participated. Of these, 19.5%, 27.9%, and 29.8% had good, moderate, and low stroke knowledge, respectively; 22.8% had no stroke knowledge. Overall, 39.4% of patients (47.5% with good stroke knowledge) perceived AF as very/extremely serious. The OAC attribute ranked as most important was stroke prevention followed by major bleeding risk, other side effects, dosing frequency, antidote availability, dietary restrictions, and use with/without food. In the conjoint analysis, stroke risk reduction was the most valued property, followed by reduction in major bleeding risk, less frequent administration, and administration with/without food. Preferences did not differ with level of stroke knowledge, perception of seriousness of AF, concern of stroke, or medication burden.

Conclusions

Most AF patients consider efficacy and safety to be the most important OAC attributes, whereas dosing frequency was deemed as less important.

Association Among Opioid Use, Treatment Preferences, and Perceptions of Physician Treatment Recommendations in Patients With Neck and Back Pain

OBJECTIVE

The purpose of this study was to explore the relationship between self-reported use of opioids by patients with neck and back pain and their demographics, pain characteristics, treatment preferences, and recollections of their physicians' opinions regarding treatment options.

METHODS

We analyzed 2017 Gallup Poll survey data from 1680 US adults who had substantial spine pain in the past year and used logistic regression to explore the aforementioned relationships.

RESULTS

Our multiple regression analysis indicated that adults with neck or back pain severe enough to have sought health care within the last year were more likely to have used opioids in the last year if they (in descending order of marginal impact) had pain that had lasted 1 year or less (adjusted odds ratio [OR] = 34.35, 90% confidence interval [CI] 17.56-74.32); concurrently used benzodiazepines (OR = 6.02, 90% CI 2.95-12.33); had Medicaid as an insurance source (OR = 3.29, 90% CI 1.40-7.48); indicated that they preferred to use pain medications prescribed by a doctor to treat physical pain (OR = 3.24, 90% CI 1.88-5.60); or were not college educated (OR = 1.83, 90% CI 1.05-3.25). Compared with patients aged 65 years and older, those aged 18 to 34 years were less likely to have used opioids in the past year (OR = 0.09, 90% CI 0.01-0.40, 0.50 for 95% CI). Respondents' perceptions of medical doctors' positive or negative opinions regarding a variety of neck and back pain treatment options were not significantly associated with opioid use.

CONCLUSIONS

Patients with neck and back pain who use opioids differ from those who do not use opioids in that they are more likely to have pain that is of shorter duration, to use benzodiazepines, to have Medicaid as an insurance source, and to prefer to use pain medications. Those characteristics should be considered when developing opioid use prevention strategies.

The value of orthodontics: Do parents' willingness to pay values reflect the IOTN?

Introduction

Given the limited evidence about the benefits of orthodontic treatment, many health care systems have rationed access to orthodontic care with the Index of Orthodontic Treatment Need (IOTN) being one tool used to attempt to allocate resources based on need. However, it is not clear whether patient and public valuations of different levels of need (as described by the IOTN) reflect the resource allocation decisions. The aim of this project was therefore to determine the values parents placed on correction of malocclusions at different IOTN levels using the willingness to pay (WTP) technique.

Method

401 parents of children attending hospital-based orthodontic clinics in the North of England were recruited to complete a questionnaire eliciting WTP for the correction of seven malocclusions with different IOTN scores. In addition demographic and orthodontic history characteristics were collected. Results were analysed with appropriate pairwise significance tests and regression.

Results

A significant difference in WTP was noted between all the possible pairs of malocclusions with the exception of overjets with moderate versus great need of treatments. At moderate levels, correction of crowding was valued less than overjet but this was reversed at great need levels. Very little of the variance in WTP was explained by the variables collected. When looking at factors affecting percentage difference between values for different pairs of malocclusions, in general, no factors predicted the magnitude of difference.

Conclusion

Median valuations for correction of malocclusions vary significantly for different levels of need (as judged by IOTN), with increasing levels of need generating higher values. However, there was a limited effect of demographic or orthodontic characteristics on the magnitude of percentage difference in values for correcting malocclusions different levels of need.

Predicting Future Elective Colon Resection for Diverticulitis Using Patterns of Health Care Utilization

Background

Recurrent diverticulitis is the most common reason for elective colon surgery and, although professional societies now recommend against early resection, its use continues to rise. Shared decision making decreases use of low-value surgery but identifying which patients are most likely to elect surgery has proven difficult. We hypothesized that Machine Learning algorithms using health care utilization (HCU) data can predict future clinical events including early resection for diverticulitis.

Study Design

We developed models for predicting future surgery among patients with new diagnoses of diverticulitis (2009-2012) from the MarketScan® database. Claims data (diagnosis, procedural, and drug codes) were used to train three Machine Learning algorithms to predict surgery occurring between 52 and 104 weeks following diagnosis.

Results

Of 82,231 patients with incident diverticulitis (age 51 ± 8 years, 52% female), 1.2% went on to elective colon resection. Using maximal training data (152 consecutive weeks of claims), the Gradient Boosting Machine model predicted elective surgery with an area under the curve (AUC) of 75% (95% uncertainty interval [UI] 71-79%). Models trained on less data resulted in less accurate prediction (AUC: 68% [64-74%] using 128 weeks, 57% [53-63%] using 104 weeks). The majority of resections (85%) were identified as low-value.

Conclusion

By applying Machine Learning to HCU data from the time around a diagnosis of diverticulitis, we predicted elective surgery weeks to months in advance, with moderate accuracy. Identifying patients who are most likely to elect surgery for diverticulitis provides an opportunity for effective shared decision making initiatives aimed at reducing the use of costly low-value care.

A Discrete Choice Study of Patient Preferences for Dialysis Modalities

BACKGROUND AND OBJECTIVES

Improved knowledge about factors that influence patient choices when considering dialysis modality could facilitate health care interventions to increase rates of home dialysis. We aimed to quantify the attributes of dialysis care and the tradeoffs that patients consider when making decisions about dialysis modalities.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a prospective, discrete choice experiment survey with random parameter logit analysis to quantify preferences and tradeoffs for attributes of dialysis treatment in 143 adult patients with CKD expected to require RRT within 12 months (predialysis). The attributes included schedule flexibility, patient out of pocket costs, subsidized transport services, level of nursing support, life expectancy, dialysis training time, wellbeing on dialysis, and dialysis schedule (frequency and duration). We reported outcomes using β-coefficients with corresponding odds ratios and 95% confidence intervals for choosing home-based dialysis (peritoneal dialysis or hemodialysis) compared with facility hemodialysis.

RESULTS

Home-based therapies were significantly preferred with the following attributes: longer survival (odds ratio per year, 1.63; 95% confidence interval, 1.25 to 2.12), increased treatment flexibility (odds ratio, 9.22; 95% confidence interval, 2.71 to 31.3), improved wellbeing (odds ratio, 210; 95% confidence interval, 15 to 2489), and more nursing support (odds ratio, 87.3; 95% confidence interval, 3.8 to 2014). Respondents were willing to accept additional out of pocket costs of approximately New Zealand $400 (United States $271) per month (95% confidence interval, New Zealand $333 to $465) to receive increased nursing support. Patients were willing to accept out of pocket costs of New Zealand $223 (United States $151) per month (95% confidence interval, New Zealand $195 to $251) for more treatment flexibility.

CONCLUSIONS

Patients preferred home dialysis over facility-based care when increased nursing support was available and when longer survival, wellbeing, and flexibility were expected. Sociodemographics, such as age, ethnicity, and income, influenced patient choice.

Patient Perspectives on Discussions of Electronic Cigarettes in Primary Care

PURPOSE

Patient preferences regarding the role of the primary care provider (PCP) in discussing electronic cigarette (e-cigarette) use are unknown.

METHODS

We administered a cross-sectional survey to 568 adult patients in a family medicine clinic to explore e-cigarette use, sources of information on e-cigarettes, perceived knowledge about e-cigarette health effects, views regarding PCP knowledge of e-cigarettes, interest in discussing e-cigarettes with PCPs and preferred format for e-cigarette information. We performed χ² testing with a 2-tailed P < .05 to assess associations between e-cigarette use and these measures.

RESULTS

The prevalence of e-cigarette use was 10% for recent (≤30 days) use and 29% for nonrecent (>30 days) use. Prevalence was significantly higher among those who were younger, less educated, or smoked cigarettes, but did not vary by sex or self-reported health status. Roughly one quarter of participants believed they were knowledgeable about the health effects of e-cigarettes, secondhand smoke, and quitting cigarettes. Sources of e-cigarette information included television advertisements (56.6%), friends and family (49.9%), or e-cigarette shops (25.5%), but included physician offices much less frequently (6.0%). Although 30.2% disagreed that their PCP knew a lot about e-cigarettes, 62.0% were comfortable discussing e-cigarettes with their PCP. However, only 25% of all patients wanted their PCP to discuss e-cigarettes with them, but 62.0% of recent e-cigarette users wanted such a discussion. Most preferred a brief discussion or handout to a lengthy discussion.

CONCLUSION

PCPs were infrequent sources of information for patients regarding e-cigarette use. PCPs need evidence-based strategies to help them address e-cigarettes in primary care.

Supporting shared decision-making and people's understanding of medicines: An exploration of the acceptability and comprehensibility of patient information

Background

Patient information may assist in promoting shared decision-making, however it is imperative that the information presented is comprehensible and acceptable to the target audience.

Objective

This study sought to explore the acceptability and comprehensibility of the ' Medicines in Scotland: What's the right treatment for you?' factsheet to the general public.

Methods

Qualitative semi-structured telephone interviews were conducted with members of the public. An interview schedule was developed to explore the acceptability and comprehensibility of the factsheet. Participants were recruited by a researcher who distributed information packs to attendees (n=70) of four community pharmacies. Interviews, (12-24 minutes duration), were audio recorded, transcribed verbatim and analysed using a framework approach.

Results

Nineteen participants returned a consent form (27.1%), twelve were interviewed. Six themes were identified: formatting of the factsheet and interpretation; prior health knowledge and the factsheet; information contained in the factsheet; impact of the factsheet on behaviour; uses for the factsheet; and revisions to the factsheet.

Conclusions

The factsheet was generally perceived as helpful and comprehensive. It was highlighted that reading the leaflet may generate new knowledge and may have a positive impact on behaviour.

"Finding the Right FIT": Rural Patient Preferences for Fecal Immunochemical Test (FIT) Characteristics

PURPOSE

Colorectal cancer (CRC) is the third leading cause of cancer death in the United States, yet 1 in 3 Americans have never been screened for CRC. Annual screening using fecal immunochemical tests (FITs) is often a preferred modality in populations experiencing CRC screening disparities. Although multiple studies evaluate the clinical effectiveness of FITs, few studies assess patient preferences toward kit characteristics. We conducted this community-led study to assess patient preferences for FIT characteristics and to use study findings in concert with clinical effectiveness data to inform regional FIT selection.

METHODS

We collaborated with local health system leaders to identify FITs and recruit age eligible (50 to 75 years), English or Spanish speaking community members. Participants completed up to 6 FITs and associated questionnaires and were invited to participate in a follow-up focus group. We used a sequential explanatory mixed-methods design to assess participant preferences and rank FIT kits. First, we used quantitative data from user testing to measure acceptability, ease of completion, and specimen adequacy through a descriptive analysis of 1) fixed response questionnaire items on participant attitudes toward and experiences with FIT kits, and 2) a clinical assessment of adherence to directions regarding collection, packaging, and return of specimens. Second, we analyzed qualitative data from focus groups to refine FIT rankings and gain deeper insight into the pros and cons associated with each tested kit.

FINDINGS

Seventy-six FITs were completed by 18 participants (Range, 3 to 6 kits per participant). Over half (56%, n = 10) of the participants were Hispanic and 50% were female (n = 9). Thirteen participants attended 1 of 3 focus groups. Participants preferred FITs that were single sample, used a probe and vial for sample collection, and had simple, large-font instructions with colorful pictures. Participants reported challenges using paper to catch samples, had difficulty labeling tests, and emphasized the importance of having care team members provide verbal instructions on test completion and follow-up support for patients with abnormal results. FIT rankings from most to least preferred were OC-Light, Hemosure iFOB Test, InSure FIT, QuickVue, OneStep+, and Hemoccult ICT.

CONCLUSIONS

FIT characteristics influenced patient's perceptions of test acceptability and feasibility. Health system leaders, payers, and clinicians should select FITs that are both clinically effective and incorporate patient preferred test characteristics. Consideration of patient preferences may facilitate FIT return, especially in populations at higher risk for experiencing CRC screening disparities.

Patient Willingness to Have Tests to Guide Antibiotic Use for Respiratory Tract Infections: From the WWAMI Region Practice and Research Network (WPRN)

INTRODUCTION

The majority of consultations for acute respiratory tract infections (RTIs) lead to prescriptions for antibiotics, which have limited clinical benefit. We explored patients' willingness to have blood tests as part of the diagnostic work-up for RTIs, and patient knowledge about antibiotics.

METHODS

Patients at 6 family medicine clinics were surveyed. Regression modeling was used to determine independent predictors of willingness to have venous and point-of-care (POC) blood tests, and knowledge of the value of antibiotics for RTIs.

RESULTS

Data were collected from 737 respondents (response rate 83.8%), of whom 65.7% were women, 60.1% were white, and 25.1% were current smokers; patients' mean age was 46.9 years. Sex (female), race (white), and a preference to avoid antibiotics were independent predictors of greater level of antibiotic knowledge. A total of 63.1% were willing to have a venous draw and 79% a POC blood test, to help guide antibiotic decision-making. Non-American Indian/Alaskan Native race, current smoking, and greater knowledge of antibiotics were independent predictors of willingness to have a POC test.

CONCLUSION

A large majority of patients seemed willing to have POC tests to facilitate antibiotic prescribing decisions for RTIs. Poor knowledge about antibiotics suggests better education regarding antibiotic use might influence patient attitudes towards use of antibiotics for RTIs.

Qualitative Interviews Exploring Palliative Care Perspectives of Latinos on Dialysis

BACKGROUND AND OBJECTIVES

Compared with non-Latino whites with advanced illness, Latinos are less likely to have an advance directive or to die with hospice services. To improve palliative care disparities, international ESRD guidelines call for increased research on culturally responsive communication of advance care planning (ACP). The objective of our study was to explore the preferences of Latino patients receiving dialysis regarding symptom management and ACP.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Qualitative study design using semistructured face-to-face interviews of 20 Latinos on hemodialysis between February and July of 2015. Data were analyzed using thematic analysis.

RESULTS

Four themes were identified: Avoiding harms of medication (fear of addiction and damage to bodies, effective distractions, reliance on traditional remedies, fatalism: the sense that one's illness is deserved punishment); barriers and facilitators to ACP: faith, family, and home (family group decision-making, family reluctance to have ACP conversations, flexible decision-making conversations at home with family, ACP conversations incorporating trust and linguistic congruency, family-first and faith-driven decisions); enhancing wellbeing day-to-day (supportive relationships, improved understanding of illness leads to adherence, recognizing new self-value, maintaining a positive outlook); and distressing aspects of living with their illness (dietary restriction is culturally isolating and challenging for families, logistic challenges and socioeconomic disadvantage compounded by health literacy and language barriers, required rapid adjustments to chronic illness, demanding dialysis schedule).

CONCLUSIONS

Latinos described unique cultural preferences such as avoidance of medications for symptom alleviation and a preference to have family group decision-making and ACP conversations at home. Understanding and integrating cultural values and preferences into palliative care offers the potential to improve disparities and achieve quality patient-centered care for Latinos with advanced illness.

A Trainable Hearing Aid Algorithm Reflecting Individual Preferences for Degree of Noise-Suppression, Input Sound Level, and Listening Situation

OBJECTIVES

In an effort to improve hearing aid users' satisfaction, recent studies on trainable hearing aids have attempted to implement one or two environmental factors into training. However, it would be more beneficial to train the device based on the owner's personal preferences in a more expanded environmental acoustic conditions. Our study aimed at developing a trainable hearing aid algorithm that can reflect the user's individual preferences in a more extensive environmental acoustic conditions (ambient sound level, listening situation, and degree of noise suppression) and evaluated the perceptual benefit of the proposed algorithm.

METHODS

Ten normal hearing subjects participated in this study. Each subjects trained the algorithm to their personal preference and the trained data was used to record test sounds in three different settings to be utilized to evaluate the perceptual benefit of the proposed algorithm by performing the Comparison Mean Opinion Score test.

RESULTS

Statistical analysis revealed that of the 10 subjects, four showed significant differences in amplification constant settings between the noise-only and speech-in-noise situation (P<0.05) and one subject also showed significant difference between the speech-only and speech-in-noise situation (P<0.05). Additionally, every subject preferred different β settings for beamforming in all different input sound levels.

CONCLUSION

The positive findings from this study suggested that the proposed algorithm has potential to improve hearing aid users' personal satisfaction under various ambient situations.

The Evolving Ethics of Dialysis in the United States: A Principlist Bioethics Approach

Throughout the history of dialysis, four bioethical principles - beneficence, nonmaleficence, autonomy and justice - have been weighted differently based upon changing forces of technologic innovation, resource limitation, and societal values. In the 1960s, a committee of lay people in Seattle attempted to fairly distribute a limited number of maintenance hemodialysis stations guided by considerations of justice. As technology advanced and dialysis was funded under an amendment to the Social Security Act in 1972, focus shifted to providing dialysis for all in need while balancing the burdens of treatment and quality of life, supported by the concepts of beneficence and nonmaleficence. At the end of the last century, the importance of patient preferences and personal values became paramount in medical decisions, reflecting a focus on the principle of autonomy. More recently, greater recognition that health care financial resources are limited makes fair allocation more pressing, again highlighting the importance of distributive justice. The varying application and prioritization of these four principles to both policy and clinical decisions in the United States over the last 50 years makes the history of hemodialysis an instructive platform for understanding principlist bioethics. As medical technology evolves in a landscape of changing personal and societal values, a comprehensive understanding of an ethical framework for evaluating appropriate use of medical interventions enables the clinician to systematically negotiate and optimize difficult ethical situations.

Do Cancer Patients Prefer to Know the Diagnosis? A Descriptive Study Among Iranian Patients

BACKGROUND

There are important differences regarding cancer disclosure in various geographical populations (Europeans, Western Asia, Eastern Asia), depending on multiple sociocultural factors, and therefore, there is no standard protocol on this issue, especially in Iran.

OBJECTIVES

To evaluate the amount of information that Iranian patients have and their preference for the disclosure of the cancer diagnosis.

PATIENTS AND METHODS

In this cross sectional descriptive research, patients admitted in the oncology departments of 3 referral medical centers, Imam Hussein, Shohada-e-Tajrish and Modarres, in Tehran, from March 2007 to April 2008, were questioned about their awareness and knowledge regarding their diagnosis. Two different structured questionnaires were designed for the people who know and who didn't know their diagnosis. For the former, the survey concerned their psychological reactions to their situations, whether they would prefer to know about their diagnosis and by whom they are preferred to be informed .For the latter, the questionnaire included their preference whether to know the diagnosis and their current emotional state. Descriptive statistics and chi square test was applied to analyze gathering Data, using SPSS version 14.

RESULTS

60.3% of the patients knew their diagnosis. Among the subjects who did not know their diagnosis, 88% preferred to be more informed about their diagnosis and 68% had some psychological reaction to their situations. Among the subjects who knew their diagnosis, 92.1 % preferred to know their diagnosis, 73.6% preferred to be informed directly by their physicians. Following the diagnostic disclosure, 81.5% reported that they had felt nervous, anxious and worried.

CONCLUSIONS

The majority of Iranian patients with malignancy want to know the truth and they prefer to be informed directly by their doctors.

The attitudes of pharmacists, students and the general public on mHealth applications for medication adherence

Background:

During recent years mobile technology has developed tremendously and has infiltrated the healthcare field. Mobile healthcare (mHealth) applications, or apps, may be used to support patient adherence to medication thus promoting optimal treatment outcomes and reducing medication wastage.

Objective:

This study shall consider the opinions of United Kingdom (UK) based pharmacists, pharmacy undergraduates and members of the general public towards the use of mHealth apps to promote adherence to prescribed medication regimens.

Methods:

On Liverpool John Moores University (LJMU) ethical approval, the 25 item questionnaire was distributed to UK registered pharmacists within inner city Liverpool and Manchester (n=500), pharmacy undergraduates studying at LJMU (n=420) and members of the general public within Liverpool City Centre (n=400). The questions were formatted as multiple choice, Likert scales or the open answer type. The data were analysed using simple frequencies, cross tabulations and non-parametric techniques in the SPSS v22 program.

Results:

The number of completed questionnaires from the pharmacist, student and general public cohorts were 245, 333 and 400; respectively. The data indicated that the general public rely heavily upon daily routine to take medication as prescribed (54.1%) with mHealth app use being extremely low (1.5%); a similar trend was noted for the pharmacist / student cohorts. The age of the individual is an important consideration, with the younger generation likely to engage with mHealth apps and the older generation less so. Here, education and training are important. Pharmacists (82.3%) would be happy to deliver training packages to the public who would in turn happily receive such training (84%). Key barriers precluding mHealth app use include data reliability, security and technical difficulties.

Conclusion:

Adherence apps hold great promise to support the patient and their healthcare needs. In order to increase acceptance and uptake simple, user-friendly designs must be considered and constructed. In addition, such technology requires effective promotion and end user training in order to reach its full potential. Furthermore, the regulation of mobile adherence apps will be essential in order to overcome underlying patient concerns.

Patient Preferences for Receiving Reports of Test Results

INTRODUCTION

The general public's preferences for modes of communication (other than in-person communication) for medical test results were investigated. We hypothesized that patients would prefer a variety of methods to receive common tests results (blood cholesterol and colonoscopy) compared with genetics test results.

METHODS

This study was a cross-sectional survey.

RESULTS

A total of 409 participants responded to the survey. Among these participants, ≥50% reported that they were comfortable receiving results for a blood cholesterol test or colonoscopy via 4 of the 7 non-in-person communication methods (password-protected website, personal voicemail, personal E-mail, and letter were preferred over home voicemail, fax, and mobile phone text message). In comparison, >50% of participants were comfortable with only 1 non-in-person communication method for non-HIV sexually transmitted infections (STIs) and none for genetic tests. Patients were least comfortable receiving any information via fax, regardless of test type. There were statistical differences among comfort levels for blood cholesterol and colonoscopy tests and both STIs and genetic testing for personal voicemail, personal E-mail, mobile phone text message, and password-protected website, but there were no differences between STIs and genetic testing. No correlation was found between "familiarity" with test and "comfort" of receiving information about specific test.

CONCLUSIONS

Participants demonstrated preferences in how they received test results by non-in-person communication methods, preferring personal E-mail and password-protected websites, but did not prefer fax. Importantly, participants also demonstrated that preference was dependent on test type.

The role of patients' expectation of appropriate initial manual therapy treatment in outcomes for patients with low back pain

OBJECTIVES

The purpose of this study was to compare the outcomes of patients with low back pain who had a matched, unmatched, or were indifferent with their pretreatment expectation/preference to the manual therapy thrust or nonthrust intervention. A secondary purpose was to explore baseline patient characteristics affiliated with a preference of manual therapy treatment type (thrust or nonthrust manipulation).

METHODS

The study is a secondary analysis of a prospective randomized controlled trial that enrolled 149 patients with low back pain, from 16 distinct outpatient physical therapy practices within the United States. Patient's pretreatment expectations were identified before randomization. The intervention included manual therapy (thrust or nonthrust manipulation) with a standardized exercise program, which was carried out for 2 treatment sessions. Six outcomes captured the constructs of (a) disability, (b) pain perception, (c) care intensity, (d) fear avoidance behaviors, and (e) perception of extent of recovery. Descriptive statistics, analysis of variance (and Tukey, a post hoc test), Fisher exact test, and a multivariate logistic regression analysis were used for analysis.

RESULTS

There were no statistical differences in any of the 6 dedicated outcomes measures between the matched, unmatched, and no preference groups. Therapist-determined patient "irritability" was associated with patient preference of nonthrust treatment, and higher body mass index was associated with patient preference of thrust treatment.

CONCLUSIONS

This study shows that patients demonstrated no statistical difference in disability or pain outcome measures when matched, unmatched, or indifferent to the intervention.