Greater Patient Involvement Research Articles

Balancing influence between actors in healthcare decision making

BackgroundHealthcare costs in most developed countries are not clearly linked to better patient and public health outcomes, but are rather associated with service delivery orientation. In the U.S. this has resulted in large variation in healthcare availability and use, increased cost, reduced employer participation in health insurance programs, and reduced overall population health outcomes. Recent U.S. healthcare reform legislation addresses only some of these issues. Other countries face similar healthcare issues.DiscussionA major goal of healthcare is to enhance patient health outcomes. This objective is not realized in many countries because incentives and structures are currently not aligned for maximizing population health. The misalignment occurs because of the competing interests between "actors" in healthcare. In a simplified model these are individuals motivated to enhance their own health; enterprises (including a mix of nonprofit, for profit and government providers, payers, and suppliers, etc.) motivated by profit, political, organizational and other forces; and government which often acts in the conflicting roles of a healthcare payer and provider in addition to its role as the representative and protector of the people. An imbalance exists between the actors, due to the resources and information control of the enterprise and government actors relative to the individual and the public. Failure to use effective preventive interventions is perhaps the best example of the misalignment of incentives. We consider the current Pareto efficient balance between the actors in relation to the Pareto frontier, and show that a significant change in the healthcare market requires major changes in the utilities of the enterprise and government actors.SummaryA variety of actions are necessary for maximizing population health within the constraints of available resources and the current balance between the actors. These actions include improved transparency of all aspects of medical decision making, greater involvement of patients in shared medical decision making, greater oversight of guideline development and coverage decisions, limitations on direct to consumer advertising, and the need for an enhanced role of the government as the public advocate.

Navigating patient-centered goal setting in inpatient stroke rehabilitation: How clinicians control the process to meet perceived professional responsibilities

ObjectivePatient-centered goal setting, while central to contemporary rehabilitation, has been associated with growing uncertainty regarding its application in clinical practice. We aimed to examine the application of goal setting in inpatient stroke rehabilitation. MethodsData collected from 44 participants (nine patients, seven family members, 28 health professionals), using multiple data sources (interviews, recorded clinical sessions, team meetings, participant-observation, and clinical documentation), were analyzed using constant comparative methods. ResultsCertain goals (characterized by short timeframes, conservative estimation of outcomes, and physical function) were privileged over others. Involvement of patients and family in goal setting resulted in interactional dilemmas when their objectives, skills and perceived capacity did not align with privileged goals. When alignment did occur, greater patient involvement still did not appear to influence clinical reasoning. ConclusionThis study raises questions about how ‘patient-centered’ current goal setting practices are and whether a ‘patient-centered’ approach is even possible in inpatient stroke rehabilitation when considering predominant funding and health system models. Practice implicationsFor ‘patient-centered’ goal setting to be more than rhetorical, clinicians need to examine the values they attribute to certain types of goals, the influence of organizational drivers on goal selection, and how goals are actually used to influence clinical practice.

Dynamics of Trust in Medical Decision Making

Patient trust in medical decision makers is a crucial facilitator of effective health care. Greater patient involvement in decision making requires improved understanding of how such trust is built, maintained, and lost in medical contexts. The study investigates how trust in clinicians is affected by the 4 main diagnostic outcomes proposed by signal detection theory: true positives, true negatives, false positives, and false negatives. Cognitive appraisals of, and affective reactions to, the decisions were measured to investigate the psychological mechanisms underpinning effects on trust. Members of an Internet research panel (N = 1162) participated in a between-participant experimental study using hypothetical cancer diagnosis scenarios. Overall, correct diagnoses bolstered trust as much as incorrect ones undermined it. Consistent with recent findings in other decision-making domains, trust was not as precarious as generally believed. The influence of decisions and outcomes on trust was mediated through cognitive assessments and affective responses in line with current appraisal theories in psychology. Prior levels of trust in clinicians affected sympathy for doctors, highlighting the role that trust plays in responding to new information. Trust in (hypothetical) clinicians is sensitive to information about their past diagnostic performance. Greater understanding of the cognitive and affective mechanisms by which this occurs may help maintain current high levels of trust. Further research is needed to examine whether findings generalize to real medical decision-making contexts. Clinicians may want to consider the impact their diagnoses have on trust alongside medical and financial considerations.

National-scale clinical information exchange in the United Kingdom: lessons for the United States.

Over the last four decades, the UK has made large investments in healthcare information technology. The authors conducted interviews and reviewed published and unpublished documents to describe national-scale clinical information exchange in England, how it was achieved, and the problems experienced that the USA might avoid. Clinical information exchange in the UK was accomplished by establishing a foundation of policy, infrastructure, and systems of care, by creating and acquiring clinical computing applications and with strong use of financial and clinical incentives. Many software and hardware vendors played a part in this effort; they participated in a national framework created by the NHS in which standards for exchange are specified and their applications designed to make clinical information exchange part of normal practice. Great potential exists for cost reduction, increased safety, and greater patient involvement as a result of clinical information exchange.

Negotiating care: patient tactics at an urban South African hospital

To examine the various ways in which patients sought to influence the care they received in the admission and adult medical services of a large urban, academic hospital in South Africa. These included the steps taken by patients to increase their access to services and improve their experience of care. Part of a qualitative study of rationing behaviour, the methods combined, observations, interviews and a survey. Patient's actions were oriented to two main goals: obtaining care and preserving their sense of self and dignity. These actions shaped patients' pathways in five key ways: meeting the entry criteria for admission; presenting as a cooperative, expert patient; mobilizing social networks among health care staff; making use of complaints mechanisms; and deploying narratives of resistance. Patients made tactical use of small spaces at the margins of the health care system. Although, with some exceptions, they had limited impact on the care received in the hospital, they highlight patients as active players and point to the ways in which patient agency can be strengthened in the light of the shift towards chronic disease care and greater patient involvement in care.

Effect of participation in a clinical trial on glycemic control in type 2 diabetic patients

Effect of participation in a clinical trial on glycemic control in type 2 diabetic patients

Decision Involvement and Receipt of Mastectomy Among Racially and Ethnically Diverse Breast Cancer Patients

Few studies have evaluated the association between patient decision involvement and surgery received among racially and ethnically diverse patients or patients' attitudes about surgery and the role of family and friends in surgical treatment choices. Women diagnosed with nonmetastatic breast cancer from June 2005 through February 2007 and reported to the Los Angeles or Detroit Surveillance, Epidemiology, and End Results registries were mailed a survey after diagnosis (N = 3133). Latina and African American women were oversampled. The response rate was 72.4%. The analytic sample (N = 1651) excluded those with stage IIIA or higher disease, self-reported clinical contraindications to breast-conserving surgery with radiation, and unclear race or ethnicity. The dependent variable was receipt of mastectomy initially. The primary independent variables were patient involvement in decision making, race or ethnicity, attitudes about recurrence, the effects of radiation, the impact of surgery on body image, and the role of others in decision making. Latinas were categorized as low or high acculturated. The association between patient involvement in decision making and the receipt of mastectomy was evaluated using logistic regression while controlling for other independent variables. All statistical tests were two-sided. The analytic sample was 23.9% Latina (12.0% low acculturated, 11.9% high acculturated), 27.1% African American, and 48.9% white, and 17.2% received a mastectomy initially. For each racial or ethnic group, more women who reported a patient-based decision received mastectomy than those who reported a shared or surgeon-based decision (P = .022 for low-acculturated Latinas, P < .001 for other groups). Women who reported that concerns about recurrence or radiation effects were very important in their surgery decision were more likely to receive mastectomy than those less concerned (for recurrence concerns, estimated relative risk [RR] = 1.66, 95% confidence interval [CI] = 1.28 to 2.10; for radiation concerns, estimated RR = 2.35, 95% CI = 1.88 to 2.85). Women who reported that body image concerns and their spouse's opinion were very important in their surgery decision less often received mastectomy than those less concerned about body image or who placed less weight on their spouse's opinion (for body image concerns, estimated RR = 0.47, 95% CI = 0.30 to 0.74; for spouse's opinion, estimated RR = 0.53, 95% CI = 0.36 to 0.78). Greater patient involvement in decision making was associated with receipt of mastectomy for all racial and ethnic groups. Patient attitudes about surgery and the opinions of family and friends contribute to surgical choices made by women with breast cancer.

Proposed interventions to decrease the frequency of missed test results

Numerous studies have identified that delays in diagnosis related to the mishandling of abnormal test results are an import contributor to diagnostic errors. Factors contributing to missed results included organizational factors, provider factors and patient-related factors. At the diagnosis error conference continuing medical education conference in 2008, attendees attended two focus groups dedicated to identification of strategies to lower the frequency of missed results. The recommendations were reviewed and summarized. Improved standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow up of test results, and systems re-engineering to improve the management and presentation of data. Focusing the initial interventions on the specific tests which have been identified as high risk for adverse impact on patient outcomes such as tests associated with a possible malignancy or acute coronary syndrome will likely have the most significant impact on clinical outcome and patient satisfaction with care.

Whose health, whose care, whose say? Some comments on public involvement in new NHS commissioning arrangements

Recent health policy in England has demanded greater involvement of patients and the public in the commissioning of health and social care services. Public involvement is seen as a means of driving up service quality, reducing health inequalities and achieving value in commissioning decisions. This paper presents a summary and analysis of the forms that public involvement in commissioning are to take, along with empirical analysis from a qualitative study of service-user involvement. It is argued that the diversity of constituencies covered by the notion of ‘public involvement’, and the breadth of aims that public involvement is expected to achieve, require careful disaggregation. Public involvement in commissioning may encompass a variety of interest groups, whose inputs may include population needs assessment, evaluation of service quality, advocacy of the interests of a particular patient group or service, or a combination of all of these. Each of these roles may be legitimate, but there are significant tensions between them. The extent to which the structures for public involvement proposed recognize these possible tensions is arguably limited. Notably, new Local Involvement Networks (LINks), which will feed into commissioning decisions, are set as the arbiters of these different interests, a demanding role which will require considerable skill, tenacity and robustness if it is to be fulfilled effectively.

Optimal Referral is Early Referral

The number of patients receiving renal replacement therapy in the United Kingdom is rapidly rising. Chronic kidney disease (CKD) is a worldwide public health problem with significant comorbidity and mortality. Several organizational guidelines have been developed in an attempt to identify when appropriate referral to nephrology services should occur; however, many of these guidelines provide conflicting recommendations on referral. Recent surveys suggest that more than 30% of patients with CKD are referred later than is ideal. Late referral of patients with CKD is associated with increased patient morbidity and mortality, increased need for and duration of hospital admission, and increased initial costs of care following commencement of dialysis. Additional benefits of early referral include identifying and treating reversible causes of renal impairment and managing the multiple coexisting conditions associated with CKD. Referral time also affects the choice of treatment modality. Patients and their families should receive sufficient information regarding the nature of their CKD and the options for treatment so that they can make informed decisions concerning their care. Literature addressing when to refer to low-clearance or pre-dialysis clinics is limited. Existing data suggest that such clinics and patient education programs may facilitate improved medical care for patients, greater patient involvement in selection of the mode of dialysis, reduction in the need for "urgent start" dialysis, and improved short-term survival and quality of life after initiation of dialysis. Audit of our pre-dialysis clinic has demonstrated improved patient outcomes, and we view the early-referral service as an essential component of the patient pathway.

Time Trends in Type 2 Diabetes Patients’ Disease Management and Outcomes: Evidence from Two KORA Surveys in Germany

To explore time trends in diabetes management and intermediate health outcomes of people with type 2 diabetes, data from two population-based survey studies were compared. The surveys were conducted in the Augsburg region of Southern Germany in 1997/98 and in 2004/05, and included physical examinations, interviews, self-administered questionnaires and laboratory tests. Data from 334 participants aged 40-84 were analysed, including a longitudinal sub-sample of 50 persons. Results show significant time trends towards improvements over the seven year period. Controlling for age, sex, education and duration of diabetes, people felt better informed about diabetes (Odds Ratio (OR) 1.87; 95% CI: 1.12, 3.14) and stated greater adherence to the treatment plan (OR 4.42; CI: 2.62, 7.45) as well as higher participation in diabetes education programmes (OR 2.20; CI: 1.44, 3.38). Mean haemoglobin A1c levels decreased by -0.97% from 7.3% to 6.3% (CI:-0.66%, -1.28%). Physical activity (> or =1 h/week) was more frequent (OR 2.75; CI: 1.65, 4.59), although Body Mass Index increased by 1.43 kg/m (2) (CI: 0.86, 2.00). The positive changes in disease management and metabolic outcomes for type 2 diabetic patients between 1997/98 and 2004/05 indicate a shift towards greater patient involvement in diabetes care and possibly more efficient medical management practices.

The 2008 Canadian Hypertension Education Program recommendations: The scientific summary – an annual update

The present paper summarizes and highlights key messages of the 2008 Canadian Hypertension Education Program recommendations for the diagnosis and management of hypertension. The 2008 recommendations emphasize proper self-measurement of blood pressure as a step toward greater patient involvement in hypertension management. Home measurement is a better predictor of cardiovascular events than office measures; it can also confirm the diagnosis of hypertension, improve blood pressure control, reduce the need for medications in some patients, screen for white coat and masked hypertension, and improve medication adherence in nonadherent patients. The recommendations continue to emphasize the importance of reducing dietary sodium and implementing other lifestyle changes to prevent and control hypertension. Furthermore, regular assessment of blood pressure at all appropriate visits and identification and management of all cardiovascular risk factures continue to be the cornerstone of the Canadian Hypertension Education Program. Most of the new evidence in 2008 confirmed previous Canadian Hypertension Education Program recommendations. A notable new recommendation is the option to initiate pharmacotherapy with two first therapies if blood pressure is higher than 20/10 mmHg above target. Recently, the Ontario Blood Pressure survey found the treatment and control rate of hypertension in Ontario to be far higher than anywhere else in the world. This speaks to the success of primary care and the Canadian health system in diagnosing, treating and controlling hypertension.

Decision making in local therapy for breast cancer

Shared decision making has been accepted as a desirable approach to medical care, but our understanding of patient satisfaction with the process and its impact on treatment selection is limited. The local therapy of breast cancer is an ideal model for studying the decision-making process because there is a large body of high-quality evidence on which to base decisions. To study decision making, we used a population-based sample of all women with ductal carcinoma in situ (DCIS) and a 20% sample of those with invasive breast cancer diagnosed in 2002 and reported to the Los Angeles and Detroit Surveillance, Epidemiology, and End Results registries. There was a 77% response rate to the survey, yielding 1,884 patients. More than 90% were contacted within 6 months of diagnosis [1]. The mean patient age was 60 years and 70% were white. Less than a high school level of education was reported by 27%; 61% graduated from high school or had some college education, and 13% were college graduates. The mastectomy rate was 30% for patients with both DCIS and invasive cancer. Accepted clinical contraindications to breast-conserving surgery were reported by 11.5% of the study population. In 41% of cases the patient reported that she was the primary decision maker, the decision was shared in 37%, and was made by the surgeon in 22% of cases. The therapy recommended by the surgeon was breast-conserving surgery in 49%, mastectomy in 15%, and patients reported being offered a choice between the two procedures in 37% of cases. Greater patient involvement in the decision-making process was significantly correlated with treatment by mastectomy after adjustment for multiple clinical and demographic variables. Only 5.8% of women whose surgeon made the treatment decision had a mastectomy, as compared with 16.8% who reported a shared decision and 27% of women who reported that they made the decision (P = 0.003). Concern about disease recurrence was the most influential factor in treatment choice, with 40% of women reporting that their treatment choice was greatly influenced by this concern. Concerns about disease recurrence were strongly associated with receipt of mastectomy; 52% of women who were greatly concerned about disease recurrence received a mastectomy, as compared with 19% of those who were not influenced, or only slightly influenced, by this concern (P < 0.001) [1]. Patients expressed a high level of confidence in decision making, with more than 80% of women of all ages being very or extremely confident about their treatment choice. However, fewer than 50% were able to answer correctly a true-false question about the lack of a survival difference after treatment by mastectomy or lumpectomy and radiation. We also examined the match between decision control and patient preference in a subset of 1,028 patients with no contraindications to breast-conserving therapy who were treated by 270 surgeons [2]. We found a rate of mismatch between desired and actual level of involvement of 31%. In 20% of cases actual involvement in decision making was greater than preferred, whereas in 11% it was less than preferred. Twenty per cent of patients reported that they asked for but did not receive a treatment recommendation, and 16% noted that they did not ask for but received a treatment recommendation. Patients who perceived too little involvement in the decision-making process were younger, reported that only one treatment option (mastectomy or breast conservation) was discussed, and were more likely to have been seen by a high-volume surgeon. Patients who perceived too much involvement in decision making had lower levels of education and felt that they asked for but did not receive a treatment recommendation. Lack of satisfaction with the decision-making process was expressed by 37%, lack of satisfaction with the relationship with the surgeon by 23%, and lack of satisfaction with communication with the surgeon by 24% of patients [3]. Satisfaction with the decision-making process did not correlate with surgeon sex, years in practice, or treatment in a cancer centre. Increased satisfaction with decision making was significantly associated with high-volume breast surgeons, and a trend toward increased satisfaction with higher breast surgery volume was observed for other aspects of the treatment selection process. The results of these studies suggest that although patients believe that they are informed about their treatment choices and are confident in their decisions, major knowledge gaps exist. In addition, for a significant number of patients there is a mismatch between the preferred level of involvement in decision making and what actually occurs. As in the treatment of breast cancer, the style of decision making must be tailored to the individual.

What can physicians do to promote patient involvement in decision making (DM) in the oncology consultation?

19553 Background: Facilitating patient involvement in TDM is a desirable feature of the oncology consultation. Greater patient involvement in TDM may lead to improved patient satisfaction, compliance and reduced psychological morbidity. However, there is little empiric evidence defining physician behaviors and attributes that facilitate patient involvement in TDM. This study used qualitative methods to identify such behaviors and attributes suggested by both practicing oncologists and patients. Methods: Semi-structured interviews were conducted with 11 medical, 10 radiation oncologists and 19 patients with breast, lung, GI, or GU cancer to determine physician behaviors and attributes that facilitate patient involvement in TDM. Interviews were audiotaped and transcribed verbatim, then analyzed independently by two researchers using inductively derived coding categories and predetermined coding rules. Behaviors and attributes were identified and coded into common themes. Six focus groups with an additional 37 patients were conducted to review these behaviors and attributes. Results: A total of 231 individual physician behaviors and attributes were identified by physicians (179) and patients (52) that facilitate patient involvement in DM. Common behaviors and attributes identified from the interviews include: assessing patient’s understanding and preferences, providing information, explaining the DM process, providing information on treatment options, allowing time to consider treatment options, checking patient understanding of options and inviting patient input into decisions. Other behaviors such as physicians’ communication skills were reported as facilitating TDM. Specific physician personality attributes, such as empathy, were identified as important facilitators. Conclusions: Physicians and patients identify a large number of physician behaviors and attributes that may facilitate patient involvement in TDM. These include both behaviors that are important in general physician-patient communication, as well as those that are specifically related to the decision making process. Further research is ongoing to determine the importance of these factors and approaches to encourage their use in the oncology consultation. No significant financial relationships to disclose.

SE13 ACCURACY, ACCEPTANCE AND COMPLIANCE IN THE USE OF A WEB BASED AUDIT TOOL – RESULTS OF PHASE 1

Background Patient privacy related concerns are thought to be a major impediment to the use of modern web‐based database systems in clinical audit and multi‐centre research. Most new electronic health record systems are ‘opt out’ models in which all patients are included within the system by default.1Aim The aim of the first phase of this ‘multi’‐centre study is to assess the level of community acceptance of an ‘opt in’ model in which individual parents are given a choice of having their child’s medical information stored on a customised, highly secure, commercially available web‐based data management system.Materials and methods Parents/guardians of all children presenting with any of a pre‐determined set of conditions are invited to complete a questionnaire after reading an information leaflet. The questionnaire is designed to correlate community attitudes to web‐bases electronic health records with factors such as expected duration of requirement for health services, availability of mobile phone and internet services, usage of other web based services as well as parental demographics.Results The recruitment rate of ‘eligible’ parents has been 100% so far. Overall, 64.5% have responded in favour of a web based databank, 17.5% were unsure and 17.5% not in favour of a web based databank. 90% of parents with children requiring ‘medium’ and ‘long’ term follow up were definitely in favour.Conclusions Greater involvement of patients and clinicians may overcome one of the major impediments in the use of web based audit tools.

The new GMS contract: impact and implications for managing the changes

In February 2003, a new General Practitioner (GP) contract was agreed between the profession's leaders and the government, which was later accepted following a national ballot of GPs. However, the ballot simply required respondents to vote for or against the proposal; it did not provide any opportunity to identify which aspects of the new contract were more or less acceptable. Since the proposed changes were far reaching, the implications of implementing and managing these were considerable. Consequently, some information about how GPs viewed various components of the new contract would enable a more targeted and effective management strategy to be developed that would facilitate the introduction of all aspects of the contract. To survey GPs working within the West Midlands region regarding their opinions on each of the key features of the new contract. A postal survey of 360 GPs was undertaken, using a specially devised questionnaire. Four factors emerged as the most acceptable aspects of the contract: option to opt out of out-of-hours work, flexibility in the services provided, prediction of future income levels and linking practice to performance targets. Least acceptable were: performance monitoring systems, the new financial formula for calculating income, greater patient involvement in service development and 24/48 hour access. With regard to potential outcomes of the contract, the most positive were considered to be increased proportion of salaried GPs, increased salaries, appropriate quality standards for care, earlier retirement; the factors least likely to be of potential benefit were: reduction in occupational stress, simplification of the regulatory framework, improved equity of workload and improved staff retention. Further analysis of the results using inferential statistics revealed a range of subgroup differences in reaction to the contract. Overall, those aspects of the new contract that are perceived to reduce workload and enhance salary were supported, while those that increase targets and bureaucracy were not. Generally, there was only moderate support for the changes, which could be explained by a general scepticism about any top-down modifications, the practicality and power of the changes to impact upon practice and/or a genuine belief that the modifications are unacceptable. Taken together, these results provide an indicative focus for managing the implementation of the new contract, especially with regard to its least acceptable components and the emerging differences between subgroups of GPs.

Improving patient and carer communication, multidisciplinary team working and goal-setting in stroke rehabilitation

To determine the extent to which three forms of multidisciplinary team (MDT) care in stroke rehabilitation meet the standards set by the United Kingdom National Service Framework (NSF). Consecutive assessment of the three forms of care was completed. The study included three groups of 25 stroke inpatients on the stroke rehabilitation ward. (1) A standard weekly MDT meeting using a standard form for documentation; (2) a standard MDT meeting using a newly devised form; and (3) a novel MDT ward round using the new form, and attended by doctors. MDT ward rounds result in significantly better consideration of patients' needs (median 7 per patient compared with 0 and 5 in phases one and two), enhanced SMART (specific, measurable, achievable, realistic and time framed) goal-setting (median 3 per patient compared to 1 in phases one and two); greater patient involvement (12 patients compared to 0 and 4 in phases one and two); and improved team working (measured using the team climate inventory) than do MDT meetings. In the present study, standard weekly MDT meetings did not meet the standards set for MDT care by the NSF. The use of a MDT ward round allows these standards to be achieved.

VA Says `Culture Change' Will Transform MH Services

Back to table of contents Previous article Next article Government NewsFull AccessVA Says `Culture Change' Will Transform MH ServicesKate MulliganKate MulliganSearch for more papers by this authorPublished Online:5 Nov 2004https://doi.org/10.1176/pn.39.21.00390029Federal agencies were asked to respond to the recommendations of the New Freedom Commission on Mental Health after submission of the commission's report to President George W. Bush in July 2003.Among the first federal agencies to come up with an action agenda was the Department of Veterans Affairs (VA), which released “Achieving the Promise: Transforming Mental Health in the VA” on December 1, 2003.Frances M. Murphy, M.D., M.P.H., emphasizes the need for a culture change that focuses on “functional recovery.”Photo courtesy of the Department of Veterans AffairsDeputy Under Secretary for Health for Health Policy Coordination Frances M. Murphy, M.D. M.P.H., who served on the commission and chaired the work group that produced the VA report, told Psychiatric News that before the commission's work, “the VA had already begun a process for transformation” that is not yet complete.She emphasized the importance of a “culture change” that focuses on the idea of functional recovery, rather than merely symptom reduction.Work group members offered a candid assessment of key challenges.Mental health workloads increased by 34 percent between 1995 and 2002.Murphy said, “During Fiscal 2003, a total of 794,581 veterans, 16.9 percent of all VA patients, received specialized VA mental health [services].”According to the report, “[Veterans] may have a higher prevalence of multiple diagnoses [and] mental health problems, such as PTSD and substance abuse, when compared with the general population.”The group wrote, “To date, the VA has not developed enough capacity in outpatient or community-based programs to adequately serve enrolled veterans' needs for screening, prevention, crisis treatment, and coordinated chronic health care.”The inadequacy of the capacity is exacerbated by the“ variability” in quality and extent of mental health services, including those for substance abuse, depending on geographic location.“[O]nly about one-third of the veterans who meet utilization criteria for Mental Health Intensive Case Management are currently enrolled in such programs. Consistent access to mental health care in Community-Based Outpatient Clinics (CBOCs) has not yet been achieved. Of 616 CBOCs in Fiscal 2001, 258 had no mental health visits, and an additional 78 report that mental health care accounts for under 5 percent of their workload.”Murphy pointed out that the VA also has substantial strengths.“Parity is not an issue. There is no restriction on the number of visits [to a mental health practitioner].”She added that VA Secretary Anthony Principi “is such a champion for mental health.”(In 2002, Principi was the recipient of the APA Speaker's Award. He was praised particularly for his support of services for veterans with PTSD and for homeless veterans with serious mental illness.)The work group agreed on a nine-item agenda to guide action (see box).Murphy noted that the work group had identified a target date of 2008 to eliminate variability in access to mental health, substance abuse, and homeless services and to long-term psychiatric care.That change will require expansion of specialty mental health services to all CBOCs. Telepsychiatry might be used in rural areas where it is difficult to recruit specialists who can treat such illnesses as PTSD.The emphasis of the commission's report on promoting recovery and on greater involvement of patients and family members in making treatment choices is reflected in the recommendations of the VA's work group in the 2003 report.The work group singled out 12 recommendations “of such high importance that implementation should begin in January 2004.”Among them are to adopt the recovery model in VA mental health programs nationwide, to educate VA staff on recovery, to develop a strategic plan for mental health research that supports VA recovery-based mental health, to initiate a national Recovery and Rehabilitation Task Force, and to develop a manual on establishing a peersupport program.Murphy said that supported employment programs are a particular priority in terms of promoting recovery and the ability of veterans to live productively in the community.Several recommendations promote the integration of mental and primary health care services.How can mental health practitioners be confident that integration of services will not result in further erosion of resources for mental health care?Murphy said, “Everyone worries they might lose something, but the VA is trying to increase access to high-quality care... .There will always be a need for mental health and substance abuse specialists.”She said that the goal is to “detect mental health problems early” and “keep care integrated as long as possible.”Murphy added that the veterans' population is aging. Those veterans prefer to have a primary care team coordinate their treatment.“By involving mental health practitioners in the work of primary care clinics, veterans get a clear message that mental health is essential to their overall health.” ▪ ISSUES NewArchived

Long-term follow-up of anglian germ cell cancer group surveillance versus patients with stage 1 nonseminoma treated with adjuvant chemotherapy

Objectives To study survival and late events after adjuvant chemotherapy in Stage 1 nonseminoma. Methods From 1978 to 1986, all patients had surveillance. From 1986, adjuvant chemotherapy (initially a 3-day regimen of etoposide, bleomycin, and cisplatin, but, more recently, bleomycin, Oncovin, and cisplatin) was offered to patients at a high risk of relapse (greater than 30%). Results A total of 382 patients with Stage 1 nonseminoma treated between 1978 and 2000 were reviewed. Of the 234 patients treated by surveillance, 71 (30%) had relapses (5 after 2 years), 6 died (2.6%) of germ cell cancer, and 3 developed second primary testicular cancer. Of the 148 men treated with adjuvant chemotherapy, 6 (4%) had relapses and 2 (1.4%) died of chemoresistant cancer. After one course of etoposide, bleomycin, and cisplatin, 3 (6.5%) of 46 developed a relapse; after two courses, 1 (3.6%) of 28 did so; and after bleomycin, Oncovin, and cisplatin every 10 days ×2, 2 (2.7%) of 74 patients did so. Of the high-risk patients who were offered adjuvant treatment, 24% declined. As a consequence, the relapse rate of the surveillance patients only fell from 36% to 27% after the introduction of adjuvant therapy, although for the total cohort treated in the adjuvant era, the relapse rate was 16%. Conclusions Adjuvant chemotherapy is more effective than retroperitoneal lymph node dissection for reducing the relapse risk in high-risk Stage 1 nonseminoma. However, given the uncertainty about the incidence of postchemotherapy late events, surveillance and retroperitoneal lymph node dissection remain justified alternatives. With positron emission tomography and laparoscopy showing increasing promise in these cases, quality-of-life studies and greater patient involvement in treatment selection are needed.

Informed decision making: what is its role in cancer screening?

Interest in informed decision making (IDM) has grown in recent years. Greater patient involvement in decision making is consistent with recommendations to improve health care quality. This report provides an overview of IDM; clarifies the differences between IDM, shared decision making (SDM), and informed consent; and reviews the evidence to date about IDM for cancer screening. The authors also make recommendations for research. We define IDM as occurring when an individual understands the disease or condition being addressed and comprehends what the clinical service involves, including its benefits, risks, limitations, alternatives, and uncertainties; has considered his or her preferences and makes a decision consistent with them; and believes he or she has participated in decision making at the level desired. IDM interventions are used to facilitate informed decisions. The authors reviewed the evidence to date for IDM and cancer screening based primarily on published meta-analyses and a recent report for the Centers for Disease Control and Prevention's Guide to Community Preventive Services. IDM and SDM interventions, such as decision aids, result in improved knowledge, beliefs, risk perceptions, and combinations of these. Little or no evidence exists, however, regarding whether these interventions result in 1) participation in decision making at a level consistent with patient preferences or 2) effects on patient satisfaction with the decision-making process. These variables generally either were not assessed or were not reported in the articles reviewed. Results of interventions on uptake of screening were variable. After exposure to IDM/SDM interventions, most studies showed small decreases in prostate cancer screening, whereas four studies on breast and colorectal cancer screening showed small increases. Few data are available by which to evaluate current practices in cancer screening IDM. Patient participation in IDM should be facilitated for those who prefer it. More research is needed to assess the benefits of IDM/SDM interventions and to tailor interventions to individuals who are most likely to desire and benefit from them. There are many system barriers to IDM/SDM and few tools. More work is needed in this area as well. In addition, research is needed to learn how to incorporate IDM into ongoing clinical practice and to determine whether there are unintended negative consequences of IDM.