Incorporating Patient Preferences Research Articles

Patient preferences for noninsulin diabetes medications: a systematic review.

OBJECTIVEAn evidence-based synthesis of patient preferences for management of hyperglycemia is needed. Our objective was to systematically review patient preferences for noninsulin diabetes medications in adults with type 2 diabetes.RESEARCH DESIGN AND METHODSWe searched the PubMed, Embase, CINAHL, and EconLit databases for articles published on or before 23 January 2013. We included English-language studies of adult patients with type 2 diabetes that assessed patient preferences for diabetes medication treatment. Titles, abstracts, and articles were reviewed by at least two independent reviewers. Study data and quality were abstracted with standard protocols.RESULTSOf 2,811 titles identified in our original search, 10 articles met inclusion criteria for the systematic review. Studies were conducted from 2007 to 2012 among diverse patient populations in the U.S., Sweden, Denmark, and the U.K. Methods used to assess patient preferences included discrete choice experiments (e.g., conjoint analysis), time tradeoff exercises, standard gamble, and patient surveys. Key attributes of diabetes medication associated with patient preferences included treatment benefits (e.g., glycemic control and weight loss/control), treatment burden (e.g., administration, frequency, and cost), and side effects (e.g., weight gain, gastrointestinal effects, and hypoglycemia).CONCLUSIONSVarious clinical and quality of life–related factors influence patient preferences for noninsulin diabetes medications. Treatment efficacy with regard to glycemic control and weight loss/control and the risk of treatment-related hypoglycemia and gastrointestinal effects are reported to be important drivers of patient treatment selections. Future work is needed to identify practical methods for incorporating patient preferences into treatment decision making and patient-centered care.

In Response

We agree with Tsai and Grondin1 that the time frame of the cost-effectiveness analysis is an important parameter that investigators need to carefully choose when creating a computer model of the impact of a treatment or intervention. A long-term time horizon incorporating an expansive array of possible outcomes and expenses is ultimately preferable since limiting the analysis to only a brief period after the intervention may miss important potential developments such as an increased risk of complications (e.g., increased risk of developing placenta accreta in a subsequent pregnancy if the external cephalic version (ECV) is unsuccessful, and a cesarean delivery is required). When designing the computer model to study the economics of an intervention, the investigator must decide on a time frame that is long enough (such as hospital discharge) to be helpful for the clinician, but not so long that analytical and modeling errors are introduced. This balance is complex; expanding the time horizon results in increased possibilities of patient outcomes that become very difficult to quantify. Another real challenge existing for public health users is implementing the cost-effectiveness intervention and organizing the system of care to make certain that all patients that should receive the intervention actually receive it on a consistent basis. Just because an intervention such as neuraxial anesthesia to facilitate ECV is deemed cost-effective may not necessarily lead to increased use. Many patients in the United States and the world may not receive neuraxial anesthesia to facilitate ECV for a variety of reasons, including those specific to the individual physician, the hospital, or related to the broader structure of the entire health care system. Implementation science, or the study of methods to promote the integration of research findings and evidence into health care practice, is the next important step for economic analyses in health care to actually impact patient care. Finally, although the cost-effectiveness analysis result may support an intervention for a large group of hypothetical patients, the findings may not apply to an individual patient. This is because patients may have very different preferences about their care. For example, if a patient has a strong preference to avoid a cesarean delivery, then an ECV trial with neuraxial anesthesia may be more desirable than for another patient with breech fetal presentation who does not have a strong preference against a cesarean delivery. Real-world application of cost-effectiveness analysis needs to consider and incorporate patient preferences and societal values toward the intervention or treatment. Alex Macario, MD MBA Brendan Carvalho, MBBCh, FRCA Department of Anesthesiology Stanford University School of Medicine Palo Alto, California [email protected] Jonathan M. Tan, MD MPH Department of Anesthesiology Children’s Hospital of Pittsburgh Pittsburgh, Pennsylvania Pervez Sultan, MBChB, FRCA Department of Anesthesiology Royal Free Hospital London, United Kingdom Yasser Y. El-Sayed, MD Department of Obstetrics and Gynecology Stanford University School of Medicine Palo Alto, California

Shared Decision Making

Patients have traditionally entrusted decision making to physicians. However, during the past several decades, patients have been encouraged to become more activated and involved in their health decisions. These situations abound in cardiology, for example, therapy for stable coronary artery disease, anticoagulation for atrial fibrillation, and placement of implantable cardioverter-defibrillators. Each condition demands patient participation in the decision-making process because patients live with the consequences of medical decisions in their day-to-day lives. Unfortunately, research has also shown that patients often are misinformed about the risks and benefits associated with treatments and have little involvement in the decision-making process.1,2 Thus, 1 of the great challenges of increasing patient engagement is ensuring that patients make informed, evidence-based decisions that are consistent with their values and preferences. Shared decision making (SDM) has come to the forefront as a way to improve clinical care for patients by encouraging the production and dissemination of accurate, balanced, understandable health information and increasing patient participation in care. SDM interventions have been shown to improve patients’ understanding of the available treatment options, increase the proportion of patients with realistic expectations of benefits and harms, stimulate patients’ involvement in decision making, and improve agreement between patients’ values and treatment choices.3 Incorporating patient preferences into the decision-making process may also lead to improved patient well-being through better adherence to treatment, fewer concerns about illness, and higher satisfaction with health outcomes.4,5 In this article, we review the state of the science in the field of SDM. We discuss models of SDM, as well as methods for providing decision support to patients, including best practices for risk communication, efficacy of decision aids (DAs) for decision support, and use of decision coaches to facilitate shared decision making. SDM was first invoked by the President’s Commission for …

Health Literacy and Patient-Centered Care in Audiology – Implications for Adult Aural Rehabilitation

A fundamental principle in adult audiological rehabilitation should be the incorporation of patient preferences and health literacy into the counseling, intervention and management of older adults with hearing impairment. However, there is a lack of field-specific research to help guide audiologists in delivery of gold standard, evidence-based practice in this arena. This is a pressing concern, given the demographic shift to an aging population in which hearing impairment is increasing in both prevalence and severity. This paper examines how Patient-Centered Care (PCC) and health literacy form the interlocking foundations that can greatly influence an individual’s decision making, adherence to treatment, health outcome and overall health status. A brief review of the literature is included, together with a discussion of relevant resources for clinicians who wish to integrate health literacy and PCC into rehabilitative practice.

Patients’ preferences for selection of endpoints in cardiovascular clinical trials

BackgroundTo reduce the duration and overall costs of cardiovascular trials, use of the combined endpoints in trial design has become commonplace. Though this methodology may serve the needs of investigators and trial sponsors, the preferences of patients or potential trial subjects in the trial design process has not been studied.ObjectiveTo determine the preferences of patients in the design of cardiovascular trials.DesignParticipants were surveyed in a pilot study regarding preferences among various single endpoints commonly used in cardiovascular trials, preference for single vs. composite endpoints, and the likelihood of compliance with a heart medication if patients similar to them participated in the trial design process.ParticipantsOne hundred adult English-speaking patients, 38% male, from a primary care ambulatory practice located in an urban setting.Key resultsAmong single endpoints, participants rated heart attack as significantly more important than death from other causes (4.53 vs. 3.69, p=0.004) on a scale of 1–6. Death from heart disease was rated as significantly more important than chest pain (4.73 vs. 2.47, p<0.001), angioplasty/PCI/CABG (4.73 vs. 2.43, p<0.001), and stroke (4.73 vs. 2.43, p<0.001). Participants also expressed a slight preference for combined endpoints over single endpoint (43% vs. 57%), incorporation of the opinions of the study patient population into the design of trials (48% vs. 41% for researchers), and a greater likelihood of medication compliance if patient preferences were considered during trial design (67% indicated a significant to major effect).ConclusionsPatients are able to make judgments and express preferences regarding trial design. They prefer that the opinions of the study population rather than the general population be incorporated into the design of the study. This novel approach to study design would not only incorporate patient preferences into medical decision making, but it also has the potential to improve compliance with cardiovascular medications.

A survey of Australian chiropractors’ attitudes and beliefs about evidence-based practice and their use of research literature and clinical practice guidelines

BackgroundResearch into chiropractors’ use of evidence in clinical practice appears limited to a single small qualitative study. The paucity of research in this area suggests that it is timely to undertake a more extensive study to build a more detailed understanding of the factors that influence chiropractors’ adoption of evidence-based practice (EBP) principles. This study aimed to identify Australian chiropractors’ attitudes and beliefs towards EBP in clinical practice, and also examine their use of research literature and clinical practice guidelines.MethodsWe used an online questionnaire about attitudes, beliefs and behaviours towards the use of EBP in clinical practice that had been developed to survey physiotherapists and modified it to ensure that it was relevant to chiropractic practice. We endeavoured to survey all registered Australian chiropractors (n = 4378) via email invitation distributed by Australian chiropractic professional organisations and the Chiropractic Board of Australia. Logistic regression analyses were conducted to examine univariate associations between responses to items measuring attitudes and beliefs with items measuring: age; years since registration; attention to literature; and use of clinical practice guidelines.ResultsQuestionnaires were returned by 584 respondents (response rate approximately 13%). The respondents’ perceptions of EBP were generally positive: most agreed that the application of EBP is necessary (77.9%), literature and research findings are useful (80.2%), EBP helps them make decisions about patient care (66.5%), and expressed an interest in learning or improving EBP skills (74.9%). Almost half of the respondents (45.1%) read between two to five articles a month. Close to half of the respondents (44.7%) used literature in the process of clinical decision making two to five times each month. About half of the respondents (52.4%) agreed that they used clinical practice guidelines, and around half (54.4%) agreed that they were able to incorporate patient preferences with clinical practice guidelines. The most common factor associated with increased research uptake was the perception that EBP helps make decisions about patient care.ConclusionsMost Australian chiropractors hold positive attitudes towards EBP, thought EBP was useful, and were interested in improving EBP skills. However, despite the favourable inclination towards EBP, many Australian chiropractors did not use clinical practice guidelines. Our findings should be interpreted cautiously due to the low response rate.

Development of a pancreas kidney transplant program: Evaluation of the influence of the learning curve. Results for 4 years

Clinical decision analysis has become an important tool for evaluating specific clinical scenarios and exploring public health policy issues. A decision analysis model that incorporates patient preferences regarding various outcomes, as well as cost, may be particularly informative in patients with type I diabetes and end-stage renal disease (ESRD). Such a model that includes pancreas transplantation as a treatment choice has not been performed and is presented in this study. The decision tree consisted of a choice between four possible treatment strategies: dialysis, kidney-alone transplant from a cadaver (KA-CAD) or living donor (KA-LD), and simultaneous pancreas-kidney (SPK) transplant. The analysis was based on a 5-year model, and the measures of outcome used in the model were cost and cost adjusted for quality of life. The measure of preference for quality of life was obtained using the "Standard Reference Gamble" method in 17 SPK transplant recipients who underwent transplantation between January, 1992 and June, 1996 at our center. The measures for various outcome states (mean +/- 1 SD) were dialysis-free/insulin-free = 1, dialysis- free/insulin-dependent = 0.6 (0.4 to 0.8), dialysis-dependent/insulin- free = 0.5 (0.36 to 0.64), dialysis-dependent/insulin-dependent = 0.4 (0.21 to 0.59), and death = 0. The expected 5-year costs for each of the treatment strategies in the model were dialysis, $216,068; KA-CAD transplant, $214,678; KA-LD transplant, $210,872; and SPK transplant, $241,207. The expected cost per quality-adjusted year for each of the treatment strategies in the model were dialysis, $317,746; KA-CAD transplant, $156,042; KA-LD transplant, $123,923; and SPK transplant, $102,422. SPK transplantation remained the optimal strategy after varying survival probabilities, costs, and utilities over plausible ranges by means of one-way sensitivity analysis. In conclusion, according to the 5-year cost-utility model presented in this study, SPK transplantation is the most cost-effective treatment strategy for a patient with type I diabetes and ESRD. From a policy standpoint, looking at the cost alone of pancreas transplantation is deceiving. In these patients, who may view various outcome states differently, it would be important to take into account cost adjusted for quality of life when evaluating this procedure. (Am J Kidney Dis 1998 May;31(5):794-802)

Linking Evidence-Based Nursing Practice and Patient-Centered Care Through Patient Preferences

Calls for both patient-centered care and evidence-based practice (EBP) have increased dramatically over the last decade despite a tension between the two. Patient preferences, one of the cornerstones of EBP, can provide the link between the two. Although current research supports the added value of patient preferences in care, there is currently a "gap" between EBP and patient-centered care, with the two often viewed as opposing ideas. The purpose of this article is to provide an overview of patient preferences, summarize research on patient preferences, and discuss implications for nursing and nursing administration. Efforts to incorporate patient preferences into nursing care must be multifaceted, targeting multiple levels from individual nurses to organizations and systems. Four critical elements have been identified for integrating patient preferences into EBP: (1) health care redesign, (2) decision support, (3) empowered organizational culture, and (4) informed and empowered nurses.

QUANTITATIVE PATIENT PREFERENCE EVIDENCE FOR HEALTH TECHNOLOGY ASSESSMENT: A CASE STUDY

We conducted a systematic review of quantitative research regarding patients' preferences, perspectives and values for ventilation among chronic obstructive pulmonary disease (COPD) patients. Our objective was to explore the feasibility and desirability of incorporating patient preferences within the health technology assessment (HTA) process by working through a case study. Medical and economic databases were searched for studies published in English from 1990 through March 4, 2011. Studies were selected based on title and abstract. Due to the heterogeneity of the studies, data were analyzed using a narrative synthesis approach. Among 1833 identified citations, twelve studies met our inclusion criteria. Ten of these studies pertained to COPD patient preferences for ventilation. Results indicate that a significant proportion of COPD patients are willing to forgo ventilation, particularly when it is expressed as "indefinite life support" (60-78 percent) rather than as temporary modality. Results indicate that patient preferences for mechanical or noninvasive ventilation cannot be predicted by covariates (e.g., age, quality of life) or by others who are frequently called upon to make decisions are their behalf. We found that it is indeed feasible to conduct a systematic review of quantitative preference-related evidence for an HTA topic. However, the process of conducting this preference-related case study also revealed several challenges because there is a high degree of variation in taxonomy, instrumentation, and study design. Therefore, we do not recommend it as a routine part of the HTA process, but we suggest that it is a promising area to pursue for preference-sensitive technological decisions.

A survey to examine patient awareness, knowledge, and perceptions regarding the risks and consequences of surgical site infections

We surveyed patients to determine awareness and knowledge regarding risks and consequences of and prevention of surgical site infection (SSI), and we found that 26% of respondents thought that education for SSI prevention could be improved and that 16% could not recall discussing SSI risks and prevention with a health care worker at all. Only 60% of patients recalled receiving an informational flyer in the hospital. Our results show that better educational and engagement interventions incorporating patient preferences are needed to promote awareness and patient engagement regarding SSI prevention.

Influence of Patient Characteristics on Assessment of Diabetes Self-Management Support

Factors contributing to patient-reported experiences of diabetes self-management support are not understood well, particularly over time. The aim of the study was to identify the contribution of patient characteristics to patient-reported quality of SMS. Using secondary data from a prospective clinical trial (n = 339) comparing three approaches of providing diabetes self-management support (Group Medical Visits, Automated Telephone Support, and Usual Care) in a diverse, underserved population, the influence of patient characteristics (e.g., age, gender, income, and health status) was examined on Patient Assessment of Chronic Illness Care ratings. At baseline, older age (p = .014), being female (p = .038), and having lower income (p = .001) were associated with lower ratings. Income and interactions involving income combined explained 12% of the variance in baseline ratings. Compared with White patients, African American and Asian patients tended to have higher baseline ratings (p = .076 and p = .045, respectively). Race or ethnicity influenced perceptions throughout the trial, explaining 5% of the variance at baseline and 2% of the variance in 1-year changes in Patient Assessment of Chronic Illness Care ratings. As expected, over 1 year, ratings increased more for patients in both intervention groups compared with the control group (p < .001). Ratings of healthcare quality are influenced by patient characteristics independent of the nature of the care provided. Understanding more precisely how these differences are associated with differences in clinical processes will be particularly important for efforts aiming to integrate patient-reported measures into assessments of healthcare quality during routine clinical care and clinical trials.

Orthopaedic Healthcare Worldwide: Shared Medical Decision Making in Orthopaedics

Orthopaedic Healthcare Worldwide: Shared Medical Decision Making in Orthopaedics

Current status and future prospects for electronic point-of-care clinical decision support in diabetes care.

Early efforts to use point-of-care clinical decision support (CDS) were limited to the use of prompts and reminders, which improved test ordering but not intermediate outcomes of care, such as glucose, blood pressure, or lipid levels. More sophisticated diabetes CDS tools are now available that use electronic medical record data to provide patient-specific advice on medication use on the basis of previous treatment, distance from goal, and other clinical data. These tools have shown modest but significant improvement in glucose and blood pressure control. Promising next-generation developments will include prioritizing clinical actions that have maximum benefit to a given patient at the point of care and developing effective methods to communicate CDS information to patients to better incorporate patient preferences in care decisions.

Evaluating a preference-tailored decision tool for increasing colorectal cancer screening.

10 Background: Incorporating patient preferences into CRC screening decisions has been identified as one method for improving informed decision making and increasing screening adherence, yet the impact of tailoring screening recommendations to patients’ preferences on these outcomes has not been evaluated. Methods: We compared the effect of a web-based preference-tailored decision tool (intervention) to a standard information decision tool (control) through an RCT at two VA sites. Eligible subjects were age 50-77, due for CRC screening, with a scheduled primary care visit. Participants arrived 45 minutes early to complete consent and were randomized online. Telephone surveys were conducted 3-5 days post-enrollment and CRC screening adherence was collected from medical charts 6 months later. We evaluated the effect of the tool on adherence and compared stated test preferences to test recevived through Chi-square tests and regression. Results: 468 subjects were enrolled from two VAs. CRC screening adherence 6-months post-enrollment was 38.6% and was not significantly different between groups (37.4% intervention, 39.7% control). Most were adherent with fecal occult blood test (FOBT) (22.4%), followed by colonoscopy (COL) (16.7%). The most commonly recommended test by physicians was COL (59.2% of tests recommended), though veterans most commonly stated a preference for FOBT (60.1%). The features of tests most important to veterans were nature of the test (32.8%), effectiveness (27.1%), and risk of complications (17%). Participants significantly more often adhered to the test that they stated they preferred after the intervention than with a non-preferred test (30.4% adhered to preferred test vs. 7.6% adhered to non-preferred test, P&lt;0.001). Conclusions: CRC screening adherence in this population of veterans was low and the preference-tailored intervention did not significantly improve adherence relative to standard information. Veterans preferred a non-invasive test (FOBT) despite higher rates of recommendation for COL by their physicians. Improving concordance between physician recommendations and patients’ preference may be one method for improving CRC screening adherence in this population.

Employer-based patient-centered medication therapy management program: Evidence and recommendations for future programs

To evaluate a patient-centered employer-based medication therapy management (MTM) program. Randomized controlled study. Health promotion program at the University of Michigan from June 2009 to December 2011. Employees, retirees, and their dependents taking seven or more prescription medications. Focus on Medicines (FOM) was a two-visit, patient-centered service with a 4-month follow-up. A comprehensive medication review occurred during the first visit. Pharmacists provided recommendations and a medication action plan at the second visit. The MAP incorporated patient preferences for problem resolution. Patient uptake, medication cost, medication adherence, patient satisfaction with treatment, patient reasons for participation, patient satisfaction with the FOM program, drug-related problems, pharmacist recommendations, implementation of recommendations. The FOM program attracted 128 individuals wanting information about their medications and an individualized drug regimen assessment to ensure that their therapy was safe and effective and that all medications were necessary. On average, 3.3 medication therapy problems were identified per patient; most were safety related. Overall, 63% of pharmacist recommendations were implemented. When a prescriber was contacted, 83% of pharmacist recommendations were implemented. A reduction in drug cost for patients and the employer was shown. Patients reported improved convenience in taking medications and rated the program favorably. A personalized dialogue about medication use appears to meet a need among individuals taking large numbers of medications. Understanding why patients participate in MTM programs and what program features patients appreciate is useful in designing quality MTM programs.

A Systematic Review and Meta-Analysis of Utility-Based Quality of Life in Chronic Kidney Disease Treatments

Chronic kidney disease (CKD) is a common and costly condition to treat. Economic evaluations of health care often incorporate patient preferences for health outcomes using utilities. The objective of this study was to determine pooled utility-based quality of life (the numerical value attached to the strength of an individual's preference for a specific health outcome) by CKD treatment modality. We conducted a systematic review, meta-analysis, and meta-regression of peer-reviewed published articles and of PhD dissertations published through 1 December 2010 that reported utility-based quality of life (utility) for adults with late-stage CKD. Studies reporting utilities by proxy (e.g., reported by a patient's doctor or family member) were excluded. In total, 190 studies reporting 326 utilities from over 56,000 patients were analysed. There were 25 utilities from pre-treatment CKD patients, 226 from dialysis patients (haemodialysis, n = 163; peritoneal dialysis, n = 44), 66 from kidney transplant patients, and three from patients treated with non-dialytic conservative care. Using time tradeoff as a referent instrument, kidney transplant recipients had a mean utility of 0.82 (95% CI: 0.74, 0.90). The mean utility was comparable in pre-treatment CKD patients (difference = -0.02; 95% CI: -0.09, 0.04), 0.11 lower in dialysis patients (95% CI: -0.15, -0.08), and 0.2 lower in conservative care patients (95% CI: -0.38, -0.01). Patients treated with automated peritoneal dialysis had a significantly higher mean utility (0.80) than those on continuous ambulatory peritoneal dialysis (0.72; p = 0.02). The mean utility of transplant patients increased over time, from 0.66 in the 1980s to 0.85 in the 2000s, an increase of 0.19 (95% CI: 0.11, 0.26). Utility varied by elicitation instrument, with standard gamble producing the highest estimates, and the SF-6D by Brazier et al., University of Sheffield, producing the lowest estimates. The main limitations of this study were that treatment assignments were not random, that only transplant had longitudinal data available, and that we calculated EuroQol Group EQ-5D scores from SF-36 and SF-12 health survey data, and therefore the algorithms may not reflect EQ-5D scores measured directly. For patients with late-stage CKD, treatment with dialysis is associated with a significant decrement in quality of life compared to treatment with kidney transplantation. These findings provide evidence-based utility estimates to inform economic evaluations of kidney therapies, useful for policy makers and in individual treatment discussions with CKD patients.

Improving the efficiency and relevance of evidence-based recommendations in the era of whole-genome sequencing: an EGAPP methods update.

To provide an update on recent revisions to Evaluation of Genomic Applications in Practice and Prevention (EGAPP) methods designed to improve efficiency, and an assessment of the implications of whole genome sequencing for evidence-based recommendation development. Improvements to the EGAPP approach include automated searches for horizon scanning, a quantitative ranking process for topic prioritization, and the development of a staged evidence review and evaluation process. The staged process entails (i) triaging tests with minimal evidence of clinical validity, (ii) using and updating existing reviews, (iii) evaluating clinical validity prior to analytic validity or clinical utility, (iv) using decision modeling to assess potential clinical utility when direct evidence is not available. EGAPP experience to date suggests the following approaches will be critical for the development of evidence based recommendations in the whole genome sequencing era: (i) use of triage approaches and frameworks to improve efficiency, (ii) development of evidence thresholds that consider the value of further research, (iii) incorporation of patient preferences, and (iv) engagement of diverse stakeholders. The rapid advances in genomics present a significant challenge to traditional evidence based medicine, but also an opportunity for innovative approaches to recommendation development.

Evidence, Preferences, Recommendations—Finding the Right Balance in Patient Care

The authors of this report use a clinical case to highlight the difficulties of integrating patient preferences in making decisions in medical care based on evidence-based medicine. As an increasing number of evidence-based performance measures are used to monitor care, there has been growing awareness that patient preferences should play a major part in medical decisions. It has been suggested that some physicians, in the interest of patient autonomy, tend to place too much of the burden of medical decision-making responsibilities on patients. Although it is clear that patients’ preferences and values should not be the sole drivers of clinical decisions, it is also increasingly clear that wide gaps remain in the practice of shared decision making. The case involved a 75-year-old man with congestive heart failure with repeated admissions to a hospital. Because he was not a candidate for a heart transplant, his cardiologist recommended a destination ventricular assist device (VAD). The patient was ambivalent about trying the VAD. Progress has been made in incorporating patient preferences in medical decision making, but much more work is needed. To this end, the authors have developed a 5-step framework for incorporating the best features of an evidence-based and preference-based approach. The first step in practicing preference-based medicine is to have an effective meeting of the patient, family members, and appropriate members of the treatment team. Clinicians must carefully clarify the medical evidence concerning benefits and burdens of future treatment. The second step involves sharing information and expertise with the patient and family. The treating physicians should explain treatment options and prognosis with and without the treatment while learning about the patient’s values, priorities, and expectations in light of the medical facts. Patient preferences may be broad in that some may lean toward aggressive interventions to prolong life and others toward naturalism. The third step is to critically evaluate the evidence and identify physician and patient biases that might influence decision making. Unrealistic overly optimistic expectations of prolonged life or acceptance of the likelihood of death have a major impact in patient preferences. The fourth step involves integration of the information from the evidence-based and preference-based approaches and making a recommendation on future care. In the case of the patient with end-stage congenital heart defect, the treating cardiologist evaluated the benefits of a VAD in light of patient and family expectations, goals, and clear understanding of the likely outcome with and without VAD insertion. With input from the VAD and palliative care teams, the cardiologist recommended against a VAD. After discharge to home hospice, the patient continued his heart-failure treatments, hoping to live as well and as long as he could without further invasive interventions. In the fifth step, physician performance is evaluated. All aspects of the decision-making process are examined to ensure that the recommendation of the clinicians incorporated the preferences of patients and families. This case demonstrates that medical decisions regarding future care that allow patients to get the most out of medical interventions are those that integrate the preferences of informed patients and families who understand the clinical implications of the decision.

Therapy for Sleep Hypoventilation and Central Apnea Syndromes

• Primary Central Sleep Apnea (CSA): We would recommend a trial of Positive Airway Pressure (PAP), acetazolamide, or zolpidem based on thorough consideration of risks and benefits and incorporation of patient preferences.• Central Sleep Apnea Due to Cheyne-Stokes Breathing Pattern in Congestive Heart Failure (CSR-CHF): We would recommend PAP devices such as continuous positive airway pressure (CPAP) or adaptive servo-ventilation (ASV) to normalize sleep-disordered breathing after optimizing treatment of heart failure. Oxygen may also be an effective therapy. Acetazolamide and theophylline may be considered if PAP or oxygen is not effective.• Central Sleep Apnea due to High-Altitude Periodic Breathing: We would recommend descent from altitude or supplemental oxygen. Acetazolamide may be used when descent or oxygen are not feasible, or in preparation for ascent to high altitude. Slow ascent may be preventative.• Central Sleep Apnea due to Drug or Substance: If discontinuation or reduction of opiate dose is not feasible or effective, we would recommend a trial of CPAP, and if not successful, treatment with ASV. If ASV is ineffective or if nocturnal hypercapnia develops, bilevel positive airway pressure-spontaneous timed mode (BPAP-ST) is recommended.• Obesity hypoventilation syndrome: We would recommend an initial CPAP trial. If hypoxia or hypercapnia persists on CPAP, BPAP, BPAP-ST or average volume assured pressure support (AVAPS™) is recommended. Tracheostomy with nocturnal ventilation should be considered when the above measures are not effective. Weight loss may be curative.• Neuromuscular or chest wall disease: We would recommend early implementation of BPAP-ST based on thorough consideration of risks and benefits and patient preferences. AVAPS™ may also be considered. We recommend close follow up due to disease progression.

Hemodialysis Reliable Outflow (HeRO) device in end-stage dialysis access: a decision analysis model

BackgroundThe Hemodialysis Reliable Outflow (HeRO) dialysis access device is a permanent tunneled dialysis graft connected to a central venous catheter and is used in patients with end-stage dialysis access (ESDA) issues secondary to central venous stenosis. The safety and effectiveness of the HeRO device has previously been proven, but no study thus far has compared the cost of its use with tunneled dialysis catheters (TDCs) and thigh grafts in patients with ESDA. Materials and methodsA decision analytic model was developed to simulate outcomes for patients with ESDA undergoing placement of a HeRO dialysis access device, TDC, or thigh graft. Outcomes of interest were infection, thrombosis, and ischemic events. Baseline values, ranges, and costs were determined from a systematic review of the literature. Total costs were based on 1year of post-procedure outcomes. Sensitivity analyses were conducted to test model strength. ResultsThe HeRO dialysis access device is the least costly dialysis access with an average 1-year cost of $6521. The 1-year cost for a TDC was $8477. A thigh graft accounted for $9567 in a 1-year time period. ConclusionsThe HeRO dialysis access device is the least costly method of ESDA. The primary determinants of cost in this model are infection in TDCs and leg ischemia necessitating amputation in thigh grafts. Further study is necessary to incorporate patient preference and quality of life into the model.