Involvement In Shared Decision Research Articles

Abstract P185: Patient Portal Access, Health Literacy, Patient Trust in Health System, and Shared Decision Making Among US Adults with Hypertension: A National Cross-Sectional Study

Background: Shared decision-making (SDM) is increasingly recognized as central to delivering patient-centered care and improving hypertension control. However, there is limited understanding of the association between patients' access to patient portals, health literacy, trust in the health system, and involvement in SDM. Objectives: This study investigated the associations between patients' access to patient portals, health literacy, trust in the health system, and patients’ involvement in SDM among adults with hypertension in the United States (US). Methods: This cross-sectional study utilized data from the 2022 Health Information National Trends Survey (HINTS 6) conducted among US adults. The exposure variables were patient portal use, health literacy, patients' trust in health systems, and whether the participant was offered access to patient portals by healthcare providers. The outcome of interest was whether patients were always involved in SDM (Yes/No) during the past 12 months. Analyses were weighted according to HINTS 6 methodology. We performed three weighted sequential multivariable logistic regression models (Fig. 1, Models 1-3). The fully adjusted model included demographics, clinical characteristics, and social determinants of health and resources for implementing SDM and was stratified by age (<65 and ≥65 years). Results: We included 1703 adults with hypertension (mean age of 61.6, SD 13.9 years; 52.5% male; and 64.9% White adults). About 86.4% of participants were offered online access to patient portals by their healthcare providers. In the fully adjusted model (Fig. 1, Model 3), adults who were offered access to patient portals (adjusted odds ratio [aOR] 1.90, 95% CI 1.03-3.49), with higher health literacy levels (aOR 2.18, 95% CI 1.42-3.34), and with higher trust in health systems (aOR 3.08, 95% CI 2.26-4.21) were more likely to engage in SDM than their counterparts. These associations were similar among adults <65 years (Fig. 2). However, among adults ≥65 years, offering online access to patient portals was not associated with involvement in SDM; while those who used the patient portal 6-9 times during the past 12 months were more likely to engage in SDM than those who never used it (aOR 2.26, 95% CI 1.06-4.83). Conclusion: Offering access to patient portals may enhance SDM among US adults with hypertension, especially for adults with higher health literacy levels and greater trust in health systems. These associations differed by age.

Exploring Patient Preferences Related to Shared Decision-Making in Chronic Disease Management.

Background and objective Shared decision-making (SDM) in healthcare has transitioned from a paternalistic model to a collaborative approach, particularly significant in chronic disease management. This shift focuses on aligning healthcare decisions with patient preferences and values, thereby enhancing patient engagement and treatment adherence. However, patient preferences regarding involvement in SDM vary widely, influenced by demographic, disease-specific, psychological, cultural, and social factors. This study aimed to explore patient preferences related to SDM in chronic disease management in Saudi Arabia, by assessing attitudes towardSDM, the impact of decision aids, and the role of clinician communication in influencing these preferences. Methods A cross-sectional survey design was employed, involving 409 adult outpatients with chronic diseases attending four public hospitals in Saudi Arabia. Participants were selected using purposive and convenience sampling. The survey, translated into Arabic, collected demographic data and information on preferences and experiences in decision-making, communication, and information sharing. The data were analyzed using SPSS Statistics (IBM Corp., Armonk, NY) to identify patterns and correlations. Results Key findings indicated a strong preference among the participants for involvement in treatment decisions (n=303, 74.2%) and clear communication using layman's terms (n=338, 82.6%). Major barriers to active participation in SDM included lack of time during appointments (n=275, 67.2%), difficulty understanding medical terminology (n=220, 53.9%), and feeling intimidated to ask questions (297, 72.6%).Comfort in SDM was highest intheage group of 41-50 years[mean=4.16, standard deviation (SD)=28.44; F=2.3287, p=0.0739]. Patient satisfaction was significantly higher in the age group of 18-30 years(mean=3.42, SD=1.09; F=3.0503, p=0.0284). Conclusions Our findings highlightthe need for incorporating patient preferences into chronic disease management strategies to enhance engagement and satisfaction.

Patient experience and satisfaction with shared decision-making: A cross-sectional study among outpatients

ObjectivesThis study aimed to investigate how doctor-patient communication, trust in doctors impacted patients’ experience and satisfaction in shared decision-making (SDM). MethodsThis study is based on the data from a cross-sectional survey (n = 12,401) conducted in 27 public specialist outpatient clinics in Hong Kong. ResultsThe multivariable regression models revealed that doctors’ better communication skills were associated with lower decision-making involvement (odd ratio, 0.75 [95 % CI, 0.88–0.94], P < .001) but higher satisfaction with involvement (odd ratio, 6.88 [95 % CI, 5.99–7.93], P < .001). Similarly, longer consultation durations were associated with reduced involvement in decision-making (odd ratio, 0.71 [95 % CI, 0.66–0.73], P < .001) but increased satisfaction with involvement (odd ratio, 1.91 [95 % CI, 1.80–2.04], P < .001). Trust in doctors significantly mediated these associations, except for the association between consultation duration and patients’ satisfaction with decision-making involvement. ConclusionDoctors’ better communication skills and longer consultations might not necessarily increase patient involvement in SDM but correlated with increased satisfaction with involvement. Trust in doctors emerged as a mediator for participation and satisfaction in decision-making. Practice implicationsClinics should consider patients’ preferences and capabilities when tailoring communication strategies about decision-making and optimizing patient satisfaction.

Empowered hospitalized patients are involved in shared decision making on antibiotic therapy: a quantitative analysis

BackgroundHalf of hospitalised patients receive antibiotics, but they are rarely involved in shared decision making (SDM) on antibiotic therapy. We sought to understand the association between patient empowerment and their involvement in SDM on antibiotic therapy. MethodsFrom March 2021 to April 2022, we conducted a cross-sectional survey on hospitalised patients receiving antibiotic therapy for ≥1 day in a 1600-bed adult general hospital in Singapore. The questionnaire included 7 items (5-point Likert scale) on involvement in SDM from SDM-Q-9 (Kriston,2012) and 10 items (4-point Likert scale) on patient empowerment from HCEQ-10 (Gagnon,2006). A multivariable logistic regression model was constructed to assess for independent associations between the three constructs of patient empowerment and involvement in SDM on antibiotic therapy. ResultsOf 636 hospitalised patients, mean age was 57.6 (SD 15.5) years, 61% were males and 37% had tertiary-level education. The majority (90%) were aware that they were on antibiotic therapy, but only 11% of them knew the name of the antibiotic given. After adjusting for age, gender, ethnicity, educational level, and duration of hospital stay, patients with a high-level of involvement in decisions (Adjusted odds ratio[AOR] 3.63, 95% CI 2.19-6.01), interactions with healthcare professionals (AOR 1.77, 95% CI 1.03-3.02), and degree of control over their hospital care (AOR 1.90, 95% CI 1.15-3.12) were more likely to have a high-level of involvement in SDM on antibiotic therapy. ConclusionsEmpowering hospitalised patients with involvement in decisions, interactions with healthcare professionals, and control of their hospital care can increase their participation in SDM on antibiotic therapy in hospitals.

Parenteral versus enteral fluids for infants hospitalized with bronchiolitis: The PREFER shared decision-making prospective observational study protocol.

Incorporating shared decision-making (SDM) with children and families in hospitals was a top priority identified by patients, caregivers, and clinicians. Bronchiolitis, a common and costly reason for hospitalization in children, is an exemplar condition to study SDM in hospitals. Internationally, clinical practice guidelines differ when recommending intravenous (IV or parenteral) or nasogastric (NG or enteral) fluids for hospitalized infants with bronchiolitis who are unsafe to be fed orally. While evidence indicates that either IV or NG fluids are safe and effective, parent involvement in SDM in selecting IV or NG fluids is unknown. Our aim is to generate knowledge of SDM with parents in choosing between IV or NG fluids and the benefits and harms of these two treatment options for hospitalized children with bronchiolitis. This is a multicenter, prospective, observational study, including children aged <12 months admitted to hospital with bronchiolitis requiring supplemental IV or NG fluids. The primary outcome will evaluate the extent of SDM in choosing IV versus NG fluids using the validated CollaboRATE tool. Secondary outcomes include the proportion of parents provided a choice of IV versus NG fluids; parent knowledge of fluid therapy; rate of fluids; length of hospital stay; and complications. This study will evaluate the extent of SDM in hospitalized infants with bronchiolitis who require IV or NG fluids and will evaluate both patient-centered and clinical outcomes that are relevant to clinical practice.

Associations between physicians' SDM behaviour and participation of older patients and family members in triadic decision-making: An observational study

BackgroundMedical consultations with older patients often include triadic conversations and decision-making processes involving physicians, patients, and family members. The presence of family members may change the communication dynamics and therefore increase the complexity of the consultation and decision-making process. ObjectiveThis study explored associations between physicians' shared decision-making (SDM) behaviour and patients' and family members' participation in the decision-making process. MethodsUsing an observational design, we analysed 95 recorded consultations between medical specialists, patients aged ≥65 years, and accompanying family members at a Dutch hospital. The OPTIONMCC was used to assess the physicians' SDM behaviour and patients' and family members' levels of involvement in SDM. ResultsWe found a strong positive correlation between physicians' behaviour and patients' and family members' participation in SDM (0.68 and 0.64, respectively, p < .01). Family members were more involved in SDM for patients aged 80 and older. ConclusionWhile not asserting causation, our study suggests physicians potentially play a facilitating role in shaping the SDM process together with proactive contributions from patients and family members. InnovationThe results offer new insights into triadic SDM and provide suggestions for refining the OPTIONMCC. Further research is recommended into participants' mutual directional influences in triadic SDM.

The effect of care team-patient relationship on decision-making in relapsed/refractory multiple myeloma.

e19530 Background: Understanding patient involvement in shared decision making is critical for informed decision-making for relapsed/refractory multiple myeloma (RRMM) patients. This study explored the relationships between care teams and patients, who patients talk to and quantify the level of involvement, satisfaction, and comfort in the process of reaching a final change in treatment decision. Methods: HealthTree Cure Hub (PMID: 35271305) was used to conduct a survey for RRMM patients for their first change of therapy decision. Five-point Likert scales were used (1-Not at All Influential to 5-Extremely Influential; 1-Very Satisfied to 5-Very Dissatisfied), along with dichotomous and categorical choices. Results: 294 patients with RRMM were included with a mean age of 66±9, 53% were female, and 49% had graduate level education. Of 219 demographics respondents, 91% were white. Of the people patients talked to, the most influential individuals ranked by somewhat to extremely influential were: 1) myeloma specialist (84%), 2) community hematologist/oncologist (69%), and 3) spouse, partner or significant other (56%). Additionally, 67% of patients talked with nurses, PAs, or RNAs, with 49% finding them somewhat to extremely influential. Seeking a second opinion from a myeloma specialist was reported by 34% of patients and 50% of patients reported talking to other patients about treatment decisions. Patients varied in their description of their relationship/communication approach with their doctor: the doctor makes recommendations, the patients ask questions and they discuss preferences, then 1) patient proposes ideas and the decision is made together (37%), 2) then the patient makes the final decisions (21%) and 3) then the patient follows the doctor’s suggestions (14%). Importantly, a weak positive relationship existed between these levels of patient involvement in the treatment decisions and their involvement-satisfaction in choosing a treatment (r = 0.251, p &lt; 0.001). About half of patients (51%) followed their care team recommendations without changes, while 31% opted for significant alterations, and 19% chose a modified option. Most patients reported making the final decision (59%), followed by their doctor (40%), and the minority reported a caregiver or partner (1%). Conclusions: This study identified that about half of patients engage in a collaborative and active decision-making process, which was related to their involvement-satisfaction of the treatment decision. Patients actively engaged with various individuals, including myeloma specialists, community hematologists/oncologists, and spouse/partners. Notably, discussions with nurses, PAs, and RNAs played a significant role, along with interactions with peers. Taken together a multifaceted engagement highlights the active role of patients in determining their treatment paths within a complex healthcare network.

The role of shared decision-making in cancer pain management: Insights from a systematic review.

e24078 Background: Effective pain management in cancer care is crucial for patient quality of life. Shared decision-making (SDM) interventions are increasingly recognized for their potential to improve patient outcomes by facilitating patient engagement in care decisions. This systematic review synthesizes evidence on the impact of SDM interventions in cancer pain management. Methods: This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We conducted a comprehensive search across multiple databases, including PubMed, EMBASE, Scopus, CINAHL, PsycINFO, Web of Science, and the Cochrane Library. The search also extended to grey literature sources such as conference proceedings, dissertations, and unpublished reports to ensure a thorough coverage of the subject matter. Our search strategy employed a combination of MeSH terms and keywords related to 'decision making,' 'patient participation,' 'pain management,' and 'cancer.' This strategy was tailored to each database's unique syntax and search operators. Results: Ten studies, including six pilot and feasibility studies and four randomized controlled trials (RCTs) and Preintervention-Postintervention studies, were systematically reviewed. The interventions implemented diverse SDM strategies ranging from digital tools and personalized education to clinical decision support systems, targeting key aspects of pain management and patient-provider communication. Frequent intervention components included patient-reported outcome dashboards, symptom management support, and educational resources for pain management. The Tailored Education and Coaching (TEC) intervention notably increased pain-specific patient communication by 31%, while the PAINRelieveIt intervention did not significantly impact analgesic adherence but effectively reduced pain misconceptions among caregivers. Some interventions, like the Carevive CPS, showed high patient involvement in SDM (94.1%) and compliance with quality oncology practice initiative metrics (98%). However, the effectiveness of these interventions varied, with some showing no significant impact on primary pain outcomes. The variability in measured outcomes such as pain intensity, analgesic adherence, and patient satisfaction indicates a context-dependent effectiveness of SDM interventions, highlighting the importance of personalized approaches and the role of implementation strategies in influencing patient engagement and intervention success. Conclusions: SDM interventions in cancer pain management are diverse in structure and impact. Some interventions show promise in improving communication and reducing misconceptions, but their direct effect on pain outcomes varies.

Patients’ experiences with shared decision-making in home-based palliative care – navigation through major life decisions

BackgroundThis study addresses the issue of shared decision-making (SDM) in a Norwegian home-based palliative care setting. The significance of patient involvement in SDM is widely acknowledged, and many patients want to participate in decisions about care and treatment. Yet, it remains a need for more knowledge regarding the initiators and approaches of SDM in the context of home-based palliative care, particularly from the patients’ perspective. The aim of this study is to understand patients' experiences and preferences for SDM in home-based palliative care, seeking to enhance the quality of care and direct the planning of healthcare services.MethodsWe used a qualitative explorative design. A hermeneutic approach was employed, and data was collected through in-dept interviews with 13 patients.ResultsThe study uncovered an overarching theme of "Navigating to reach own decisions," comprising three sub-themes: “To be trapped in life without decisions to act on”; “To surrender to others and let others deal with decisions”; “To continue to be oneself without focusing on disease and decision-making”.ConclusionsThe findings underscore the need for flexible, person-centered approaches in SDM, tailored to the fluctuating health literacy and changing preferences of patients in palliative care settings. Our study contributes to the understanding of SDM in palliative care by highlighting how patients navigate the balance between autonomy and reliance on HCPs. Future research should explore how healthcare systems, including HCPs’ roles in the system, can adapt to the patients’ dynamic needs, to ensuring that SDM will remain a supportive and empowering process for patients at all stages of their disease.

A survey on service users' perspectives about information and shared decision‐making in psychotropic drug prescriptions in people with intellectual disabilities

AbstractBackgroundIn people with intellectual disabilities and mental disorders and/or challenging behaviours, rates of psychotropic drug prescription are high. In clinical treatments and evaluations, all stakeholders should be involved in a process of shared decision‐making (SDM). We aimed to investigate the perspectives of clients and their carers on clients’ treatments with psychotropic drugs.MethodsWe conducted a survey among adults with intellectual disabilities in a Dutch mental healthcare centre providing community, outpatient and inpatient care. Data were collected between January and June 2022. Questions focused on experiences with the provision of information, treatment involvement and SDM and participants' wishes in this regard.FindingsRespondents (57 clients and 21 carers) were largely satisfied with the overall care from their clinicians, and with how information on the pharmacological treatment was provided verbally, but written information was insufficient or not provided. Seventy per cent of clients and 60% of carers reported being involved in medication decision‐making. However, over 75% of participants desired greater involvement in SDM and over 60% in medication reviews.ConclusionsService users and representatives were satisfied about the treatment and verbal information on their psychotropic drug use. The provision of written information, the SDM process and ongoing evaluation of psychotropic medication use could be improved.

Involvement of family members of older patients with cancer in triadic decision-making processes during medical consultations on an outpatient ward - an observational exploratory study using quantitative and qualitative methods

IntroductionThere is a growing interest in the involvement of family members of older patients with cancer in decision-making processes. The aim of this study is to identify how and to what extent family members, together with patients and physicians, are involved in triadic decision-making processes in clinical practice. Materials and MethodsThis study was conducted using an exploratory observational design. The Observer Patient Involvement Scale for patients with Multiple Chronicle Conditions (OPTIONMCC) was used to assess the interaction in triadic decision-making between patients, family members, and physicians. Physicians' behaviour was scored on a Likert-scale ranging from 0 (not observed) to 4 (executed to a high standard), while the behaviour of patients and their family members was scored on a scale from 0 (no or minimum participation) to 2 (active participation). Atlas.ti software was used to facilitate coding, and the SPSS statistical analysis platform was used to explore correlations between the shared decision-making (SDM) skills of the physician and the participation of patients and their family members. ResultsIn total, ten physicians performed 25 consultations with older patients and 30 family members. Patients showed higher levels of participation in the SDM process than family members (OPTIONMCC mean scores 0.96 vs 0.61). Physicians' SDM skills were observed at a low or moderate skill level (OPTIONMCC mean score 1.81). Exploratory correlation analysis showed that higher physician scores were related to higher levels of both patients' and family members' involvement in the decision-making process. The level of family members' involvement in SDM varied from no involvement at all to active involvement. Qualitative analysis of family involvement revealed that relatives are likely to: emphasize patients' values and goals of care; inquire about different treatment options; assist in the deliberation process; and ask for clarification of the further medical process. Physicians showed responsive behaviour towards family members but seldom actively involved them in the SDM process. DiscussionThe study findings suggest that there is a need to include strategies to facilitate family involvement in current SDM models for older patients with cancer. Healthcare professionals in geriatric oncology might benefit from additional training covering family dynamics and managing challenging situations.

Decision aids for promoting shared decision-making: A review of systematic reviews.

In the context of shared decision-making (SDM), experts have advocated the use of validated decision aids (DAs) as valuable tools for facilitating SDM in various healthcare scenarios. This comprehensive review attempts to analyze a vast corpus of DA research by performing thorough searches across four prominent databases (PubMed, CINAHL, Embase, and Web of Science). Independent reviewers selected relevant reviews, extracted data, and assessed review quality using the AMSTAR II tool. A total of 34 systematic reviews were identified and evaluated in this review, encompassing a wide range of outcomes associated with using DAs. These outcomes include patient knowledge, patient involvement in SDM, decision conflict, decision regret, satisfaction, and adherence. In addition, DAs positively affect healthcare provider outcomes by increasing satisfaction, reducing decision conflicts, and lengthening clinical consultations. This review highlights the need for additional research in specific contexts such as long-term care, mental health, and reproductive health to better understand the benefits and challenges of implementing DAs in these settings. Such research can contribute to the improvement of SDM practices and patient-centered care.

Description of care pathways for benzodiazepine and sedative hypnotic discontinuation in older adults: protocol of a multicentre qualitative study

Introduction: Benzodiazepines and sedative hypnotics (BSHs) may represent a threat to patient safety, especially among older adults. The project BE-SAFE (Implementing a patient-centred and evidence-based intervention to reduce BEnzodiazepine and sedative-hypnotic use to improve patient SAFEty and quality of care) is a 5-year research project funded through the Horizon Europe Research Programme (Grant agreement n° 101057123). Its goal is to improve patient safety by addressing knowledge and practice gaps related to the reduction of BSHs used for sleep problems in older adults. Within the project, a patient-centred and evidence-based intervention will be developed to reduce the use of BSHs for sleep problems in older adults. This intervention will be tested in a cluster randomized controlled trial in different hospitals of six European countries (Belgium, Greece, Norway, Poland, Spain and Switzerland). Understanding current care pathways and healthcare systems in relation to BSH discontinuation should help tailor the BE-SAFE intervention to target contexts. This understanding should also shed light on the conditions for patient involvement in shared-decision making and interprofessional and interorganisational collaboration. These elements are expected to be key to the success of the intervention.&#x0D; &#x0D; Objective: To describe care pathways, including interprofessional and interorganisational collaborations, and healthcare systems in relation to BSH discontinuation in the six countries participating in the BE-SAFE trial, from the perspective of healthcare professionals and patients.&#x0D; Methods: A qualitative study will be conducted in the hospitals where the trial will take place and in other healthcare settings that are part of the care pathway, such as primary care. This study will follow four phases: 1) exploring healthcare systems, 2) mapping a typical care pathway for BSH discontinuation, including stakeholder analysis with patients, healthcare professionals and managers, 3) characterising healthcare systems in relation to BSH discontinuation, and 4) validation of results with stakeholders. Participants will be healthcare professionals, especially those involved in BSH discontinuation, managers and patients over 65 years of age either taking BSHs for sleep problems or who have undergone BSH discontinuation in the last three months. Data will be collected through self-administered questionnaires, semi-structured interviews and focus groups. The “6 W” multidimensional model of care trajectories (1) and the “Context and Capabilities for Integrating Care” framework (2) will be used to guide data collection and analyses.&#x0D; Expected results: We will obtain an in-depth description of care pathways and healthcare systems in relation to BSH discontinuation in each of the six countries participating in the BE-SAFE trial. These results will help to inform intervention development through the creation of logic models and to fit the BE-SAFE intervention to target contexts. By May 2023, we will have an initial version of the description of care pathways in each country.&#x0D; 1.Vanasse A, Courteau M, Ethier JF. The ‘6W’ multidimensional model of care trajectories for patients with chronic ambulatory care sensitive conditions and hospital readmissions. Public Health. 2018 Apr 1;157:53–61.&#x0D; 2.Evans JM, Grudniewicz A, Baker GR, Wodchis WP. Organizational context and capabilities for integrating care: A framework for improvement. Int J Integr Care. 2016 Jun 24;16(3):1–14.&#x0D; &#x0D;

The Role of Language Concordant Care on Increasing Parental Engagement in Shared Decision Making

BACKGROUND: Shared decision making (SDM) allows patients and physicians to make decisions together by incorporating clinical expertise and patient preference. While SDM can improve patient satisfaction, preferences on the extent of involvement in SDM vary, particularly among different cultures and languages. We sought to describe preferences in decision making and degree of SDM among Spanish-speaking caregivers receiving pediatric Otolaryngology care. We hypothesized that language-concordant encounters would have higher SDM scores. METHODS: A cross-sectional study of Spanish-speaking caregivers undergoing consultation with pediatric otolaryngology was performed (May-August 2022). Care was provided in a language-concordant (LC) setting in which the physician and caregiver communicate in Spanish, or a language–discordant (LD) setting in which the physician communicates with interpreter support. Following their appointment, caregivers were invited to complete the Spanish Control Preferences Scale (CPS, select 2 of 5 options) to determine their two most preferred roles in medical decision making, and the Shared Decision-Making Questionnaire (SDM-Q-9; scored 0-100) to assess perceived SDM. Descriptive statistics, Fisher’s exact and the Mann-Whitney U test were used for analysis. RESULTS: Sixty-one caregivers were enrolled. CPS scores revealed the passive-collaborative medical decision making role was the most favored (59%), followed by an active-collaborative role (26%), and passive role (13%). Median SDM-Q-9 score for all caregivers was 100.00 (mean=93.70). The median SDMQ-9 score was 100 in LC visits, and 97.78 in LD visits (p = 0.428). No differences in SDM-Q-9 scores were detected for CPS categories between LC and LD visits. CONCLUSION: High levels of SDM were observed among Spanish-speaking caregivers using both LC and LD care. Most caregivers preferred a passive-collaborative role in medical decision making. Results may be influenced by positive response bias given the high scores observed. Further studies with larger sample sizes can further our understanding of the impact of LC care in SDM.

Views, attitudes, and reported practices of nephrology nurses regarding shared decision-making in end-of-life care.

End-stage renal disease (ESRD) is the final stage of chronic kidney disease. Yet dialysis is not suitable for all ESRD patients. Moreover, while shared decision-making (SDM) is the preferred model for making medical decisions, little is known about SDM between nephrology nurses and ESRD patients in Israel. Assessing the views, attitudes, practices, and ethical dilemmas of nephrology nurses in Israel regarding SDM with ESRD patients. Using the descriptive quantitative approach, questionnaires were completed by 444 nephrology nurses in Israel. In addition to conducting descriptive statistics, t-tests for independent samples, f-tests for analysis of variance, and both tests for independence were also performed. The research aims, expected advantages and risks have been explained to respondents before completing the questionnaire to secure informed consent. Anonymity and confidentiality were ensured throughout the study. The study was approved by the Research Ethics Committee at the University of Haifa (Approval # 411/21). About one-third (30%-36.5%) of nurses reported discussing quality of life issues with ESRD patients, asking about their advance directives/power of attorney, exploring cultural/religious beliefs in end-of-life care, and ask about their preferred place of death. Nurses who convey high levels of patient-centered care (68.9%, p<0.0001), have high end-of-life training (76.2%, p<0.0001), and report cooperating with interdisciplinary teams (63.8%, p = 0.0415), also reported higher SDM practices than others. Nurses who refer less patients to palliative care (70%, p<0.0001) reported higher involvement in SDM compared to other nurses. Nephrology nurses in Israel do not tend to implement the SDM model, despite its potential for improving quality of life for ESRD patients and their families and increasing conservative care options. Policy makers and educators in Israel should develop and implement training programs and support in the workplace, to enhance SDM between nephrology nurses and ESRD patients.

Disparities in Breast-Conserving Therapy vs. Mastectomy among Asian American and Pacific Islander Women

Multiple randomized trials support the use of breast-conserving therapy (BCT), defined as lumpectomy followed by adjuvant radiotherapy, as an alternative to mastectomy for definitive treatment of early-stage (T1-2N0) breast cancer. However, data suggest that Asian American, Native Hawaiian, and Pacific Islander (AANHPI) may undergo mastectomy at higher rates than BCT and may experience barriers to receipt of BCT. The purpose of this study was to examine BCT utilization by disaggregated AANHPI groups to identify differences in receipt of mastectomy versus BCT. The 2004-2017 National Cancer Database was queried to identify women age ≥18 years old diagnosed with cT1-2N0M0 breast cancer treated with either BCT or mastectomy without post-mastectomy radiation therapy. Women were classified based on self-reported race. Multivariable logistic regression defined adjusted odds ratios (OR) assessing the association between race and receipt of BCT versus mastectomy for all patients and separately by cT1-2 stage. All models were adjusted for relevant sociodemographic and clinical factors. Of 794,403 women with cT1-2N0M0 breast cancer, 239,801 (30%) received mastectomy and 554,602 (70%) received BCT. After adjusting for clinical and sociodemographic factors, AANHPI women had greater odds of receiving mastectomy over BCT, compared to White women (OR [95% CI], 1.35 [1.30-1.39]; p<0.001). In contrast, Black women were less likely than White women to receive mastectomy (0.86 [0.84-0.87]; p<0.001). Upon disaggregation, Chinese, Japanese, Filipino, Korean, Vietnamese, and Asian Indian & Pakistani women were more likely to receive mastectomy over BCT compared to White women (p<0.001 for all). Treatment at academic (1.30 [1.27-1.32]), integrated (1.24 [1.21-1.27]), and comprehensive community cancer centers (1.15 [1.13-1.17]) were all associated with greater odds of mastectomy compared to treatment at community cancer programs (all p<0.001). Greater distance from treatment facility (≥50 mi. vs. 0 to <10 mi. [reference], OR 1.50 [1.47-1.53]) and cT2 disease (1.85 [1.82-1.87]) were also associated with greater odds of receiving mastectomy (all p<0.001). In this evaluation of women with early-stage breast cancer, women from several AANHPI groups were more likely to receive mastectomy (as opposed to BCT) compared to White women. While sociocultural preferences, differences in access to and interest in reconstruction, as well as prevalent tumor-to-breast ratios may partially explain the disparities, collectively our data suggest an ongoing need for greater patient involvement in shared-decision making, particularly in vulnerable and understudied Asian populations.

Understanding how shared decision-making approaches and patient aids influence patients with advanced cancer when deciding on palliative treatments and care: A realist review.

Patients with advanced incurable cancer face difficult decisions about palliative treatment options towards their end of life. However, they are often not provided with the appropriate information and support that is needed to make informed decisions. This review aimed to identify contexts and mechanisms associated with communication tools, patient decision-aids and shared decision-making (SDM) approaches that influence patient outcomes. We used a realist review method to search for published studies of patients (adults > 18) with advanced cancer who were expected to make a decision about palliative treatment and/or supportive care in consultationwith healthcare practitioners. We appraised and synthesised literature describing the contexts of (when and how) decision aids and SDM approaches are used, and how these contexts interact with mechanisms (resources and reasoning) which impact patient outcomes. Stakeholders including academics, palliative healthcare professionals(HCPs) and people with lived experience of supporting people with advanced incurable cancer contributed to identifying explanatory accounts. These accounts were documented, analysed and consolidated to contribute to the development of a programme theory. From the 33 included papers, we consolidated findings into 20 explanatory accounts to develop a programme theory that explains key contexts and mechanisms that influence patient and SDM. Contexts include underlying patients' and HCPs'attitudes and approaches. These need to be understood in relation to key mechanisms, including presenting information in multiple formats and providing adequate time and opportunities to prepare for and revisit decisions. Contexts influenced mechanisms which then influence the levels of patient decisional satisfaction, conflict and regret. Our programme theory highlights mechanisms that are important in supporting shared treatment decisions for advanced noncurative cancer. The findings are informative for developing and evaluating interventions to improve understanding and involvement in SDM for patients with advanced incurable cancer. We included patient and public involvement (PPI) representatives in four stakeholder meetings. PPI helped to define the scope of the review, identify their unique experiences and perspectives, synthesise their perspectives with our review findings, make decisions about which theories we included in our programme theory and develop recommendations for policy and practice and future research.

Evaluating the Impact of a Training Program in Shared Decision-Making for Neurologists Treating People with Migraine.

Migraine symptoms vary significantly between patients and within the same patient. Currently, an increasing number of therapeutic options are available for symptomatic and preventive treatment. Guidelines encourage physicians to use shared decision-making (SDM) in their practice, listening to patients' treatment preferences in order to select the most suitable and effective therapy. Although training for healthcare professionals could increase their awareness of SDM, results concerning its effectiveness are inconclusive. This study aimed to analyze the impact of a training activity to promote SDM in the context of migraine care. This was addressed by evaluating the impact on patients' decisional conflict (main objective), patient-physician relationship, neurologists' perceptions of the training and patient's perception of SDM. A multicenter observational study was conducted in four highly specialized headache units. The participating neurologists received SDM training targeting people with migraine in clinical practice to provide techniques and tools to optimize physician-patient interactions and encourage patient involvement in SDM. The study was set up in three consecutive phases: control phase, in which neurologists were blind to the training activity and performed the consultation with the control group under routine clinical practice; training phase, when the same neurologists participated in the SDM training; and SDM phase, in which these neurologists performed the consultation with the intervention group after the training. Patients in both groups with a change of treatment assessment during the visit completed the Decisional conflict scale (DCS) after the consultation to measure the patient's decisional conflict. Also, patients answered the patient-doctor relationship questionnaire (CREM-P) and the 9-item Shared Decision-Making Questionnaire (SDM-Q-9). The mean ± SD scores obtained from the study questionnaires were calculated for both groups and compared to determine whether there were significant differences (p < 0.05). A total of 180 migraine patients (86.7% female, mean age of 38.5 ± 12.3years) were included, of which 128 required a migraine treatment change assessment during the consultation (control group, n = 68; intervention group, n = 60). A low decisional conflict was found without significant differences between the intervention (25.6 ± 23.4) and control group (22.1 ± 17.9; p = 0.5597). No significant differences in the CREM-P and SDM-Q-9 scores were observed between groups. Physicians were satisfied with the training and showed greater agreement with the clarity, quality and selection of the contents. Moreover, physicians felt confident communicating with patients after the training, and they applied the techniques and SDM strategies learned. SDM is a model currently being actively used in clinical practice for headache consultation, with high patient involvement in the process. This SDM training, while useful from the physician's perspective, may be more effective at other levels of care where there is still room for optimization of patient involvement in decision-making.

Perceived shared decision-making among patients undergoing lower-limb amputation and their care teams: A qualitative study.

Shared decision-making (SDM) is increasingly advocated in the care of vascular surgery patients. The goal of this investigation was to gain a greater understanding of the patient and provider experience of SDM during clinical decision-making around the need for lower-extremity amputation and amputation level related to chronic limb-threatening ischemia (CLTI) in the Veterans Health Administration. Semistructured interviews in male Veterans with CLTI, vascular surgeons, physical medicine and rehabilitation physicians, and podiatric surgeons. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions. We interviewed 22 patients and 21 surgeons and physicians and identified 4 themes related to SDM: (1) providers recognize the importance of incorporating patient preferences into amputation-level decisions and strive to do so; (2) patients do not perceive that they are included as equal partners in decisions around amputation or amputation level; (3) providers perceive several obstacles to including patients in amputation level decisions; and (4) patients describe facilitators to their involvement in SDM. Despite the recognized importance SDM in amputation decision-making, patients often perceived that their opinion was not solicited. This may result from provider perception of significant challenges to SDM posed by the clinical context of amputation. Patients identified key features that might enhance SDM including presentation of clear, concise information, and the importance of communicating concern during the discussion. These findings point to gaps in the provision of patient-centric care through SDM discussions at the time of amputation.

Patient Involvement in Shared Decision-Making: Do Patients Rate Physicians and Nurses Differently?

Shared decision-making implies that patients and healthcare professionals make decisions together about clinical exams, available treatments, choice of options, and the benefit or downside of every choice. Patients involved in the shared decision-making process are more compliant with treatments and have a reduced risk of complications related to the pathology. In Italy, patient involvement in caring processes is still barely investigated. To investigate patients' perceptions about shared decision-making with physicians and nurses, respectively, and to examine the relationship between shared decision-making and patient satisfaction and perceived quality of care/treatment. The study was performed between March and June 2019 in two wards of one Italian hospital. A questionnaire was administered to inpatients at the time of admission and again at discharge, including demographic information and measurement scales regarding patient involvement in shared decision-making, patient satisfaction, and perceived quality of treatment/care. A total of 151 out of 301 patients completed questionnaires at both admission and discharge. Patients' scores for shared decision-making (information, patient needs, treatment planning) were significantly different for physicians and nurses. At both admission and discharge, patients rated shared decision-making significantly higher for physicians compared to nurses, while there were no differences in their satisfaction ratings. Patient ratings of physicians did not change from admission (information: mean (M) = 3.50, standard deviation (SD) = 0.81; patient need: M = 3.05, SD = 1.05; treatment planning: M = 2.75, SD = 1.23) to discharge (information: M = 3.50, SD = 0.79; patient need: M = 3.17, SD = 1.02; treatment planning: M = 2.66, SD = 1.23) (p = 0.924, p = 0.098, p = 0.293, respectively), but patients' ratings of nurses' behavior increased significantly from admission (information: M = 2.44, SD = 1.23; patient need: M = 2.27, SD = 1.17; treatment planning: M = 2.12, SD = 1.19) to discharge (information: M = 2.62, SD = 1.22; patient need: M = 2.53, SD = 1.24; treatment planning: M = 2.35, SD = 1.21) (p = 0.019, p = 0.001, p = 0.003, respectively). Attention to patients' needs was the key determinant of both satisfaction with nurses (OR = 3.65, 95% CI = 1.31-10.14, p = 0.013) and perceived quality of care (OR = 3.97, 95% CI = 1.49-10.55, p = 0.006). Providing appropriate information about disease progress and treatments was a key determinant of both satisfaction with physicians (OR = 19.75, 95% CI = 7.29-53.55, p &lt; 0.001) and perceived quality of treatment (OR = 8.03, 95% CI = 3.25-19.81, p &lt; 0.001). Nurses should be sensitized to involving patients in the decision-making process, especially upon hospital admission. Specific training about effective communication techniques can be implemented to manage relationships with patients in different caring situations. Practical implications and future directions are discussed.