Patient-physician Conversations Research Articles

Preoperative opioid use and its association with postoperative complications

ABSTRACT Background The negative impact of opioid use in the U.S. has led providers to seek alternative methods for pain control. More specifically, preoperative opioid usage has been demonstrated to adversely affect patients and clinical outcomes. This study aims to assess the extent of the relationship between preoperative opioid use on postoperative outcomes across surgical disciplines using statewide population databases. Methods The study used the Utah All Payers Claims Database and Utah Population Database to identify a cohort of adult patients who underwent a single surgery between 2013 and 2016 and had continuous insurance enrollment. Preoperative opioid prescription within one year prior to the index surgery was the independent variable, while complications and hospital admissions one year following the index surgery were the primary outcomes. Results Our model of 18,647 patients found that the odds of any complication with preoperative opioid use was 1.28. Depression (OR 1.17) and drug misuse (OR 1.41) were also associated with a higher risk of postoperative complications. Rates of hospital readmission in the preoperative opioid use group compared to the opioid naïve group were increased (19.43% vs. 12.44%, p < .01). Conclusion The data can be used to guide patient-physician conversations and better inform prescribing habits perioperatively.

Investigating the Impact of AI on Shared Decision-Making in Post-Kidney Transplant Care (PRIMA-AI): Protocol for a Randomized Controlled Trial.

Patients after kidney transplantation eventually face the risk of graft loss with the concomitant need for dialysis or retransplantation. Choosing the right kidney replacement therapy after graft loss is an important preference-sensitive decision for kidney transplant recipients. However, the rate of conversations about treatment options after kidney graft loss has been shown to be as low as 13% in previous studies. It is unknown whether the implementation of artificial intelligence (AI)-based risk prediction models can increase the number of conversations about treatment options after graft loss and how this might influence the associated shared decision-making (SDM). This study aims to explore the impact of AI-based risk prediction for the risk of graft loss on the frequency of conversations about the treatment options after graft loss, as well as the associated SDM process. This is a 2-year, prospective, randomized, 2-armed, parallel-group, single-center trial in a German kidney transplant center. All patients will receive the same routine post-kidney transplant care that usually includes follow-up visits every 3 months at the kidney transplant center. For patients in the intervention arm, physicians will be assisted by a validated and previously published AI-based risk prediction system that estimates the risk for graft loss in the next year, starting from 3 months after randomization until 24 months after randomization. The study population will consist of 122 kidney transplant recipients >12 months after transplantation, who are at least 18 years of age, are able to communicate in German, and have an estimated glomerular filtration rate <30 mL/min/1.73 m2. Patients with multi-organ transplantation, or who are not able to communicate in German, as well as underage patients, cannot participate. For the primary end point, the proportion of patients who have had a conversation about their treatment options after graft loss is compared at 12 months after randomization. Additionally, 2 different assessment tools for SDM, the CollaboRATE mean score and the Control Preference Scale, are compared between the 2 groups at 12 months and 24 months after randomization. Furthermore, recordings of patient-physician conversations, as well as semistructured interviews with patients, support persons, and physicians, are performed to support the quantitative results. The enrollment for the study is ongoing. The first results are expected to be submitted for publication in 2025. This is the first study to examine the influence of AI-based risk prediction on physician-patient interaction in the context of kidney transplantation. We use a mixed methods approach by combining a randomized design with a simple quantitative end point (frequency of conversations), different quantitative measurements for SDM, and several qualitative research methods (eg, records of physician-patient conversations and semistructured interviews) to examine the implementation of AI-based risk prediction in the clinic. ClinicalTrials.gov NCT06056518; https://clinicaltrials.gov/study/NCT06056518. PRR1-10.2196/54857.

Understanding the impact of non-alcoholic steatohepatitis with metabolic comorbidities on adults: a real-world qualitative study

Objective Limited real-world evidence exists to better understand the patient experience of living with symptoms and impacts of non-alcoholic steatohepatitis (NASH). This study aimed to (1) describe patient-reported perspectives of NASH symptoms and impacts on patients’ daily lives and (2) develop a patient-centered conceptual NASH model. Methods A cross-sectional study using semi-structured qualitative interviews was conducted among adults (≥18 years) in the United States living with NASH. Eligible participants were diagnosed with NASH, had mild to advanced fibrosis (F1-F3), and no other causes of liver disease. The interview guide was informed by a targeted literature review (TLR) to identify clinical signs, symptoms, impacts, and unmet treatment needs of NASH. Participants described their experiences and perspectives around NASH and the symptoms, symptom severity/bother, and impact of NASH on their daily activities. Interviews were audio-recorded and transcribed verbatim for coding and thematic analysis. Results Twenty participants (age: 42.4 years; female: 50.0%) were interviewed. Participants discussed their experience with NASH symptoms (most frequent: fatigue [75.0%]; weakness/lethargy [70.0%]) and impacts (most frequent: physical and psychological/emotional [70.0% each]; dietary [68.4%]). Participants considered most symptoms to be moderately severe or severe and moderately or highly bothersome. Findings from the TLR and qualitative interviews were incorporated into a conceptual model that describes patient-reported symptoms and impacts of NASH, clinical signs, risk factors, and unmet treatment needs. Conclusion Our study provides insights into patients’ perspectives of NASH symptoms and their impact on their daily lives. These findings may guide patient-physician conversations, supporting patient-centered treatment decisions and disease management.

Return to Play Criteria After Adult Lumbar Spinal Fractures: A Review of Current Literature and Expert Recommendations.

Understanding the management of lumbar spinal fractures and return to play (RTP) criteria is an essential component of care for adult athletes. Appropriate management of lumbar spinal fractures must balance minimizing time away from physical activity while also minimizing risk of reinjury. The purpose of this review is to summarize current recommendations on lumbar spinal fracture management and RTP guidelines and to provide expert opinion on areas of discrepancy in the field. There is a paucity of high-level evidence on the management and return to play criteria for adult lumbar spine fractures in athletes. Much of the data and recommendations are based on expert opinion and studies in pediatric or osteoporotic patients, which may not be applicable to adult athletes. These data presented here may be used to aid patient-physician conversations and provide guidance on expectations for patients, coaches, and athletic trainers. In general, we recommend that patients be free of lumbar pain, neurologically intact, and have full strength and motion of the lumbar spine and lower extremities before returning to play. Adequate protective equipment is recommended to be worn at all times during practice and play.

Maintaining vulvar, vaginal and perineal health: Clinical considerations.

Knowledge of female genital anatomy and physiology is often inadequate or incorrect among women. Precise patient-physician conversations can be inhibited by a reluctance or inability to speak accurately about the vulva and vagina, with the terms often being used interchangeably. There is a paucity of scientific evidence and clinical guidelines to support women and physicians in ensuring best practices in feminine hygiene. In this review, the unmet needs in the field are highlighted. Evidence is provided for the complex array of physiological and pathological systems, mechanisms and behaviours that either protect or, if inappropriate, predispose the vulva and vagina to infections, irritation or other conditions. The need for attention to perineal health is recommended, given the interdependence of perineal and vulvar microbiota and the risk of colonic pathogens reaching the vulva and the vagina. Differences in feminine hygiene practices can vary widely across the world and among varying age groups, and suboptimal habits (such as vaginal douching or the use of certain cleansers) can be associated with increased risks of vulvar and vaginal conditions. Critical areas for discussion when advising women on their intimate health include: advice surrounding aesthetic vulvar cosmetic trends (such as depilation and genital cosmetic surgery), bowel health and habits, and protection against sexually transmitted infections. Routine, once-daily (maximum twice-daily) washing of the vulva with a pH-balanced, mild cleanser is optimal, ideally soon after bowel voiding, when feasible. Due to the finely balanced ecosystems of the vulva, the vagina and the perineal area, a scientific and clinical perspective is essential when determining the most appropriate vulvar cleansers based on their components. Correct intimate care may contribute to improved genital and sexual health and overall well-being. An increased awareness of correct practices will empower women to be the advocates of their own intimate health.

Explaining risks and benefits of loco-regional treatments to patients.

Treatment for early-stage breast cancer is complex, requiring multidisciplinary care with a multitude of treatment options available for each patient. Coupled with the rising importance of shared decision-making, patient-physician conversations are progressively more complicated. These conversations require frank disclosure of risks and benefits of the different treatment modalities in a way that is individualized for each patient and simple to understand. In most patients, breast conserving therapy with radiation should be presented as the gold-standard local treatment given similar long-term and improved quality of life outcomes. De-escalation is currently at the forefront of research in loco-regional treatments, and further investigations are required to best determine the optimal patient populations for reduced sentinel lymph node sampling, omission of sentinel lymph node biopsy altogether and omission of radiation treatment. For future trials, better endpoints need to be established considering patient-centered outcomes as well as recurrence.

Communicating the External Beam Radiotherapy Experience (CEBRE) Discussion Guides: Real World Implementation and Evaluation

Communicating about the radiotherapy treatment process can be difficult for patients and healthcare professionals. The "Communicating the External Beam Radiotherapy Experience" (CEBRE) and Communicating the Gynecologic Brachytherapy Experience (CoGBE) discussion guides use graphic narrative to explain external beam radiotherapy and gynecologic high-dose rate brachytherapy, respectively. The CEBRE, CoGBE, and CEBRE en Español guides have been available for free download since 10/2018, 6/2020, and 8/2021, respectively. This study aims to characterize how the guides are being implemented and used in practice. Global downloads of the CEBRE, CoGBE, and CEBRE en Español guides were analyzed. Email addresses submitted at the time of download were used to contact study subjects. Duplicate emails, fake addresses, and expired emails were removed resulting in 500 individuals being invited to participate in the survey. A data collection web application survey was distributed on 1/27/23. Two reminders were sent prior to the survey closing on 2/13/23. The survey addressed how physicians or other radiotherapy team members use the CEBRE guides, where they are used, and how the guides can be improved. Likert-type data (1 = strongly disagree, 5 = strongly agree) are reported as median [interquartile range]. As of 10/16/22, the CEBRE guides (English) had been downloaded 602 times, CoGBE 86 times, and CEBRE en Español 63 times. 42/500 individuals responded to the survey for an 8% response rate. 40/42 (95%) of participants were healthcare providers with 35/40 (87.5%) radiation oncologists. 16/40 (40%) have used the CEBRE guides in some way. 6/16 (37.5%) "always use," 2/16 (12.5%) "often use," and 3/16 (18.8%) "sometimes use" the guides during consultation. 8/16 (50%) report using the guides for education of medical students, residents, and fellows. The 16 respondents that use the guides felt the guides were useful overall (5[5-5]), felt "very confident" using the guides (4.5[4-5]), and felt the guides "help patients prepare for their treatment" (5[4-5]). 40 respondents provided suggestions on additional language translations with 19/40 (48%) recommending translation into Mandarin, 6/40 (15%) into Cantonese, Portuguese, French and Arabic, and 5/40 (12.5%) into Haitian, Hindi, and Vietnamese. The majority of respondents did not use the CEBRE guides which may be due to difficulty with implementation. However, respondents who use the guides are confident using them and rate them as useful for patients. These data, although limited by the low response rate, suggest that the CEBRE guides have accomplished the goal of facilitating patient-physician conversations. Moreover, there is an interest in translating the guides into additional languages other than Spanish. Due to the low response rate, definitive conclusions cannot be made from these data. Therefore, further research such as interviews and focus groups may be beneficial.

Pain management following total shoulder arthroplasty: what are patients reading online?

BackgroundThis study aims to assess the quality and readability of online resources regarding postoperative pain control for patients having undergone total shoulder arthroplasty (TSA), along with identifying gaps among the types of information. MethodsThree search engines were used to conduct internet searches utilizing a combination of TSA and pain management search phrases. The top 20 web pages from each search engine were gathered, reviewed, and scored by five different evaluators. Scoring was performed using 30-point criteria, integrated into an overall quality of resource (QR) score considered significant for patient education about TSA and pain management according to American Pain Society and American Academy of Orthopaedic Surgeons’ published recommendations (Table I). Domain scores (route of administration, type of analgesia, opioid-specific, and general guidance) were calculated by summing the total points and dividing by the total possible score for each domain. The reading level of the Flesch-Kinkaid grade level, the Flesch reading ease, and the simple measure of gobbledygook index was also assessed. ResultsThe overall readability was low, with a mean Flesch-Kincaid grade level score of 10.3 ± 2.0 and Simple Measure of Gobbledygook score of 9.9 ± 1.5. According to this index, only one website (2.3%) was written below the suggested 6th grade reading level. There was a mean QR score of 9.6/30 points, ranging from 2 to 22 (Table II). Most resources (90.9%) did not achieve greater than 50% of the total available points (greater than 15 out of 30). Of the domains, the mean score for route of administration was 31.8%, types of analgesia was 43.6%, opioid-specific was 11.4%, and general guidance was 43.2%. Opioid-specific scores were lower than all three other domain scores (all P < .001). ConclusionAccording to our findings, current online resources for pain management following TSA are written above the average literacy level for adults in the United States and lack educational content, especially regarding opioid-specific discussion and recommendations. Resources must target gaps in online patient education to better inform patients of postoperative pain control, convey expectations, and encourage patient-physician conversations and decision-making.

Preoperative Pain Control Discussion With EMR Documentation Prompt to Guide Opioid Prescriptions for Laparoscopic Sterilization Surgery [ID: 1377197

INTRODUCTION: Our objective was to evaluate whether implementing a standardized patient–physician counseling and documentation process about pain and opioid use after laparoscopic bilateral salpingectomy (LSC BS) decreased opioid prescribing. METHODS: In this study, we evaluated a quality improvement project aimed at decreasing opioid overprescribing and promoting patient–physician conversations and documentation surrounding pain control after surgery. An electronic medical record (EMR) standardized smart phrase was implemented in the Resident GYN Specialty Clinic at the Obstetrics and Gynecology Care Center in order to standardize patient–physician counseling and documentation about postoperative pain, opioid use, storage, and disposal, providing written and verbal education at the time of preoperative and postoperative appointments for Lap BS. We collected EMR data from patients who had a LSC BS preintervention (January 2019 to December 9, 2020) and postimplementation (March 2021 to October 2022). To have 90% power to detect a 25% reduction in morphine milligram equivalents (MMEs) from preimplementation to postimplementation, we needed 78 patients per group. RESULTS: A total of 78 patients met inclusion criteria for both groups. Patients postintervention were prescribed significantly fewer opioids (58.3 versus 31.35 MME, P&lt;.001, or 7.8 versus 4.2 oxycodone 5 mg tablets) compared to patients preintervention. Significant differences were also seen in secondary outcomes with increased documentation of discussion surrounding the addictive properties of opioids and expected pain postoperatively postintervention compared to preintervention. CONCLUSION: Implementation of physician education combined with EMR prompts decreased the amount of opioids prescribed and increased documentation of patient–physician communication about safe opioid use and pain control.

Google Trends and Injectable Products: The Next-Best Tool for Anticipating Patient Concerns in Plastic and Reconstructive Surgery.

Professional health care organizations including the American Society of Plastic Surgeons (ASPS) historically provide guidance to medical providers in the wake of major medical news and events. Consider, for example, the ASPS guidance published in response to the December 17, 2020 Food and Drug Administration (FDA) briefing document of the Vaccines and Related Biological Products Advisory Committee for the Moderna COVID-19 (coronavirus disease 2019) Vaccine.[1] This information provides a framework for physicians to guide patient-physician conversations in formalized health care settings. However, it provides little insight into tangible patient concerns during the contemplation stage of decision-making prior to formalized patient consultations. We suggest utilizing Google Trends (GT) as a real-time tool to aid in identifying patient concerns.

Changes in infant food-specific serum IgE testing from 2015 to 2020

Food allergy affects approximately 8% of children in the United States.1 Direct medical costs account for an estimated $4.3 billion annually2 and the economic impact of serum food-specific IgE (sIgE) testing is likely substantial. Beginning in 2012, the Choosing Wisely initiative highlighted subjects for patient–physician conversations with an emphasis on unnecessary tests. Two topics chosen by the American Academy of Allergy, Asthma & Immunology included statements discouraging the use of indiscriminate IgE tests for allergy evaluation and recommending that food IgE testing not be performed in the absence of a history consistent with IgE-mediated food allergy.

Patient-physician conversations about life-sustaining treatment: Treatment preferences and participant assessments.

In 2019, the Danish parliament issued legislation requiring Danish physicians to clarify and honor seriously ill patients' treatment preferences. The American POLST (Physician Orders for Life-Sustaining Treatment) document could be a valuable model for this process. The aim of the study was to examine patients' preferences for life-sustaining treatment and participant assessment of a Danish POLST form. The study is a prospective intervention based on a pilot-tested Danish POLST form. Participant assessments were examined using questionnaire surveys. Patients with serious illness and/or frailty from seven hospital wards, two general practitioners, and four nursing homes were included. The patients and their physicians completed the POLST form based on a process of shared decision-making. A total of 95 patients (aged 41-95) participated. Hereof, 88% declined cardiopulmonary resuscitation, 83% preferred limited medical interventions or comfort care, and 74% did not require artificial nutrition. The preferences were similar within age groups, genders, and locations, but with a tendency toward younger patients being more in favor of full treatment and nursing home residents being more in favor of cardiopulmonary resuscitation. Questionnaire response rates were 69% (66/95) for patients, 79% (22/28) for physicians, and 31% (9/29) for nurses. Hereof, the majority of patients, physicians, and nurses found that the POLST form was usable for conversations and decision-making about life-sustaining treatment to either a high or very high degree. The majority of seriously ill patients did not want a resuscitation attempt and opted for selected treatments. The majority of participants found that the Danish POLST was usable for conversations and decisions about life-sustaining treatment to either a high or a very high degree, and that the POLST form facilitated an opportunity to openly discuss life-sustaining treatment.

Efficacy of Motivational Interviewing to Improve Utilization of Mental Health Services Among Youths With Chronic Medical Conditions

Despite the high prevalence of anxiety and depression in youths with chronic medical conditions (CMCs), physicians encounter substantial barriers in motivating these patients to access mental health care services. To determine the efficacy of motivational interviewing (MI) training for pediatricians in increasing youths' use of mental health care. The COACH-MI (Chronic Conditions in Adolescents: Implementation and Evaluation of Patient-Centered Collaborative Healthcare-Motivational Interviewing) study was a single-center cluster randomized clinical trial at the University Children's Hospital specialized outpatient clinics in Düsseldorf, Germany. Treating pediatricians were cluster randomized to a 2-day MI workshop or treatment as usual (TAU). Patient recruitment and MI conversations occurred between April 2018 and May 2020 with 6-month follow-up and 1-year rescreening. Participants were youths aged 12 to 20 years with CMCs and comorbid symptoms of anxiety and depression; they were advised by their MI-trained or untrained physicians to access psychological counseling services. Statistical analysis was performed from October 2020 to April 2021. MI physicians were trained through a 2-day, certified MI training course; they recommended use of mental health care services during routine clinical appointments. The primary outcome of uptake of mental health care services within the 6-month follow-up was analyzed using a logistic mixed model, adjusted for the data's cluster structure. Uptake of mental health services was defined as making at least 1 appointment by the 6-month follow-up. Among 164 youths with CMCs and conspicuous anxiety or depression screening, 97 (59%) were female, 94 (57%) had MI, and 70 (43%) had TAU; the mean (SD) age was 15.2 (1.9) years. Compared with patients receiving TAU, the difference in mental health care use at 6 months among patients whose physicians had undergone MI training was not statistically significant (odds ratio [OR], 1.96; 95% CI, 0.98-3.92; P = .06). The effect was moderated by the subjective burden of disease (F2,158 = 3.42; P = .04). Counseling with an MI-trained physician also led to lower anxiety symptom scores at 1-year rescreening (F1,130 = 4.11; P = .045). MI training was associated with longer conversations between patients and physicians (30.3 [16.7] minutes vs 16.8 [12.5] minutes; P < .001), and conversation length significantly influenced uptake rates across conditions (OR, 1.03; 95% CI, 1.01-1.06; P = .005). In this study, use of MI in specialized pediatric consultations did not increase the use of mental health care services among youths with CMCs but did lead to longer patient-physician conversations and lower anxiety scores at 1 year. Additional research is required to determine whether varying scope and duration of MI training for physicians could encourage youths with CMCs to seek counseling and thus improve integrated care models. German Trials Registry: DRKS00014043.

Self-Reported Reproductive Health Experiences in Women with Von Willebrand Disease: A Qualitative Interview-Based Study

Background: Women with von Willebrand disease (VWD) may experience multiple reproductive health challenges, particularly related to menstruation and pregnancy. Patient-reported experiences in this setting have not been well characterized.Aim: To elicit patient-reported menstrual health experiences in women with VWD.Methods: We conducted a physician-administered telephone survey of women seen at Mayo Clinic for workup and/or management of VWD. Patients were asked to discuss their diagnosis of VWD and questioned about menstrual health, contraception, and pregnancy and asked to describe how their VWD had impacted their reproductive health experiences. Quantitative data were analyzed using R (version 3.2.0). Qualitative comments were analyzed by frequency of response (specific adjectives) and general thematic elements.Results: Of 130 women diagnosed with VWD, 82 (63%) agreed to participate, including 58 (71%) with type 1, 9 (11%) with type 2A, 4 (5%) with type 2B, 8 (10%) with type 2M, 1 (1%) with type 2N, and 3 (2%) with type 3. 89% of women self-reported a history of heavy menstrual bleeding; for 23 (28%) this was their first bleeding event. 28 women (34%) ultimately underwent hysterectomy for heavy menstrual bleeding. Women used several forms of contraception, most commonly estrogen-containing oral contraceptives (61, 74%) and intrauterine device (9, 11%). 65 women (79%) reported at least one pregnancy. There were 200 total pregnancies (median 3 per woman, range 1-10). 142 pregnancies (71%) resulted in live term birth, 47 (24%) in spontaneous abortion (at a median of 12 weeks), 9 (4%) in a live preterm birth, and 2 (1%) in therapeutic abortion. Patients' self-reported comments are described in the Table, with responses in bold indicating the same themes were used by more than one patient. Women used primarily negative adjectives to describe heavy menstrual bleeding and reported a significant negative impact on their academic, home, and sexual lives. Despite this, women often reported that they “just dealt with it” and “thought it was normal.” Regarding pregnancy and VWD, women again used primarily negative adjectives to describe their experiences. Many described pregnancy-associated bleeding events (generally postpartum hemorrhage). Overall, women reported that it was often “uncomfortable” to discuss their reproductive concerns with their medical providers (including hematologists). One woman reported that she “wished [she] had been more confident speaking with [her] doctor” and another that “it is important to be your own advocate.”Conclusions: VWD is a relatively common bleeding condition which appears to significantly impact women's reproductive health. In this qualitative interview study, women often used negative adjectives to describe their reproductive experiences as related to VWD. Additionally, many were uncomfortable discussing their reproductive health with their providers. Physicians (particularly hematologists and obstetrician-gynecologists) should be trained to recognize the impact of VWD on reproductive health and include reproductive health as part of their essential health maintenance conversations with their patients. More compassionate and informational patient-physician conversations may help to optimize reproductive health experiences and outcomes in women with VWD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Abstract PS9-47: A scoping review characterizing “choosing wisely” recommendations for breast cancer management

Abstract Background: Choosing Wisely (CW)® was created by the American Board of Internal Medicine (ABIM) to promote patient-physician conversations about unnecessary medical tests and treatment. It is estimated that 20% of healthcare cost is wasted on ineffective interventions. National societies such as American Society of Clinical Oncology, Americal Society of Breast Surgeons, and American Society for Radiation Oncology have developed lists of recommendations within the Choosing Wisely initiative to to eliminate non-evidence based practices and improve patient outcomes. Similarly, other countries outside of the US have created their own national panels of experts called “CW® campaigns” which typically review recommendations submitted by that country’s oncology societies. We performed a scoping review to consolidate CW® recommendations from different groups with respect to breast cancer care. Methods: A systematic search of Medline and Embase for English language publications presenting CW® recommendations for breast cancer care practices was conducted from Jan 1, 2011 - May 11, 2020. The search was designed and peer reviewed by information specialists. We also reviewed the CW® websites of ABIM and associated international CW® campaigns. Two reviewers independently screened studies for inclusion and performed data extraction, and findings were summarized narratively. Results: Review of ABIM CW® recommendations showed 26 breast cancer-related recommendations. These pertained to: screening (n=5), radiological staging (n=2), treatment (n=15), surveillance (n=2), and miscellaneous (genetic testing and pathology; n=2). Treatment recommendations were sub-classified into surgery (n= 9), chemotherapy (n= 2), radiation therapy (n= 2), and supportive therapy (n= 2). Of 20 countries which have a CW® campaign and endorse recommendations for a range of diseases, 13 have published recommendations for breast cancer. While most international campaigns published recommendations on the same topics as the ABIM campaign, 6 campaigns developed recommendations on new topics. These included: follow-up visits (Canada), involvement of multi-disciplinary teams and imaging in palliative care setting (India) and comparison of screening imaging modalities (Portugal). There was concordance in screening, treatment, and surveillance recommendations between the CW® campaigns. Conclusion: CW® recommendations focus on reducing overutilization of investigations and treatments. Breast cancer screening and treatment were most frequently addressed by CW® recommendations. There was a high rate of consensus between international CW® recommendations with respect to breast cancer care. As health care systems globally move attention to reduce low value care, further studies are required to address adherence to these current recommendations and develop new recommendations addressing topics not currently included in the US CW campaigns. Citation Format: Hely Shah, Julian Surujballi, Arif A Awan, Brian Hutton, Angel Arnaout, Risa Shorr, Lisa Vandermeer, Meshari J Alzahrani, Mark Clemons. A scoping review characterizing “choosing wisely” recommendations for breast cancer management [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS9-47.

Novel Computational Linguistic Measures, Dialogue System and the Development of SOPHIE: Standardized Online Patient for Healthcare Interaction Education

In this article, we describe the iterative participatory design of SOPHIE, an online virtual patient for feedback-based practice of sensitive patient-physician conversations, and discuss an initial qualitative evaluation of the system by professional end users. The design of SOPHIE was motivated from a computational linguistic analysis of the transcripts of 383 patient-physician conversations from an essential office visit of late stage cancer patients with their oncologists. We developed methods for the automatic detection of two behavioral paradigms, lecturing and positive language usage patterns (sentiment trajectory of conversation), that are shown to be significantly associated with patient prognosis understanding. These automated metrics associated with effective communication were incorporated into SOPHIE, and a pilot user study identified that SOPHIE was favorably reviewed by a user group of practicing physicians.

A scoping review characterizing "Choosing Wisely®" recommendations for breast cancer management.

Choosing Wisely (CW)® was created by the American Board of Internal Medicine (ABIM) to promote patient-physician conversations about unnecessary medical interventions. Similarly, other countries created their own panels of experts called "CW® campaigns" which review recommendations submitted by that country's oncology societies. We performed a scoping review to consolidate CW® recommendations from different groups with respect to breast cancer care. A systematic search of Medline and Embase was designed by an information specialist for publications presenting CW® recommendations for breast cancer care practices from 2011-2020. We also reviewed the websites of all CW® campaigns and reference sections of each CW® recommendation. Two reviewers independently screened studies for inclusion and performed data extraction. Findings were summarized narratively. Review of ABIM CW® recommendations showed 19 breast cancer-related recommendations pertaining to; screening (n = 4), radiological staging (n = 2), treatment (n = 10), surveillance (n = 2), and miscellaneous (genetic testing; n = 1). Of 22 countries with CW® campaigns, 10 published recommendations for breast cancer. Over half (57%) of recommendations were supported by more than one country. No recommendations were refuted between campaigns. Two campaigns developed 3 novel recommendations on new topics, including chemotherapy in ductal carcinoma in situ (Italy) and comparison of screening imaging modalities (Portugal). CW® recommendations focus on reducing overutilization of investigations and treatments. There was a high rate of consensus between different CW® campaigns. As health care systems globally move attention to reduce low-value care, further studies are required to address adherence to these current recommendations and develop new recommendations.

Tactile Hand Sensation Following Split Thickness Radial Forearm Free Flap Phalloplasty

PURPOSE: Radial forearm free flap (RFFF) phalloplasty is often referred to as the gold standard for gender-affirming phalloplasty procedures.1 Forearm neuropathy, a frequently listed complication of RFFF phalloplasty, has yet to be quantified in patients who undergo this procedure with a device as precise as the Pressure Specified Sensory Device (PSSD). The purpose of this study was to determine whether there is a change in tactile hand sensation following RFFF phalloplasty, and whether these changes vary by cutaneous region of the hand. The results of this study will help counsel patients who may view potential neuropathy as a barrier to pursuing this procedure. METHODS: A total of 9 patients undergoing split thickness RFFF phalloplasty were tested preoperatively and 1-week postoperatively for tactile hand sensation. Testing was conducted using a 2-point static (2 PS) test with a Disk-Criminator and PSSD. The testing sites included the cutaneous regions of the dorsal first webspace and the first phalanx of the index finger and pollex of the RFFF donor arm. The 2 PSSD prongs were set at a distance determined by initial testing with the Disk-Criminator. The PSSD measured the threshold of pressure necessary for the patient to discriminate 2 points. Two-sided paired t tests compared the pre- and postoperative pressure values on each of the 3 hand locations. The numerical differences in pre- and postoperative pressures were then compared between each of the 3 locations to determine whether or not there was a difference in postoperative sensation based on hand region. The PSSD pressure values were standardized based on the prong distance determined by the Disk-Criminator, and percent change in standardized PSSD score differences for each cutaneous region was calculated. All tests were considered significant at P < 0.05. RESULTS: There were no significant differences between pre- and postoperative PSSD pressures for all cutaneous regions tested (P > 0.05). However, on average, patients required 8.04% more pressure applied in the dorsal first webspace in order to discriminate 2 points, 8.43% more in the first phalanx of the index finger, and 16.7% more in the first phalanx of the pollex postphalloplasty (all n.s.). Furthermore, when comparing each of the three cutaneous regions to each other, there was no difference in the change in pressures between each region (P > 0.05). In other words, each of the three regions of the hand was similarly impacted by the operation. CONCLUSIONS: The results of this study suggest that while past literature reports cases of numbness and/or tingling post-RFFF phalloplasty,1 immediate postoperative sensation is not significantly different than preoperative sensation. The fear of donor arm neuropathy is a potential barrier for patients seeking this life-changing procedure, yet this study quantifies the degree of neuronal damage and may encourage patients to undergo the procedure. These results will help guide patient-physician conversations regarding RFFF phalloplasty in order to create realistic patient expectations for postoperative outcomes. REFERENCE: 1. Kovar A, Choi S, Iorio ML. Donor site morbidity in phalloplasty reconstructions: outcomes of the radial forearm free flap. Plast Reconstr Surg Glob Open. 2019;7:e2442.

Austrian male patients\u2019 gender role conflict is associated with their wish for interpersonal violence to be addressed during patient-physician conversations: a questionnaire study

BackgroundExperiencing interpersonal violence and disclosing this experience to physicians can be associated with fear, shame, denial or emotional turmoil. Expressions of such feelings additionally conflict with masculine gender role ideologies and may be experienced as masculine gender role conflict. Masculine gender role conflict is often associated with men’s unwillingness to seek professional help. The current study analyzed the association between masculine gender role conflict and men’s wish for patient-physician conversations to include questions about interpersonal violence they might have experienced.MethodsIn structured closed-ended interviews conducted at an Austrian hospital 129 male patients (Mage = 59.4, SD = 14.7) were asked what forms of interpersonal violence they had experienced. Additionally, a study-specific questionnaire was used to find out whether male patients wanted future physician-patient conversations to include questions about interpersonal violence they might have experienced. Men’s gender role conflict was assessed with the Gender Role Conflict Scale-Short Form.ResultsHalf of the male patients (50%) reported having experienced at least one form of interpersonal violence. Nearly half of the men (48%) wanted their physician to ask them in future about any violence they might have experienced. One pattern of gender role conflict was positively associated with men’s wish to be asked in patient-physician conversations about potential interpersonal violence. Namely, men who reported conflicts between work and family relations were more likely to state that they wanted such conversations (OR = 1.6, 95%CI = 1.1–2.4) than were men who did not often experience this pattern of gender role conflict.ConclusionsExperiences of interpersonal violence should be an important part of physician-patient conversations with male patients. Overall, male patients would welcome their physician initiating a potential conversation about violence. Using an approach that takes consideration of masculine gender role ideologies may further increase some men’s willingness to approach the topic of interpersonal violence. Men who adhere to the norm of being preoccupied with work may be more willing to talk about this subject if healthcare situations are framed in a way that men perceive the possibility to uphold masculine gender role ideologies of self-sufficiency or of being in control.

Infrequent patient-physician conversations about sexual health at an Austrian university hospital

Abstract Background Many physical diseases are associated with sexual health problems. Studies concerning physicians’ barriers to patient-physician conversations concerning sexual health often fail to go beyond descriptive analyses of such barriers. The current study focused on finding those barriers that best predict the frequency of patient-physician conversations concerning sexual health. Methods An online-questionnaire assessed physicians’ sociodemographic information, frequency of holding a discussion on sexual health issues with their patients, and self-perceived barriers to asking patients about sexual health issues. The study was conducted at an Austrian university hospital. 102 physicians (53.9% women/46.1% men) participated. Logistic regression models were calculated to analyze associations between physicians’ barriers and the frequency of patient-physician conversations concerning sexual health in everyday practice. Results Of the physicians, 61.8% reported having a discussion on sexual health with their patients at least rarely in their everyday clinical practice. Physicians’ barriers that predicted low frequency of patient-physician conversations concerning sexual health were: expecting the patient to initiate such a conversation, not feeling responsible for this health issue, fear of offending the patient, and one’s own shame and discomfort. Conclusions In contrast to other studies about physicians’ barriers to patient-physician conversations concerning sexual health, in the current study time constrains were not a prominent barrier to such conversations. Future training should help physicians recognize the relevance of sexual health in one’s medical discipline and they should be taught how to overcome their feelings of shame or how to cope with patients’ negative reactions during patient-physician conversations concerning sexual health. Key messages University hospital physicians rarely address sexual health issues in patient-physician conversations. Physicians most often handed the responsibility to initiate such conversations to the patient.