Shared Decision-making Framework Research Articles

Enhancing prostate cancer diagnosis communication: A multicenter study evaluating the impact of animated videos, CartDiag Prostate study.

TPS12148 Background: Prostate cancer is the leading cancer among men. Advances in therapeutic techniques, personalized medicine, and the integration of targeted therapies have significantly improved patient outcomes, resulting in a 5-year overall survival of 93%. However, effective patient care requires a shared decision-making framework and clear communication between healthcare professionals and patients. The initial step in patient care involves disclosing the cancer diagnosis during a dedicated consultation, laying the foundation for the patient-physician trust relationship. Nowadays, less than 50% of patients declared that they understood the information provided during the announcement consultation. The main objective of our study is to assess the effect of the announcement system, reinforced by animated videos, on patients' overall understanding of their diagnosis and treatment. Methods: To enhance the disclosure process, animated videos were developed to outline the patient care journey. This multicenter, controlled before-and-after study aimed to evaluate the impact of the usual disclosure process enhanced by animated videos on patients' understanding of advanced or metastatic prostate cancer. Patients were sequentially assigned to two arms: the standard arm (first 45 patients) received usual written and oral information, while the intervention arm (next 45 patients) received written and oral information supplemented by animated videos. To evaluate the effect of the enhanced disclosure process on patients' overall understanding of their diagnosis and treatment using the EORTC QLQ-INFO25 questionnaire at baseline (Day 0) and after 1 month (Day 30), compared to the standard group without enhanced disclosure. This prospective study is the first to assess the impact of supplementing the standard disclosure process with animated videos positively impacts patients' comprehension of advanced or metastatic prostate cancer. The findings will support the potential value of integrating visual aids into the diagnostic disclosure consultation to enhance patient understanding and promote informed decision-making. Clinical trial information: NCT06117696 .

Workshop on cultivating shared decision making to improve surgical outcomes for pelvic organ prolapse

This invited Workshop addressed the treatment of pelvic organ prolapse (POP) through the lens of a shared decision-making framework, based on individual discussions to balance benefits and risks of POP treatment. The framework begins with a consideration of bothersome symptoms as the basis for intervention, and highlights new research to investigate the relationship between POP symptoms and specific anatomical defects. This is followed by a consideration of treatment options including observation, pessaries, and surgery, offering a logical progression. We further consider surgery, focusing on surgical approach and uterine preservation as variables that influence benefits and risks of surgery. Finally, we consider individual variables that further modify specific benefit/risk ratios for a given patient and treatment modality. The goal is to provide a framework that incorporates all of these parameters into evidence informed discussion.

Shared Decision Making in Oncology and Its Implementation in Cervical Cancer Management in the Philippines: A Narrative Review.

Shared decision making (SDM) is an approach where clinicians and patients make decisions together using the best available evidence. Although much studied, recognized to be ethically imperative, and recommended in international health policies, it remains poorly implemented. In the Philippines, there are limited studies on patient decision making preferences and SDM. Practical guidance on the implementation of SDM or use of patient decision aids (PtDAs) is often not detailed in existing national clinical practice guidelines in oncology. We performed a systematic search of Philippine literature on SDM in oncology and an iterative review of international literature on the philosophy and methods of SDM, the utility and effectiveness of PtDAs, and the facilitators and barriers to implementation or usage. We contextualized our review to the cervical cancer management and health service delivery in the Philippines. Local literature is limited to five scientific publications and two registered studies. International literature encompasses patient decisional preferences, the role of PtDAs and the standards for their development and evaluation, their effectiveness, and barriers and facilitators to their use in cancer-related decision making. We discussed the implications on the management of cervical cancer in the Philippines, challenges in health service delivery and standards, and SDM research. Local SDM research is limited. Our preliminary experience in a multicenter clinical trial in Manila on PtDA use in the framework of SDM in cervical cancer suggest good patient and clinician acceptability. Challenges to implementation such as unfavorable financial situations, urgency of clinical decisions, low patient or caregiver educational attainment, and poor integration of multidisciplinary and SDM in organizational workflows will be important when implementing SDM in different settings.

(288) Trends in Penile Prosthesis Placement in Men with Erectile Dysfunction

Abstract Introduction Erectile Dysfunction (ED) is a common problem impacting 20% of all men. Current treatment options include oral medications, vacuum erection devices, intraurethral suppositories, intracavernosal injections, and penile prosthesis placement (PPP). A shared decision-making framework is increasingly utilized for treatment decisions where an appropriate treatment is selected from all options based on the values and priorities of the patient and their partner. Objective Our objective is to identify trends in PPP, including the proportion of patients who pursue PPP as an initial treatment as well as the time from ED diagnosis to PPP. Methods We retrospectively reviewed all men with an ED diagnosis based on ICD9/ICD10 codes using the IBM MarketScan insurance claims database. The initial treatment option processed through an insurance claim following an ED diagnosis was identified and categorized using ICD, HCPCS, NDC, J, and CPT codes. Time from ED diagnosis to PPP was also recorded. Only patients with at least one year of enrollment pre-ED diagnosis and with at least one year of follow-up were included. Linear regressions were performed to investigate the trends of each year based on the time of initial ED diagnosis. Results We identified a total of 670,096 patients diagnosed with ED between 2012-2019. The mean age was 56 years (47-62). Of those patients, 11% were smokers, 29% had diabetes, 24% had cardiovascular disease, 65% had hypertension, and 29% were obese. Among those who received treatment, the most common initial treatment was oral medications in 26% of patients. PPP was an initial treatment in <1% of patients. The proportion of patients who underwent this surgical intervention as an initial treatment significantly decreased from 2012-2019 (P<0.001) as patients utilized other initial treatment modalities more commonly. Over the same period, the time from ED diagnosis to PPP significantly decreased from approximately 500 days in 2012 to <200 days in 2019 (P=0.001). Conclusions Although the proportion of patients who utilize other ED treatment options prior to PPP is higher, patients diagnosed with ED more recently undergo PPP in a significantly shorter timeframe. Utilization of other treatment modalities as an initial treatment option may stem from changes in insurance coverage. Patients moving more quickly from an ED diagnosis to PPP is likely due to several factors, including improvements in the device leading to less mechanical and infectious complications, familiarity with the device due to marketing, and an earlier discussion with the physician about the device based on a shared decision-making model. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Inherent bio, Paterna bio, Firmtech, Turtle health, Maximus, Carrot.

Shared Decision-Making During Virtual Care Regarding Rheumatologic and Chronic Conditions: Qualitative Study of Benefits, Pitfalls, and Optimization.

Virtual care (VC) is an accepted modality of care delivery, and shared decision-making (SDM) benefits patients with rheumatologic and chronic conditions (RCCs). Unfortunately, research suggests reduced quality of SDM during VC. This study explores the benefits and shortcomings of SDM regarding RCCs during VC with suggestions for optimally using VC during SDM. Following Stiggelbout's framework for SDM, we conducted focus groups of patients with RCCs and providers to understand their experiences with SDM during VC, probing for facilitating and challenging factors. We conducted content analysis of the transcripts, defining themes, and inductively reasoned to identify relationships among themes. We summarized the facilitators, barriers, and opportunities for improving SDM during VC that participants proposed. Virtual SDM shares several similarities with in-person practice, as both draw upon trusting patient-provider relationships, following the same general steps, and relying on effective communication. VC presents solutions for known barriers to in-person SDM, expanding time for making decisions and access to care. Technology and virtual health systems introduce new barriers to SDM, and participants list opportunities for overcoming these concerns. VC is a tool that can enhance and even support superior SDM compared with in-person visits when implemented successfully, a condition requiring the development of nuanced skills to correctly identify when and how to best use VC for SDM as well as technology and health care structures that integrate SDM into VC. Therefore, patients, providers, insurance carriers, and policy makers all contribute to the success of SDM among RCCs during VC.

The ethical imperative to honor autistic clients' autonomy in mental health treatment.

Autistic adolescents and adults commonly experience mental health concerns; however, mental health clinicians may hold implicit stigmatizing views of autism that contribute to case conceptualization and treatment goal setting that align more with caregivers' than clients' goals. This impingement on client autonomy is concerning, problematic, and potentially harmful for autistic clients who are of an age to set their own treatment agenda regardless of co-occurring intellectual disability and/or language delays. An application of the shared decision-making framework, an evidence-based tool for promoting client autonomy, can help to avoid these challenges in treatment. In this perspective, we use a case vignette as an anchor for discussing the imperative of honoring autistic clients' autonomy in mental health treatment and guiding shared decision-making to reduce stigma, promote autonomy, and increase collaborative care for autistic clients in mental health treatment.

Evaluating shared decision making for dialysis initiation: A qualitative study on patient refusal of long-term dialysis in Taiwan.

Previous studies have explored shared decision making (SDM) implementation to determine the renal replacement therapy modality; however, the SDM approach for dialysis initiation, especially when patients refuse physician suggestions for long-term dialysis, remains unclear. This study aimed to explore physicians' responses towards patients' refusal of long-term dialysis during the SDM process and the thinking processes of both physicians and patients regarding dialysis refusal. We conducted in-depth semi-structured interviews with 10 patients diagnosed with end-stage renal disease, each of whom refused long-term dialysis after physicians employed the SDM framework, and nine nephrologists at the Chang Gung Memorial Hospital, Taiwan, from March to May 2020. Interviews were audio-recorded, transcribed, and translated from Mandarin to English. They were then thematically analysed. Three main themes on dialysis initiation SDM implementation and the differences between physician and patient perceptions on patient treatment refusal were yielded. While the SDM approach for dialysis initiation developed by nephrologists in Taiwan respects patient decisions, physicians often actively persuade patients to undergo dialysis in case of treatment refusal. The motivation behind this approach is to promote the patient's best medical interests, particularly post-dialysis life quality, and to ensure a 'rational' medical decision is made. However, patients' perceptions of treatment refusal differ significantly from those of physicians, and their decision-making process is often iterative and based on comprehensive evaluation of immediate concerns beyond biomedical factors. Findings suggest that the current physician-led SDM approach for dialysis initiation characterises active persuasion with physicians' perspectives predominating the clinical encounter. To improve SDM implementation, we propose that physicians should acknowledge and understand patients' reasoning for dialysis refusal and the distinction between objective health and subjective well-being during the decision-making process.

Problem-based shared decision-making in diabetes care: a secondary analysis of video-recorded encounters

ObjectivesTo describe the range of collaborative approaches to shared decision-making (SDM) observed in clinical encounters of patients with diabetes and their clinicians.DesignA secondary analysis of videorecordings obtained in a randomised...

P362 Systematic review: Oncological outcomes of patients with Inflammatory Bowel Disease undergoing segmental colonic resections for colorectal cancer and dysplasia

Abstract Background Current international guidelines recommend that patients with inflammatory bowel disease (IBD) diagnosed with high grade dysplasia (HGD), or colorectal cancer undergo a proctocolectomy, and that proctocolectomy is considered within a shared decision-making framework with the patient in cases of low grade (LGD) or indeterminate (IND) dysplasia. However, segmental colectomy (surgical resection leaving remaining colon or rectum) is considered by some as a valid alternative, with less physiological stress, stoma avoidance and thus acceptability to patients. This systematic review aims to assess oncological and post-operative outcomes in studies reporting on segmental colectomy or proctocolectomy for patients with IBD and colonic or rectal dysplasia and cancer. Methods This systematic review was prospectively registered with PROSPERO (CRD42021292891) and carried out in line with the PRISMA guidelines. Studies published between 1990 and 2022 reporting on oncological and surgical outcomes of adult patients undergoing segmental resection and/or proctocolectomy that included at least three cases of neoplasia were included. Descriptive statistics were used in the context of significant heterogeneity. A meta-analysis was performed for outcomes with at least three results. Results The search returned 2178 results, and after screening 12 studies were included in the final analysis. A total 12,701 patients were included reporting on outcomes of 10,386 segmental resections and 2,315 proctocolectomies. The pooled incidence of missed synchronous cancers (i.e. identified in remaining colon or rectum within 6 months of surgery) in the segmental resection group was 1.4%, and dysplasia 0.5%; metachronous cancer recurrence was 1.4% (1.1% in subtotal colectomy, 11.8% in any other segmental resection), and dysplasia recurrence 5.3% (4.7% in subtotal colectomy, 7.5% in any other segmental). Average time to recurrence for metachronous cancer was 6.5 years. Recurrence of metastatic cancer was 0.2% for proctocolectomy, and 0.1% for segmental resection (OR 1.28, 95% CI 0.19 - 8.65, p =ns). Conclusion Segmental colectomy does not disadvantage against metastatic cancer recurrence. The incidence of missed synchronous lesions is low. There is increased metachronous cancer risk, however this is mitigated by subtotal colectomy. These results may help to counsel patients regarding the risks and benefits of segmental resection for IBD-related dysplasia and cancer. The risk of metachronous cancer after segmental resection reiterates the need for enhanced high quality post-operative surveillance. The paucity of data in this field is also demonstrated here by the high inter-study heterogeneity, highlighting the need for prospective studies.

Patient Preferences and Satisfaction With Decisions in Stage-III Melanoma: A Mixed Methods Study

IntroductionRapid accumulation of data in surgical and medical oncology has changed the treatment landscape for patients with stage-III melanoma, introducing options for active surveillance and adjuvant systemic therapy; however, these options have increased the complexity of decision making. MethodsWe conducted an explanatory sequential mixed-methods study consisting of surveys and semistructured interviews among patients diagnosed with stage-III melanoma at a single institution from August 2019 to December 2021. The survey included the validated 30-point satisfaction with decision scale (SWD). The interview guide was developed using a shared decision-making framework. ResultsTwenty-six participants completed the survey (response rate 40%) and 17 were interviewed. In the survey, 69% of participants reported receiving a recommendation for active surveillance and 23% received a recommendation for adjuvant systemic therapy. Overall SWD for treatment of the lymph node basin and adjuvant systemic therapy was high at 27.94 and 26.21 out of 30, respectively. In the interviews, participants stressed the importance of the physician's recommendation as well as the desire to minimize intervention and avoid potential side effects in their decisions. However, they demonstrated persistent knowledge gaps in their understanding of the treatment options. ConclusionsLike other cancer types where the option for active surveillance exists, the physician's recommendation is influential in shaping decisions for patients with stage-III melanoma. Physicians can improve shared decision making in this complex treatment landscape through improved multidisciplinary collaboration and mechanisms for ensuring patients' understanding of the treatment options.

Initial adaptation of the OnTrack coordinated specialty care model in Chile: An application of the Dynamic Adaptation Process.

In 2005, Chile became the first country in Latin America to guarantee universal free access for the diagnosis and treatment of schizophrenia. A cluster randomized control trial utilizing the Dynamic Adaptation Process framework is underway to adapt and test the OnTrack coordinated specialty care model to provide recovery-oriented, person-centered care by a multidisciplinary team for individuals with first episode psychosis (FEP) in Chile. A qualitative formative research study was conducted to inform the initial adaptation of the OnTrack Chile (OTCH) program. We conducted key informant interviews (n = 17) with various stakeholders (policymakers; directors/managers of community mental health centers; mental health professionals) and focus group discussions (n = 6) with individuals with FEP and caregivers (n = 35 focus group participants total). Data was analyzed using thematic analysis, organized by participants' perspectives on the benefits, barriers, and recommendations for the key principles, multidisciplinary team, psychosocial components, and the training and supervision model of OnTrack. Participants expressed enthusiasm and support for OnTrack's recovery-oriented and person-centered principles of care. While many participants lauded the emphasis on shared decision-making and family involvement, some reported reticence, citing that it is culturally normative for patients and families to adopt a passive role in treatment. Peer specialists, and the family psychoeducation and support and supported education and employment components were perceived as aspects that could encourage the promotion of personhood and autonomy development. However, implementation challenges, including the prevailing biomedical approach, professional hierarchy, and the lack of infrastructure, human, and financial resources necessitate some modifications to these aspects. Some mental health professionals further conveyed reservations regarding the perceived hierarchical structure of the supervision model. OnTrack represents a shift from a biomedical model to a valued, aspirational, person-centered and culturally responsive model that focuses on recovery, shared decision-making and psychosocial care. With the appropriate governmental and agency-level provision of resources and modifications to some of the program components, particularly regarding the shared decision-making framework, peer specialist, family engagement, and the training supervision model, OTCH could be a transformative program for a more comprehensive, evidence-based care for individuals with FEP in Chile.

Definition of a tool to assess shared decision-making (SDM) on women with breast cancer: A value-based approach.

Background and AimsIn oncology, there is increasing talk of personalized treatment and shared decision‐making (SDM), especially when multiple treatment options are available with different outcomes depending on patient preference. The present study aimed to define the set of main dimensions and relative tools to assess the Value brought to patients from a Breast Cancer's Clinical pathway structured according to a dynamic SDM framework.MethodsStarting from our previous systematic review of the literature, a deep search of the main evidence‐based and already validated questionnaires was carried out. In the second phase, to corroborate this grid, a Delphi survey was conducted to assess each questionnaire identified for each dimension, against the following seven value‐based criteria: Clinical Benefit, Safety, Care Team Well Being, Patient Reported Outcomes Measures, Green Oncology, Impact on Health Budget, and Genomic Profile.ResultsThe resulting 7‐dimension questionnaire is composed of 72 questions. Of these, some quantitatively and objectively assess the evolution of the patient's disease state, whereas others aim to ask patients about their active involvement in decisions affecting them and to investigate whether they were free to explore their preferences. Furthermore, to frame the analyzed phenomenon at the right time, for each questionnaire section, the specific, evidence‐based timing of administration is indicated.ConclusionThe resulting questionnaire is validated in its entirety and it is composed of a set of questions and relative time point for data collections to assess the Value brought to patients undertaking a Breast Cancer's Clinical pathway, structured according to a dynamic SDM framework. It constitutes a quantitative instrument to integrate patient centeredness with a personalized perspective in the care management of women with breast cancer.

Growing Need for Primary Care Physicians Caring for Cancer Survivors.

A rising population of cancer survivors is accompanied by a shortage of oncologists for continuity of care. This study examined the physicians who provided most of the care for cancer survivors, along with written information provided to the survivors before transfer of care. Data were collected through the CDC-sponsored Behavioral Risk Factor Surveillance System. Our analysis involved states whose respondents completed a cancer survivorship module from 2016 to 2020. Primary measures were the proportions of physician specialists who provided most of their subsequent health care and the proportions of survivors who received written summaries of their care and instructions. The 36,737 cancer survivor respondents came from 33 states. Most of their health care came from primary care physicians [family physicians (42.3%, 95% CI: 41.3-43.2%) and general internists (26.0%, 95% CI: 25.2-26.9%)]. When seen by primary care physicians rather than subspecialists, a lower proportion of patients recalled receiving summaries of either their cancer treatments (44.3%, 95% CI: 42.5 to 46.2 vs 50.5%, 95% CI: 49.4 to 51.7%) or follow-up instructions (69.9%, 95% CI: 68.8 to 71.0% vs 78.7%, 95%CI 77.1 to 80.2%), regardless of their cancer type. Regardless of their cancer type, two-thirds of survivors received most of their health care from primary care physicians. Collaborative community-based care within a shared decision-making framework is essential to prioritize and individualize patients' understandings and needs in this growing population.

Shared Decision-Making Concerning Anal Cancer Screening in Persons With Human Immunodeficiency Virus.

Anal high-grade squamous intraepithelial lesion (aHSIL) is the immediate precursor of anal cancer. Anal cytology is a recommended screening test to identify aHSIL among people with human immunodeficiency virus (HIV; PWH). Heterogeneity of risk for invasive anal cancer among PWH suggests the value of a shared decision-making framework regarding screening. Using a longitudinal HIV cohort with a comprehensive anal cancer screening program, we estimated the adjusted probabilities of having aHSIL on the first anal cytology. We used logistic regression models with inverse probability weighting to account for differential screening in the cohort and to construct a predicted probability nomogram for aHSIL. Sensitivity analysis was performed to estimate aHSIL prevalence corrected for misclassification bias. Of 8139 PWH under care between 2007 and 2020, 4105 (49.8%) underwent at least 1 anal cytology test. First-time cytology aHSIL was present in 502 (12.2%) PWH. The adjusted probability of having aHSIL varied from 5% to 18% depending on patient characteristics. Prespecified factors in the aHSIL prediction model included nadir CD4 cell count, ethnicity, race, age, sex, gender identity, and HIV risk factors. The ability of the model to discriminate cytological aHSIL was modest, with an area under the curve of 0.63 (95% confidence interval, .60-.65). PWH are at increased risk for aHSIL and invasive anal cancer. Risk, however, varies by patient characteristics. Individual risk factor profiles predictive of aHSIL can be modeled and operationalized as nomograms to facilitate shared decision-making conversations concerning anal cancer screening.

Functional Rehabilitation: An Integrated Treatment Model for Patients With Complex Physical and Psychiatric Conditions.

The health care delivery system in the United States, structured to provide single-disease care, presents unique challenges for patients with complex physical and psychiatric comorbidities. Patients in these populations are often referred to multiple specialty clinics, encounter little continuity of care or collaboration among their providers, incur high health care costs, and experience poor treatment outcomes. Given these barriers, questions remain about the extent to which siloed and fragmented care, as opposed to the complex nature of the illnesses themselves, contribute to poor outcomes. If given the opportunity to receive well-integrated, consistent, and personalized care, can patients with historically difficult-to-treat comorbid medical and mental illnesses make progress? This article describes an innovative model of care called functional rehabilitation that is designed to address existing barriers in treatment. The functional rehabilitation program seeks to disrupt the escalating effects of interacting comorbidities by offering highly collaborative treatment from a small team of clinicians, personalized interventions using a shared decision-making framework, multipronged treatment options, colocation in a large hospital system, and significant 1:1 time with patients. The article includes a case example with longitudinal outcome data that illustrates how progress can be made with appropriate programmatic supports. Future research should examine the cost-effectiveness of this model of care.

Intra-abdominal cancer risk with abdominal pain: a prospective cohort primary care study.

Quantifying cancer risk in primary care patients with abdominal pain informs diagnostic strategies. To quantify oesophagogastric, colorectal, liver, pancreatic, ovarian, uterine, kidney, and bladder cancer risks associated with newly reported abdominal pain with or without other symptoms, signs, or abnormal blood tests (that is, features) indicative of possible cancer. This was an observational prospective cohort study using Clinical Practice Research Datalink records with English cancer registry linkage. The authors studied 125 793 patients aged ≥40 years with newly reported abdominal pain in primary care between 1 January 2009 and 31 December 2013. The 1-year cumulative incidence of cancer, and the composite 1-year cumulative incidence of cancers with shared additional features, stratified by age and sex are reported. With abdominal pain, overall risk was greater in men and increased with age, reaching 3.4% (95% confidence interval [CI] = 3.0 to 3.7, predominantly colorectal cancer 1.9%, 95% CI = 1.6 to 2.1) in men ≥70 years, compared with their expected incidence of 0.88% (95% CI = 0.87 to 0.89). Additional features increased cancer risk; for example, for men, colorectal or pancreatic cancer risk with abdominal pain plus diarrhoea at 60-69 years of age was 3.1% (95% CI = 1.9 to 4.9) predominantly colorectal cancer (2.2%, 95% CI = 1.2 to 3.8). Abdominal pain increases intra-abdominal cancer risk nearly fourfold in men aged ≥70 years, exceeding the 3% threshold warranting investigation. This threshold is surpassed for the >60 years age group only with additional features. These results will help direct appropriate referral and testing strategies for patients based on their demographic profile and reporting features. The authors suggest non-invasive strategies first, such as faecal immunochemical testing, with safety-netting in a shared decision-making framework.

What Is the Role of Shared Decision-Making With Parents of Children With Bronchiolitis?

What Is the Role of Shared Decision-Making With Parents of Children With Bronchiolitis?

Abstract 10796: Patient and Clinician Perspectives of Decision Quality Surrounding Atrial Fibrillation Ablation: A Mixed-Methods Study

Introduction: Catheter ablation is a common treatment for atrial fibrillation (AF) with nuanced risks and benefits. Shared decision-making (SDM) could guide the decision to undergo ablation based on patient values and goals of care. Understanding whether and how SDM about ablation is conducted in clinical practice would allow us to determine how to optimize patient decision making and decision quality. The objective of this study was to investigate decision quality and SDM practices surrounding AF ablation. Methods: We conducted a mixed-methods study guided by Sepucha & Scholl’s (2014) SDM framework which specifies decision antecedents, processes, and outcomes. We recruited a convenience sample of AF ablation patients (n=15) and clinicians (n=5; 3 MDs, 1 PA, 1 NP) from a hospital in Queens, New York. Patients completed the AF Symptom Survey (AFSS), Controls-Preferences scale (CPS), and Decisional Conflict scale (DCS), which were summarized using descriptive statistics (median, interquartile range [IQR], and frequency). Patients and clinicians completed semi-structured interviews, which were analyzed using directed content analysis. Participants received $25 as compensation. The Weill Cornell Medicine IRB approved this study. Results: Patients’ median age was 71.0 years (IQR 69.0-78.5), 27% were female, 67% were White, and 73% spoke English. The median AFSS score was 0 (IQR 0-1.0) out of 35 indicating low symptom burden post-ablation. The median DCS score was 7.0 (IQR 0-16.4) out of 100 indicating low levels of conflict. On the CPS 4 patients (27%) preferred to have some control in decision-making; the remainder preferred to share control or relinquish it to clinicians. Qualitative findings underscore low levels of decisional conflict but limited patient agency (Table) . Conclusion: Findings suggest opportunities to improve decision quality surrounding AF ablation by bolstering patient agency, possibly through educational materials and decision aids.

Institutional dependencies in climate adaptation of transport infrastructures: an Institutional Network Analysis approach

Climate adaptation measures are shaped and implemented through processes of governance, where the interactions and decision-making among actors lead to the creation and reinforcement of institutions. Institutions in this respect are the rules that shape the interactions of actors in different phases of climate adaptation. Currently there is no comprehensive method to systematically identify and map dependencies between institutions. This study proposes the Institutional Network Analysis (INA) approach that is based on the Institutional Grammar as a systematic and comprehensive tool to (1) visualise institutional dependencies, (2) identify points of concern in the institutional landscape such as conflicts and voids, and (3) provide quantitative insights into the centrality of actors, embeddedness of institutional outcomes, and dependencies between institutions. The approach is applied to the case of climate adaptation of transport infrastructures surrounding the Port of Rotterdam, the Netherlands. The analysis reveals a conflict in the use of risk assessment criteria, as parties in the Port may follow their own matrices in the presence of a shared decision-making framework. Nonetheless, the network metric analysis reveals that the criteria, whether shared or individual, build on the same source of risk analysis, suggesting that this duality may not be detrimental for climate adaptation efforts. Additionally, an institutional void is identified for financial responsibilities in locations where infrastructures overlap. Finally, the network metrics show high dependency between institutions in the risk dialogue phase, and reveal the centrality of infrastructure owners ProRail and RWS in the institutional landscape instead of local or regional governmental bodies.

Relationships among Antecedents, Processes, and Outcomes for Shared Decision Making: A Cross-Sectional Survey of Patients with Lumbar Degenerative Disease.

Among musculoskeletal disorders, lumbar degenerative disease (LDD) is the leading cause of total disability-adjusted life years globally. Clinical guidelines for LDD describe multiple treatment options in which shared decision making becomes appropriate. To explore the relationships among measures of decision antecedents, process, and outcomes in patients with LDD. Patients with LDD were recruited from outpatient clinics in a teaching hospital in Taiwan and administered surveys to collect measures of decision antecedents, processes, and outcomes. Multiple linear regression was conducted to assess the association between decision antecedents and the decision making process. Hierarchical linear regression was conducted to assess the relationships among decision antecedents, the decision making process, and decision outcomes. A total of 132 patients (mean age, 61 years) completed the survey. After adjustment for personal factors, 2 decision antecedents (namely, decision making self-efficacy and readiness) significantly predicted patients' experiences of engaging in shared decision making (SDM). Decision making readiness and process were associated with fewer decisional conflicts and greater decision satisfaction. Models derived from cross-sectional surveys cannot establish causal relationships among decision antecedents, decision making processes, and decision outcomes. Our results support the SDM framework, which proposes relationships among decision antecedents, the decision making process, and decision outcomes.