Shared Decision-making Process Research Articles

Deployment of SHARE model in ADLIFE project to boost Shared Decision Making in a patient-centered approach.

Introduction: Serious illness raises the stakes for engaging patients and families in healthcare decisions. They include those with critical life-threatening illnesses, advanced stages of major chronic diseases, or multi-morbidity and frailty. Patients confront debilitating symptoms and impending threats to function, decision-making capacity, and survival. Patients, caregivers, and health care practitioners identify communication and shared decision-making (SDM) as essential components of good care in serious illness. SDM is a process where clinicians and patients work together to clarify treatment, management, or self-management support goals, sharing information about options and preferred outcomes to reach a mutual agreement on the best course of action.
 ADLIFE is an EU-funded project to improve the quality of life of older people with advanced chronic diseases by providing integrated intelligent personalized care via a digitally enabled holistic and integrated supportive care ICT Toolbox. ADLIFE care model aims to respond to the individual patient's situation and improve the relationship between patients, carers, and professionals. This patient-centred approach, in which the patient's values and preferences are incorporated, enables the definition of an individualized and personalized treatment for the patient.
 Methods: The project seeks to promote, encourage, and offer the possibility of promptly integrating SDM through the Personalized Care Plan Management Platform (PCPMP). From more than 22 accepted definitions of shared decision-making, the project has implemented the adapted SHARE approach (https://www.ahrq.gov/) for exploring and comparing care options through meaningful dialogue about what matters most and benefits the patient. The model includes a five-task process:
 (i) Seeking the involvement of the patient (healthcare professional);
 (ii) Helping the patient explore and compare treatment options;
 (iii) Assessing the patient's values and preferences;
 (iv) Making a decision;
 (v)Evaluating the patient's decision after a period of time. 
 The SHARE approach proposes the involvement of patients and professionals in different tasks such as information transfer, risk communication, and preference elicitation, tailoring options, or broader decision-making. The model offered in ADLIFE to healthcare professionals includes information and evidence that supports the approach, establishing the relation and connection between the tasks and actors involved in the process.
 Results: In ADLIFE the SDM process is suggested by the PCPMP. The suggestions appear in specific situations to engage in shared decision-making. Professionals can choose to engage in the process at any other moment. Based on the SHARE approach, professionals will be provided with quick help for each of the five tasks, including the definition of the task, aids for professionals and for patients, and support about how and when to carry out the task (information and materials).
 Discussion and Conclusions: The SDM model implemented boosts in a useful way how professionals and patients can be involved in a clinical decision. ADLIFE focuses on motivating healthcare professionals to engage in SDM routinely and promote patient autonomy, involvement, voice, emotions, and trust. The project can ultimately create an SDM culture and encourage and improve the ability and skills of clinicians to perform SDM activities. 
 Acknowledgements: 
 ADLIFE (GA 875209) received funding from the EU Horizon 2020. The authors thank all partners within ADLIFE.

Out-of-pocket spending and health care utilization associated with initiation of different medications for opioid use disorder: Findings from a national commercially insured cohort

IntroductionBuprenorphine and naltrexone are effective medications for opioid use disorder (MOUD). Naltrexone requires complete detoxification from opioids before initiation while buprenorphine does not, which leads to a differential clinical induction challenge. Few studies have evaluated economic costs associated with MOUD initiation. MethodsWe conducted a retrospective cohort analysis using the 2014–2019 Merative MarketScan database. We included individuals diagnosed with opioid use, abuse, or dependence from 2014 to 2019 who initiated one of three MOUD types: 1) buprenorphine, 2) extended-release naltrexone, or 3) oral naltrexone. We calculated total and monthly out-of-pocket spending, for overall and MOUD-specific claims, for the three months prior through three months after MOUD initiation. We also calculated utilization of detoxification, inpatient, and outpatient services monthly over this period. ResultsOur cohort included 27,133 individuals; 19,536, 1886, and 5711 initiated buprenorphine, extended-release naltrexone, and oral naltrexone, respectively. Individuals who initiated naltrexone had the highest out-of-pocket spending over the study period. MOUD-specific spending did not contribute substantially to total out-of-pocket spending. Difference in overall spending by MOUD type was driven by a subset of individuals who initiated naltrexone and had very high out-of-pocket spending in the month prior to MOUD initiation. In this month, mean monthly out-of-pocket spending for high-spenders (above 90th percentile within MOUD type category) was $5734 (95 % confidence interval [CI]: $5181–$6286) and $4622 (95 % CI: $4161–$5082) for those who initiated oral and extended-release naltrexone, respectively, compared with $1852 (95 % CI: $1754–$1950) for those who initiated buprenorphine. In the month prior to MOUD initiation, those who initiated naltrexone also had higher detoxification, inpatient, and outpatient episode/visit frequency. In the month prior to initiation, 28.8 % (95 % CI: 27.7 %–30.0 %) and 25.5 % (95 % CI: 23.6 %–27.5 %) of individuals who initiated oral and extended-release naltrexone had detoxification episodes, compared with 9.7 % (95 % CI: 9.3 %–10.1 %) of those who initiated buprenorphine. ConclusionFindings suggest that individuals who initiated naltrexone utilized more intensive health services, including detoxification, in the period prior to MOUD initiation, resulting in significantly higher out-of-pocket spending. Out-of-pocket spending is a patient-centered outcome reflecting potential patient burden. Our results should be considered as part of the shared decision-making process between patients and providers when choosing treatment for OUD.

Optimising a co-production framework for developing public health interventions: application and testing of school-based Research Action Groups

Existing frameworks for developing public health interventions have limited guidance for researchers on how to work with stakeholders to co-produce context-specific interventions. To address this, a promising framework for the co-production of public health interventions was developed through a previous review of school-based co-production. The present study aimed to optimise this co-production framework through applying and testing it in real-world secondary school contexts. Within schools, Research Action Groups (RAGs) were established with multiple school stakeholders supported by an external facilitator to use school data to produce school-specific mental health and wellbeing interventions. A mixed method process evaluation of two contextually diverse case study secondary schools in the UK was used to optimise the co-production framework. The process evaluation sought the views of those involved (students, school staff, school Senior Management Team (SMT) members, and the external co-production facilitator/researcher) on the co-production functions they were involved in so they could be modified, if needed. Data collected for the process evaluation during co-production were a researcher diary (n = 45 entries), and observations of student photography (n = 21) and RAG meetings (n = 8). Post co-production, interviews, and surveys with RAG students (n = 18) and staff (n = 8), and two school-specific SMT focus groups (n = 10) were conducted. The study identified four recommendations to optimise and integrate co-production into real world practice. They include the need to: assess schools for their readiness to undertake co-production; more effectively communicate the necessity to have stakeholders from the whole system involved; work with SMTs throughout co-production functions; involve stakeholders outside the school to support producing solutions to change school mental health and wellbeing priorities. The framework is intended to be used by researchers to integrate stakeholders into a shared decision-making process to develop interventions that meet the needs and contexts of individual schools. It could be transferred to other settings to support the development of public health interventions for other health areas, and populations. Further evaluation to test its use in other settings is needed.

Association of Sputum Eosinophilia With Easily Measured Type-2 Inflammatory Biomarkers in Untreated Mild Persistent Asthma

A multicenter clinical trial in patients with mild persistent asthma indicated that response to inhaled corticosteroids (ICS) is limited to those with sputum eosinophilia. However, testing for sputum eosinophilia is impractical in most clinical settings. We examined associations between sputum eosinophilia and type 2 inflammatory biomarkers in untreated mild persistent asthma. Induced sputum, blood eosinophil count (BEC), fractional exhaled nitric oxide (FeNO), and serum periostin were obtained twice during the 6-week run-in period in a clinical trial that enrolled patients 12 years and older with symptomatic, mild persistent asthma without controller therapy. The optimal threshold for each biomarker was based on achieving 80% or greater sensitivity. Performance of biomarkers (area under the receiver operating characteristics curve [AUC], range 0.0-1.0) in predicting sputum eosinophilia 2% or greater was determined; AUCs of 0.8 to 0.9 and more than 0.9 define excellent and outstanding discrimination, respectively. Of 564 participants, 27% were sputum eosinophilic, 83% were atopic, 70% had BEC of 200/uL or higher or FeNO of 25 ppb or greater; 64% of participants without sputum eosinophilia had elevated BEC or FeNO. The AUCs for BEC, FeNO, and both together in predicting sputum eosinophilia were all below the threshold for excellent discrimination (AUC 0.75, 0.78, and 0.79, respectively). Periostin (in adults) had poor discrimination (AUC 0.59; P= .02). In untreated mild persistent asthma, there is substantial discordance between sputum eosinophilia, BEC, and FeNO. Until prospective trials test the ability of alternative biomarkers to predict ICS response, BEC or FeNO phenotyping may be an option to consider ICS through a shared decision-making process with consideration of other clinical features.

Expert consensus on the management of interstitial lung disease during the COVID-19 epidemic

Expert consensus on the management of interstitial lung disease during the COVID-19 epidemic

Treat-to-Target in Atopic Dermatitis.

Atopic dermatitis is one of the most common inflammatory skin diseases among children and adults. Over the last 5 years, the armamentarium for the treatment of this disease, with both topical and systemic drugs, has increased. Treat-to-target is basically the concept where a treatment goal and a time frame for that goal is set at initiation of a new treatment, and if the goals are not achieved in time, treatment will be adjusted. In clinical trials, treatment targets are based on scoring systems for disease severity as recommended by the Harmonizing Outcome Measure for Eczema (HOME) initiative, with the primary endpoint being a reduction of at least 75% of the baseline Eczema Area and Severity Index (EASI) score (EASI-75). The question, however, is if these are useful targets in real-world settings and how this should be implemented in everyday clinical practice. In rheumatology, setting a measurable target and a time frame for an instigated therapy has been shown to lead to more efficient and successful treatment. For atopic dermatitis, the instruments recommended by HOME form the core outcome measures for the treat-to-target frameworks published to date, which are based on expert consensus and Delphi processes. Although atopic dermatitis patients have a high risk of co-morbidities, including physical, psychological and socioeconomic, instruments to measure the severity of co-morbidities have not been included in these existing frameworks. In order to apply a treat-to-target strategy that is meaningful for both the patient and the doctor, validated tools for the measurement of treatment effect on co-morbidities exist and should be included in a shared decision-making process with the individual patient when choosing which targets to aim for and what should be considered treatment success. An obvious limitation for the implementation of a treat-to-target strategy in the clinical setting with atopic dermatitis is that retrieving the data needed is very time consuming. This could to some degree be mitigated by the use of electronic applications in which patients could report their outcomes.

Living Longer or Better-Patient's Choice in Cardiac Surgery Is Gender-Dependent-A Multicenter Study.

In view of the increasing age of cardiac surgery patients, questions arise about the expected postoperative quality of life and the hoped-for prolonged life expectancy. Little is known so far about how these, respectively, are weighted by the patients concerned. This study aims to obtain information on the patients' preferences. Between 2015 and 2017, data were analyzed from 1349 consecutive patients undergoing cardiac surgery at seven heart centers in Germany. Baseline data regarding the patient's situation as well as a questionnaire regarding quality of life versus lifespan were taken preoperatively. Patients were divided by age into four groups: below 60, 60-70, 70-80, and above 80 years. As a result, when asked to decide between quality of life and length of life, about 60% of the male patients opted for quality of life, independent of their age. On the other hand, female patients' preference for quality of life increased significantly with age, from 51% in the group below sixty to 76% in the group above eighty years. This finding suggests that female patients adapt their preferences with age, whereas male patients do not. This should impact further the treatment decisions of elderly patients in cardiac surgery within a shared decision-making process.

Perspectives and perception of haemophilia gene therapy by French patients.

A national survey was initiated by representatives of French patients with haemophilia (AFH) and the French reference centre for haemophilia, in order to appreciate the awareness and knowledge of these patients regarding haemophilia gene therapy (HGT) and understand better their position about this innovative treatment that will soon become available. Of 143 answers received, 137 could be analysed, representing about 3.5% of patients with severe or moderate haemophilia over 16year-old. They were 80.3% with haemophilia A and 19.7 % with haemophilia B, with a severe form of the disease for 80.3 % of them. Curiosity for HGT was formulated by 64.2% of the participants, 33.6 % being interested by this approach as soon as it will be available and 38.7 % preferring to wait until more patients have been treated. Only 3.6 % of the participants would never consider receiving HGT. The level of awareness and knowledge was estimated to be limited by 39.5 % of the patients. More than 60 % of them declared having never or almost never discussed HGT with the team of their haemophilia centre. Before deciding to get HGT, 54.4 % of the participants considered that it will be very important to compare it with their current treatment and 53.7 % would like to be better informed by their care providers. These results highlight the need for training and education for patients, but also for professionals at haemophilia centres, about HGT and the shared decision-making process. Objective, unbiased and transparent information must be available for patients about this very promising therapy which nonetheless carries more uncertainty and unknowns compared to other haemophilia treatments.

Abstract A041: The iCCARE Consortium for Prostate Cancer in Black men: Evaluability assessment of the implementation of a care plan for black prostate cancer survivors

Abstract Despite notable progress in early detection, prevention, and treatment of prostate cancer within the United States, racial disparities are present very early in the patient journey of Black men, starting with the shared decision-making process. The disproportionately higher number of Black men diagnosed with prostate cancer also suggests that Black men must also contend with the management of associated physiological and psychosocial symptoms. The survivorship care plan was designed to communicate critical information that cancer survivors and their health care advocates need as a guidebook for long term post treatment care, and improved survivorship. An associated systematic literature review conducted by our multidisciplinary investigative team revealed there was a severe underutilization of survivorship care plans within cancer survivorship care especially with Black men. The considerable lack of utilization and/or tailoring of survivorship care plans may be a significant contributor to the worsening of health disparities in this population. Co-designing survivorship care plans with key stakeholders, specifically Black survivors and their health care advocates, is imperative to ensure that the plan meets the needs and preferences that Black men have for survivorship care. This presentation will discuss the steps the investigative team used to address the disparities in shared decision-making, and the subsequent underutilization of survivorship care plans. The investigative team utilized semi-structured interviews and focus group methodology to explore how the lived experiences of Black male prostate cancer survivors are incorporated and addressed in the construction and contents of a culturally tailored survivorship care plan (CaP_SCP- Black Men). An evaluability assessment was conducted to determine whether implementation of the newly created survivorship care plan is feasible, appropriate, and addresses the specific needs of the population before full implementation. This presentation will discuss how this combination of approaches allowed the investigative team to understand how survivorship care plans affect the unique complexities of survivorship in Black men, and allows for the feasibility study of the implementation of a culturally relevant survivorship care plan (CaP_SCP- Black Men) in a population that bears the greatest burden nationally and globally. Citation Format: Timethia Bonner, Kimlin Ashing, Folakemi Odedina. The iCCARE Consortium for Prostate Cancer in Black men: Evaluability assessment of the implementation of a care plan for black prostate cancer survivors [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A041.

Abstract A065: “He didn’t tell me anything” – A qualitative analysis of patient-provider communication and treatment decision-making among Latino prostate cancer patients

Abstract BACKGROUND: Prostate cancer is the second most diagnosed cancer among Latino men in the United States. There are disparities in prostate cancer patterns of care and adherence to active surveillance among Latino men. However, little is known about the reasons for these disparities, including patient-provider communication, knowledge, attitudes, and beliefs. PURPOSE: This single institution study explored how patient-provider communication influences treatment decision-making for Latino patients and show how these experiences might contribute to knowledge and beliefs about prostate cancer and prostate cancer treatment. METHODS: We conducted semi-structured focus groups and individual interviews in Spanish or English with 26 Latino prostate cancer patients, lasting between 30 – 60 minutes from July 2021 to October 2022. Patients were men recently diagnosed with prostate cancer in Urology clinics at the USC Norris Comprehensive Cancer Center and Los Angeles General Medical Center. Interviews were audio-recorded, transcribed, translated, and uploaded into Dedoose software for analysis. Using thematic analysis, two independent coders analyzed the interview transcripts utilizing both deductive and inductive approaches. RESULTS: Participants included 26 Latino prostate cancer patients aged 53 to 85 years old (mean = 65.3; SD = 8.42), 65% were monolingual Spanish speakers. Patients described the interactions they had with their physicians at the time of diagnosis and the role that these providers played in their decision-making for prostate cancer treatment. A large proportion of patients described negative experiences during the diagnosis and treatment of their prostate cancer, such as the physician “not explaining anything”, “not telling them anything”, or having “crude” tones. Patients who experienced these negative patient-provider relationships often reported poor communication, mistrust of their provider, and subsequently had limited knowledge about their prostate cancer and treatment. On the other hand, patients who described a shared decision-making process with their provider shared that this resulted in increased knowledge of prostate cancer and treatment. Moreover, patients who described a positive patient-provider relationship stated this resulted in having full confidence and trust in their provider’s treatment decision and/or recommendation. CONCLUSIONS: Themes of patient-provider relationships, decision-making, and knowledge of prostate cancer identified in this study support possible mechanisms that may contribute to disparities in treatment patterns and adherence to active surveillance among Latino men. Our results indicate that positive patient-provider relationships shape shared treatment decision-making and knowledge about prostate cancer and prostate cancer treatment for Latino men. Thus, healthcare providers and staff should ensure culturally competent and patient-centered communication and care to support the knowledge and outcomes of prostate cancer among Latino men. Citation Format: Victoria E. Rodriguez, Briseyda Mendoza-Aguayo, Janet Rodriguez, Carla M. Ramirez, Daniel Soto, Jennifer B. Unger, Jamal Nabhani, Andre Luis Abreu, Rojine Ariani, Lourdes Baezconde-Garbanati, Leslie Ballas, Mariana C. Stern. “He didn’t tell me anything” – A qualitative analysis of patient-provider communication and treatment decision-making among Latino prostate cancer patients [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A065.

Factors Affecting Patient and Caregiver Preferences for Treatment of Myeloma and Indolent Lymphoma.

Treatment options for myeloma and indolent lymphoma are increasing exponentially, with distinct efficacy, side effects, and cost. We aim to determine the factors influencing patient and caregiver treatment preferences. Patients and caregivers of patients with myeloma and indolent lymphoma were recruited from two cancer centers in Singapore. Preferences were elicited using a discrete choice experiment. Attributes and levels were selected based on a previous qualitative study. The relative preference for levels within each attribute (part worth utility values) and the extent to which an attribute would influence decision making (relative importance) were calculated. Patient and caregiver participation in the treatment plan selection process were assessed using the Control Preference Scale. One hundred ninety-nine patients and 169 caregivers were recruited. Patients placed the highest importance on out-of-pocket costs (relative importance = 35%), followed by efficacy (25%), persistent side effects (19%), administration route (8%), treatment duration (7%), and short-term side effects (5%). Caregivers ranked efficacy (27%) as the most important attribute, over out-of-pocket costs (24%). Most patients preferred a collaborative role in the shared decision-making process, while similar proportions of caregivers favored active and collaborative roles. Our study demonstrates that both patients and caregivers consider cost seriously when making treatment decisions. Furthermore, as patient and caregiver preferences may differ, there are implications for treatment selection and counseling, especially in cultures where caregivers have more prominent roles in treatment planning.

Abstract A059: The role of conversational chatbots in enhancing shared decision making for African American men with early stage prostate cancer

Abstract Introduction : Enhancing shared decision making (SDM) for African American (AA) men with early stage prostate cancer using conversational chatbots (CCs) aims to improve communication, provide information, and empower them in their treatment decision making process. SDM is a collaborative approach that involves patients and healthcare providers working together based on medical evidence and patient preferences. However, AA men face significant disparities in prostate cancer (PCa) outcomes, including higher incidence and mortality rates compared to other racial/ethnic groups in the United States. Limited access to recommended PCa information and inadequate information during SDM conversations contribute to the challenges AA men face when making treatment decisions. The purpose of this study was to develop a conversational chatbot (CC) to provide PCa information in real time thus, enhancing SDM for AA men with PCa. Methods: The Ottawa Decision Support Framework and the International Patient Decision Aids Standards provided guidance and framework for the development of the CC. Our participatory research approach involved a diverse Community-Based Participatory Research Advisory Board (CBPRAB) consisting of twelve members. The CBPRAB included AA PCa survivors, AA men, caregivers, advocates, community leaders, and cancer care providers. Through training in research methods and focus group facilitation, CBPRAB members actively contributed their valuable insights, ensuring a collaborative and inclusive research process. Results: Five stakeholder focus groups (n = 44) comprising AA men, PCa survivors, spouses, healthcare professionals, and advocates provided valuable input for the development of the CC. In total, 819 questions were generated through interviews conducted during the focus groups. These questions were either inferred from the discussions or explicitly provided by the participants. The answers to these questions were developed from evidence based sources, such as the American Cancer Society and National Comprehensive Cancer Network Guidelines. An Android-based smartphone application that allows users to submit questions via speech was created. The application matches the user's question within the data set of 819 questions and provides answers in both voice and text formats. Conclusion : The Android-based smartphone application was alpha tested on four stakeholder focus groups (n=35). The CC developed in the smartphone application demonstrated the capacity to provide real time responses to user questions sourced from an 819-question database derived from our stakeholder focus groups. By offering evidence based information and directing users to additional resources if the question is not in the database, the CC can improve accessibility to medical information, thus enhancing the SDM process regarding early stage prostate cancer. Citation Format: Angela D. Adams. The role of conversational chatbots in enhancing shared decision making for African American men with early stage prostate cancer [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A059.

Towards data-informed shared decision making: what do we need?

Background:The increasing availability of data offers new possibilities for supporting quality of care in long-term care (LTC) for older adults, also for dementia care units in nursing homes. Examples are quantitative data in electronic health records (i.e. medication), data collected by technological devices such as sensors and wearables (i.e. data related to psychical and mental health including for example heart rate and sleeping patterns), but also qualitative data stored in texts (e.g. transcribed conversations about perceived quality of life). LTC organisations currently lack tools to interpret and integrate the data in the shared decision-making (SDM) process. This project investigates the necessities for data-informed SDM.Methods:The study was conducted in co-design with the knowledge group ‘Data Science’ residing in the Living Lab in Ageing and Long-Term Care, Maastricht. A focus group-setting, in which a diverse set of stakeholders, including data/ICT-specialists, care managers and client representatives, took place to discuss bottlenecks, possibilities and solutions related to data-informed SDM.Results:In total, representatives (n=18) from 7 care organisations participated in three separated focus groups. This resulted in several themes that were deemed necessary for data-informed SDM: 1) an organisational vision on data and data-informed SDM, 2) investment in data-driven care SDM, 3) the instalment of multidisciplinary teams, including clients, informal and formal caregivers, 4) a planned implementation process is needed, and 5) the use of living lab constructions.Conclusion:A well-thought-out, integral learning process, including a vision statement on data and the installation of multidisciplinary teams working on data-problems, is deemed necessary in order for LTC organisations to accomplish data-informed SDM. A concrete step-by-step plan, which can provide LTC organizations with tools to embed data in the current SDM process, is suggested to help organisations in their quest to data-informed personal care.

Position of the Academy of Nutrition and Dietetics: Medical Nutrition Therapy Behavioral Interventions Provided by Dietitians for Adults With Overweight or Obesity, 2024

Providing interventions that facilitate improvement of dietary intake and other health behaviors can improve nutrition-related outcomes in adults with overweight or obesity. Medical nutrition therapy (MNT) behavioral interventions require expertise from registered dietitian nutritionists or international equivalents (dietitians), which no other health care provider can provide for adults with obesity. Current evidence supports the role of MNT behavioral interventions for adults with overweight or obesity as an effective treatment option, when appropriate for and desired by the client. This Academy of Nutrition and Dietetics Position Paper describes potential benefits and concerns regarding dietitian-provided MNT behavioral interventions for adults with overweight and obesity and informs dietitians about implications for practice. This Position Paper is supported by a systematic review examining effectiveness of MNT interventions provided by dietitians and by an evidence-based practice guideline. It is the position of the Academy of Nutrition and Dietetics that MNT behavioral interventions for adults (aged 18 years and older) with overweight or obesity should be a treatment option, when appropriate and desired by the client, to improve cardiometabolic, quality of life, and anthropometric outcomes. Dietitians providing MNT recognize the complex contributors to overweight and obesity, and thus individualize interventions, based on a shared decision-making process, and deliver interventions in an inclusive, compassionate, and client-centered manner. Interventions should include collaboration with an interprofessional team when needed. Dietitians strive to increase health equity and reduce health disparities by advocating and providing opportunities for increased access to effective nutrition care services. This position remains in effect until December 31, 2031.

A shared decision-making model in pediatric palliative care: a qualitative study of healthcare providers

BackgroundPediatric shared decision-making (SDM) is a fundamental part of family-centered care. Pediatric palliative care (PPC) is one of the more difficult fields for healthcare providers when choosing to utilize SDM. However, to our knowledge, there are still few structured approaches of SDM in PPC. We aimed to build a model of SDM in PPC that achieves better care and outcomes for children and their family members.MethodsThis study is a descriptive phenomenology study. Participants included physicians, nurses, and social workers in the PPC team. Participants were individually interviewed face-to-face or via an online meeting software. Data were collected in semi-structured interviews and analyzed using a thematic framework analysis.ResultsIn total, 27 healthcare providers were interviewed. The model of SDM in PPC identified three themes, including the participants, the principle and the process of SDM. Decision participants involved the children, parents, the PPC team and others. The decision principle had three sub-themes including type, standard and precondition. The decision process describes the fundamental process of SDM and provides suggestions for mobilizing patients and parents to engage in decision-making and seeking conflict resolution.ConclusionsThis is the first study to develop a SDM model in PPC. This model can provide guidance to PPC teams on SDM practices. In addition, the model contributes to the existing body of knowledge by providing a conceptual model for SDM in the context of PPC.

Non-discontinuation of antiseizure medication in seizure-free epilepsy patients.

In patients with epilepsy and sustained seizure freedom, guidelines recommend considering discontinuation of antiseizure medication (ASM) based on shared decision-making. This study aims to identify factors associated with non-discontinuation of ASM in seizure-free patients. Retrospective data from three sites of an academic outpatient clinic were analyzed. Adult patients with epilepsy who have been seizure-free for ≥24 months on ASM monotherapy were included. The primary end-point was non-discontinuation of ASM, defined as no discontinuation or no dose reduction of ≥25% at the last outpatient clinic visit in the ultimate seizure-free interval. Secondary end-points included frequency of discussion on discontinuation attempts between patients and physicians, adherence to ASM discontinuation decisions, and post-discontinuation seizure outcomes. Out of 338 included patients, 81.7% did not discontinue ASM and did not reduce its dose, 11.5% discontinued ASM and 6.8% had a significant dose reduction. Factors independently associated with non-discontinuation of ASM were history of focal to bilateral or generalized tonic-clonic seizures (odds ratio [OR] 2.33, 95% confidence interval [CI] 1.08-5.06), history of breakthrough seizures (OR 3.32, 95% CI 1.10-10.04), history of failed attempts to discontinue or reduce the ASM dose (OR 4.67, 95% CI 1.03-21.11) and higher ASM load at the index visit (OR 6.10, 95% CI 2.09-17.78). Discontinuation attempts were made during the entire period of seizure freedom and were most commonly undertaken ≥10 years after the last seizure. This study provides insights into factors associated with the shared decision-making process regarding ASM discontinuation in seizure-free patients and highlights the importance of considering individual patient characteristics and seizure history.

Clinical case report: considerable improvement of severe and difficult-to-treat obsessive-compulsive disorder with comorbid depression under treatment with esketamine and concomitant psychotherapy

A 28-year-old man was admitted to our psychiatric ward with severe obsessive-compulsive disorder (OCD) and comorbid depression. At intake, obsessive-compulsive symptoms were present most time of the day and were related to an intense fear of causing interpersonal misunderstandings. Various treatment attempts, including cognitive-behavioural therapy (CBT) with exposure and response prevention (ERP), selective serotonin reuptake inhibitors, clomipramine, and add-on antipsychotics were either ineffective and/or were not tolerated, and the patient’s condition worsened progressively. Following an in-depth multidisciplinary team discussion and a shared decision-making process, an off-label treatment trial with esketamine and concomitant psychotherapy was started. The patient received 10 esketamine + psychotherapy sessions over a period of about 2 months, followed by two maintenance sessions in about 3-week intervals. After this, he was discharged into regular outpatient care where he continued to receive maintenance esketamine treatment every 4–6 weeks and, independent of this, individual CBT. Following the establishment of esketamine with concurrent psychotherapy, the patient exhibited a remarkable clinical improvement. Obsessive-compulsive symptoms showed a clear and sustained response (Y-BOCS before treatment >35, Y-BOCS at week 8 = 23, Y-BOCS at week 26 = 14). Paralleling this, depressive symptoms also decreased (MADRS before treatment = 47, MADRS at week 9 = 12, MADRS at week 26 = 3). At a naturalistic follow-up at week 66, obsessive-compulsive symptoms were still mild (Y-BOCS = 13), and depression was still in remission (MADRS < 6). This clinical case suggests that (es)ketamine plus concomitant psychotherapy may hold promise as a therapeutic strategy for difficult-to-treat OCD and depression and its full clinical potential should be evaluated in more comprehensive future studies.

Not Just Non-Consensual Pelvic Exams

Not Just Non-Consensual Pelvic Exams

Cancer advance care planning: development of a screening tool

ObjectivesAdvance care discussions are a useful communication tools for medical preferences and beneficial for shared decision-making processes in hospital settings. The present study developed the first screening tool for need...

Effect of a Peer Comparison and Educational Intervention on Medical Test Conversation Quality

Medical test overuse and resulting care cascades represent a costly, intractable problem associated with inadequate patient-clinician communication. One possible solution with potential for broader benefits is priming routine, high-quality medical test conversations. To assess if a peer comparison and educational intervention for physicians and patients improved medical test conversations during annual visits. Randomized clinical trial and qualitative evaluation at an academic medical center conducted May 2021 to October 2022. Twenty primary care physicians (PCPs) were matched-pair randomized. For each physician, at least 10 patients with scheduled visits were enrolled. Data were analyzed from December 2022 to September 2023. In the intervention group, physicians received previsit emails that compared their low-value testing rates with those of peer PCPs and included point-of-care-accessible guidance on medical testing; patients received previsit educational materials via email and text message. Control group physicians and patients received general previsit preparation tips. The primary patient outcome was the Shared Decision-Making Process survey (SDMP) score. Secondary patient outcomes included medical test knowledge and presence of test conversation. Outcomes were compared using linear regression models adjusted for patient age, gender, race and ethnicity, and education. Poststudy interviews with intervention group physicians and patients were also conducted. There were 166 intervention group patients and 148 control group patients (mean [SD] patient age, 50.2 [15.3] years; 210 [66.9%] female; 246 [78.3%] non-Hispanic White). Most patients discussed at least 1 test with their physician (95.4% for intervention group; 98.3% for control group; difference, -2.9 percentage points; 95% CI, -7.0 to 1.2 percentage points). There were no statistically significant differences in SDMP scores (2.11 out of 4 for intervention group; 1.97 for control group; difference, 0.14; 95% CI, -0.25 to 0.54) and knowledge scores (2.74 vs 2.54 out of 4; difference, 0.19; 95% CI, -0.05 to 0.43). In poststudy interviews with 3 physicians and 16 patients, some physicians said the emails helped them reexamine their testing approach while others noted competing demands. Most patients said they trusted their physicians' advice even when inconsistent with educational materials. In this randomized clinical trial of a physician-facing and patient-facing peer comparison and educational intervention, there was no significant improvement in medical test conversation quality during annual visits. These results suggest that future interventions to improve conversations and reduce overuse and cascades should further address physician adoption barriers and leverage patient-clinician relationships. ClinicalTrials.gov Identifier: NCT04902664.