Shared Medical Decision Research Articles

Developing culturally competent physicians: Empathy, inclusivity, moral distress training and ethical reflections during the Medicine Clerkship

Purpose We aimed to develop a tool that would allow assessment of ethics competency and moral distress during the Internal Medicine Clerkship and to introduce curricular changes that could empower students to better address ethical dilemmas and challenges encountered during the clerkship. Materials and Methods A structured ethics assignment was introduced where students could reflect on impactful stressful scenarios and address questions related to emotional responses, identified ethical issues, management themes, and professional obligations. A 4-tiered grading rubric and individual narrative feedback was provided for each assignment, and small-group debriefing sessions were introduced for reflective thought and future planning. De-identified assignments were analyzed and classified into subgroups according to 5 main ethical issue subgroups and 10 specific management themes. Assignments were also analyzed for the presence of moral distress. Results 357 students completed the reflective ethics activities. The most commonly identified ethical issues were related to Shared Medical Decision Making (>40%), Primary of Patient Welfare challenges, (>20%), and Social/Organizational dilemmas. Management themes often pertained to Patient Wishes/Legal Obligations, Professional Behaviors, and Limited Resources. 87% of assignments demonstrated moral distress. Conclusion Medical school is a stressful time and challenges are augmented during clinical years. Our reflective activity demonstrated significant exposures to ethical dilemmas, reviewed earlier principles of ethics training, and provided a safe forum in which to discuss these important aspects of healthcare. We captured powerful images of challenging situations eliciting moral distress, and students greatly appreciated the activity. We encourage future investigations that support student well-being and enable smooth transitions into residency training.

Interpreting a randomized trial in oncology: Key points for the clinician

The analysis of randomized clinical trials presents a challenge for clinicians. A set of critical elements can facilitate their interpretation. One must question whether the inclusion and exclusion criteria accurately mirror clinical practice. Does the control arm align with what is currently recognized as best practice? Do patients in the control group have access to the best options when the cancer progresses or recurs? The degree of confidence with which phase II trial results can be interpreted also warrants consideration. Finally, informative censoring can be searched for by comparing early censoring rates between treatment arms. Faced with the challenges of interpreting scientific literature, these keys can help the clinician and guide the eventual integration of new results into shared medical decision-making.

Creation of a Shared Medical Decision Support Tool for the Management of Abdominal Aortic Aneurysms

ObjectivePatients with an unruptured abdominal aortic aneurysm (AAA) at the surgical threshold may benefit from aneurysmal exclusion either by open surgery or endovascular repair. A patient decision aid (PtDA) could be useful to help patients and their surgeons choose between the two techniques. The aim of this study was to develop a shared medical decision support tool, in french language, for the surgical treatment of AAA. MethodsFollowing the steps recommended by the International Patient Decision Aids Standards, we carried out a qualitative study using semi-structured interviews with patients and vascular surgeons and focus group with patients to identify their main points of interest. After analyzing the interviews using grounded theory with independent double coding, the verbatims were discussed at a steering committee, at the end of which a prototype of the tool was created. Results4 surgeons and 14 patients were interviewed. No new codes emerged from the last two interviews. At the end of the steering committee meeting, the informations selected for inclusion in the PtDA tool were the definition of an AAA, a description of the two surgical techniques (approach, duration of operation), the main complications, the peri-operative mortality rate, and post operative follow-up (length of hospital stay, monitoring frequency, risk of re-intervention). It had to be produced on a synthetic paper format, with six illustrations and a simple vocabulary. ConclusionWe developed a PtDA tool for use in a sharing decision making process with the patient during the consultation with the vascular surgeon and the general practitioner. Further studies are needed to validate the tool and to test it in clinical practice.

Substitution treatments for chronic kidney disease in geriatrics: dialysis, transplantation and medical treatment without dialysis

Kidney disease, whether acute or chronic, is a particularly common condition in the elderly, due to its main risk factors, the prevalence of which increases with age, and the fact that recovery from acute tubular damage is slower. Wherever possible, treatment of renal failure should be anticipated and discussed with the patient as part of a shared medical decision. Numerous treatment options are available to ensure maximum integration into the patient's life and care plan: renal transplantation for the most robust patients, hemodialysis in a care facility or at home, peritoneal dialysis at home, or medical treatment without dialysis. The choice of one of these treatments must leave the patient free to change his or her treatment modality at any time.

Shared medical decision in prostate cancer screening in primary care: a systematic literature review of current evidence.

Prostate cancer screening has not significantly reduced mortality. International guidelines strongly endorse shared decision-making to navigate risks, emphasizing its crucial role prior to prescribing a prostate-specific antigen test. This study aims to provide insight into the current role of shared decision-making in primary care for prostate cancer screening and suggest ways to improve the process. PubMed, Cochrane, and Lissa databases were searched for following terms: 'prostate-specific antigen' or 'prostate cancer screening' combined with 'shared decision making', 'informed decision making' or 'decision support' and 'primary care'. All studies were screened by two independent reviewers. This systematic review followed the PRISMA guidelines. Of 85 articles screened, 34 were included. Key findings included heterogenous and poor quality implementation of shared decision-making in practice, patients with limited knowledge of shared decision-making, clinicians infrequently discussing patients' views, decision aids that could be better integrated into practice, and finally, changes in care systems to support the expansion of shared decision-making in prostate cancer screening. Decision aids are essential tools in the informed decision-making process. Integrating these elements into practice would require training for doctors and adjustments to the healthcare system.

Evaluation of the nocebo effect after switching from etanercept or adalimumab originator to a biosimilar: a retrospective study of patients with inflammatory rheumatism.

Despite significant savings with biosimilars, their negative perception can lead to the occurrence of a nocebo effect (NE), therefore we aimed to quantify the NE in inflammatory rheumatism after switching from adalimumab or etanercept originators to biosimilars. This retrospective study was conducted in 4 hospitals in Normandy, France between January 2018 and July 2022. The study included patients with rheumatoid arthritis or spondyloarthritis in remission under adalimumab or etanercept originators before switching to biosimilars. The occurrence of a NE was considered in patients who did not maintain biosimilars at 12 months and who presented a subjective adverse event (AE). A comparative analysis of the quantitative data collected before and after switching was performed. The AE that led to biosimilar discontinuation was identified. Additional analyses were performed to identify potential risk factors for the occurrence of a NE. Among 183 patients included,13.1% presented a NE. Objective AEs were observed, including rheumatism reactivation (15.3%), intolerance (8.2%), infection (1.6%) and allergic reactions (0.5%). Morning stiffness duration was significantly different before and after the switch in the spondyloarthritis group (p=0.01). No risk factors were associated with the occurrence of a NE within the limits of the studied parameters. The occurrence of a NE after switching to a biosimilar remains acceptable. It appears less frequent when the switch is supervised by the practitioner rather than being systematic (up to 33% in some countries). A shared medical decision seems to be essential in a subset of patients, which remains to be defined.

The desire for side-effect information in pain treatment: an experimental analysis of contextual and individual difference factors.

Informing patients about potential side effects of pain treatment is a requirement that protects patients and aids decision making, but it increases the likelihood of unwanted nocebo side effects. If patients do not desire all side-effect information, it may be possible to ethically reduce nocebo effects through authorized concealment of side effects, whereby patients and clinicians engage in shared decision-making to regulate the disclosure of side-effect information. Currently, there is no experimental data clarifying the factors that causally influence desire for side-effect information in pain treatment. In 2 cross-sectional, between-subjects scenario experiments (experiment 1 N = 498, experiment 2 N = 501), 18 to 79-year-old community adults learned about a lower back pain treatment, and potential side-effect severity, frequency, and duration were manipulated. Individual differences in information avoidance were also recorded. In both experiments, participants reported high desire for side-effect information, but the desire was reduced when side effects were described as less severe, less frequent, and participants scored high in information avoidance. Results were not moderated by participants' level of contact with the health care system, chronic health condition, or clinical pain history. Additional analyses indicated that low side-effect severity and frequency lessen desire for side-effect information because these variables reduce belief that side-effect information will be needed in the future and lower feelings of anticipated regret. The experiments identify situational and individual-difference factors that decrease the desire for side-effect information and provide evidence on when and for whom it may be useful for physicians to engage in shared medical decision-making with the goal of reducing nocebo side effects.

Breast cancer: a randomized controlled trial assessing the effect of a decision aid on mammography screening uptake: study protocol.

Breast cancer (BC) is the primary cancer among women. The World Health Organization recommends a bilateral screening mammogram every 2 years for women aged 50 to 74 years. However, it has been shown that there is an absence of information about the benefits and risks of screening. Shared medical decision-making is important to ensure patients are involved in the decision process. Decision aids can facilitative this decision-making process. This article presents a protocol to evaluate the effect of a decision aid on participation rates in the French organized BC screening program. Design and setting. The design is a 2 arm randomized controlled study, performed in the Pays de la Loire region (French West Coast). Randomization will be based on general medicine practices (Primary Care). Women aged between 50 and 74 years, eligible for BC screening. In this region, there are 75000 women, and 2800 general practitioners eligible for recruitment. In the « Decision aid for organized cancer screening » arm, the intervention will distribute invitation letters to eligible women combined with the provision of decision aid to these women and their general practitioners and an incentive to implement shared medical decision-making. In the « Standard organized cancer screening » arm, only the screening invitation will be sent to eligible women. BC screening participation rates will be assessed after an 18-month follow-up period. In this non-inferiority trial, the percentage of women who are up-to-date with their screening at 18 months after the intervention will be compared across arms using a generalized mixed linear model. The research team expect to demonstrate that providing a better explanation of the benefits and risks of BC screening is not at odds with screening participation. The study results should help policy makers thinking about implementing shared medical decision-making within the framework of organized BC screening programs in the future. On 6 December 2021, the protocol received a favorable opinion from the French Committee for the Protection of Persons (2021-A01583-38). This study is registered with ClinicalTrials.gov, number NCT05607849. (Version 1, November 7, 2022; https://www.clinicaltrials.gov/ct2/show/NCT05607849). The study findings will be used for publication in peer-reviewed scientific journals and presentations in scientific meetings.

Prescription-free consultation in France and Europe: Rates’ evolution, physicians’ and patients’ perceptions from 2005 to 2019, a systematic review

In 2005, the rate of prescription-free consultations in Europe varied widely: 57% in the Netherlands, 28% in Germany, 17% in Spain and 10% in France. To assess the number of prescription-free consultations in European countries since 2005 and to analyse the perceptions of patients and general practitioners (GPs). This was a systematic review of the literature from 2005 to 2019, including both quantitative and qualitative studies on prescription-free consultations. Of 13,380 studies, 28 were included. The rates of prescription-free consultations were 30% in Belgium, 41% in Slovenia, 47% in the UK and 22% in France, according to the most recent figures. Swedish GPs estimated their prescription-free consultation rate at 70%. The only significant factor that decreased the number of prescription-free consultations was laboratory visits. According to the qualitative data, the main constraint was lack of time; the main facilitating factor was a shared medical decision. Medical visits decreased the number of prescription-free consultations. According to qualitative studies, the main barrier was lack of time. The countries with the highest drug consumption levels were those with the lowest number of prescription-free consultations. Achieving prescription-free consultations to combat overmedication and for the quality of care and the environment is a priority. To understand and analyse consultations without prescriptions, a quantitative observational study was launched in France in 2020.

Validated anxiety assessments among pediatric patients with peanut allergy on oral immunotherapy

BackgroundAlthough efficacy, safety, and quality of life measures associated with peanut oral immunotherapy (OIT) have been studied, the relationship between peanut OIT and clinical anxiety has not yet been evaluated. The latter is important to help providers and families have an improved shared medical decision discussion around the benefits of initiating OIT. ObjectiveTo investigate the relationship between undergoing OIT and anxiety in patients with peanut allergy. MethodsIn this prospective cross-sectional cohort study, using validated and age-appropriate anxiety scales administered with electronic survey questionnaires, we used generalized linear regressions to compare anxiety between patients undergoing OIT and similar patients with peanut allergy but not on OIT (controls). ResultsIn the younger cohort (<7 years, n = 80), there was generally a low prevalence of diagnosable anxiety across patients on OIT and controls. In the older cohort (>7 years, n = 125), there was a higher prevalence of anxiety but no clinically meaningful difference between anxiety scores of patients on OIT and controls. In the older cohort, patients with asthma were more likely to have higher mean anxiety scores (P = .04), as were female patients compared with male patients (P = .004). A subanalysis of separation anxiety scores in the older cohort revealed that younger age (7-12 years vs >12 years, P < .001), non-White race (P = .04), and eczema (P = .02) were found to be meaningful predictors of higher scores. A subanalysis of social anxiety on the older cohort pointed toward non-White race as a meaningful predictor of higher scores (P < .02). ConclusionThe clinical implications of these findings suggest that allergists should particularly consider screening children with food allergy for anxiety and anxiety subtypes among patients who are non-White, female, or have asthma.

Towards adaptive structuring of the lupologist’s consultation to transform the care pathway of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a complex autoimmune disease, which can be clinically heterogeneous in the same patient over the disease process and has an unpredictable evolution. Although its prevalence is increasing, SLE remains a rare disease with frequent extra-articular manifestations managed by multiple specialists. Among these, the internist is a key player in the overall coordination of the care pathway. The dramatic improvement in the short-term prognosis of SLE observed over the past few decades has favoured the emergence of more chronic disease-associated morbidities, especially infectious, cardiovascular and/or related to sequelae, notably renal. Thus, every lupologist is confronted with the difficulty of having to address, in an educational, individualised but also systematic way, a certain number of key items on which the short-, medium- and long-term medical future of patients who develop SLE at a relatively young age depend. In recent years, in addition to the creation of a network of reference centres and the drafting of regularly updated national therapeutic guidelines and therapeutic education programs, international consensus about the factors to consider in SLE patients has been reached, including the definition of therapeutic objectives according to a treat-to-target (T2T) strategy. However, the translation of these new objectives/paradigms in real-life has encountered a number of difficulties. As part of a multidisciplinary team involving SLE patients, we developed practical tools in the form of CHECKLISTs addressing the problems of refractory SLE (D2T), the management of comorbidities and toxicities (BASICs), and, more recently, therapeutic de-escalation with a shared medical decision (T2U). It appears that there is an opportunity to transform the care pathway of SLE patients by allowing the implementation of these tools within adaptive structuring of the consultation, which has the advantage of defining a starting point within the care pathway as a common denominator for lupologists, regardless of their specialty or where they work.

"If You Don't Trust Your Doctor That Much...You'd Feel Less Confident Doing a Research Study": Factors Influencing Black Patient Participation in Hematology Trials

Background Racial disparities exist in incidence and survival from hematological cancers. These differences are driven by multiple factors, including disease biology and access to high-quality cancer care (e.g., enrollment in a clinical trial). Black persons constitute 5-7% of participants in therapeutic cancer clinical trials (Bhatnagar et al. 2017, S. Al Hadidi et al. 2020, S. Al Hadidi et al. 2022), despite accounting for 14% of the US population. While previous studies have broadly focused on understanding factors that underpin that disparity in clinical trials, very few have focused explicitly on populations with hematological cancers. Further, research evaluating the perspectives of hematologists on factors that influence clinical trial enrollment for the Black population remains limited. The objective of this study was to understand factors that influenced Black participant enrollment in hematology-focused clinical trials by examining the perspectives of Black patients with multiple myeloma and their hematologists. Methods Between August 2021-January 2022, hematologists were recruited to participate in single semi-structured 60-minute virtual interviews, while patients diagnosed with multiple myeloma were asked to participate in focus group discussions (FGDs) lasting up to 90 minutes via videoconferencing. Through the Sort and Sift, Think, and Shift approach (Maietta et al. 2021),analytic memoing and diagramming of key quotations were used to assess topics and identify larger conceptual themes. We tabled and grouped themes, topics, and associated quotations at multiple levels using the National Institute on Minority Health and Health Disparities Research framework. Topics and themes from FGDs and hematologist interviews were then distilled into key claims. Results We conducted 6 FGDs with 23 patients and 13 semi-structured interviews with hematologists. Hematologists perceived trust at multiple levels (e.g., patient-provider, patient-health care system) as an influential determinant of Black patients' enrollment in clinical trials (Table 1). Factors that fostered patient-hematologist trust included the length of the relationship, use of transparent and empathic communication, and shared racial identities of patients and hematologists. For patients, trust in the hematologist, health care system, and proposed trial intervention were determinants of whether Black patients enrolled in a clinical trial. Patients also emphasized the importance of hematologists acknowledging the historical events that led to the intentional harm of Black persons engaged in research-related activities and recommended additional efforts to foster shared medical decision-making. Some hematologists perceived clinical trial discussions as potentially harmful when building trust in their patient relationships. Hematologists also considered patient context--such as geographic location, socioeconomic challenges, and health literacy along with study eligibility criteria--when deciding to offer a clinical trial (Figure 1). Hematologists also viewed lack of time, trial availability, and adequate clinical trial infrastructure as barriers to discussing and enrolling Black patients in clinical trials. Conclusion Black patients and hematologists perceived trust at multiple levels as critical to enhancing the enrollment of Black participants in hematology-focused cancer clinical trials. Additionally, hematologists' perceptions about patients, including the additional burdens associated with clinical trial participation, also impacted whether or not Black patients are given the opportunity to participate in a clinical trial. Addressing disparities in clinical trial enrollment among Black participants requires multilevel interventions such as 1) fostering patient-clinician relationships, 2) increasing clinical trial availability and partners in community-based settings, 3) providing support to overcome logistical barriers, 4) acknowledging and finding strategies to address physician biases. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Project rebuild the evidence base (REB): A method to interpret randomised clinical trials and their meta-analysis to present solid benefit-risk assessments to patients

Evidence-based medicine is the cornerstone of shared-decision making in healthcare today. The public deserves clear, transparent and trust-worthy information on drug efficacy. Yet today, many drugs are prescribed and used without solid evidence of efficacy. Clinical trials and randomised clinical trials (RCTs) are the best method to evaluate drug efficacy and side effects. In a shared medical decision-making approach, general practitioners need drug assessment based on patient-important outcomes. The aim of project rebuild the evidence base (REB) is to bridge the gap between the data needed in clinical practice and the data available from clinical research. The drugs will be assessed on clinical patient important outcomes and for a population. Using the Cochrane tools, we propose to analyse for each population and outcome: 1) a meta-analysis based on RCTs with a low risk of bias overall; 2) an evaluation of results of confirmatory RCTs; 3) a statistical analysis of heterrogeneity between RCTs and 4) an analysis of publication bias. Depending on the results of these analyses, the evidence will be categorized in 4 different levels: firm evidence, evidence (to be confirmed), signal or absence of evidence. Project REB proposes a method for reading and interpreting RCTs and their meta-analysis to produce quality data for general practitioners to focus on risk-benefit assessment in the interest of patients. If this data does not exist, it could enable clinical research to better its aim.

Influences of decision preferences and health literacy on temporomandibular disorder treatment outcome

BackgroundShared decision-making is defined as the process by which physicians and informed patients make a shared medical decision, taking into account the preferences and values of the patients. It is well known that shared decision-making practices improve both clinicians’ and patients’ satisfaction and lead to better treatment outcomes. The aim of the study was to assess associations between patients’ roles in decision-making, health literacy levels, and treatment outcomes of temporomandibular disorders (TMDs).MethodsIn total, 131 participants were enrolled. Participants underwent interview and physical examination at baseline and six months after TMD management. TMD was diagnosed according to Diagnostic Criteria/TMD criteria. Myofascial trigger points were bilaterally evaluated in the two masticatory muscles including the temporalis and masseter muscles. The roles that participants preferred to play or had perceived during decision-making and their health literacy levels were assessed using Control Preferences Scale and Newest Vital Sign, respectively.ResultsParticipants who perceived themselves as occupying active roles in decision-making showed higher health literacy levels than those with passive perceived roles. Participants with appropriate health literacy showed higher perceived participation levels in decision-making than did those with limited health literacy. The extent of subjective symptomatic improvement after six months of treatment showed significant associations with perceived role in decision-making, despite lack of significant relationships between perceived role in decision-making and the extent of improvement of objective parameters.ConclusionActive participation of patients in decision-making improves the satisfaction but limited health literacy constitutes barriers to effective patient engagement during TMD management.

Knowledge Measure for Ovarian Cancer Research (KnoMOR): Development and psychometric testing results of a patient-centered knowledge measure (029)

<b>Objectives:</b> Knowledge is a prerequisite to informed choice. There are no validated measures of ovarian cancer (OC) to assess patients' knowledge systematically. Through efforts to create shared medical decision tools for OC, we sought to develop and validate an OC knowledge measure with sub-scales focusing on general knowledge and maintenance therapy (MT) to assess patients' understanding of their disease and treatment. <b>Methods:</b> Gaps in OC and MT knowledge were identified from qualitative interviews with patients and non-medical caregivers. Content experts supplemented these gaps with key facts that OC patients should know. Sample questions were drafted, iteratively refined with feedback from content experts, and cognitively tested with nine patients. The knowledge measure (true/false/not sure and multiple choice) was administered to women with OC and then re-administered 30 days later to assess test-retest reliability. "Not sure" answers were coded as incorrect. Reading level was assessed by the Flesch-Kincaid Grade Level test. Item difficulty (% of correct responses) and item uncertainty (% of "not sure" responses) were calculated for each question. Internal consistency reliability was assessed using the Kuder-Richardson Formula 20 (KR-20). Test-retest reliability was estimated with the intraclass correlation coefficient (ICC). Physicians were recruited from a national convenience sample to test for known-group validity. The percentage of correct responses to the OC and MT scales were compared for physicians and patients with an independent samples t-test. <b>Results:</b> The 31-item (14 OC general knowledge, 17 MT knowledge) measure was completed by 146 OC patients, 65 newly diagnosed and 81 with recurrent disease recruited between October 2020 and June 2021. A total of 27 physicians participated. Two items were dropped due to ceiling effects or overlapping constructs, resulting in a 29-item knowledge measure (12-item general OC knowledge; 17-item MT knowledge scales) with a reading level of grade 11.3. Additional items with high item uncertainty were retained due to their importance in informed decision-making and potential to be impacted by decision support interventions. Internal consistency reliability of the final scale was acceptable (OC scale, KR-20: 0.80, MT scale, KR-20: 0.76). Test-retest reliability was good (OC scale, ICC: 0.70, MT scale, ICC: 0.79). There were significant differences in knowledge between patients and physicians on the OC scale (patients' mean correct responses, 58.7%; physicians' mean correct responses, 88.1%; p<0.001). Similarly, patients answered 43.9% of MT questions correctly compared to 84% of physicians (p<.001). <b>Conclusions:</b> We developed a brief, valid, and reliable indicator of ovarian cancer patients' knowledge of key concepts central to making an informed decision about MT. The patient-centered measure is a simple and convenient tool that can be incorporated into a broader assessment of the quality of patients' decision-making about ovarian cancer.

Internet : source fiable d’information pour des patientes éligibles à la reconstruction mammaire par lambeau de DIEP ?

Informing breast reconstruction patients is a major factor in shared medical decision-making. In the light of the development of multimedia, patients face a paradoxical duality: the possibility of consulting various sources while having impression of a lacking the needed information. The objective of this study is to assess the quality of the available information around MR by DIEP on Youtube. For this descriptive study, we reviewed 531 videos resulted from the terms "DIEP breast reconstruction". 39 videos were analyzed in detail. The evaluation criteria established from the SOFCPRE sheet were listed in 43 items divided into 4 themes. A score representing the percentage of correct information is then calculated. The average length of the videos is 40'05″±46'45″. The average total score is 42.52%. Concerning the subgroups, the themes generalities and physiopathology have the highest result (66.10% of the correct items). This is followed by technique and perioperative preparation (51.65%), postoperative (27.35%) and finally complications (22.76%). Only 2 videos have an excellent total score (>80%). The information on breast reconstruction by DIEP flap on Youtube seems insufficient and lacks quality. The surgeon should strive to provide the highest quality of information and refer patients to reliable sources.

How are patients’ preferences for anti-TNF influenced by quality of life? A discrete choice experiment in Crohn’s disease patients

Background and objective Anti-TNFs have been shown to significantly improve the health-related quality of life (HRQoL) in Crohn’s disease (CD) patients. The purpose of this study was to investigate to what extend the patients’ preferences for these intravenous (IV) and subcutaneous (SC) treatments differ based on respondents’ quality of life. An online discrete choice experiment (DCE) was conducted to understand patient trade-offs in treatment choice. Methods Fifty-seven Crohn's disease anti-TNF naïve patients were asked to choose between two different scenarios, considering the following attributes: mode of administration (MODE), total availability for injection (TIME), speed of onset (DELAY), risk of anti-TNF administration despite a contraindication (RISK) and total monthly out-of-pocket expenses (COST). At the same time, patients completed the IBDQ-32 questionnaire. Conditional logit models without and with interaction terms were estimated to evaluate attribute weights. Results Patients preferred to self-administer SC anti-TNF rather than have a primary care nurse do it, whereas the preference for IV route was negative. After adding interaction terms however, the IV route became preferred for patients with impaired HRQoL, this preference having decreased as HRQoL increased. Surprisingly, patients with impaired HRQoL were less willing to spend more time on treatment, and this effect diminished as HRQoL (overall and in each dimension) became higher. Conclusions HRQoL level changed patients’ preferences for the anti-TNF treatment. The results suggest the need to optimise the management of IV infusions in the hospital and reinforce the importance of patient-reported outcome measures (PROMS) as a common practice to improve shared medical decision making.

The impact of shared medical decision making on patient satisfaction in psychiatry

IntroductionThe era of the paternalisation of the patient is over, gradually giving way to new models, in particular that of “shared medical decision making”, with the aim of responding to the growing desires of the patient and giving priority to his autonomy.Objectivesto establish the influence of the new active position of the patient in the therapeutic process on the satisfaction of the psychiatric patient.MethodsThis is a descriptive cross-sectional study that took place over a period of 5 months from April 2019 to August 2019 in two university hospital psychiatry departments of Razi Hospital in Tunisia . The questionnaire was administered outside any period of hospitalisation, in order to increase the reliability of responses. We used a pre-established form including socio-demographic data, clinical data concerning the patient’s mental disorder followed by a patient satisfaction questionnaire regarding the quality of care received in a psychiatric setting.ResultsThe patients interviewed in our study reported a good level of satisfaction (67.5%) with their involvement in the therapeutic process. However, 45.5% of the patients expressed dissatisfaction with the information provided to them by their doctor about their mental health status. The majority of the subjects surveyed expressed satisfaction with the quality of the interviews conducted during hospitalisation (71%) and with the time spent with the doctor (67%).ConclusionsDespite the fact that providing information to patients with mental health problems is a key element of patient satisfaction, not enough doctors actually include it in their daily practice.DisclosureNo significant relationships.

Shared Medical Decision Making Reconsidered: Challenging an Overly Cognitivist Perspective with a Linguistic Approach

ABSTRACT This article critically examines the four patterns of shared medical decision making (physician-dominated; physician-defined, patient-made; patient-defined, physician-made; and patient-dominated) suggested by Lippa et al. (2017). The aim of the study is to challenge these patterns with a new data set of conversations between physicians and cancer patients in a hospital ward. We recorded 13 physician–patient-conversations during the medical round in an Austrian hospital, which in total lasted about 1.5 h (language: German). We then categorized the medical decisions found in the data following Lippa et al.’s instructions and further analyzed them with a fine-grained linguistic approach. The study revealed no patient-dominated decisions and one decision, which could not be categorized with one of the patterns. Results from the linguistic approach call into question the generalizability, distinctiveness and validity of the patterns. Finally, the relationship between shared decision making and clinical distributed cognition is discussed.

0368 Leveraging the Electronic Health Record to Facilitate Shared-Medical Decision Making in a Large Health System: Response to the PAP Recall

Abstract Introduction The positive airway pressure (PAP) device manufacturer recall afflicting ~4 million users has posed a major challenge for the care of patients with sleep disordered breathing. We report on the Cleveland Clinic enterprise-wide response efforts and relevant predictors of medical decision-making surrounding this recall. Methods A taskforce developed a strategic response to the recall with the goal of distributing enterprise-wide communications; providing key guidance to providers and patients. For patients, a multi-pronged, tiered approach of MyChart messaging, phone and mailings instructing device registration and continuing use of PAP until discussed with the provider was implemented. For providers, an Epic smartphrase, embedded with a tracker, was developed as a resource including details of a decision-making algorithm while awaiting remediation. A team of mid-level providers was trained in the use of the algorithm; and the smartphrase was utilized for targeted virtual visits and communications. Presented is a retrospective cohort analysis of demographics and comorbid predictors between the group of patients advised to continue therapy, versus those advised to discontinue. Wilcoxon rank sum test or t-test was used for comparisons. Results 15,759 patients were contacted; message confirmed read/heard for 99.3%. Analysis of smartphrase use yielded 1135 instances (median,IQR): age:61.0 [51,70];48.5% female, 13.6% African American, body mass index(BMI) 33.5[29,38.9] kg/m2, apnea hypopnea index(AHI)=22.8[11.7,46.1] of whom n=770(67.8%) were advised to continued therapy. Predictors of provider guidance to continue versus temporarily hold PAP therapy respectively include: age:63[53,71] vs. 58[47,67] p&amp;lt;0.001, female:44% vs. 57%,p&amp;lt;0.001, BMI:33.9[29.5, 39.7] vs. 32.0[28.0,37.5],p&amp;lt;0.001, AHI:31.9[15.5, 58.0] vs.15.7[9.1,21.2],p&amp;lt;0.001 and the following comorbidities: hypertension:61.0% vs. 46.3%,p&amp;lt;0.001, coronary artery disease,11.3% vs. 3.6%,p&amp;lt;0.001,heart failure:2.6% vs. 0.6%,p&amp;lt;0.001, atrial fibrillation:9.5% vs. 2.5%,p&amp;lt;0.001 and chronic obstructive pulmonary disease:5.8% vs. 1.6%,p&amp;lt;0.001,but not diabetes. Conclusion We conclude that EHR tools can be used to coordinate device recall response efforts and guide both providers and patients. The use of a system smartphrase facilitated provider-patient shared medical decision-making to continue versus temporarily discontinue use of PAP therapy efficiently. Those advised to continue PAP therapy had higher burden of sleep apnea and cardiopulmonary comorbidity. Support (If Any)