Team Decision Research Articles

OGC SO04 - Impact of COVID-19 on Decision-making and Survival in Esophago-Gastric Cancer Treatment: Insights from a Multidisciplinary Approach

Abstract Background The COVID-19 pandemic necessitated rapid adaptation in healthcare delivery, affecting cancer care pathways. This study assesses the impact of these changes on multidisciplinary team (MDT) decision-making and survival outcomes in esophago-gastric cancer patients across pre-pandemic, peak pandemic, and post-pandemic periods. Method A retrospective cohort study involving patients referred to a UK tertiary EG cancer center during distinct six-month intervals mirroring the pandemic's evolution. Analysis focused on MDT recommendations, treatment pathways, and two-year survival rates, comparing deviations from standard care across periods. Results The study revealed a significant reduction in patient referrals and expedited treatment decisions during the pandemic peak, with a shift towards palliative care in post-pandemic cases. Although no statistically significant difference in two-year survival rates was observed, the post-pandemic period showed an increase in tumor aggressiveness and positive resection margins, suggesting potential long-term impacts of delayed diagnosis and treatment. Conclusion COVID-19 has significantly influenced MDT decision-making and patient pathways in esophago-gastric cancer care, underlining the necessity of resilient healthcare systems. Despite maintaining survival rates, the observed increase in tumor aggressiveness post-pandemic highlights the critical need for uninterrupted cancer diagnosis and treatment services during global health emergencies.

Supporting prescriber progression: a group concept mapping study

Abstract Introduction Education reforms allow pharmacists to become prescribers earlier in their career and from 2026, new registrants will be independent prescribers.1 In NHS Scotland, an operational framework supports the development of pharmacist independent prescribing.2 We wanted to supplement the operational framework by identifying our core areas of prescribing to articulate prescribing progression and inform education and training provision. Aim To develop a core prescribing framework to support safe prescribing and a spiral approach to expanding scope of practice. Methods We conducted a participatory mixed-method approach using group concept mapping methodology.3 Phase 1 (brainstorming): all hospital pharmacists working in a patient-facing clinical role were invited to enter statements on a cloud-based platform (Padlet®) using the prompt ‘In my day-to-day practice I prescribe and/or make prescribing recommendations about the following medicines / conditions …’. The statements were triangulated with electronic inpatient pharmacist prescribing data over the previous three months. Phase 2 (sorting and rating): a project group comprised of pharmacists with different levels of practice and areas of clinical expertise, individually sorted the statements into groups based on the statements’ conceptual similarity and rated each statement by level of practice (post-registration foundation, advancing, advanced) and importance for including in a core framework (5-point Likert scale). R software applied multidimensional scaling to sorting data to create a similarity matrix, cluster map and Go-Zones. ChatGPT generated cluster titles. The project group discussed the results and following a few revisions, consensus was achieved on the content of the prescribing framework. This study was not considered research and was approved by the pharmacy quality improvement team in line with local governance process. Results Forty-three pharmacists participated in the brainstorming phase and generated 158 statements. Fourteen pharmacists participated in the sorting and rating phase. Multidimensional scaling analysis identified three clusters of prescribing activities: initiating, adjusting and deprescribing. The data identified activities involving initiating medicines and autonomous decision making rated at advancing/advanced level practice while adjusting/deprescribing medicines (often with the caveat of within guidelines, protocols or team decisions) was rated at post-registration foundation level. The prescribing framework includes the activities considered important and is organised by cluster and level of practice. Discussion / Conclusion This study provides a structured conceptualisation of prescribing across the levels of practice. The prescribing framework reflects the needs of our patients and hospital inpatient service and provides a scaffolded approach to progressing from inexperienced to more advanced prescribing roles. Post-registration foundation prescribing activities focus on processes or types of prescribing, whilst advanced are more autonomous and complex. Limitations we didn’t collect clinical area of practice as part of the demographic information for the brainstorming phase and some specialities may not be represented. Further work includes a training needs analysis and developing entrustable professional activities for core and higher risk areas of prescribing (e.g. post-operative pain).

Analysis of NBA player salary based on multiple linear regression model

Abstract. This study explores the use of machine learning techniques to predict NBA player salaries. Traditional salary evaluation methods often rely on subjective expert judgment, whereas data-driven approaches can provide more objective and accurate predictions. With the advancement of data analysis techniques and machine learning algorithms, it is now feasible to predict player salaries based on performance data. This study employs advanced statistical and machine learning techniques to analyze detailed player performance data, including points scored, rebounds, assists, steals, and blocks, to establish a data- and algorithm-based salary prediction model. This model can assist team management in making more scientific decisions during contract negotiations and player acquisitions, thereby avoiding the overvaluation or undervaluation of players and achieving a more balanced and fair salary distribution. Accurate salary predictions help teams allocate their limited salary cap more effectively, optimizing budget management and enhancing overall team competitiveness. This study not only demonstrates the practical value of data analysis and machine learning methods in the sports field but also promotes the further development of data science in sports management. Additionally, the results of the prediction model can provide valuable references for fans and media, enhancing their understanding of player salaries and team management strategies. This transparency enriches the overall fan experience and media coverage of the sport, facilitating more informed discussions and debates about player value and team decisions.

Operationalizing shared decision making in clinical practice.

Shared decision-making (SDM) requires a clear-eyed view of evidence certainty, context, and equipoise in clinical care. This paradigm of care builds on the foundational ethical principle of patient autonomy, further leveraging beneficence, nonmaleficence, and justice to provide bespoke care in the appropriate clinical setting. When evidence is carefully evaluated together with acceptability and feasibility, equity, cost-effectiveness, resources, and patient preferences, an individualized assessment of the trade-off between possible benefits and harms can optimize patient management. In the setting of a conditional recommendation, it is appropriate to engage in SDM with patient partners, to the extent each patient is willing and able to engage in the SDM process. Three conversations inform SDM and include team talk, option talk, and decision talk with discussion of the plan of care. During these conversations, clear communication strategies that are specific, measurable, achievable, realistic, time sensitive, and provide assessment of absolute (not just relative) risk are important to provide necessary education to patient partners. Follow-up is key to ensure that decisions lead to effective treatment. Through this process, it is necessary to minimize cognitive overload and promote a minimally disruptive medicine approach. The acronym "HOW" promotes a holistic appraisal of evidence in context, open-minded teamwork with patients and families, and willingness to be a listening presence while serving as a partner and guide and appreciating the multidimensional and unique nature of each individual. SDM is and will continue to remain a cornerstone of appropriate medical care in settings of clinical equipoise.

Outcomes of Balloon-Expandable Transcatheter Aortic Valve Replacement in Younger Patients in the Low-Risk Era

Guidelines advise heart team assessment for all patients with aortic stenosis, with surgical aortic valve replacement recommended for patients younger than 65 years or with a life expectancy greater than 20 years. If bioprosthetic valves are selected, repeat procedures may be needed given limited durability of tissue valves; however, younger patients with aortic stenosis may have major comorbidities that can limit life expectancy, impacting decision-making. To characterize patients younger than 65 years who received transcatheter aortic valve replacement (TAVR) and compare their outcomes with patients aged 65 to 80 years. This retrospective registry-based analysis used data on 139 695 patients from the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (TVT) Registry, inclusive of patients 80 years and younger undergoing TAVR from August 2019 to September 2023. Balloon-expandable valve (BEV) TAVR with the SAPIEN family of devices. Comorbidities (heart failure, coronary artery disease, dialysis, and others) and outcomes (death, stroke, and hospital readmission) of patients younger than 65 years compared to patients aged 65 to 80 years. In the years surveyed, 13 849 registry patients (5.7%) were younger than 65 years, 125 846 (52.1%) were aged 65 to 80 years, and 101 725 (42.1%) were 80 years and older. Among those younger than 65, the mean (SD) age was 59.7 (4.8) years, and 9068 of 13 849 patients (65.5%) were male. Among those aged 65 to 80 years, the mean (SD) age was 74.1 (4.2) years, and 77 817 of 125 843 patients (61.8%) were male. Those younger than 65 years were more likely to have a bicuspid aortic valve than those aged 65 to 80 years (3472/13 755 [25.2%] vs 9552/125 001 [7.6%], respectively; P < .001). They were more likely to have congestive heart failure, chronic lung disease, diabetes, immunocompromise, and end stage kidney disease receiving dialysis. Patients younger than 65 years had worse baseline quality of life (mean [SD] Kansas City Cardiomyopathy Questionnaire score, 47.7 [26.3] vs 52.9 [25.8], respectively; P < .001) and mean (SD) gait speed (5-meter walk test, 6.6 [5.8] seconds vs 7.0 [4.9] seconds, respectively; P < .001) than those aged 65 to 80 years. At 1 year, patients younger than 65 years had significantly higher readmission rates (2740 [28.2%] vs 23 178 [26.1%]; P < .001) and all-cause mortality (908 [9.9%] vs 6877 [8.2%]; P < .001) than older patients. When propensity matched, younger patients still had higher 1-year readmission rates (2732 [28.2%] vs 2589 [26.8%]; P < .03) with similar mortality to their older counterparts (905 [9.9%] vs 827 [10.1%]; P = .55). Among US patients receiving BEV TAVR for severe aortic stenosis in the low-surgical risk era, those younger than 65 years represent a small subset. Patients younger than 65 years had a high burden of comorbidities and incurred higher rates of death and readmission at 1 year compared to their older counterparts. These observations suggest that heart team decision-making regarding TAVR for most patients in this age group is clinically valid.

Adaptation and Validation of Decision-Making Questionnaire Among Physicians of Obstetrics and Gynecology

Abstract: Introduction: Healthcare decision-making is a critical yet understudied aspect of medical education. It holds significant importance among healthcare professionals and influences their overall behavior. We adapted and validated the Decision-Making Questionnaire, which measures factors affecting decision-making among obstetricians and gynecologists. Methods: We used a cross-sectional survey design to establish the construct validity of the DMQ. We established content validity using the Lawshe content validity ratio and conducted a survey to establish the construct validity. Results: Exploratory factor analysis ( n = 150) revealed three factors, task-related, context-related, and individual-related, having eigenvalues greater than 1 and adequate alpha reliability. Confirmatory factor analysis ( n = 197) found adequate model fit indices. We assessed the reliability coefficient of the Decision-Making Questionnaire using Cronbach’s alpha and McDonald’s Omega coefficient, which showed an acceptable range (0.86–0.90). Hence, the scale appears to be psychometrically sound and a practical measure for obstetricians and gynecologists. Discussion: The Decision-Making Questionnaire demonstrated convergent validity by positively correlating with the Team Decision-Making Questionnaire and divergent validity by showing correlations with the measure of professional quality of life. The scale is useful for practitioners and researchers to measure factors affecting decision-making in naturalistic settings.

Long-term outcomes in patients with dual pathology aortic stenosis and cardiac amyloidosis referred for valve intervention

Abstract Background The coexistence of aortic stenosis (AS) and cardiac amyloidosis (CA) is common. If treated with transcatheter aortic valve implantation (TAVI), patients with the combined phenotype (AS-CA) have a comparable short term survival to those with lone AS, whereas data on longer term outcomes is currently lacking. Purpose This study aimed to evaluate the clinical outcomes of AS-CA compared to lone AS over a 5-year follow-up. Methods Using a prospective, multicentre, observational, case-control design, we screened consecutive patients with severe AS referred for TAVI for co-existing CA. CA screening included blinded 99mTc-DPD bone scintigraphy (Perugini Grade-0 negative, 1-3 increasingly positive) with additional SPECT/CT and light chain assessment prior to intervention. Transthyretin CA (ATTR) was diagnosed by bone scintigraphy and unremarkable light chain assessment, light-chain CA (AL) by endomyocardial biopsy. Mortality (all-cause and cardiovascular [CV]) and hospitalisation for heart failure (HHF) were captured as clinical endpoints. Results 376 patients (83±7 years, 52% female, EuroSCORE-II 4.9±2.9) were recruited, of which 43 (11.4%) had AS-CA (42 ATTR, 1 AL). Compared to lone AS, patients with AS-CA were older with higher cardiac biomarkers (NT-proBNP, high-sensitive Troponin-T) and a higher prevalence of atrial fibrillation. Heart team decision yielded valve replacement in 320 (85%) and conservative management in 56 (15%) patients, without differences between AS-CA and lone AS. Over a median follow-up of 5.4 (Q1: 4.9; Q3: 5.7) years, 230 (61.1%) patients died and 67 (17.8%) experienced HHF (with a total HHF number of 91). AS-CA was associated with higher all-cause mortality (crude HR 1.64, 95%CI 1.15-2.35; log-rank, p=0.006), which remained significant after multivariate adjustment for clinical confounders (EuroSCORE-II, valve replacement; adjusted HR 1.63, 95%CI 1.15-2.32; p=0.006). AS-CA was not associated with CV mortality (log-rank, p=0.18) or time to first HHF (log-rank, p=0.43), but the rate of HHF was significantly higher in AS-CA compared to lone AS (5.7 versus 3.5 per 1,000 patient years, p=0.022). Conclusions Among elderly patients referred for TAVI, long-term outcomes of AS-CA are characterized by higher mortality and a higher rate of heart failure hospitalisations compared to patients with lone AS. Studies evaluating the role of CA-specific treatments are warranted in this population.

Assessing the practice of total neoadjuvant therapy for rectal cancer: an online survey among radiation oncology departments in Germany and German-speaking regions of Austria and Switzerland.

Total neoadjuvant therapy (TNT) of rectal cancer improves rates of pathological complete remission and progression-free survival. With improved clinical response rates, interest grew in a non-operative approach/watch and wait (WaW) for this disease. In 2020, the working groups of ACO/AIO/ARO published a consensus statement on the use of TNT, including a non-operative approach. However, the best combination scheme remains unclear. Despite the increasing use of TNT, there is a lack of comprehensive data on its current implementation and practices. To address this knowledge gap, a multicenter survey was conducted to capture the use of TNT protocols in German-speaking radiotherapy departments. At the beginning of 2023, a GDPR-compliant online survey was conducted in Germany, Austria, and German-speaking Switzerland. The questionnaire comprised 43 questions covering various aspects of TNT, including chemotherapy and WaW concepts. Most respondents (98.4%) confirmed awareness of the consensus on TNT for rectal cancer. Institutions treated an average of 30.22 rectal cancer patients annually. Most respondents (76.2%) reported treating over 80% of patients neoadjuvantly. Regarding TNT, 33.3% treated 21-50% with such a protocol. No significant association was found between the institution type and TNT application. In 62/63 cases, tumor board discussion was standard before offering TNT. VMAT was the predominant technique (82.5%). For rectal cancer dosing, the 50/50.4Gy scheme was most common, followed by 45Gy with a boost and the 5 × 5Gy scheme. Dosing schemes for TNT varied slightly, with more participants reporting the use of 5 × 5Gy compared to radiation therapy for rectal cancer in general. CBCT was the primary IGRT method (88.9%). Larger hospitals typically administered chemotherapy themselves, while private practices collaborated with medical oncologists (p < 0.0001). The most common concurrent chemotherapy drugs were 5-fluorouracil/capecitabine (64.4%) and oxaliplatin (37.3%). A WaW strategy was reported to be institutional implemented by 63.8%. The timing of offering WaW was split, with 50% offering it after radiochemotherapy and 47% during the informed consent talk. For planned WaW, 62% prefer normofractionated TNT. TNT appears to be widely implemented in the German-speaking radio-oncological community, regardless of the type of institution. Image-guided therapy, multidisciplinary team decisions, and internal guidelines play an important role. TNT seems to have already altered treatment protocols for rectal cancer toward an organ-preserving approach in selected cases. In these WaW cases, normofractionation appears to be preferred over hypofractionation.

Early oncological outcomes of delayed radical prostatectomy: A prospective, international, follow‐up analysis of the COVIDSurg‐Cancer study

AbstractObjectivesThe objective of this study is to compare the early oncological outcomes of delayed (&gt;90 days) versus scheduled (≤90 days) radical prostatectomy (RP).Patients and methodsPatients with prostate cancer due to undergo surgery between March 2020 and June 2020 who were enrolled in the COVIDSurg‐Cancer international, observational study were prospectively followed up for 1 year. Time to surgery was defined as the difference between the operation date and the multi‐disciplinary team decision to offer surgery. The primary outcome was the positive surgical margin (PSM) rate. Biochemical recurrence (BCR), upgradation and upstaging were secondary oncological outcomes. The Independent t‐test and Mann Whitney U test were used to compare means between groups and regression models and were used to investigate factors associated with the primary outcome.ResultsFour hundred seventy‐six (78.7%) patients underwent RP from 605 that were eligible. Three hundred seven (64.5%) patients underwent scheduled RP, and 169 (35.5%) underwent delayed RP. A small proportion of men (n = 35, 6.8%) did not undergo RP within the 1‐year follow‐up period. More men with high‐risk disease (72.8%) underwent scheduled RP compared to men with intermediate‐risk disease (60.2%) (p &lt; 0.05). There was no statistically significant difference in the PSM rate between the two groups (p = 0.512). Delay in surgery was not associated with an increased PSM or BCR on univariable or multivariable analyses. There was statistically significantly greater upstaging (p &lt; 0.05) in the delayed group but no difference in upgradation.ConclusionHigh‐risk men were prioritised for surgery during the COVID‐19 pandemic. Our prospective data support previous retrospective, cancer‐registry evidence suggesting no adverse oncological impact after delaying RP across all risk groups. Our study is limited by the short follow‐up period, and therefore, longer term conclusions cannot be drawn.

Gender-Tailored Heart Team Decision Making Equalizes Outcomes for Female Patients after Aortic Valve Replacement through Right Anterior Small Thoracotomy (RAST).

Little is known about gender-dependent outcomes after aortic valve replacement (AVR) through right anterior thoracotomy (RAST). The aim of our study was to analyze the mid-term outcomes of our cohort. This study is a retrospective analysis of 338 patients (2013-2022). Subgroup analysis included a gender-dependent comparison of age groups ≤60 and >60 years. Women were older (69.27 ± 7.98 vs. 64.15 ± 11.47, p < 0.001) with higher Euroscore II (1.25 ± 0.73 vs. 0.94 ± 0.45, p < 0.001). Bypass and cross-clamp time were shorter (109.36 ± 30.8 vs. 117.65 ± 33.1 minutes, p = 0.01; 68.26 ± 21.5 vs. 74.36 ± 23.3 minutes, p = 0.01), while ICU, hospital stay and atrial fibrillation were higher (2.48 ± 8.2 vs. 1.35 ± 1.4 days, p = 0.005; 11 ± 7.8 vs. 9.48 ± 2.3 days, p = 0.002; 6.7% vs. 4.4%, p = 0.024). Mortality was 0.9%, while stroke was 0.6%. Age subgroup analysis showed that women were older (p = 0.025) with longer ICU and hospital stays (p < 0.001, p = 0.007). On mid-term follow-up (4.52 ± 2.67 years) of 315 patients (94.3%), there was no significant difference in survival, MACCE and re-intervention comparing gender and age groups. Despite older age, higher Euroscore II, longer ICU and hospital stay in women, mortality, MACCE and reoperation were low and comparable in gender and age groups. We believe that our patient-tailored heart team decision making combined with RAST translates into gender-tailored medicine, which equalizes the widely reported negative outcomes of female patients after cardiac surgery.

The Influence of Cultural Backgrounds on Team Dynamics and Decision Making in Multicultural Environments

With the deepening development of globalization, cross-cultural communication is becoming increasingly frequent, and the role of multicultural teams in enterprises, education, scientific research, and other fields is becoming increasingly prominent. However, while multicultural teams bring innovation and competitive advantages, they also face challenges such as cultural conflicts and communication barriers. This study aims to explore the strategies and challenges of multicultural teams in cross-cultural communication, as well as how to improve team effectiveness through effective management. Using case analysis method, multiple multinational corporations were selected as research objects, and data was collected through literature review and other methods to analyze the operational mode and management strategy of multicultural teams. Research has found that cultural sensitivity training, cultivation of cross-cultural communication skills, establishment of shared values, and flexible management styles are key strategies for enhancing the effectiveness of multicultural teams. Meanwhile, cultural conflicts and communication barriers are the main challenges. Effective management of multicultural teams is crucial for enhancing team effectiveness. Enterprises should attach importance to cross-cultural training, strengthen communication and understanding among team members, in order to overcome the challenges brought by cultural differences and achieve collaborative development of the team.

Shared decision-making in the treatment of bipolar disorder: findings from a nationwide naturalistic cohort study in everyday clinical practice.

Shared decision-making (SDM) is of increasing importance in mental health care, however, large studies on the effects of SDM in bipolar disorder (BD) are scarce. To gain insight into the relationships between SDM, guideline concordance of treatments in everyday practice, satisfaction with care, and medication adherence in BD. In a nationwide observational study on the treatment of BD, patients were asked questions about their involvement in treatment. These questions were clustered according to the three-talk model (TTM) for SDM, which involves team talk, option talk, and decision talk. A composite concordance score for multimodal treatments was made, and satisfaction with care (score 1 to 10) and medication adherence (DAI-10) were measured. 839 patients with BD from various outpatient treatment centers were included. Patients were highly involved in decision-making. In multiple regression, team talk was significantly positively associated with guideline concordance (b = 5.10, p = .045), and decision talk was positively associated with satisfaction with care (b = 0.82, p < .001) and medication adherence (b = 1.18, p = .003). Positive associations were found between SDM, guideline concordance, satisfaction with care, and medication adherence, suggesting that investing in these steps of the decision-making process together with patients and their significant others, will help to improve quality of care.

Fostering collective action for adolescent well-being: citizen science in a Colombian semi-rural area.

We present findings from the Our Voice in Barú project, examining adolescent engagement in citizen science to address environmental and social factors affecting well-being in a semi-rural Afro-descendant community in Latin America. The project aimed to identify barriers and enablers of well-being, informing adolescent-led actions for sustainable environmental changes relevant to adolescent health. Utilizing the Our Voice citizen science method, which involved technology-enabled walks, participatory cartography workshops and community meetings, we engaged adolescents and other community members. Complex systems framework was employed to analyze results and assess the promotion of collective action and local change. Local enablers of well-being included availability of quality sports and recreational venues as safe spaces, educational settings and cultural aspects, fostering safety, community pride, and personal growth. Conversely, barriers included environmental contamination, deteriorated sports venues and drug addiction, indicating the community's limited access to services and exposure to harmful substances. Adolescent citizen scientists, in partnership with the research team and relevant community decision-makers, successfully achieved changes aimed at identified barriers, including infrastructural enhancements like the repair of pumps to remove stagnant water, improvements in the quality and safety of recreational venues, and the implementation of community-led initiatives to address substance abuse and promote healthier behaviors. The Our Voice in Barú project empowered adolescents to advocate for change and promoted collective action to tackle barriers identified as significant to their well-being.

Factors affecting problem-solving court team decisions about medications for opioid use disorder

BackgroundProblem-solving courts (PSCs) provide alternatives to prosecution and incarceration for drug-related crimes and offer integrated support for people who have lost custody of children due to drug use. Methadone and buprenorphine are lifesaving medications for opioid use disorder (MOUD) but are underused by PSC clients. Even when PSCs lack a court-level prohibition against MOUD, court staff still make individualized decisions about whether a court client can use MOUD. Therefore, we sought to identify factors involved in such individualized PSC court decisions about clients' use of MOUD. MethodsWe conducted semi-structured interviews and focus groups between Summer and Fall 2022 with a convenience sample of 54 PSC staff members from 33 courts across four states. Data were analyzed using iterative categorization. ResultsInterviewees indicated that their courts had eliminated blanket prohibitions against MOUD due to federal and state policy funding requirements, widespread dissemination of voluntary best practice standards, fear of lawsuits, and MOUD education targeting courts. Courts allowed MOUD if the court client accessed it through a treatment provider with whom the court collaborates. Some courts only allowed court clients to access MOUD from non-partnering treatment providers after a court-led “vetting” process of the proposed MOUD provider. MOUD provider characteristics considered during the vetting process included the provider's willingness to communicate with the court, frequent drug testing, adjustments of medication or dosage in response to aberrant results, offering of counseling, and acceptance of Medicaid or sliding scale payments. PSC staff were least comfortable with court clients using methadone treatment. ConclusionsThe presence (or lack of) a PSC-MOUD partnership is a key factor involved in court staff decisions when a court client desires MOUD. Therefore, increasing the number of partnerships between PSCs and MOUD providers could lead to higher rates of MOUD utilization. It is unclear whether court-led vetting processes for non-partnering MOUD treatment providers are necessary or appropriate, and such vetting processes could reduce treatment choice or access in communities with few MOUD providers.

TCT-838 Clinical Futility in Patients With Active Malignancy Undergoing Transcatheter Aortic Valve Replacement After Multidisciplinary Heart Team Decision

TCT-838 Clinical Futility in Patients With Active Malignancy Undergoing Transcatheter Aortic Valve Replacement After Multidisciplinary Heart Team Decision

Coaching doctors to improve ethical decision-making in adult hospitalized patients potentially receiving excessive treatment. The CODE stepped-wedge cluster randomized controlled trial.

The aim of this study was to assess whether coaching doctors to enhance ethical decision-making in teams improves (1) goal-oriented care operationalized via written do-not-intubate and do-not attempt cardiopulmonary resuscitation (DNI-DNACPR) orders in adult patients potentially receiving excessive treatment (PET) during their first hospital stay and (2) the quality of the ethical climate. We carried out a stepped-wedge cluster randomized controlled trial in the medical intensive care unit (ICU) and 9 referring internal medicine departments of Ghent University Hospital between February 2022 and February 2023. Doctors and nurses in charge of hospitalized patients filled out the ethical decision-making climate questionnaire (ethical decision-making climate questionnaire, EDMCQ) before and after the study, and anonymously identified PET via an electronic alert during the entire study period. All departments were randomly assigned to a 4-month coaching. At least one month of coaching was compared to less than one month coaching and usual care. The first primary endpoint was the incidence of written DNI-DNACPR decisions. The second primary endpoint was the EDMCQ before and after the study period.Because clinicians identified less PET than required to detect a difference in written DNI-DNACPR decisions, a post-hoc analysis on the overall population was performed. To reduce type I errors, we further restricted the analysis to one of our predefined secondary endpoints (mortality up to 1year). Of the 442 and 423 clinicians working before and after the study period, respectively 270 (61%) and 261 (61.7%) filled out the EDMCQ. Fifty of the 93 (53.7%) doctors participated in the coaching for a mean (standard deviation [SD]) of 4.36 (2.55) sessions. Of the 7254 patients, 125 (1.7%) were identified as PET, with 16 missing outcome data. Twenty-six of the PET and 624 of the overall population already had a written DNI-DNACPR decision at study entry, resulting in 83 and 6614 patients who were included in the main and post hoc analysis, respectively. The estimated incidence of written DNI-DNACPR decisions in the intervention vs. control arm was, respectively, 29.7% vs. 19.6% (odds ratio 4.24, 95% confidence interval 4.21-4.27; P < 0.001) in PET and 3.4% vs. 1.9% (1.65, 1.12-2.43; P = 0.011) in the overall study population. The estimated mortality at one year was respectively 85% vs. 83.7% (hazard ratio 2.76, 1.26-6.04; P = 0.011) and 14.5% vs. 15.1% (0.89, 0.72-1.09; P = 0.251). The mean difference in EDMCQ before and after the study period was 0.02 points (- 0.18 to 0.23; P = 0.815). This study suggests that coaching doctors regarding ethical decision-making in teams safely improves goal-oriented care operationalized via written DNI-DNACPR decisions in hospitalized patients, however without concomitantly improving the quality of the ethical climate.

53 Challenges of Team Decision making in the “grey zone” for difficult airway management: a case report

53 Challenges of Team Decision making in the “grey zone” for difficult airway management: a case report

A Case Study for Training Interprofessional Teams in Addressing the Social Determinants of Health in Older Adults.

This case study addresses the interwoven nature of the social determinants of health, fall prevention, older adults, and home healthcare as a topic for teaching interprofessional education across professional development or academic settings. The case study challenges interprofessional learners to dissect and discuss the profile of the patient and other stakeholders, care team decisions, evidence-based research, and the considerations of significant variables on the implications for clinical reasoning and practice. Interprofessional education that includes case studies leads to the development of better skills related to clinical assessments and problem-solving. Sample facilitation questions and extensive research and resources are provided to assist those preparing to implement and facilitate the case study during an interprofessional education training session. We concluded our article by encouraging practitioners to share teaching strategies through publication so we can strengthen interprofessional education learning, as this contributes to stronger, more effective interprofessional education experiences, a need highlighted in the literature.

Team Factors in Ethical Decision Making: A Content Analysis of Interviews with Scientists and Engineers

The ethical decision making of researchers has historically been studied from an individualistic perspective. However, researchers rarely work alone, and they typically experience ethical dilemmas in a team context. In this mixed-methods study, 67 scientists and engineers working at a public R1 (very high research activity) university in the United States responded to a survey that asked whether they had experienced or observed an ethical dilemma while working in a research team. Among these, 30 respondents agreed to be interviewed about their experiences using a think-aloud protocol. A total of 40 unique ethical incidents were collected across these interviews. Qualitative data from interview transcripts were then systematically content-analyzed by multiple independent judges to quantify the overall ethicality of team decisions as well as several team characteristics, decision processes, and situational factors. The results demonstrated that team formalistic orientation, ethical championing, and the use of ethical decision strategies were all positively related to the overall ethicality of team decisions. Additionally, the relationship between ethical championing and overall team decision ethicality was moderated by psychological safety and moral intensity. Implications for future research and practice are discussed.

Chronic thromboembolic pulmonary disease.

Chronic thromboembolic pulmonary hypertension is a complication of pulmonary embolism and a treatable cause of pulmonary hypertension. The pathology is a unique combination of mechanical obstruction due to failure of clot resolution, and a variable degree of microvascular disease, that both contribute to pulmonary vascular resistance. Accordingly, multiple treatments have been developed to target the disease components. However, accurate diagnosis is often delayed. Evaluation includes high-quality imaging modalities, necessary for disease confirmation and for appropriate treatment planning. All patients with chronic thromboembolic pulmonary disease, and especially those with pulmonary hypertension, should be referred to expert centres for multidisciplinary team decision on treatment. The first decision remains assessment of operability, and the best improvement in symptoms and survival is achieved by the mechanical therapies, pulmonary endarterectomy and balloon pulmonary angioplasty. With the advances in multimodal therapies, excellent outcomes can be achieved with 3-year survival of >90%.