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Let’s Get Engaged: On the Evidence of Patient Engagement Tools and Their Integration in Patient Pathways

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  • Research Group Digital Health at Technische Universität Dresden
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Abstract

Patient pathways are a means to structure the care process for patients with complex and long-term diseases in integrated care networks. Simultaneously, they have a stronger emphasis on the patient perspective and engagement than related pathway concepts. Still, there are no common mechanisms for patient engagement concepts in patient pathway models. This paper therefore explores the state-of-the-art of patient engagement tools as well as evidence on their effectivity and feasibility, picking the Option Grid, the Patient Diary, and the Question Prompt Sheet (QPS) as representative examples. Based on this, we propose recommendations for the representation of such tools in patient pathway models and demonstrate them with the application of the QPS in a colorectal cancer patient pathway. To conclude, the evidence on patient engagement tools is still diverse but promising. Anchoring successful tools in patient pathways holds the potential to support their broader application and enhance individualized care.

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![][1] It is more than 30 years since I first heard the expression ‘patient empowerment’, 25 years since I heard ‘shared decision making’, and 12 years since Edwards and Elwyn first published their multi-author edited volume Evidence-Based Patient Choice .1 Even the stirring maxim ‘No decision about me without me’ is beginning to sound old hat. Few of us are opposed to patient autonomy or shared decision-making. But there is a substantial gap between what we support in principle and what we can or do deliver within the confines of a 10-minute consultation. Be honest. What happens when a patient attends your surgery … [1]: /embed/graphic-1.gif
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Patient participation in medical consultations has been demonstrated to benefit their subsequent psychological well being. Question asking is one way in which patients can be active. We investigated 2 means of promoting cancer patient question asking. One was the provision of a question prompt sheet to patients prior to their initial consultation with their oncologist. The second was the active endorsement and systematic review of the question prompt sheet by their oncologist. 318 patients with heterogeneous cancers, seeing one of 5 medical and 4 radiation oncologists for the first time, were randomised to either receive or not receive a question prompt sheet. Doctors were randomised to either proactively address or passively respond to the question prompt sheet in the subsequent consultation. Anxiety was assessed prior to the consultation. Consultations were audiotaped and content analysed. Anxiety was assessed again immediately following the consultation. Within the next 10 days patients completed questionnaires assessing information needs, anxiety and satisfaction and were given a structured telephone interview assessing information recall. Patients provided with a question prompt sheet asked more questions about prognosis compared with controls and oncologists gave significantly more prognostic information to these patients. Provision of the question prompt sheet prolonged consultations and increased patient anxiety; however, when oncologists specifically addressed the prompt sheet, anxiety levels were significantly reduced, consultation duration was decreased and recall was significantly improved. A patient question prompt sheet, used proactively by the doctor, is a powerful addition to the oncology consultation.
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Active participation in the medical consultation has been demonstrated to benefit aspects of patients' subsequent psychological well-being. We investigated two interventions promoting patient question-asking behaviour. The first was a question prompt sheet provided before the consultation, which was endorsed and worked through by the clinician. The second was a face to face coaching session exploring the benefits of, and barriers to, question-asking, followed by coaching in question-asking behaviour employing rehearsal techniques. Sixty patients with heterogeneous cancers, seeing two medical oncologists for the first time, were randomly assigned to one of three groups: two intervention groups and one control group. Sociodemographic variables and anxiety were assessed prior to the intervention which preceded the consultation. The consultations were audiotaped and subsequently analysed for question-asking behaviour. Anxiety was assessed again immediately following the consultation. Questionnaires to assess patient satisfaction, anxiety and psychological adjustment were sent by mail 2 weeks following the consultation. Presentation and discussion of the prompt sheet significantly increased the total number of questions asked and the number of questions asked regarding tests and treatment. Coaching did not add significantly to the effects of the prompt sheet. Psychological outcomes were not different among the groups. We conclude that a question prompt sheet addressed by the doctor is a simple, inexpensive and effective means of promoting patient question asking in the cancer consultation.
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Clinical pathways (CP) are nowadays used in numerous institutions, but their real impact is still a matter of debate. The optimal design of a clinical pathway remains unclear and is mainly determined by the expectations of the individual institution. The purpose of the here described pilot project was the development of two CP (colon and rectum carcinoma) according to Business Process Modeling Notation (BPMN) and Tangible Business Process Modeling (t.BPM). BPMN is an established standard for business process modelling in industry and economy. It is, in the broadest sense, a computer programme which enables the description and a relatively easy graphical imaging of complex processes. t.BPM is a modular construction system of the BPMN symbols which enables the creation of an outline or raw model, e.g. by placing the symbols on a spread-out paper sheet. The thus created outline can then be transferred to the computer and further modified as required. CP for the treatment of colon and rectal cancer have been developed with support of an external IT coach. The pathway was developed in an interdisciplinary and interprofessional manner (55 man-days over 15 working days). During this time, necessary interviews with medical, nursing and administrative staffs were conducted as well. Both pathways were developed parallel. Subsequent analysis was focussed on feasibility, expenditure, clarity and suitability for daily clinical practice. The familiarization with BPMN was relatively quick and intuitive. The use of t.BPM enabled the pragmatic, effective and results-directed creation of outlines for the CP. The development of both CP was finished from the diagnostic evaluation to the adjuvant/neoadjuvant therapy and rehabilitation phase. The integration of checklists, guidelines and important medical or other documents is easily accomplished. A direct integration into the hospital computer system is currently not possible for technical reasons. BPMN and t.BPM are sufficiently suitable for the planned modelling and imaging of CP. The application in medicine is new, and transfer from the industrial process management is in principle possible. BPMN-CP may be used for teaching and training, patient information and quality management. The graphical image is clearly structured and appealing. Even though the efficiency in the creation of BPMN-CP increases markedly after the training phase, high amounts of manpower and time are required. The most sensible and consequent application of a BPMN-CP would be the direct integration into the hospital computer system. The integration of a modelling language, such as BPMN, into the hospital computer systems could be a very sensible approach for the development of new hospital information systems in the future.
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Full-text of this article is not available in this e-prints service. This article was originally published in Management Research News, published by and copyright Emerald Group Publishing Ltd. This article offers support and guidance for students undertaking a literature review as part of their dissertation during an undergraduate or Masters course. A literature review is a summary of a subject field that supports the identification of specific research questions. A literature review needs to draw on and evaluate a range of different types of sources including academic and professional journal articles, books, and web-based resources. The literature search helps in the identification and location of relevant documents and other sources. Search engines can be used to search web resources and bibliographic databases. Conceptual frameworks can be a useful tool in developing an understanding of a subject area. Creating the literature review involves the stages of: scanning, making notes, structuring the literature review, writing the literature review, and building a bibliography.
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Active participation and asking questions are important ways in which patients can ensure they understand what the doctor has said. This study evaluated a question prompt sheet designed to encourage patients to ask questions in the cancer consultation. Patients (n = 142) were randomised to receive (i) a question prompt sheet or (ii) a general sheet informing patients of services available through the regional Cancer Council. Recall of information was assessed in a structured interview 4-20 days after the consultation. Questionnaires to assess patient satisfaction and adjustment to cancer were sent by mail. The question prompt sheet had a significant effect in one content area: prognosis. Thirty-five percent of patients who received the question handout asked questions about prognosis compared to 16% of those receiving the information handout. The prompt sheet did not increase the mean number of questions asked overall. Age, in/out-patient status, gender and involvement preference were predictive of both number and duration of patient questions. A question prompt sheet has a limited but important effect on patient question asking behaviour in the cancer consultation.
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The authors outline a new visual tool that can help patients assess the benefits and risks of different treatments.
Article
Background: Patients with poor underlying prognosis experiencing surgical emergencies face challenging treatment decisions. The Best Case/Worst Case (BC/WC) framework has improved shared decision-making by surgeons, but it is unclear whether residents can be similarly trained. We evaluated senior general surgical residents’ acceptance of the BC/WC tool and their attitudes, confidence and actions before and after training. Methods: Two-hour training included a didactic session, live demonstration, small-group practice and debriefing. We developed questionnaires to evaluate residents’ attitudes, confidence and actions at 3 time points: before the intervention, after the intervention and 6 months after the intervention. We used the Ottawa Decision Support Framework Acceptability questionnaire to evaluate acceptability and a structured observation form to evaluate performance. Results: Eighteen (50%) of 36 invited residents participated. Most residents (83%) felt that a new communication tool would be useful. Almost all (94%) used BC/WC in practice. Residents found the tool acceptable and useful to enhance preference-sensitive communications. They felt that the training was valuable and that role play was its greatest strength but that these situations were challenging to simulate. Barriers to BC/WC use included time constraints and difficulty defining the best and worst cases precisely. Summative attitudes and confidence scores were not different before and after the intervention; however, actions scores were higher after the intervention (p = 0.04). Residents performed a median of 15 (interquartile range 13–17) of the 19 elements on the formative performance evaluation. Commonly missed items were narrating outcomes of palliative approaches, prompting deliberation and providing treatment recommendations. Conclusion: Senior residents found the BC/WC tool to be acceptable and useful, and are amenable to training in this type of communication. After training, self-reported actions scores increased, and observed performance was accurate.
Article
Background: Attention to symptoms of weight gain and dyspnea are central tenets of patient education in heart failure (HF). However, it is not known whether diary use improves patient outcomes. The aims of this study were to compare mortality among rural patients with HF who completed versus did not complete a daily diary of weight and symptom self-assessment and to identify predictors of diary use. Methods and results: This is a secondary analysis of a 3-arm randomized controlled trial on HF education of self-care with 2 intervention groups versus control who were given diaries for 24 months to track daily weight, HF symptoms, and response to symptom changes. Mean age was 66±13, 58% were men, and 67% completed diaries (n=393). We formed 5 groups (no use, low, medium, high, and very high) based on the first 3 months of diary use and then analyzed time to event (cardiac mortality, all-cause mortality, and HF-related readmission) starting at 3 months. Compared with patients with no diary use, high and very high diary users were less likely to experience all-cause mortality (P=0.02 and P=0.01, respectively). Self-reported sedentary lifestyle was associated with less diary use in an adjusted model (odds ratio, 0.66; 95% confidence interval, 0.46-0.95; P=0.03). Depression and sex were not significant predictors of diary use in the adjusted model. Conclusions: In this study of 393 rural patients with HF, we found that greater diary use was associated with longer survival. These findings suggest that greater engagement in self-care behaviors is associated with better HF outcomes. Clinical trial registration: URL: https://www.clinicaltrials.gov. Unique Identifier: NCT00415545.
Article
Background: Patient engagement has become a major focus of health care improvement efforts nationally. Although evidence suggests patient engagement can be beneficial to patients, it has not been consistently defined, operationalized, or translated into practice. Objectives: Our objective was to develop a toolkit to help providers increase patient engagement and reduce disparities in patient engagement. Research design: We used qualitative interviews and observations with staff at primary care sites nationally to identify patient engagement practices and resources used to engage patients. We then used a modified Delphi process, that included a series of conference calls and surveys, where stakeholders reduced lists of engagement practices based on perceived feasibility and importance to develop a toolkit for patient engagement. Sampling: Sites were selected for interviews and site visits based on the concentration of minority patients served and performance on a measure of patient engagement, with the goal of highlighting practices at sites that successfully serve minority patients. Results: We created a toolkit consisting of patient engagement practices and resources. No identified practice or resource specifically targeted patient engagement of minorities or addressed disparities. However, high-performing, high-minority-serving sites tended to describe more staff training opportunities and staff feedback mechanisms. In addition, low-performing and high-minority-serving sites more often reported barriers to implementation of patient engagement practices. Conclusions: Stakeholders agreed on feasible and important engagement practices. Implementation of this toolkit will be tracked to better understand patient engagement and its effect on patient-centered care and related disparities in care.
Article
Background Patient empowerment is recognized as an important component of a multimodal strategy to improve hand hygiene adherence. We examined the attitudes of adult patients and parents of pediatric patients toward a new patient empowerment tool (PET) at our hospital. We also surveyed physicians to determine their perceptions about the PET. Methods A cross-sectional survey was performed of hospitalized children's parents and adult patients in a 531-bed tertiary care teaching hospital in West Virginia. Surveys were anonymous and self-administered. A separate survey was administered via e-mail to resident and attending physicians from the departments of internal medicine, pediatrics, and family medicine. Results Most parents and adult patients felt it was their role to speak up if a provider did not perform hand hygiene, but a smaller number actually felt comfortable using the PET. Only 54.9% of physicians felt that patients should be involved in reminding providers to perform hand hygiene. Overall, physicians indicated that they would prefer a patient to use words rather than the PET to remind them to perform hand hygiene. Conclusions In our study, parents and adult patients supported use of the PET, but physicians were less supportive. As the patient empowerment movement grows, we should work to improve physician acceptance of patient involvement if it is to be successful.
Article
Objective: Given the strong push to empower patients and make them partners in their health care, we evaluated the current capability of hospitals to offer health information technology that facilitates patient engagement (PE). Materials and methods: Using an ontology mapping approach, items from the American Hospital Association Information Technology Supplement were mapped to defined levels and categories within the PE Framework. Points were assigned for each health information technology function based upon the level of engagement it encompassed to create a PE-information technology (PE-IT) score. Scores were divided into tertiles, and hospital characteristics were compared across tertiles. An ordered logit model was used to estimate the effect of characteristics on the adjusted odds of being in the highest tertile of PE-IT scores. Results: Thirty-six functions were mapped to specific levels and categories of the PE Framework, and adoption of each item ranged from 23.5 to 96.7%. Hospital characteristics associated with being in the highest tertile of PE-IT scores included medium and large bed size (relative to small), nonprofit (relative to government nonfederal), teaching hospital, system member, Midwest and South regions, and urban location. Discussion: Hospital adoption of PE-oriented technology remains varied, suggesting that hospitals are considering how technology can create partnerships with patients. However, PE functionalities that facilitate higher levels of engagement are lacking, suggesting room for improvement. Conclusion: While hospitals have reached modest levels of adoption of PE technologies, consistent monitoring of this capacity can identify opportunities to use technology to facilitate engagement.
Article
Importance: Although many older adults prefer to avoid burdensome interventions with limited ability to preserve their functional status, aggressive treatments, including surgery, are common near the end of life. Shared decision making is critical to achieve value-concordant treatment decisions and minimize unwanted care. However, communication in the acute inpatient setting is challenging. Objective: To evaluate the proof of concept of an intervention to teach surgeons to use the Best Case/Worst Case framework as a strategy to change surgeon communication and promote shared decision making during high-stakes surgical decisions. Design, setting, and participants: Our prospective pre-post study was conducted from June 2014 to August 2015, and data were analyzed using a mixed methods approach. The data were drawn from decision-making conversations between 32 older inpatients with an acute nonemergent surgical problem, 30 family members, and 25 surgeons at 1 tertiary care hospital in Madison, Wisconsin. Interventions: A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework. Main outcomes and measures: We scored conversation transcripts using OPTION 5, an observer measure of shared decision making, and used qualitative content analysis to characterize patterns in conversation structure, description of outcomes, and deliberation over treatment alternatives. Results: The study participants were patients aged 68 to 95 years (n = 32), 44% of whom had 5 or more comorbid conditions; family members of patients (n = 30); and surgeons (n = 17). The median OPTION 5 score improved from 41 preintervention (interquartile range, 26-66) to 74 after Best Case/Worst Case training (interquartile range, 60-81). Before training, surgeons described the patient's problem in conjunction with an operative solution, directed deliberation over options, listed discrete procedural risks, and did not integrate preferences into a treatment recommendation. After training, surgeons using Best Case/Worst Case clearly presented a choice between treatments, described a range of postoperative trajectories including functional decline, and involved patients and families in deliberation. Conclusions and relevance: Using the Best Case/Worst Case framework changed surgeon communication by shifting the focus of decision-making conversations from an isolated surgical problem to a discussion about treatment alternatives and outcomes. This intervention can help surgeons structure challenging conversations to promote shared decision making in the acute setting.
Article
Objective: Question prompt lists (QPLs) and consultation audio-recordings (CARs) are two communication strategies that can assist cancer patients in understanding and recalling information. We aimed to explore clinician and organisational barriers and facilitators to implementing QPLs and CARs into usual care. Methods: Semi-structured interviews with twenty clinicians and senior hospital administrators, recruited from four hospitals. Interviews were recorded, transcribed verbatim and thematic descriptive analysis was utilised. Results: CARs and QPLs are to some degree already being initiated by patients but not embedded in usual care. Systematic use should be driven by patient preference. Successful implementation will depend on minimal burden to clinical environments and feedback about patient use. CARs concerns included: medico-legal issues, ability of the CAR to be shared beyond the consultation, and recording and storage logistics within existing medical record systems. QPLs issues included: applicability of the QPLs, ensuring patients who might benefit from QPL's are able to access them, and limited use when there are other existing communication strategies. Conclusions: While CARs and QPLs are beneficial for patients, there are important individual, system and medico-legal considerations regarding usual care. Practice implications: Identifying and addressing practical implications of CARs and QPLs prior to clinical implementation is essential.
Article
Rational: Tools used in clinical encounters to illustrate to patients the risks and benefits of treatment options have been shown to increase shared decision making. However, we do not have good information about how these tools are viewed by clinicians and how clinicians think patients would react to their use. Objective: Our aim was to examine clinicians' views about the possible and actual use of tools designed to support patients and clinicians to collaborate and deliberate about treatment options, namely, Option Grid decision aids. Method: We conducted a thematic analysis of qualitative interviews embedded in the intervention phase of a trial of an Option Grid decision aid for osteoarthritis of the knee. Interviews were conducted with 6 participating clinicians before they used the tool and again after clinicians had used the tool with 6 patients. Results: In the first interview, clinicians voiced concerns that the tool would lead to an increase in encounter duration, patient resistance regarding involvement in decision making, and potential information overload. At the second interview, after minimal training, the clinicians reported that the tool had changed their usual way of communicating, and it was generally acceptable and helpful to integrate it into practice. Discussion and conclusions: After experiencing the use of Option Grids, clinicians became more willing to use the tools in their clinical encounters with patients. How best to introduce Option Grids to clinicians and adopt their use into practice will need careful consideration of context, workflow, and clinical pathways.
Article
Background: Data on the use of question prompt sheets (QPS) in palliative care is limited. Our team previously developed a single page QPS using a Delphi process. The main objective of this study was to determine the perception of helpfulness of a QPS in patient-physician communication among advanced cancer outpatients. Methods: 100/104(96%) eligible patients and 68/68(100%) caregivers received the QPS during their first palliative care clinic. 12 palliative medicine specialists also participated in the study. Patient and physician perceptions about the QPS were assessed at the end of the visit. Patients' anxiety was also measured pre- and post-consultation using the Spielberger State Anxiety Inventory. Results: Among the responders, most agreed that the material was helpful in communicating with their doctor (77%), clear to understand(90%), had the right amount of information(87%), and they would use a similar material in the future(76%) and recommend it to other patients(70%).Overall, 92% were satisfied with their consultation visit. Physicians perceived that the QPS was helpful in 68% of the encounters and it did not prolong the consultation in 73% of the encounters. Physician agreement on helpfulness of the QPS was not significantly different from that of the patients (p=0.3).Patient anxiety improved after consultation from a mean(SD) STAI score of 39.2(12.8) to 33.8(10.7), p=<0.0001) CONCLUSION: The QPS was perceived as helpful in patient-physician communication among advanced cancer outpatients and it did not increase patient anxiety. Physicians similarly reported that the QPS was helpful and it did not prolong clinic visits. Further research is needed for its widespread adoption and integration into routine clinical practice.
Article
Objective: Patient engagement has been credited with contributing to improved outcomes and experiences of care. Patient engagement has become a widely used term, but remains a poorly understood concept in healthcare. Citations for the term have increased throughout the healthcare-related disciplines without a common definition. This study seeks to define the concept by identifying its attributes in the context of its use. Methods: A concept analysis of the scientific literature in the health disciplines was performed using the Rogers method. Results: The analysis revealed four defining attributes of patient engagement: personalization, access, commitment and therapeutic alliance. Patient engagement is defined as the desire and capability to actively choose to participate in care in a way uniquely appropriate to the individual, in cooperation with a healthcare provider or institution, for the purposes of maximizing outcomes or improving experiences of care. Conclusion: Patient engagement is both process and behavior and is shaped by the relationship between the patient and provider and the environment in which healthcare delivery takes place. Practice implications: The definition and the identified attributes serve as a heuristic in designing patient engagement strategies and as a basis for future development of the patient engagement concept in healthcare.
Conference Paper
Healthcare processes require continuous support in order to face the increasing demand for optimal quality of care and to provide a sound basis for integrating different sources of medical knowledge. A very important issue to consider in the medical domain is the fact that clinical process activities intertwine with data, and thus, process-oriented information systems play a crucial role in healthcare management. Business-process modeling techniques can successfully be applied in order to represent clinical pathways and guidelines in a standardized way, by giving a more understandable high-level description of evidence-based medical practice. In this paper, we address (i) the representation of clinical pathways by means of conceptual process models, and (ii) by considering process-related information. Moreover, (iii) we apply our methodology to the modeling of two clinical pathways for catheter-related bloodstream infections adopted in two different hospitals in Europe and U.S., respectively, and (iv) we take advantage of the application of our approach for comparing the resulting processes at a higher level of abstraction.
Article
Electronic health record (EHR)-linked patient portals are a promising approach to facilitate shared decision-making between families of children with chronic conditions and pediatricians. This study evaluated the feasibility, acceptability, and impact of MyAsthma, an EHR-linked patient portal supporting shared decision-making for pediatric asthma. We conducted a 6-month randomized controlled trial of MyAsthma at 3 primary care practices. Families were randomized to MyAsthma, which tracks families' asthma treatment concerns and goals, children's asthma symptoms, medication side effects and adherence, and provides decision support, or to standard care. Outcomes included the feasibility and acceptability of MyAsthma for families, child health care utilization and asthma control, and the number of days of missed school (child) and work (parent). Descriptive statistics and longitudinal regression models assessed differences in outcomes between study arms. We enrolled 60 families, 30 in each study arm (mean age 8.3 years); 57% of parents in the intervention group used MyAsthma during at least 5 of the 6 study months. Parents of children with moderate to severe persistent asthma used the portal more than others; 92% were satisfied with MyAsthma. Parents reported that use improved their communication with the office, ability to manage asthma, and awareness of the importance of ongoing attention to treatment. Parents in the intervention group reported that children had a lower frequency of asthma flares and intervention parents missed fewer days of work due to asthma. Use of an EHR-linked asthma portal was feasible and acceptable to families and improved clinically meaningful outcomes. Copyright © 2015 by the American Academy of Pediatrics.
Article
This is the protocol for a review and there is no abstract. The objectives are as follows: The objective of this review is to assess the effect of patient diaries on recovery, in comparison to standard ICU treatment, in patients recuperating from admission to an ICU and their caregivers or families.
Article
Background: It is estimated that one-third of women will experience abnormal menstrual bleeding. The majority of these cases are not due to cancer or pregnancy complications and, as a result, women are faced with a variety of treatment alternatives, the selection of which is largely dependent on personal preferences for care rather than clinical outcomes. Objective: This randomized trial was designed to evaluate a preference elicitation tool to promote physician-patient collaborative decision making for treatment of abnormal uterine bleeding (AUB). Methods: Adaptive conjoint analysis (ACA) was used to create a preference elicitation tool in English and in Spanish. Women with AUB were enrolled to the study and randomly assigned to ACA or usual counseling at the initial clinic visit at four clinics (three in Indianapolis, IN, USA, and one in Southern Pines, NC, USA). The ACA tool elicited preferences across eight attributes: treatment efficacy; sexual function; medical care; cost; fertility; frequency of medication use; permanence; and recovery time. t tests were used to compare differences in the primary outcomes of decision regret and treatment satisfaction at the follow-up visit. The study was designed to have 80 % power to detect significant differences between groups for the primary outcomes of regret and satisfaction. Results: Women were enrolled in the study between September 2009 and March 2012. 183 participants were randomized to ACA and 191 to usual counseling. Overall, mean (standard deviation) treatment satisfaction was high at 35.71 (9.72) (scale of 0-44), and decision regret was low at 25.9 (21.0) (scale of 0-100), creating ceiling effects for the selected outcome variables; there were no significant differences between the ACA and control groups at the follow-up assessment. There was a strong inverse relationship between age and decision regret (p = 0.007). Exploratory subgroup analysis in the youngest quartile comprising 64 women aged 19-35 years showed a statistically non-significant difference in mean regret scores for the ACA group versus usual counseling (24.6 vs. 34.6, respectively; p = 0.08). Conclusions: A preference elicitation tool at the initial consultation visit did not reduce decision regret or improve treatment satisfaction among patients with AUB; however, there is a need for additional research to further understand this tool's potential role in promoting collaborative decision making, which may be particularly important among younger women.
Article
Die Entwicklung von insgesamt 5klinischen Behandlungspfaden ist in 2rheumatologischen Krankenhausabteilungen fr 3 – aufgrund ihrer Fallzahl im stationren Bereich und/oder ihrer Diagnostik- und Therapiekosten ausgewhlte – entzndlich-rheumatische Erkrankungen erfolgreich gelungen. Mithilfe von 3Soll-Konzepten wurde die Harmonisierung der Behandlungsablufe (Soll-KonzeptI), die zeitliche Abstimmung der Leistungsumsetzung (Soll-KonzeptII), der konomische Umgang mit den vorgehaltenen Ressourcen sowie die transparente Festlegung der Therapieinhalte (Soll-KonzeptIII) erarbeitet. Die erstellten Soll-Konzepte wurden bisher sowohl im komplexen als auch im modularen Einsatz erprobt.Clinical pathways for three rheumatological indications have been successfully developed in the rheumatological departments of two hospitals. These diseases were selected because of the number of inpatients seen and/or the costs for diagnostics and therapy. Three quota-concepts, the coordination of treatment processes (quota-concept I), the sequence of implementing services (quota-concept II), and the economical utilization of available resources as well as the transparent definition of therapies (quota-concept III) have been established. These concepts have been tested individually as well as in complex situations.
Article
Although cancer management is becoming more structured with disease-specific guidelines and clinical pathways, many decisions remain complex. Contributing to this complexity is the need to make value tradeoffs between benefits and harms across cancer treatment and/or screening options. Since there is no "best" option for everyone, decisions are defined as being of higher quality when informed with the latest scientific evidence and based on patients' informed values associated with outcomes of options. However, clinicians are not good judges of patients' values, and patients often have inadequate knowledge, unrealistic expectations, and decisional conflict that interfere with their involvement in decision making. Effective approaches to support patient involvement into clinical decisions include clinicians trained in shared decision making, question prompt sheets, patient decision aids, and decision coaching by nurses and other allied health professionals. Based on systematic review of 23 randomized trials of cancer patient decision aids, patients exposed to decision aids are more likely to participate in decision making and achieve higher-quality decisions. This review highlights key historical changes leading to patient involvement in decision making, summarizes evidence on effective interventions to support shared decision making, explores strategies to implement these interventions in oncology practices, and identifies future directions.
Article
Multidisciplinary heart failure programs including patient education and self-management strategies such as daily recording of body weight and use of a patient diary decrease hospital readmissions and improve quality of life. However, the degree of uptake of individual components of these programs and their contribution to patient benefit are uncertain. Patients with heart failure admitted to Auckland Hospital were randomised into the management or usual care groups of the Auckland heart failure management study (AHFMS). Patients in the management group were given a heart failure diary for the recording of daily weights, attended a heart failure clinic and were encouraged to attend three education sessions. Patients in the usual care group received routine clinical care, mainly from general practitioners. Patients were followed to 12 months. This study investigated the uptake of self-management by assessing diary use and self-weighing behaviour in the group receiving the heart failure intervention, and compared the level of knowledge of heart failure self-management of the management group to the control group after 12 months. Of the 197 patients in the AHFMS, 100 patients were included in the management group and received a diary and education about heart failure self-management including monitoring weight daily. Of these patients, 76 patients used the diary. These patients were on more medication; were more likely to attend the education sessions, heart failure clinic, and primary care, and had a lower mortality rate over the course of the study. Variables independently associated with use of the diary included less severe symptoms (OR 15, 95% confidence intervals 1.7, 144), frequent attendance at the heart failure clinic (OR 15, 95% CI 3, 78) and attendance at an education session (OR 8, 95% CI 1.5, 42). Of the 76 patients who used the diary, 51 weighed themselves regularly. More of these patients owned scales at home; they were also more likely to attend the education sessions, and experienced fewer hospital admissions than those patients who did not weigh themselves regularly. Variables independently associated with regular self-weighing included the presence of scales at home (OR 6.3, 95% CI 1.7, 14.1), left ventricular ejection fraction >30% (OR 4.3, 95% CI 1.1, 17.5), and attendance at the education session(s) (OR 6.3, 95% CI 1.7, 14.1). Patients in the management group exhibited higher levels of knowledge at 12 months of follow-up and were more likely to monitor their condition using daily weighing, compared to the control group. At 12 months of follow-up, implementation of self-management strategies including daily weight monitoring and level of education on self-management was significantly higher in the management group than the control group. For the patients in the management group, not using the diary or inability to perform daily weighing were associated with less frequent attendance at the heart failure clinic and education sessions and poorer health outcomes. In this study, attendance at the education sessions was associated with the adoption of self-management, underlining the importance of education in multidisciplinary heart failure programmes. Self-weighing could be increased by provision of scales to all patients. The subset of patients who did not adopt self-management strategies in this study were at high risk of death or readmission.