MDM Policy and Practice最新文献

Background. Developing patient decision aids (PtDAs) requires considerable resources. We aimed to create a digital platform to streamline the process and investigate stakeholder perceptions of factors influencing the adoption of a mock-up of the platform. Methods. Using the Framework for Innovation, a design team developed an alpha version of the platform, with support from an advisory panel. A convenience sample of key stakeholders involved in the development of PtDAs, who were fluent in English, French, or Spanish, reviewed the mock-up in think-aloud sessions and answered open-ended questions structured along Normalization Process Theory constructs: Coherence, Cognitive Participation, Collective Action, and Reflective Monitoring. A thematic qualitative analysis was conducted by 3 researchers, iteratively improving the mock-up until no major issues emerged. Results. We recruited 20 participants, mainly women (n = 11), from 4 continents, including clinician-researchers (n = 15), patients (n = 4), and a health care manager (n = 1). Their experience in developing PtDAs ranged from none (n = 2) to more than 10 PtDAs (n = 1), with most having developed 2 to 5 PtDAs (n = 9). Participants noted that the platform could enhance the shared understanding of processes and roles (Coherence), support input from different stakeholders (Cognitive Participation), and streamline development and revision, recommending features such as version tracking (Collective Action). They also emphasized the need for customizable PtDA templates, training, and PtDA certification (Reflective Monitoring). Limitations. Few participants were from middle- or low-income countries, limiting the findings' transferability to these populations. Conclusions. Next steps include developing and evaluating a minimum viable version of the platform incorporating these findings. Implications. This innovation has the potential to scale the development of PtDAs and ultimately support evidence-based and preference-sensitive clinical decisions.

Highlights: This formative research presents an innovative infrastructure designed to scale patient decision aids through capacity-building tools and standardized templates.Stakeholder feedback suggests that the platform could enable more timely and resource-efficient development of decision aids, although its effectiveness has yet to be evaluated.The platform's collaborative features could foster partnerships between developers, clinicians, and patients by promoting a shared understanding of the process and making roles and decisions about content more transparent.To increase confidence in the quality of decision aids, future work should introduce a validation process for decision aids and integrate evidence-synthesis guidance into the platform.

Background. Shared decision making (SDM) involving adolescents with chronic conditions is a triadic process that requires engaging adolescent patients, their parent(s), and their health care provider. We sought to understand the perspectives of parents about these interactions and the parents' role in SDM. Methods. We conducted semi-structured qualitative interviews with parents of adolescents (aged 12-17 y) with chronic conditions. The interviews focused on parents' experiences of medical decision making related to their adolescent's care, followed by experiences of SDM. We specifically addressed key aspects of SDM including information exchange, options, values, and preferences. We coded and analyzed the interviews using thematic content analysis. Results. Twenty-one parents completed an interview (median age 44 y, 91% female, 53% non-White). We identified 4 themes from the data: parents want an executive role, parents as experts, parents' perceptions of others' roles, and parents' necessities for SDM. Parents described wanting to control the level to which their adolescent is involved in SDM based on their perceived knowledge of their adolescent's capabilities. Parents reported feeling pressure to understand all aspects of potential decisions. Finally, parents underscored the need for trusting relationships between all members of the triad. Conclusions. Parents identify key roles for themselves and others in triadic SDM. By understanding these perspectives, health care providers may be better prepared to promote SDM in the care of adolescents with chronic conditions. Implications. This research has implications for how decisions are shared between providers and families. Valuing parents and including them in decision making has the potential to establish stronger relationships between the family and the care team and reduce parents' anxiety about their child's health.

Highlights: This study is the first to explore parents' perspectives of triadic SDM involving an adolescent with a chronic condition.We identify situations (e.g., non-life-threatening treatment decisions, before an impending transition to adult medicine) in which parents may be more amenable to including their adolescent in the decision process.Understanding parents' perspectives on decision making can help providers establish strong relationships with the families, which may improve care for adolescents with chronic conditions.

Objective. Infections and fever after stroke are associated with poor functional outcome and death. We compared the cost-effectiveness of prophylactic metoclopramide, paracetamol, and ceftriaxone, either as monotherapies or in combination, with standard of care for reducing complications in older patients with acute stroke. Methods. We conducted a model-based analysis estimating expected lifetime costs, quality-adjusted life-years (QALYs), and net monetary benefit (NMB) from a Dutch health care perspective, given a willingness-to-pay threshold of 50,000 euros per QALY gained. The model synthesized patient-level data from the PREvention of Complications to Improve OUtcome in older patients with acute Stroke (PRECIOUS) trial with data from long-term observational studies. We conducted a value-of-information analysis to quantify the expected value of reducing decision uncertainty through additional data collection on key input parameters. Results. Combination therapy with metoclopramide, ceftriaxone, and paracetamol yielded the highest expected NMB and was the most cost-effective treatment option. When compared with standard care, this treatment option decreased costs by €6,438 and increased QALYs by 0.10, resulting in an incremental NMB of €11,721. The value-of-information analysis indicated that decision uncertainty was driven by uncertainty about the treatment effects on poststroke disability, measured by the modified Rankin Scale (mRS). Moreover, the analysis suggested that the expected value of reducing uncertainty through additional data collection on acute phase mRS scores far exceeds the expected costs. Conclusion. Our economic evaluation suggests that combination therapy with metoclopramide, paracetamol, and ceftriaxone may be the most cost-effective option for treating older patients with stroke in the Netherlands. However, there is likely great value in reducing uncertainty by conducting a new study that collects additional data on acute phase mRS scores.

Highlights: Prophylactic combination therapy with metoclopramide, paracetamol, and ceftriaxone may be the most cost-effective strategy for preventing infections and fever in elderly patients with acute stroke.There is substantial decision uncertainty, primarily driven by uncertainty regarding the treatment effects on functional outcome (modified Rankin Scale, mRS).Value-of-information analysis indicates that the value of reducing uncertainty through a new study on acute phase mRS scores is very high.

Background. Extracranial internal carotid artery stenosis (50%-99% arterial narrowing) is an important risk factor for ischemic stroke. Yet, the benefits and harms of targeted screening for asymptomatic carotid artery stenosis (ACAS) have not been assessed in population-based studies. We aimed to estimate the cost-effectiveness of one-time, targeted ACAS screening stratified by atherosclerotic cardiovascular disease (ASCVD) risk using the American Heart Association's pooled cohort equations. Methods. We developed a lifetime microsimulation model of ACAS and stroke for a hypothetical cohort representative of US adults aged 50 to 80 y without stroke history. Model parameters were derived from multiple cohort studies and the published literature. Outcomes included estimated stroke events prevented, lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) associated with ACAS screening. Costs (2023 USD) and QALYs were discounted at 3% annually. Cost-effectiveness was assessed from the health care sector perspective using a $100,000/QALY threshold. Results. We found that screening individuals with a 10-y ASCVD risk >30% was the most cost-effective strategy, with an ICER of $89,000/QALY. This strategy would make approximately 11.9% of the population eligible for screening, averting an estimated 24,084 strokes over the cohort's lifetime. In probabilistic sensitivity analysis, screening those in lower ASCVD risk groups (0%-20%) had only a 0.6% chance of being cost-effective. If the ongoing CREST-2 trial shows that revascularization reduces stroke risk by less than 30% (relative risk >0.7), it may shift the balance against any screening. Conclusions. ACAS screening may be cost-effective only for adults at relatively high ASCVD risk. These findings provide a flexible decision-analytic framework that can inform clinical and policy guidance as future trial results refine the role of revascularization and intensive medical therapy.

Highlights: Targeted screening for asymptomatic carotid artery stenosis may be cost-effective only for adults aged 50 to 80 y at high atherosclerotic cardiovascular disease (ASCVD) risk.Screening individuals with a 10-y ASCVD risk greater than 30% could substantially reduce lifetime stroke burden while remaining within accepted US cost-effectiveness thresholds.Screening lower-risk (0%-20% 10-y ASCVD risk) adults provides minimal health gains at significantly higher costs and should not be recommended.Findings offer a decision-analytic framework to inform future screening guidelines and policy decisions as results from ongoing trials, such as CREST-2, become available.

Purpose. To evaluate the level and influencing factors of shared decision making in patients with chronic hepatitis B and explore its effects on antiviral treatment adherence. Methods. A cross-sectional study was conducted with 239 chronic hepatitis B patients using a general information and disease-related information questionnaire, the 9-item Shared Decision Making Questionnaire, the Self-Efficacy for Appropriate Medication Use Scale, and the Morisky Medication Adherence Scale-8. A structural equation model was built to analyze the pathways through which shared decision making affects medication adherence. Results. The standardized shared decision-making score for patients with chronic hepatitis B was 71.99 ± 9.22, with higher levels of shared decision making observed in males and patients with cirrhosis. Shared decision making significantly affected self-efficacy for appropriate medication use (β = 0.568, P < 0.001) and adherence (β = 0.413, P < 0.001). Moreover, self-efficacy for appropriate medication mediated the relationship between shared decision making and adherence (β = 0.219, P = 0.002). Conclusions. Patients with chronic hepatitis B show above-average levels of shared decision making, with considerable individual differences. Promoting the use of shared decision making can significantly improve patients' medication self-efficacy and adherence to treatment.

Highlights: Shared decision making (SDM) in chronic hepatitis B (CHB) patients is at an above-average level, with significant individual differences.Gender and cirrhosis status are key independent factors influencing SDM levels.Higher SDM levels positively affect both medication self-efficacy and adherence, with self-efficacy serving as a mediator.

Background. Potential organ donors are carefully assessed by expert clinicians (donation specialists) who evaluate a variety of factors, including balancing potential transplant benefits and biovigilance risks, under time constraints. We aimed to identify and understand the factors that donation specialists consider when appraising a potential organ donor and how they balance the risk and benefits when determining the medical suitability to proceed to donation. Methods. Exploratory qualitative study involving semi-structured interviews with 12 donation specialists in NSW, Australia. Interviews included 1) open-ended questions focused on the general potential organ donation pathway and 2) hypothetical potential donor scenarios, with participants invited to voice their decision-making process. Interviews were audio-recorded, transcribed verbatim, and analyzed using the framework method. Results. We identified 3 themes: 1) from automatic exclusions to more collaborative decision making; (2) "risk appetite," uncertainty, and information gaps; and 3) the role of recipients and their families in decision making. Deceased donor medical suitability was determined by a complex interplay of clinical practice guidelines, guidance from colleagues, and personal risk propensity, with variability in decision making irrespective of standardized information provision. Decisions that a potential donor was unsuitable were often driven by compounding risks, accentuated in the context of missing information and incomplete medical histories. Considering both potential donor and potential recipient profiles in tandem and including potential recipients and/or their families in decision making was considered important. However, narratives were marked by frustration with patients' risk propensity and challenges with communication under time pressure. Conclusion. Clinicians assessing the medical suitability of potential deceased organ donors face challenges such as incomplete medical histories and communication barriers. Decision-support tools and early engagement with potential recipients and their families to elicit their preferences and risk tolerance could aid clinicians in making more informed decisions under time pressure.

Highlights: In this qualitative study with Australian donation specialists, we found that potential deceased donor medical suitability was determined by a complex interplay of clinical practice guidelines, guidance from colleagues, and personal risk propensity, with variability in decision making irrespective of standardized information provision.Decisions to forego a potential donor were often driven by compounding risks and worsened by missing information and incomplete medical histories.Considering both potential donor and recipient profiles in tandem and including the recipient and/or their families in decision making were considered important but challenging under time pressure.

Background. Treatment preferences of patients with high-risk localized prostate cancer (HRLPC) and metastatic hormone-sensitive prostate cancer (mHSPC) are expected to be influenced by cultural and institutional differences across countries. We aimed to evaluate this expectation by quantifying the importance of treatment outcomes for patients with HRLPC and mHSPC. Methods. A discrete-choice experiment survey included adults (≥18 y of age) diagnosed with HRLPC or mHSPC from 5 countries-France, Spain, China, South Korea, and Japan-with or without previous experience of androgen-deprivation therapy. A latent-class random-parameters logit model was used to evaluate the importance patients assigned to treatment attributes and the consistency in treatment preferences across the 5 countries. Results. In total, 468 patients completed the survey. Respondents with shared treatment preferences from all 5 countries had a chance of being in pooled class 1 (44.5%) or pooled class 2 (37.9%). The main factors of concern were skin rash, fatigue, and use of steroids for pooled class 1 and chemotherapy-associated problems for pooled class 2. Our analysis could not explain class assignments based on clinically relevant characteristics of patients, which were used as covariates. Conclusion. Despite cultural and institutional differences across the 5 countries, our model identified significant consistency in treatment preferences among patients with prostate cancer. Given the attribute levels in our study, efficacy was the most significant driver of patient preference. We also found that using 2 sets of preferences was sufficient to reasonably characterize the perspectives of about 80% of surveyed patients. That these 2 patient classes differed in terms of treatment concerns but not in clinical factors highlights the need for promoting communication between patients and clinicians about treatment choices.

Highlights: Our study demonstrates that discrete-choice experiments (DCEs) are valuable for capturing health-related preferences among patients with prostate cancer.Contextual factors, such as efficacy and the country-specific health care system in which choices are presented, influence the ability to pool DCE data across countries.DCEs have the potential to enhance patient-centered care, shaping the future of evidence-based health care decision making.

Decision science and implementation science share the common goal of improving individual and population health through choosing and providing effective health innovations at scale. In this article, we summarize a symposium we hosted at the 45th Annual Society for Medical Decision Making North American meeting. The symposium aimed to illustrate how integrating implementation science and decision science can strengthen the real-world impact and practical utility of decision science methods. The symposium was attended by 51 individuals. It included 4 presentations by early-career researchers and a moderated discussion. Presentations covered innovative work at the intersection of implementation science and decision analytic modeling and focused on policy applications because of the presenters' expertise and strong history of decision analytic modeling to inform policy decisions. The symposium's moderated discussion indicated a need for developing collaborations between implementation and decision scientists to move this type of work forward. Suggested areas of future research are modeling to identify gaps in data and considering value-of-information methods, exploring how implementation could be incorporated into simulation methods beyond those discussed in the symposium (e.g., distributional and extended cost-effectiveness analyses), and integrating implementation science into other areas of decision science (e.g., preference and prioritization research, shared decision making). We urge decision science researchers to pursue interdisciplinary research integrating decision and implementation science to best inform policy decision making and drive the scale-up of promising policies across contexts.

Highlights: Implementation science concepts could strengthen the external validity and uptake of decision science methods such as decision analytic models.The symposium discussed and highlighted innovative ways that decision science researchers could integrate implementation science frameworks and outcomes (e.g., cost, reach, fidelity) into decision analytic models to be more responsive to the multifaceted considerations of policy decision making.Supporting interdisciplinary networking and collaboration between decision scientists and implementation scientists is critical to strengthen the real-world impact and practical utility of decision science methods.

Objective. This qualitative study explores the barriers and facilitators to implementing shared decision making (SDM) for breast reconstruction (BR) from multistakeholder perspectives in the Chinese health care context. Methods. A qualitative study was conducted from November 2021 to January 2022, involving 36 participants, including patients, doctors, nurses, and hospital administrators from 3 tertiary hospitals in Beijing, Hebei, and Guangzhou. Purposeful and snowball sampling was used until data saturation. In-depth semi-structured interviews were analyzed using thematic analysis. Results. Findings from 36 stakeholders (20 patients, 16 health care providers/administrators) revealed 5 key dimensions influencing SDM implementation: decision making, patient, health care professional (HCP), organizational, and societal levels. Notable factors include patient self-efficacy, information needs, HCPs' role recognition and SDM competencies, team coordination, SDM convenience, availability of support tools, and cultural influences. Limitations. The limitations of this study primarily stem from the narrow sample source, which includes only 3 regions in mainland China. Conclusion. Successful SDM implementation in China requires optimizing clinical workflows, utilizing technological tools, providing professional training, and integrating SDM with traditional Chinese medicine philosophies. These strategies enhance decision-making quality and align SDM practices with Chinese cultural values. Practice Implications. Integrating culturally sensitive SDM into clinical workflows, supported by decision tools, training, and robust policies, is essential for BR SDM in China.

Highlights: Identified barriers and facilitators on shared decision making for breast reconstruction from multistakeholder perspectives in China's health care context.Explored cultural influences on shared decision making for breast reconstruction in Chinese patients.Emphasized the importance of integrating shared decision making into existing clinical workflows.Proposed integrating traditional Chinese medicine diagnostics with shared decision making for culturally sensitive care.

Background. Shared decision making (SDM) is an essential component of patient-centered care and especially important in high-risk populations, such as older adults. Although surgery has unique risks and the potential to cause permanent disability, which can affect the patient's quality of life, SDM is underused before surgery to explore these tradeoffs. This study's aim is to characterize the priorities, barriers, resources, and age-specific considerations for SDM in older adults undergoing surgery. Study Design. Five semi-structured focus groups were completed from February 2022 to April 2022 with 24 participants including older adult surgical patients and caregivers as well as providers involved in the care of older adult surgical patients (e.g., surgery, intensive care, geriatrics, and palliative care). Interviews were transcribed, and qualitative thematic analysis was conducted. Results. Six major themes were identified and explored: components of SDM, barriers to SDM, importance of SDM, preparation for SDM, age-specific considerations, and suggestions for improvement. Results showed differing opinions between patients and providers about important information in the SDM process, minimal preparation for SDM in both groups, and difficulties around defining outcomes for this population, particularly in the emergent setting. Conclusion. This study identifies critical components of SDM, perceived barriers, preparation and training for SDM, as well as unique considerations in older adults from the perspectives of both patients and providers. Opportunities to improve SDM include dissemination of resources, training of surgical providers, and utilization of other providers as well as patient-centered discussions about postoperative outcomes. This highlights important areas for future work and particularly the utility of SDM tools and training for surgeons.

Highlights: Critical components of shared decision making (SDM) identified in this study include understanding patient values, building trust, understanding the patient's baseline function, and defining possible treatment outcomes.Specific components of SDM in older adults include navigating companions to conversations and the challenges of navigating potential postoperative changes to cognitive or physical function.Possible areas to improve SDM include improved dissemination of SDM resources; the importance of communication skills and empathy and an emphasis on additional training for this, particularly for trainees; improved engagement of patients in the SDM process; and using other care team members such as palliative care and social work when appropriate.