Are guidelines for measurement of quality of life contrary to patient-centred care?

AIMS: A discussion of how quality-adjusted life years are used to inform resource allocation decisions and highlight how assumptions underpinning the measurement of quality of life are contrary to the principles of patient-centred care. BACKGROUND: Cost-effectiveness analyses (CEAs) can provide influential guidance for health resource allocation, particularly in the context of a budget-constrained public health insurance plan. Most national economic guideline bodies recommend that quality-adjusted life year weights for CEA be elicited indirectly (public preferences). This has potentially important implications for healthcare provision and research, as it discounts the ability of a person experiencing an illness to describe how it affects their quality of life. DESIGN: Discussion paper. DATA SOURCES: Guidelines for the conduct of health economic evaluations, influential methodological and theoretical texts, and a review of PubMed conducted in April 2017. IMPLICATIONS FOR NURSING: Nurses are increasingly interested in leveraging methods from health economics to aid in decision-making and advocacy. In this analysis, we highlight how taken-for-granted approaches to the measurement of quality of life may discount the experience of patients and lead to decisions that are contrary to the principles of patient-centred care. Nurses conducting or reading research using these methods should consider whether the approach used to measure the quality of life are appropriate for the population under consideration. CONCLUSION: Since patient and public health preferences can differ in both magnitude and direction, guideline bodies should re-evaluate their partiality for public preferences in the reference case.

Evaluating Simplified Web Interfaces of Risk Models for Clinical Use: Pilot Survey Study.

BACKGROUND: In this pilot study, we investigated sociotechnical factors that affect intention to use a simplified web model to support clinical decision making. OBJECTIVE: We investigated factors that are known to affect technology adoption using the unified theory of acceptance and use of technology (UTAUT2) model. The goal was to pilot and test a tool to better support complex clinical assessments. METHODS: Based on the results of a previously published work, we developed a web-based mobile user interface, WebModel, to allow users to work with regression equations and their predictions to evaluate the impact of various characteristics or treatments on key outcomes (eg, survival time) for chronic obstructive pulmonary disease. The WebModel provides a way to combat information overload and more easily compare treatment options. It limits the number of web forms presented to a user to between 1 and 20, rather than the dozens of detailed calculations typically required. The WebModel uses responsive design and can be used on multiple devices. To test the WebModel, we designed a questionnaire to probe the efficacy of the WebModel and assess the usability and usefulness of the system. The study was live for one month, and participants had access to it over that time. The questionnaire was administered online, and data from 674 clinical users who had access to the WebModel were captured. SPSS and R were used for statistical analysis. RESULTS: The regression model developed from UTAUT2 constructs was a fit. Specifically, five of the seven factors were significant positive coefficients in the regression: performance expectancy (ß=.2730; t=7.994; P<.001), effort expectancy (ß=.1473; t=3.870; P=.001), facilitating conditions (ß=.1644; t=3.849; P<.001), hedonic motivation (ß=.2321; t=3.991; P<.001), and habit (ß=.2943; t=12.732). Social influence was not a significant factor, while price value had a significant negative influence on intention to use the WebModel. CONCLUSIONS: Our results indicate that multiple influences impact positive response to the system, many of which relate to the efficiency of the interface to provide clear information. Although we found that the price value was a negative factor, it is possible this was due to the removal of health workers from purchasing decisions. Given that this was a pilot test, and that the system was not used in a clinical setting, we could not examine factors related to actual workflow, patient safety, or social influence. This study shows that the concept of a simplified WebModel could be effective and efficient in reducing information overload in complex clinical decision making. We recommend further study to test this in a clinical setting and gather qualitative data from users regarding the value of the tool in practice.

Pharmacological Treatments for Neonatal Abstinence Syndrome: A Systematic Review and Network Meta-analysis.

Importance: Incidence of neonatal abstinence syndrome is rising rapidly, and optimal pharmacotherapy may meaningfully reduce length of treatment. Objective: To compare pharmacological therapies for neonatal abstinence syndrome. Data Sources: Systematic review and network meta-analysis of Medline (1946-June 2018), Embase (1974-June 2018), Cochrane CENTRAL (1966-June 2018), Web of Science (1900-June 2018), and ClinicalTrials.gov (June 2018). Study Selection: Randomized clinical trials of pharmacological treatments for neonatal abstinence syndrome alone or in combination with adjuvant treatments. Abstract, title, and full-text screening were conducted independently by 2 reviewers (T.D. and C.G.). Data Extraction and Synthesis: Data extraction was conducted independently by 2 reviewers (T.D. and C.G.) according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)-Network Meta-Analyses guidelines. Quality was assessed with the Cochrane Risk of Bias tool and data were pooled with fixed-effect models as a result of the low number of trials that were included in the analysis. Main Outcomes and Measures: The primary outcome was the length of treatment. The length of stay, need for adjuvant therapy, and adverse events were considered as secondary outcomes. Results: Eighteen trials (N = 1072) were eligible for inclusion. The treatments that were included in the length of treatment analysis were buprenorphine, clonidine, diluted tincture of opium and clonidine, diluted tincture of opium, morphine, methadone, and phenobarbital. Sublingual buprenorphine was considered the optimal treatment for a reduction in the length of treatment (days: mean difference vs morphine, -12.75 [95% CI, -17.97 to -7.58]; median rank, 1 [3-1]) and length of stay (days: mean difference vs morphine, -11.43 [95% CI, -16.95 to -5.82]; median rank, 1 [3-1]) but not the need for adjuvant treatment (odds ratio vs morphine, 1.23 [95% CI, 0.46-3.44]; median rank, 3 [5-1]). The results were robust to bias but sensitive to imprecision. Conclusions and Relevance: The current evidence suggests that buprenorphine is the optimal treatment for neonatal abstinence treatment, but limitations are considerable and wide-scale adoption requires a large multisite trial. Morphine, which is considered standard of care in most hospitals, was the lowest-ranked opioid for length of treatment and length of stay.