Implementing and evaluating shared decision making in oncology practice.

Engaging individuals with cancer in decision making about their treatments has received increased attention; shared decision making (SDM) has become a hallmark of patient-centered care. Although physicians indicate substantial interest in SDM, implementing SDM in cancer care is often complex; high levels of uncertainty may exist, and health care providers must help patients understand the potential risks versus benefits of different treatment options. However, patients who are more engaged in their health care decision making are more likely to experience confidence in and satisfaction with treatment decisions and increased trust in their providers. To implement SDM in oncology practice, physicians and other health care providers need to understand the components of SDM and the approaches to supporting and facilitating this process as part of cancer care. This review summarizes recent information regarding patient and physician factors that influence SDM for cancer care, outcomes resulting from successful SDM, and strategies for implementing SDM in oncology practice. We present a conceptual model illustrating the components of SDM in cancer care and provide recommendations for facilitating SDM in oncology practice.

Folic Acid Supplementation for the Prevention of Neural Tube Defects: An Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Neural tube defects are among the most common congenital anomalies in the United States. Periconceptional folic acid supplementation is a primary care-relevant preventive intervention. Objective: To review the evidence on folic acid supplementation for preventing neural tube defects to inform the US Preventive Services Task Force for an updated Recommendation Statement. Data Sources: MEDLINE, Cochrane Library, EMBASE, and trial registries through January 28, 2016, with ongoing surveillance through November 11, 2016; references; experts. Study Selection: English-language studies of folic acid supplementation in women. Excluded were poor-quality studies; studies of prepubertal girls, men, women without the potential for childbearing, and neural tube defect recurrence; and studies conducted in developing countries. Data Extraction and Synthesis: Two investigators independently reviewed abstracts, full-text articles, and risk of bias of included studies. One investigator extracted data and a second checked accuracy. Because of heterogeneity, data were not pooled. Main Outcomes and Measures: Neural tube defects, harms of treatment (twinning, respiratory outcomes). Results: A total of 24 studies (N > 58 860) were included. In 1 randomized clinical trial from Hungary initiated in 1984, incidence of neural tube defects for folic acid supplementation compared with trace element supplementation was 0% vs 0.25% (Peto odds ratio [OR], 0.13 [95% CI, 0.03-0.65]; n = 4862). Odds ratios from cohort studies recruiting participants between 1984 and 1996 demonstrated beneficial associations and ranged from 0.11 to 0.27 (n = 19 982). Three of 4 case-control studies with data from 1976 through 1998 reported ORs ranging from 0.6 to 0.7 (n > 7121). Evidence of benefit led to food fortification in the United States beginning in 1998, after which no new prospective studies have been conducted. More recent case-control studies drawing from data collected after 1998 have not demonstrated a protective association consistently with folic acid supplementation, with ORs ranging from 0.93 to 1.4 and confidence intervals spanning the null (n > 13 990). Regarding harms, 1 trial (OR, 1.40 [95% CI, 0.89-2.21]; n = 4767) and 1 cohort study (OR, 1.04 [95% CI, 0.91-1.18]; n = 2620) found no statistically significant increased risk of twinning. Three systematic reviews found no consistent evidence of increased risk of asthma (OR, 1.06 [95% CI, 0.99-1.14]; n = 14 438), wheezing, or allergy. Conclusions and Relevance: In studies conducted before the initiation of food fortification in the United States in 1998, folic acid supplementation provided protection against neural tube defects. Newer postfortification studies have not demonstrated a protective association but have the potential for misclassification and recall bias, which can attenuate the measured association of folic acid supplementation with neural tube defects.

The rationale for patient-reported outcomes surveillance in cancer and a reproducible method for achieving it.

Patient-reported outcomes (PROs) measure quality of life, symptoms, patient functioning, and patient perceptions of care; they are essential for gaining a full understanding of cancer care and the impact of cancer on people's lives. Repeatedly captured facility-level and/or population-level PROs (PRO surveillance) could play an important role in quality monitoring and improvement, benchmarking, advocacy, policy making, and research. This article describes the rationale for PRO surveillance and the methods of the Patient Reported Outcomes Symptoms and Side Effects Study (PROSSES), which is the first PRO study to use the American College of Surgeons Commission on Cancer's Rapid Quality Reporting System to identify patients and manage study data flow. The American Cancer Society, the National Cancer Institute, the Commission on Cancer, and RTI International collaborated on PROSSES. PROSSES was conducted at 17 cancer programs that participated in the National Cancer Institute Community Cancer Centers Program among patients diagnosed with locoregional breast or colon cancer. The methods piloted in PROSSES were successful as demonstrated by high eligibility (93%) and response (61%) rates. Differences in clinical and demographic characteristics between respondents and nonrespondents were mostly negligible, with the exception that non-white individuals were somewhat less likely to respond. These methods were consistent across cancer centers and reproducible over time. If repeated and expanded, they could provide PRO surveillance data from patients with cancer on a national scale.

Perceived Impact of Incentives for Chronic Disease Prevention.

INTRODUCTION: This study evaluates the effect of program and incentive characteristics on satisfaction with incentives and perceived impact of incentives on behavior change among Medicaid beneficiaries who participated in the Centers for Medicare and Medicaid Services Medicaid Incentives for Prevention of Chronic Diseases program. METHODS: In 2014-2015, an English- and Spanish-language survey was administered to Medicaid Incentives for Prevention of Chronic Diseases program participants about their satisfaction with incentives and perceived impact of incentives. Completed surveys were received from 2,276 eligible sample members (response rate=52.7%). In 2016-2017, multilevel, multivariable, ordinal logistic regression models were performed to examine program characteristics that predict outcomes, while controlling for respondent characteristics. RESULTS: Medicaid Incentives for Prevention of Chronic Diseases participants were satisfied with program incentives. Most survey respondents strongly agreed that they liked getting incentives for taking care of their health (78%), they were happy with the incentives overall (75%), the incentives were fair (73%), and they liked how often they received incentives (67%). Participants in programs delivered by telephone reported higher satisfaction with incentives compared with those in programs delivered in person. However, participants in programs delivered both in person and by telephone were more likely to perceive a positive impact of incentives. Incentive form was a significant predictor of satisfaction with incentives but not of incentive impact. Dollar amount of incentives influenced satisfaction with incentives and impact of incentives. CONCLUSIONS: Program delivery method, incentive form, and incentive magnitude are important characteristics to consider when designing incentive programs. Incentive programs can consider providing modest incentive amounts to achieve self-reported impact on behavior change.

Participant Satisfaction and Perceptions About Program Impact in the Medicaid Incentives for Prevention of Chronic Disease Pilot Program.

PURPOSE: Evaluate the Centers for Medicare & Medicaid Incentives for Prevention of Chronic Diseases (MIPCD) program in terms of participant satisfaction and self-reported program impact. DESIGN: Participant survey (mail/telephone follow-up), English and Spanish (N = 2274). SETTINGS: Ten states in MIPCD program. PARTICIPANTS: Medicaid beneficiaries. INTERVENTION: Incentive-based health promotion programs targeting diabetes prevention and management, smoking cessation, and weight, hypertension, and cholesterol management. MEASURES: Dependent measures are (1) overall program satisfaction and (2) self-reported program impact, operationalized as whether program helped with understanding health issues, learning ways to take care of health, and encouraging healthy lifestyle changes. ANALYSIS: Multilevel multivariable ordinal logistic regression models to identify predictors of overall program satisfaction and program impact. RESULTS: Sixty-seven percent were very satisfied with the program, and 76% strongly agreed the program encouraged healthy lifestyle changes. Age (59+ vs <45 years) and being female predicted overall program satisfaction. Satisfaction with specific aspects of the program including communication with staff, accessibility, and incentives predicted higher overall satisfaction. Age (45-52 vs <45 years) and being black or Hispanic predicted higher program impact. Points redeemable for rewards performed worse than money-valued incentives in terms of encouraging lifestyle changes (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.11-0.82). Participants receiving incentives valued at $25 to <$100 were more likely to report higher agreement that the program helped them learn ways to care for their health (OR, 1.72; 95% CI, 1.21-2.44) and encouraged lifestyle changes (OR, 1.46; 95% CI, 1.02-2.10), compared to participants receiving incentives valued at $0 to <$25. Incentives valued at $100 to <$400 predicted higher agreement that the program helped with understanding of health issues (OR, 1.62; 95% CI, 1.13-2.33), compared to incentives valued at $0 to <$25. CONCLUSION: Effective chronic disease prevention programs are needed for Medicaid populations. Study findings highlight important considerations for incentive-based programs.