Integrating training in evidence-based medicine and shared decision-making: a qualitative study of junior doctors and consultants.

BACKGROUND: In the past, evidence-based medicine (EBM) and shared decision-making (SDM) have been taught separately in health sciences and medical education. However, recognition is increasing of the importance of EBM training that includes SDM, whereby practitioners incorporate all steps of EBM, including person-centered decision-making using SDM. However, there are few empirical investigations into the benefits of training that integrates EBM and SDM (EBM-SDM) for junior doctors, and their influencing factors. This study aimed to explore how integrated EBM-SDM training can influence junior doctors' attitudes to and practice of EBM and SDM; to identify the barriers and facilitators associated with junior doctors' EBM-SDM learning and practice; and to examine how supervising consultants' attitudes and authority impact on junior doctors' opportunities for EBM-SDM learning and practice. METHODS: We developed and ran a series of EBM-SDM courses for junior doctors within a private healthcare setting with protected time for educational activities. Using an emergent qualitative design, we first conducted pre- and post-course semi-structured interviews with 12 junior doctors and thematically analysed the influence of an EBM-SDM course on their attitudes and practice of both EBM and SDM, and the barriers and facilitators to the integrated learning and practice of EBM and SDM. Based on the responses of junior doctors, we then conducted interviews with ten of their supervising consultants and used a second thematic analysis to understand the influence of consultants on junior doctors' EBM-SDM learning and practice. RESULTS: Junior doctors appreciated EBM-SDM training that involved patient participation. After the training course, they intended to improve their skills in person-centered decision-making including SDM. However, junior doctors identified medical hierarchy, time factors, and lack of prior training as barriers to the learning and practice of EBM-SDM, whilst the private healthcare setting with protected learning time and supportive consultants were considered facilitators. Consultants had mixed attitudes towards EBM and SDM and varied perceptions of the role of junior doctors in either practice, both of which influenced the practice of junior doctors. CONCLUSIONS: These findings suggested that future medical education and research should include training that integrates EBM and SDM that acknowledges the complex environment in which this training must be put into practice, and considers strategies to overcome barriers to the implementation of EBM-SDM learning in practice.

Progress with the Learning Health System 2.0: a rapid review of Learning Health Systems' responses to pandemics and climate change.

BACKGROUND: Pandemics and climate change each challenge health systems through increasing numbers and new types of patients. To adapt to these challenges, leading health systems have embraced a Learning Health System (LHS) approach, aiming to increase the efficiency with which data is translated into actionable knowledge. This rapid review sought to determine how these health systems have used LHS frameworks to both address the challenges posed by the COVID-19 pandemic and climate change, and to prepare for future disturbances, and thus transition towards the LHS2.0. METHODS: Three databases (Embase, Scopus, and PubMed) were searched for peer-reviewed literature published in English in the five years to March 2023. Publications were included if they described a real-world LHS's response to one or more of the following: the COVID-19 pandemic, future pandemics, current climate events, future climate change events. Data were extracted and thematically analyzed using the five dimensions of the Institute of Medicine/Zurynski-Braithwaite's LHS framework: Science and Informatics, Patient-Clinician Partnerships, Continuous Learning Culture, Incentives, and Structure and Governance. RESULTS: The search yielded 182 unique publications, four of which reported on LHSs and climate change. Backward citation tracking yielded 13 additional pandemic-related publications. None of the climate change-related papers met the inclusion criteria. Thirty-two publications were included after full-text review. Most were case studies (n = 12, 38%), narrative descriptions (n = 9, 28%) or empirical studies (n = 9, 28%). Science and Informatics (n = 31, 97%), Continuous Learning Culture (n = 26, 81%), Structure and Governance (n = 23, 72%) were the most frequently discussed LHS dimensions. Incentives (n = 21, 66%) and Patient-Clinician Partnerships (n = 18, 56%) received less attention. Twenty-nine papers (91%) discussed benefits or opportunities created by pandemics to furthering the development of an LHS, compared to 22 papers (69%) that discussed challenges. CONCLUSIONS: An LHS 2.0 approach appears well-suited to responding to the rapidly changing and uncertain conditions of a pandemic, and, by extension, to preparing health systems for the effects of climate change. LHSs that embrace a continuous learning culture can inform patient care, public policy, and public messaging, and those that wisely use IT systems for decision-making can more readily enact surveillance systems for future pandemics and climate change-related events. TRIAL REGISTRATION: PROSPERO pre-registration: CRD42023408896.

Integrated Care in Epilepsy Management: A Scoping Review of the Models and Components of Health and Social Care Delivery.

Introduction: Epilepsy is the most common neurological condition globally. Integrating health and social care is fundamental in epilepsy management, but the scope of progress in this area is unclear. This scoping review aimed to capture the range and type of integrated care components and models in epilepsy management. Methods: Four databases were searched for articles published since 2010 that reported on integrated care in epilepsy. Data were extracted and synthesised into components of integrated care that had been implemented or recommended only. Models of integrated care were identified, and their components tabulated. Results: Fifteen common and interrelated components of integrated care emerged that were aligned with four broad areas: healthcare staff and pathways (e.g., epilepsy nurses); tasks and services (e.g., care coordination); education and engagement (e.g., shared decision making); and technology for diagnosis and communication (e.g., telehealth). Twelve models of integrated care were identified; seven were implemented and five were recommended. Discussion: There is a growing evidence-base supporting integrated, person-centred epilepsy care, but implementation is challenged by entrenched silos, underdeveloped pathways for care, and deficits in epilepsy education. Conclusion: Integrating epilepsy care relies on changes to workforce development and policy frameworks to support whole-of-system vision for improving care.

Intervention Programs Targeting the Mental Health, Professional Burnout, and/or Wellbeing of School Teachers: Systematic Review and Meta-Analyses.

This paper outlines a systematic review and meta-analyses to identify, describe, and evaluate randomised and non-randomised controlled trials of psychological programs targeting the mental health, professional burnout, and/or wellbeing of school classroom teachers. Eighty-eight unique studies were identified for inclusion in the review, and of those 46 were included in the meta-analyses (23 randomised controlled trials). In randomised controlled trials, the programs examined had large effects on stress (g=0.93), and moderate effects on anxiety (g=0.65), depression (g=0.51), professional burnout (g=0.57), and wellbeing (g=0.56) at post. In non-randomised controlled trials, programs had moderate effects on stress (g=0.50), and small effects on anxiety (g=0.38) and wellbeing (g=0.38) at post. Studies were heterogeneous in design and methodological quality was generally poor, particularly in non-randomised controlled trials. There was an inadequate number of comparisons to perform sub-group analyses, meta-regression, or publication bias analyses. Most of the programs examined required significant time, effort, and resources to deliver and complete. These programs may not translate well outside of research trials to real-world contexts due to teachers being time-poor. Priorities for research include using methodologically rigorous designs, developing programs for teachers with teachers (i.e. co-design), and considering implementation factors to ensure feasibility, acceptability, and uptake. Systematic Review Registration Number: PROPSERO - CRD42020159805. Supplementary Information: The online version contains supplementary material available at 10.1007/s10648-023-09720-w.

The effects of a sleep-focused smartphone application on insomnia and depressive symptoms: a randomised controlled trial and mediation analysis.

BACKGROUND: Rates of depression are increasing among adolescents. A novel way to reduce depression is by improving sleep. We evaluated whether an app-based intervention for insomnia improved sleep and depression, and whether changes in insomnia mediated changes in depression. METHODS: We conducted a 2-arm single-blind randomised controlled trial at the Black Dog Institute in Australia. Adolescents 12-16 years experiencing insomnia symptoms were randomly allocated to receive Sleep Ninja, an app-delivered cognitive behavioural therapy program for insomnia, or to an active control group involving weekly text message sleep tips. Assessments took place at baseline, 6 weeks (post-intervention) and 14 weeks (post-baseline). Co-primary outcomes were symptoms of insomnia and depression at post-intervention (primary endpoint). Intent-to-treat analyses were conducted. The trial is registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12619001462178. RESULTS: Between October 25, 2019, and September 6, 2020, 264 participants were randomised to receive Sleep Ninja (n = 131) or to the control group (n = 133). Relative to the control group, those allocated to the intervention reported a greater reduction in insomnia symptoms at 6 weeks (95% CI: -2.96 to -0.41, d = .41) and 14 weeks (95% CI: -3.34 to -0.19, d = .39), and a greater reduction in depression symptoms at 6 weeks (95% CI: -3.46 to -0.56, d = .28) but not 14 weeks (p < 1). Change in insomnia mediated change in depression. No adverse events were reported. CONCLUSIONS: An app-delivered program for insomnia could be a practical, non-stigmatising and scalable way to reduce symptoms of insomnia and depression among adolescents experiencing difficulties getting enough good quality sleep.

Measuring the quality of skin cancer management in primary care: A scoping review.

Skin cancer is a growing global problem and a significant health and economic burden. Despite the practical necessity for skin cancer to be managed in primary care settings, little is known about how quality of care is or should be measured in this setting. This scoping review aimed to capture the breadth and range of contemporary evidence related to the measurement of quality in skin cancer management in primary care settings. Six databases were searched for relevant texts reporting on quality measurement in primary care skin cancer management. Data from 46 texts published since 2011 were extracted, and quality measures were catalogued according to the three domains of the Donabedian model of healthcare quality (structure, process and outcome). Quality measures within each domain were inductively analysed into 13 key emergent groups. These represented what were deemed to be the most relevant components of skin cancer management as related to structure, process or outcomes measurement. Four groups related to the structural elements of care provision (e.g. diagnostic tools and equipment), five related to the process of care delivery (e.g. diagnostic processes) and four related to the outcomes of care (e.g. poor treatment outcomes). A broad range of quality measures have been documented, based predominantly on articles using retrospective cohort designs; systematic reviews and randomised controlled trials were limited.

School-based depression and anxiety prevention programs: An updated systematic review and meta-analysis.

Depression and anxiety are often first experienced during childhood and adolescence, and interest in the prevention of these disorders is growing. The focus of this review was to assess the effectiveness of psychological prevention programs delivered in schools, and to provide an update to our previous review from five years ago (Werner-Seidler, Perry, Calear, Newby, & Christensen, 2017). Three electronic databases were systematically searched for published articles of randomised controlled trials (RCTs) evaluating the efficacy of school-based prevention programs until October 2020. There were 130 articles that met inclusion criteria, representing 118 unique trials and 45,924 participants. Small between-group effect sizes for depression (g = 0.21) and anxiety (g = 0.18) were detected immediately post-intervention. Subgroup analyses suggested that targeted prevention programs (for young people with risk factors or symptoms) were associated with significantly greater effect sizes relative to universal programs for depression, which was confirmed by meta-regression. There was also some evidence that external providers conferred some benefit over school-staff delivered programs. Overall, study quality was moderate and no association between risk of bias and effect size was detected. School-delivered psychological prevention programs have small effects in reducing symptoms of depression and anxiety. Refinement of these programs, and knowledge about how they can be sustainably delivered in schools beyond the trial period is now needed for population-level preventive effects. Systematic Review Registration Number: PROPSERO - CRD42020188323.

Hunger, taste, and normative cues in predictions about food intake.

Normative eating cues (portion size, social factors) have a powerful impact on people's food intake, but people often fail to acknowledge the influence of these cues, instead explaining their food intake in terms of internal (hunger) or sensory (taste) cues. This study examined whether the same biases apply when making predictions about how much food a person would eat. Participants (n = 364) read a series of vignettes describing an eating scenario and predicted how much food the target person would eat in each situation. Some scenarios consisted of a single eating cue (hunger, taste, or a normative cue) that would be expected to increase intake (e.g., high hunger) or decrease intake (e.g., a companion who eats very little). Other scenarios combined two cues that were in conflict with one another (e.g., high hunger + a companion who eats very little). In the cue-conflict scenarios involving an inhibitory internal/sensory cue (e.g., low hunger) with an augmenting normative cue (e.g., a companion who eats a lot), participants predicted a low level of food intake, suggesting a bias toward the internal/sensory cue. For scenarios involving an augmenting internal/sensory cue (e.g., high hunger) and an inhibitory normative cue (e.g., a companion who eats very little), participants predicted an intermediate level of food intake, suggesting that they were influenced by both the internal/sensory and normative cue. Overall, predictions about food intake tend to reflect a general bias toward internal/sensory cues, but also include normative cues when those cues are inhibitory. If people are systematically biased toward internal, sensory, and inhibitory cues, then they may underestimate how much food they or other people will eat in many situations, particularly when normative cues promoting eating are present.

Self-reported overeating and attributions for food intake.

OBJECTIVE: We examined whether people's attributions for their eating behaviour differ according to whether they believe they have eaten more, less or about the same as they normally would. DESIGN: Participants were served a small or large portion of pasta for lunch. Afterwards, they were asked to compare how much they ate in the study to how much they normally eat for lunch, resulting in three intake-evaluation categories: 'ate less', 'ate about the same' or 'ate more'. MAIN OUTCOME MEASURES: How much participants ate; the extent to which they attributed their food intake to an internal cue (i.e. hunger) and an external cue (i.e. the amount of food served). RESULTS: Participants served a large portion ate more than those served a small portion, but the magnitude of the portion-size effect did not vary across intake-evaluation categories. Furthermore, although participants in all groups indicated that their hunger influenced how much they ate, only those in the 'ate more' group indicated that the amount of food available influenced how much they ate. CONCLUSION: People appear to be willing to explain their food intake in terms of an external cue only when they believe that they have eaten more than they normally would.

Conflicting internal and external eating cues: Impact on food intake and attributions.

OBJECTIVE: Social factors have a powerful influence on people's food intake but people typically fail to acknowledge the influence of such external cues, instead explaining their food intake in terms of factors such as how hungry they are. We examined whether the tendency to explain one's food intake in terms of internal cues (i.e., hunger) rather than external cues (i.e., other people's behavior) would be apparent when those cues are in conflict with one another. METHOD: Female participants (n = 104) took part in a pizza taste test after having been food deprived for 18-hr or after consuming a meal-replacement preload. Half of the participants were also exposed to a social norm that conflicted with their deprivation condition: deprived participants were exposed to a low-intake norm, whereas preloaded participants were exposed to a high-intake norm. After completing the taste test, participants indicated the extent to which their food intake was influence by how hungry they were and how much other people ate. RESULTS: Deprived participants ate less when exposed to a low-intake norm than when no norm was present, but reported that the behaviors of others had no impact on their food intake. In contrast, preloaded participants did not eat significantly more when exposed to a high-intake norm, but reported that the behavior of others made them eat more. CONCLUSIONS: Participants are generally inaccurate in the attributions they make for their food intake, and we suggest that these inaccuracies may be because of motivated misreporting. (PsycINFO Database Record

Can serving-size labels reduce the portion-size effect? A pilot study.

Research has shown that the bigger the portion that people are served, the more food they eat; this phenomenon is referred to as the portion-size effect. Providing objective serving-size information on food products has been shown to reduce the influence of external food cues on people's eating behavior. The current study examined whether providing objective serving-size information would also reduce the portion-size effect. 100 female participants were served either a small or large portion of pizza in the context of a taste test. The large portion was either unlabeled, labeled as "Contains 2 servings," or labeled as "Contains 4 servings." Food intake was lower when the large portion was labeled "Contains 4 servings" compared to when it was labeled "Contains 2 servings." Moreover, participants' intake in the large portion/4 servings condition was statistically similar to the intake of participants in the small portion condition. Thus, the standard portion-size effect was observed when the large portion was unlabeled or was labeled as "Contains 2 servings," but not when the large portion was labeled as "Contains 4 servings". These findings suggest that providing serving-size information can reduce the portion-size effect, but that the specific content (and not just the presence) of serving-size information is important in determining food intake.

Failure to report social influences on food intake: Lack of awareness or motivated denial?

OBJECTIVE: Two studies examined whether people are aware of social influences on food intake, and whether recognition of those influences is driven by the observation of mimicked eating and/or matching the amount of food eaten. METHOD: In Study 1, participants watched a video of 1 person eating alone, or a video of 2 people eating together that varied in the extent to which the target's eating behavior mimicked or matched that of the model. Participants then made attributions for the eating behavior of the target person. In Study 2, each participant watched a video of herself eating with a confederate and made attributions for her own eating behavior. In both studies, the outcome of interest was the extent to which each participant acknowledged the influence of the model's eating behavior on the target's (or her own) food intake. RESULTS: In Study 1, participants accurately recognized social influences on the food intake of the target person, and this recognition was facilitated by the presence of mimicked eating, but not by matching the total amount eaten. Study 2 showed that the extent to which people acknowledge social influences on their own food intake depended on their self-reported general responsiveness to social cues on eating. CONCLUSION: Overall, people seem to be aware that social factors can influence others' food intake. Whereas some people (high social eaters) are able to accurately report social influences on their own food intake, others (low social eaters) seem to deny those influences for reasons that merit future investigation.