Health technology assessment in traditional and complementary medicine: a scoping review of international activity and examples of acupuncture.

BACKGROUND: Traditional therapies are crucial in maintaining and improving human well-being. China's healthcare policymakers are attempting to use health technology assessment (HTA) as a decision-making supportive tool. The value assessment framework for Chinese patent medicine (CPM) has been developed and is being adopted and validated widely by research institutions. Subsequently, the healthcare decision-makers particularly hanker for the value framework of traditional non-pharmacological therapies. METHODS: To construct a practical value framework for traditional non-pharmacological therapies, a scoping review methodology was adopted to identify the evaluation domains and obstacles. A search, screening, and analysis process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Evidence was retrieved from scientific databases and HTA agencies' websites. RESULTS: The search strategy identified 5 guidelines records and 17 acupuncture HTA reports. By synthesizing the valuable reports of CPM and acupuncture evaluation in representative countries, this study found that Mainland China was promoting the comprehensive value assessment of CPM, whereas the United Kingdom, Singapore, Canada, the United States, and Malaysia had carried out the HTA evaluation of acupuncture for various conditions among which chronic pain was the most common. UK and Singapore applied the HTA results to support acupuncture reimbursement decisions. Three domains, including safety, effectiveness, and economy, were commonly adopted. The identified biggest challenge of evaluating traditional non-pharmacological therapies is the scarce high-quality clinical evidence. CONCLUSIONS: This study identified value domains and issues of traditional therapies, and pointed out future research implications, to promote the development value framework of traditional therapies.

A qualitative evaluation of factors influencing Tumor Treating fields (TTFields) therapy decision making among brain tumor patients and physicians.

BACKGROUND: Tumor Treating Fields (TTFields) Therapy is an FDA-approved therapy in the first line and recurrent setting for glioblastoma. Despite Phase 3 evidence showing improved survival with TTFields, it is not uniformly utilized. We aimed to examine patient and clinician views of TTFields and factors shaping utilization of TTFields through a unique research partnership with medical neuro oncology and medical social sciences. METHODS: Adult glioblastoma patients who were offered TTFields at a tertiary care academic hospital were invited to participate in a semi-structured interview about their decision to use or not use TTFields. Clinicians who prescribe TTFields were invited to participate in a semi-structured interview about TTFields. RESULTS: Interviews were completed with 40 patients with a mean age of 53 years; 92.5% were white and 60% were male. Participants who decided against TTFields stated that head shaving, appearing sick, and inconvenience of wearing/carrying the device most influenced their decision. The most influential factors for use of TTFields were the efficacy of the device and their clinician's opinion. Clinicians (N = 9) stated that TTFields was a good option for glioblastoma patients, but some noted that their patients should consider the burdens and benefits of TTFields as it may not be the desired choice for all patients. CONCLUSIONS: This is the first study to examine patient decision making for TTFields. Findings suggest that clinician support and efficacy data are among the key decision-making factors. Properly understanding the path to patients' decision making is crucial in optimizing the use of TTFields and other therapeutic decisions for glioblastoma patients.

Challenges Addressing Lung Cancer Screening for Patients With Multimorbidity in Primary Care: A Qualitative Study.

PURPOSE: Many individuals who are eligible for lung cancer screening have comorbid conditions complicating their shared decision-making conversations with physicians. The goal of our study was to better understand how primary care physicians (PCPs) factor comorbidities into their evaluation of the risks and benefits of lung cancer screening and into their shared decision-making conversations with patients. METHODS: We conducted semistructured interviews by videoconference with 15 PCPs to assess the extent of shared decision-making practices and explore their understanding of the intersection of comorbidities and lung cancer screening, and how that understanding informed their clinical approach to this population. RESULTS: We identified 3 themes. The first theme was whether to discuss or not to discuss lung cancer screening. PCPs described taking additional steps for individuals with complex comorbidities to decide whether to initiate this discussion and used subjective clinical judgment to decide whether the conversation would be productive and beneficial. PCPs made mental assessments that factored in the patient's health, life expectancy, quality of life, and access to support systems. The second theme was that shared decision making is not a simple discussion. When PCPs did initiate discussions about lung cancer screening, although some believed they could provide objective information, others struggled with personal biases. The third theme was that ultimately, the decision to be screened was up to the patient. Patients had the final say, even if their decision was discordant with the PCP's advice. CONCLUSIONS: Shared decision-making conversations about lung cancer screening differed substantially from the standard for patients with complex comorbidities. Future research should include efforts to characterize the risks and benefits of LCS in patients with comorbidities to inform guidelines and clinical application.

Why Health-enhancing Nudges Fail.

Nudges are means to influence the will formation of people to make specific choices more likely. My focus is on nudges that are supposed to improve the health condition of individuals and populations over and above the direct prevention of disease. I point out epistemic and moral problems with these types of nudges, which lead to my conclusion that health-enhancing nudges fail. They fail because we cannot know which choices enhance individual health-properly understood in a holistic way-and because health-enhancing nudges are often themselves bad for our health. They can be bad for our health because they assume inferior agency in their targets and accordingly regularly lead to appropriate resentment and anger-strong emotions which go along with an increased risk of health impairments. Briefly, health-enhancing nudges fail because they are based on persistent ignorance and on a presumptuous attitude.

Development and Validation of a Preoperative Nomogram for Endoscopic Management Decision Making in Upper Urinary Tract Urothelial Carcinoma.

OBJECTIVE: We aimed to develop and validate a preoperative nomogram that predicts low-grade, non-muscle invasive upper urinary tract urothelial carcinoma (LG-NMI UTUC), thereby aiding in the accurate selection of endoscopic management (EM) candidates. METHODS: This was a retrospective study that included 454 patients who underwent radical surgery (Cohort 1 and Cohort 2), and 26 patients who received EM (Cohort 3). Utilizing a multivariate logistic regression model, a nomogram predicting LG-NMI UTUC was developed based on data from Cohort 1. The nomogram's accuracy was compared with conventional European Association of Urology (EAU) and National Comprehensive Cancer Network (NCCN) models. External validation was performed using Cohort 2 data, and the nomogram's prognostic value was evaluated via disease progression metrics in Cohort 3. RESULTS: In Cohort 1, multivariate analyses highlighted the absence of invasive disease on imaging (odds ratio [OR] 7.04; p = 0.011), absence of hydronephrosis (OR 2.06; p = 0.027), papillary architecture (OR 24.9; p < 0.001), and lack of high-grade urine cytology (OR 0.22; p < 0.001) as independent predictive factors for LG-NMI disease. The nomogram outperformed the two conventional models in predictive accuracy (0.869 vs. 0.759-0.821) and exhibited a higher net benefit in decision curve analysis. The model's clinical efficacy was corroborated in Cohort 2. Moreover, the nomogram stratified disease progression-free survival rates in Cohort 3. CONCLUSION: Our nomogram ( https://kmur.shinyapps.io/UTUC_URS/ ) accurately predicts LG-NMI UTUC, thereby identifying suitable candidates for EM. Additionally, the model serves as a useful tool for prognostic stratification in patients undergoing EM.

A spatial optimal allocation method considering multi-attribute decision making and multiple BMPs random combination in sub-watersheds.

Best management practices (BMPs) have been extensively employed in effective watershed management for non-point source pollution. The weights of objective functions and the restrictive conditions of combined BMPs are the vital requirements for BMPs allocation. Therefore, it is more beneficial to explore that a spatial optimal allocation method considering multi-attribute decision making and multiple BMPs random combination. Here is the novel framework based on Soil and Water Assessment Tool (SWAT) and the Non-dominated Sorting Genetic Algorithm II (NSGA-Ⅱ), which considers multiple objectives in deriving watershed-scale pollution control practices by considering BMPs cost and combined reduction rates of total nitrogen (TN) and total phosphorus (TP). The framework also integrates combined Entropy Weight method (EWM) and Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) to solve the weights of TN and TP, and considers the attributes of the sub-basin itself, which is more local suitability. Four categories of BMPs, tillage management, nutrient management, vegetative filter strips, and landscape management, were evaluated in the Jing River Basin (JRB) and resulted in reduction rates of 9.77%, 10.53%, 16.40%, and 14.27% averagely, respectively. BMP allocation schemes, derived from multi-objective optimization, are stratified into three financial scenarios. Low-cost scenario, costing up to 2 billion RMB, primarily targets the grain for green program in 28.81% of sub-basins. Medium-cost scenario, between 2 and 6 billion RMB, predominantly utilizes the grain for green in areas with a slope greater than 15°, accounting for 20.00% of sub-basins. High-cost scenario exceeds 6 billion RMB, mainly due to the implementation of multiple combination measures. The three configuration scenarios can provide decision-makers with a trade-off between measure costs and reduction efficiency. Overall, the innovative framework not only facilitates cost-effective implementation but provides a beneficial methodology for selecting cost-effective conservation practices in other regions.

An analysis of legislation and policies that guide maternity leave decision making in Australian midwifery students.

Objective There are no guidelines to assist midwifery academics or students in determining the optimal time to return to their educational programs following pregnancy. Rather, students need to navigate balancing new motherhood with the pressures of returning to their clinical midwifery placement and completing their statutory requirements to meet the Australian Midwife Accreditation Standards before the end of their program. The aim of this study was to seek best practice information that provides guidance to academics supporting midwifery students returning to study after maternity leave. Methods An analysis of contemporary Australian legislation, workforce guidelines, professional association statements, and university policies was undertaken to determine what guidance is available to assist midwifery academics in providing advice to midwifery students about the optimal time to return to their studies following birth. This document analysis was performed during 2021-2022 and followed Altheide and Schneider's 12 step process divided into five stages to clarify best practice advice for midwifery academics to provide guidance to students returning to study after maternity leave. Results Policy documents that refer to pregnancy confirm women have legal rights, and there is clear guidance on maternity leave; however, advice for midwifery students on the optimum time to return to study and clinical placements after birth is missing from the result of this document analysis search. Conclusion Transition to motherhood during the postnatal period is an important time. Clear national guidelines are needed to provide support and recommendations regarding a safe and optimal time to return to study and placement.

Using an Adapted Tumor Board Evaluation Tool for Quality Assessment of a Thoracic Multidisciplinary Cancer Conference: A Pilot Study.

PURPOSE: Multidisciplinary cancer conferences (MCCs) are crucial for the management of complex oncology patients. Tools to evaluate MCC performance are needed. The aim of this pilot study was to assess the applicability of an existing validated performance assessment tool to evaluate the quality of thoracic MCCs (T-MCCs). METHODS: Data were collected from weekly T-MCCs over a 5-week period using the MCC Performance Assessment Tool and a self-assessment survey. Audio recordings were used to supplement observation notes. Case presentation, discussion duration, decision making contribution, recommendations, and consensus were captured. Quality of information and contribution were rated on a 1-5 scale. The data were analyzed using descriptive statistics to calculate means and composite scores representing overall MCC performance. RESULTS: A total of 44 cases were observed at the T-MCC with the mean presentation and discussion time of 6 minutes and 22 seconds. Quality of case history, radiologic and pathological information, and reason for case discussion were rated above average (>3), whereas inclusion of comorbidities and patient views were rated below average. Surgical oncologists had a higher discussion contribution compared with medical and radiation oncologists (3.6 v 2.9 and 2.4, respectively). The overall mean composite score was 55.9 (deemed average) with no cases categorized as poor or excellent. Radiologists and pathologists had mean preparation times of 81.7 and 144.0 minutes, respectively. CONCLUSION: This study demonstrated the applicability of a previously validated tool to assess the quality of a T-MCC at an academic comprehensive cancer center. The tool was found to be useful in identifying elements of the T-MCC process that needed improvement.

Competing neural representations of choice shape evidence accumulation in humans.

Making adaptive choices in dynamic environments requires flexible decision policies. Previously, we showed how shifts in outcome contingency change the evidence accumulation process that determines decision policies. Using in silico experiments to generate predictions, here we show how the cortico-basal ganglia-thalamic (CBGT) circuits can feasibly implement shifts in decision policies. When action contingencies change, dopaminergic plasticity redirects the balance of power, both within and between action representations, to divert the flow of evidence from one option to another. When competition between action representations is highest, the rate of evidence accumulation is the lowest. This prediction was validated in in vivo experiments on human participants, using fMRI, which showed that (1) evoked hemodynamic responses can reliably predict trial-wise choices and (2) competition between action representations, measured using a classifier model, tracked with changes in the rate of evidence accumulation. These results paint a holistic picture of how CBGT circuits manage and adapt the evidence accumulation process in mammals.

Red Blood Cell Transfusion: 2023 AABB International Guidelines.

Importance: Red blood cell transfusion is a common medical intervention with benefits and harms. Objective: To provide recommendations for use of red blood cell transfusion in adults and children. Evidence Review: Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed. Findings: For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence). Conclusions and Relevance: It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.

Piloting a shared decision-making clinician training intervention in maternity care in Australia: A mixed methods study.

PROBLEM: Implementation of woman-centred care in evidence-based maternity practice requires clinicians to be skilled in shared decision-making, yet there is limited training or research into such interventions. BACKGROUND: Shared decision-making enables women to make informed decisions in partnership with clinicians where there are varied clinical options in relation to indications for and timing of planned birth. AIM: We aimed to develop a shared decision-making training intervention and evaluate its feasibility and acceptability to midwives and obstetricians. METHODS: The intervention was co-designed by midwifery and medical clinician-researchers, and a consumer representative. Online training and demonstration videos were distributed to midwives and obstetricians in three Sydney hospitals, followed by two online workshops in 2021 and 2022 where participants practised shared decision-making in roleplaying scenarios tailored to timing of birth. Training was evaluated using post-workshop and post-training surveys and semi-structured qualitative interviews. FINDINGS: The training workshop format, duration and content were well received. Barriers to the uptake of shared decision-making were time, paternalistic practices and fear of repercussions of centring women in the decision-making process. DISCUSSION: The intervention enabled midwifery and medical colleagues to learn communication repertoires from each other in woman-centred discussions around timing of birth. Roleplay scenarios enabled participants to observe and provide feedback on their colleagues' shared decision-making practices, while providing a space for collective reflection on ways to promote, and mitigate barriers to, its implementation in practice. CONCLUSION: Shared decision-making training supports maternity clinicians in developing skills that implement woman-centred care in the timing of planned birth.

Understanding triage assessment of acuity by emergency nurses at initial adult patient presentation: A qualitative systematic review.

BACKGROUND: Nurses make complex triage decisions within emergency departments, which significantly affect patient outcomes. Understanding how nurses make these decisions and why they deviate from triage algorithms facilitates interventions that work with their decision-making processes, increasing acceptability and effectiveness. AIMS: This qualitative systematic review aimed to understand decision-making processes emergency nurses use to make acuity decisions during triage assessment at initial patient presentation. METHODOLOGY: Medline, CINAHL and Academic Search Complete were systematically searched to 15th December 2022. Data were analysed using thematic synthesis. Established themes were reviewed with GRADE-CERQual to evaluate certainty of evidence. RESULTS: 28 studies were included in the review. Data analysis uncovered three superordinate themes of holistic reasoning, situational awareness, and informed decision-making. The findings show nurses value holistic assessments over algorithms and rely on knowledge and experience. They also assess the wider situation in the emergency department. CONCLUSIONS: This review presents new perspectives on nurses' decision-making processes about patient's acuity. Nurses holistically gather information about patients before translating that information into acuity scores. These actions are informed by their knowledge and experience; however, the wider situation also impacts their decisions. In turn, the nurses use interpretations of patients' acuity to control the wider situation.

The dependence and risk spillover between economic uncertainties and the crude oil market: new evidence from a Copula-CoVaR approach incorporating the decomposition technique.

Understanding the risk spillover of the oil market in economic uncertainty is of great importance. However, it is difficult to take on a traditional single perspective in describing the risk spillover law of economic uncertainty in the crude oil market on different timescales. In order to fill the research gap resulting from such difficulty, this paper incorporates empirical mode decomposition into the time-varying Copula-CoVaR model, and for the first time explores the risk spillover path of economic uncertainty on the two international crude oil pricing benchmarks-Brent and West Texas Intermediate crude oil prices-using different timescales. The empirical results not only verify the necessity of research from the perspective of different timescales, but also reveal the heterogeneity of the risk spillover paths of different types of economic uncertainty on crude oil prices. The research in this paper provides a multi-perspective interpretation for understanding the complex risk spillovers between various economic uncertainties and the crude oil market, as well as providing meaningful information to support stakeholders in making rational decisions.

From measures to action: can integrating quality measures provide system-wide insights for quality improvement decision making?

BACKGROUND: Quality improvement decision makers are left to develop an understanding of quality within their healthcare system from a deluge of narrowly focused measures that reflect existing fragmentation in care and lack a clear method for triggering improvement. A one-to-one metric-to-improvement strategy is intractable and leads to unintended consequences. Although composite measures have been used and their limitations noted in the literature, what remains unknown is 'Can integrating multiple quality measures provide a systemic understanding of care quality across a healthcare system?' METHODS: We devised a four-part data-driven analytic strategy to determine if consistent insights exist about the differential utilisation of end-of-life care using up to eight publicly available end-of-life cancer care quality measures across National Cancer Institute and National Comprehensive Cancer Network-designated cancer hospitals/centres. We performed 92 experiments that included 28 correlation analyses, 4 principal component analyses, 6 parallel coordinate analyses with agglomerative hierarchical clustering across hospitals and 54 parallel coordinate analyses with agglomerative hierarchical clustering within each hospital. RESULTS: Across 54 centres, integrating quality measures provided no consistent insights across different integration analyses. In other words, we could not integrate quality measures to describe how the underlying quality constructs of interest-intensive care unit (ICU) visits, emergency department (ED) visits, palliative care use, lack of hospice, recent hospice, use of life-sustaining therapy, chemotherapy and advance care planning-are used relative to each other across patients. Quality measure calculations lack interconnection information to construct a story that provides insights about where, when or what care is provided to which patients. And yet, we posit and discuss why administrative claims data-used to calculate quality measures-do contain such interconnection information. CONCLUSION: While integrating quality measures does not provide systemic information, new systemic mathematical constructs designed to convey interconnection information can be developed from the same administrative claims data to support quality improvement decision making.

Preventing and developmental factors of sustainability in healthcare organisations from the perspective of decision makers: an exploratory factor analysis.

BACKGROUND: UN Sustainable Development Goals are part of the political agenda of most developed countries. Being a developing country, Albania has only recently adhered to this trend. Prior research at national level has sporadically focused on environmental sustainability, neglecting a holistic view of the phenomenon. To fill this gap, this study aims to explore preventing and developmental factors of sustainability in healthcare organisations from the perspective of decision makers by relying to a Triple Bottom Line approach. METHODS: Data were collected through a questionnaire administered to healthcare facilities and analysed through the Exploratory Factor Analysis. Findings revealed that the factors influencing the sustainability of the national healthcare system were five: Barriers of Organisational Sustainability; Stakeholders Pressure (regarding sustainable issues); Awareness (knowledge and measures taken for sustainability); Institutional Engagement; and Personal Interest and Involvement. The underlying factors included 19 items suitable for this sample, representing 64.371% of the total variance. RESULTS: The findings show the existence of 4 factors: Barriers of Organisational Sustainability, Stakeholders Pressure regarding Sustainable issues, Awareness/knowledge and measures taken for sustainability, Personal Interest and Involvement. CONCLUSIONS: It is evident that national health organisations should continuously improve its strategies to be consistent with the sustainable development goals of international organisations, so that their initiatives could reflect the integration of sustainability approaches at the organisational level.

The role of critical care nurses in shared decision-making for patients with severe heart failure: A qualitative study.

AIM: Patients with severe heart failure undergo highly invasive and advanced therapies with uncertain treatment outcomes. For these patients, shared decision-making is necessary. To date, the nursing perspective of the decision-making process for patients facing difficulties and how nurses can support patients in this process have not been fully elucidated. This study aimed to clarify the perceptions of critical care nurses regarding situations with patients with severe heart failure that require difficult decision-making, and their role in supporting these patients. METHODS: Individual semi-structured interviews were conducted with 10 certified nurse specialists in critical care nursing at nine hospitals in Japan. A qualitative inductive method was used and the derived relationships among the themes were visually structured and represented. RESULTS: The nurses' perceptions on patients' difficult situations in decision-making were identified as follows: painful decisions under uncertainties; tense relationships; wavering emotions during decision-making; difficulties in coping with worsening medical conditions; patients' wishes that are difficult to realize or estimate; and difficulties in transitioning from advanced medical care. Critical care nurses' roles were summarized into six themes and performed collaboratively within the nursing team. Of these, the search for meaning and value was fundamental. Two positions underpin the role of critical care nurses. The first aims to provide direct support and includes partnerships and rights advocacy. The second aims to provide a holistic perspective to enable necessary adjustments, as indicated by situation assessments and mediation. By crossing various boundaries, co-creating, and forming a good circular relationship in the search for meaning and values, the possibility of expanding treatment and recuperation options may be considered. CONCLUSIONS: Patients with severe heart failure have difficulty participating in shared decision-making. Critical care nurses should collaborate within the nursing team to improve interprofessional shared decision-making by providing decisional support to patients that focuses on values and meaning.

Probabilistic double hierarchy linguistic Maclaurin symmetric mean-MultiCriteria Border Approximation area Comparison method for multi-criteria group decision making and its application in a selection of traditional Chinese medicine prescriptions.

Traditional Chinese medicine (TCM) has gradually played an indispensable role in people's health maintenance, especially in the treatment of chronic diseases. However, there is always uncertainty and hesitation in the judgment and understanding of diseases by doctors, which affects the status recognition and optimal diagnosis and treatment decision-making of patients. In order to overcome the above problems, we lead into probabilistic double hierarchy linguistic term set (PDHLTS) to accurately describe language information in traditional Chinese medicine and make decisions. In this paper, a multi-criteria group decision making (MCGDM) model is constructed based on the MSM-MCBAC (Maclaurin symmetric mean-MultiCriteria Border Approximation area Comparison) method in the PDHL environment. Firstly, a PDHL weighted Maclaurin symmetric mean (PDHLWMSM) operator is proposed to aggregate the evaluation matrices of multiple experts. Then, combined with the BWM and maximizing deviation method, a comprehensive weight determination method is put forward to calculate the weights of criteria. Furthermore, we propose PDHL MSM-MCBAC method based on the Multi-Attributive Border Approximation area Comparison (MABAC) method and the PDHLWMSM operator. Finally, an example of a selection of TCM prescriptions is used and some comparative analyses are made to verify the effectiveness and superiority of this paper.

Educational strategies in the health professions to mitigate cognitive and implicit bias impact on decision making: a scoping review.

BACKGROUND: Cognitive and implicit biases negatively impact clinicians' decision-making capacity and can have devastating consequences for safe, effective, and equitable healthcare provision. Internationally, health care clinicians play a critical role in identifying and overcoming these biases. To be workforce ready, it is important that educators proactively prepare all pre-registration healthcare students for real world practice. However, it is unknown how and to what extent health professional educators incorporate bias training into curricula. To address this gap, this scoping review aims to explore what approaches to teaching cognitive and implicit bias, for entry to practice students, have been studied, and what are the evidence gaps that remain. METHODS: This scoping review was guided by the Joanna Briggs Institute (JBI) methodology. Databases were searched in May 2022 and included CINAHL, Cochrane, JBI, Medline, ERIC, Embase, and PsycINFO. The Population, Concept and Context framework was used to guide keyword and index terms used for search criteria and data extraction by two independent reviewers. Quantitative and qualitative studies published in English exploring pedagogical approaches and/or educational techniques, strategies, teaching tools to reduce the influence of bias in health clinicians' decision making were sought to be included in this review. Results are presented numerically and thematically in a table accompanied by a narrative summary. RESULTS: Of the 732 articles identified, 13 met the aim of this study. Most publications originated from the United States (n=9). Educational practice in medicine accounted for most studies (n=8), followed by nursing and midwifery (n=2). A guiding philosophy or conceptual framework for content development was not indicated in most papers. Educational content was mainly provided via face-to-face (lecture/tutorial) delivery (n=10). Reflection was the most common strategy used for assessment of learning (n=6). Cognitive biases were mainly taught in a single session (n=5); implicit biases were taught via a mix of single (n=4) and multiple sessions (n=4). CONCLUSIONS: A range of pedagogical strategies were employed; most commonly, these were face-to-face, class-based activities such as lectures and tutorials. Assessments of student learning were primarily based on tests and personal reflection. There was limited use of real-world settings to educate students about or build skills in biases and their mitigation. There may be a valuable opportunity in exploring approaches to building these skills in the real-world settings that will be the workplaces of our future healthcare workers.

Pivotal Role of Genetic Counselors in the Uptake of Germline Genetic Testing in Non-Metastatic Breast Cancer and the Impact of Testing on Surgical Decision Making.

BACKGROUND: Genetic testing is increasingly utilized in breast cancer patients; however, testing rates remain low. We aimed to evaluate the rate of genetic testing at a tertiary academic medical center utilizing a multidisciplinary clinic model including genetic counselor. METHODS: A single-center retrospective chart review was performed on a cohort of newly diagnosed breast cancer patients from January 2018 through February 2019. Patients were reviewed for genetic screening eligibility, consultation with a genetic counselor, and test results. RESULTS: Final analysis included 426 patients. 261 (61.3%) were found to meet National Comprehensive Cancer Network guidelines for genetic testing, of which 178 patient (68.2%) underwent testing and 32 patients (12.3%) declined testing. Of the 165 not eligible for testing, 5 patients were tested. A total of 183 patients underwent testing and 116 (63.4%) had a negative result, 17 (9.3%) were positive for at least one gene mutation and 50 (27.3%) were identified to have a variant of unknown significance (VUS). There was a positive association between those patients who met with a genetic counselor and eligibility for testing (OR 31.1, 95% CI 16.0-60.5). CONCLUSIONS: Genetic testing result has become an increasingly important factor when defining optimal surgical treatment for breast cancer patients. Increasing the availability of genetic consultation for breast cancer patients can improve testing rates and patient selection.

Clinical usefulness of the Patient-Generated Subjective Global Assessment and modified Glasgow Prognostic Score in decision making concerning the indication of enteral nutritional therapy in patients with incurable cancer receiving palliative care.

OBJECTIVES: This study aimed to identify the clinical usefulness of assessing nutritional status using validated tools for the indication of enteral nutrition for patients with incurable cancer in palliative care. METHODS: In this prospective cohort study, patients were assessed for nutritional risk using the Patient-Generated Subjective Global Assessment and for cancer cachexia (CC) using the modified Glasgow Prognostic Score upon enrollment and after ∼30 d. The outcome was stable or improved Karnofsky Performance Status. Logistic regression models were used, providing the odds ratio (OR) and 95% confidence interval (CI). RESULTS: A total of 180 patients participated. The only nutritional status parameter that was associated with function was CC. The less severe the CC, the more likely Karnofsky Performance Status was to remain stable or improve over 30 d (non-cachectic: OR = 1.95; 95% CI, 1.01-3.47; malnourished: OR = 1.06; 95% CI, 1.01-1.42). Furthermore, white skin color (OR = 1.79; 95% CI, 1.04-2.47), higher educational level (OR = 1.39; 95% CI, 1.13-2.78), and inadequate calorie intake (OR = 1.96; 95% CI, 1.02-2.81) were also associated with the outcome. CONCLUSIONS: Using the modified Glasgow Prognostic Score to identify the existence and severity of CC, which is associated with function, has the potential to help clinical decision making concerning the indication of enteral nutrition in patients with incurable cancer receiving palliative care.