Shared decision making in routine clinical care of patients with rheumatoid arthritis: an assessment of audio-recorded consultations.

OBJECTIVES: Although shared decision making (SDM) is advocated in rheumatoid arthritis (RA) treatment, it is largely unclear when, how and to what extent SDM is applied in routine clinical care of patients with RA. This study aimed to investigate the level of SDM in RA treatment from an observer perspective and to assess associations between the level of SDM and characteristics of the clinician, patient and consultation. METHODS: The level of SDM was investigated by scoring audio-recordings of 168 routine consultations with unique patients with the observer patient involvement (OPTION) scale (scale 0-100, higher OPTION scores indicating higher levels of SDM). Associations between the level of SDM and characteristics of the clinician, patient and consultation were assessed using multilevel modelling. Statistical significance was set at p<0.05. RESULTS: The mean OPTION score was 28.3 (SD=15.1). The multilevel model included four characteristics: clinician age, patient age, consultation duration and type of treatment decision. There were significant, positive associations between the level of SDM and the consultation duration (b=0.63, 95% CI 0.16 to 1.11), decision for stopping and/or starting medication (b=14.30, 95% CI 5.62 to 22.98), decision for adjusting medication doses (b=8.36, 95% CI 3.92 to 12.81) and decision for administering single dose glucocorticoids (b=15.03, 95% CI 9.12 to 20.93). Thus, a higher level of SDM was significantly associated with a longer consultation duration and the type of treatment decision. No other significant associations were found. CONCLUSIONS: Overall, the level of SDM in RA treatment leaves room for improvement. To foster SDM in routine clinical care, training programmes on patient-centred communication skills may be helpful.

Global Experience With the Nellix Endosystem for Ruptured and Symptomatic Abdominal Aortic Aneurysms.

PURPOSE: To assess the feasibility and safety of the endovascular aneurysm sealing (EVAS) technique in the treatment of acute abdominal aortic aneurysm (AAA). METHODS: A retrospective, multicenter, observational study was conducted at 8 centers (7 European and 1 in New Zealand) experienced with EVAS in the elective setting. From February 2013 to April 2015, 58 patients (mean age 74±9 years; 46 men) with an acute AAA were treated (28 ruptured and 30 symptomatic). The primary endpoint of the study was 30-day mortality; secondary endpoints included endoleak, reinterventions, and 30-day morbidity. RESULTS: The overall intensive care unit and hospital stays were 2.2±6.6 days and 9.7±11.4 days, respectively. Thirty-day mortality rates were 32% (9/28) for the ruptured group and 7% (2/30) for the symptomatic group, with morbidity rates of 57% and 17%, respectively. Early endoleak was present in only 2 (3%) patients, one in each group; both leaks were type Ia. Reinterventions within 30 days were performed in 8 patients in the ruptured group; in the symptomatic patients, the only perioperative reintervention was embolization a type Ia endoleak. The mean follow-up was 9.3±3.1 months in the ruptured group and 12.4±5.4 months in the symptomatic group. The mean aneurysm diameter at 30-day follow-up was 71.8±16.0 mm compared with 74.7±15.7 mm preoperatively in the ruptured group and 66.1±13.5 mm compared with 65.8±13.0 mm in the symptomatic group. CONCLUSION: EVAS in the acute setting appears safe and feasible and concordant with the literature for endovascular aneurysm repair. More robust prospective and comparative data are required to establish the position of the technique in the treatment algorithm of acute AAA.

Patient Satisfaction and Experience with Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass: A Mixed-Methods study.

INTRODUCTION: Same-day discharge (SDD) after laparoscopic Roux-en-Y gastric bypass (RYGB) is a safe and effective healthcare pathway. However, there is limited understanding of the patient perspective on SDD. The aim of this study was to explore patient satisfaction and experience with SDD after RYGB. METHODS: A mixed-methods study with a concurrent design was conducted in a Dutch teaching hospital, using questionnaires and interviews. Patients who underwent RYGB and were discharged on the day of the surgery completed four questionnaires of the BODY-Q (satisfaction with the surgeon, satisfaction with the medical team, satisfaction with the office staff, and satisfaction with information provision) ± 4 months postoperative. The results of the questionnaires were compared with pre-existing data from a cohort of patients who stayed overnight after surgery (i.e., control group). A subset of patients was individually interviewed for an in-depth understanding of the patient perspective on SDD. RESULTS: In the questionnaires, median scores for the control group (n = 158) versus the present group of patients (n = 51) were as follows: 92/100 vs. 92/100 (p = 0.331) for the surgeon, 100/100 vs. 92/100 (p = 0.775) for the medical team, 100/100 vs. 100/100 (p = 0.616) for the office staff, and 90/100 vs. 73/100 (p = 0.015) for information provision. Interviews with 14 patients revealed seven themes, describing high satisfaction, along with several points of interest. CONCLUSIONS: Patient satisfaction with SDD after RYGB is high, although information provision regarding the day of surgery could be improved. However, not every medically eligible patient might be suitable for this healthcare pathway, as responsibilities are shifted.

Exploring healthcare professionals' knowledge, attitudes and experiences of shared decision making in rheumatology.

OBJECTIVES: To explore physicians' and nurses' knowledge, attitudes and experiences of shared decision making (SDM) in rheumatology, to identify barriers and facilitators to SDM, and to examine whether physicians' and nurses' perspectives of SDM differ. METHODS: A cross-sectional, exploratory, online survey was used. Besides demographic characteristics, healthcare professionals' knowledge, attitudes and experiences of SDM in rheumatology were assessed. Barriers and facilitators to SDM were identified from healthcare professionals' answers. Descriptive statistics were computed and differences between physicians' and nurses' perspectives of SDM were examined with a t-test or Fisher's exact test, as appropriate. RESULTS: Between April and June 2019, 77 physicians and 70 nurses completed the survey. Although most healthcare professionals lacked a full conceptual understanding of SDM, almost all physicians (92%) and all nurses had a (very) positive attitude toward SDM, which was most frequently motivated by the belief that SDM improves patients' treatment adherence. The majority (>50%) of healthcare professionals experienced problems with the application of SDM in clinical practice, mostly related to time constraints. Other important barriers were the incompatibility of SDM with clinical practice guidelines and beliefs that patients do not prefer to be involved in decision making or are not able to take an active role. Modest differences between physicians' and nurses' perspectives of SDM were found. CONCLUSIONS: There is a clear need for education and training that equips and empowers healthcare professionals to apply SDM. Furthermore, the commitment of time, resources and financial support for national, regional and organisational initiatives is needed to make SDM in rheumatology a practical reality.

Interventions to support shared decision making for medication therapy in long term conditions: A systematic review.

OBJECTIVE: 1) To examine the effectiveness of interventions to support shared decision making (SDM) for medication therapy in long term conditions on patient outcomes; 2) to identify characteristics of SDM interventions that are associated with positive patient outcomes. METHODS: A systematic search for randomized controlled trials up to February 2019. A best evidence synthesis was performed. Intervention characteristics that are likely to be associated with positive patient outcomes were identified using descriptive statistics. RESULTS: Twenty-five articles reporting 23 studies were included. Seventeen patient outcomes were assessed using a variety of measurement instruments. There was evidence for a positive effect of SDM interventions on risk estimation and involvement in decision making. Evidence for no effect was found on four outcomes (e.g. medication adherence) and conflicting evidence on ten outcomes (e.g. decisional conflict). Electronically delivered SDM interventions and those comprising value clarification exercises were likely to be associated with positive patient outcomes. CONCLUSION: There is a lack of evidence for a positive effect of SDM interventions on the majority of patient outcomes. The mode and content of SDM interventions seem to affect patient outcomes. PRACTICE IMPLICATIONS: There is a need for standardization of patient outcomes and measurement instruments to evaluate SDM interventions.

What do patients prefer? A multinational, longitudinal, qualitative study on patient-preferred treatment outcomes in early rheumatoid arthritis.

OBJECTIVES: To explore treatment outcomes preferred by patients with early rheumatoid arthritis (RA) and how these change throughout the early disease stage across three European countries. METHODS: A longitudinal, qualitative, multicentre study was conducted in Belgium, the Netherlands and Sweden. 80 patients with early RA were individually interviewed 3-9 months after treatment initiation and 51 of them participated again in either a focus group or an individual interview 12-21 months after treatment initiation. Data were first analysed by country, following the Qualitative Analysis Guide of Leuven (QUAGOL). Thereafter, a meta-synthesis, inspired by the principles of meta-ethnography and the QUAGOL, was performed, involving the local research teams. RESULTS: The meta-synthesis revealed 11 subthemes from which four main themes were identified: disease control, physical performance, self-accomplishment and well-being. 'A normal life despite RA' was an overarching patient-preferred outcome across countries. Belgian, Dutch and Swedish patients showed many similarities in terms of which outcomes they preferred throughout the early stage of RA. Some outcome preferences (eg, relief of fatigue and no side effects) developed differently over time across countries. CONCLUSIONS: This study on patient-preferred outcomes in early RA revealed that patients essentially want to live a normal life despite RA. Our findings help to understand what really matters to patients and provide specific insights into the early stage of RA, which should be addressed by clinicians of different disciplines from the start of treatment onwards.

European Qualitative research project on Patient-preferred outcomes in Early Rheumatoid Arthritis (EQPERA): rationale, design and methods of a multinational, multicentre, multilingual, longitudinal qualitative study.

INTRODUCTION: Including the patient perspective is important to achieve optimal outcomes in the treatment of rheumatoid arthritis (RA). Ample qualitative studies exist on patient outcomes in RA. A Belgian study recently unravelled what matters most to patients throughout the overwhelming and rapidly evolving early stage of RA. The present study, European Qualitative research project on Patient-preferred outcomes in Early Rheumatoid Arthritis (EQPERA) was created to contribute to a more universal understanding of patient-preferred health and treatment outcomes by integrating the perspectives of patients with early RA from three European countries. METHODS AND ANALYSIS: In EQPERA, a qualitative, explorative, longitudinal study will be implemented in The Netherlands and Sweden, parallel to the methods applied in the previously conducted Belgian study. In each country, a purposive sample of patients with early RA will be individually interviewed 3-6 months after start of the initial RA treatment and subsequently, the same participants will be invited to take part in a focus group 12-18 months after RA treatment initiation. Data collection and analysis will be independently conducted by the local research teams in their native language. A meta-analysis of the local findings will be performed to explore and describe similarities, differences and patterns across countries. ETHICS AND DISSEMINATION: Ethics approval was granted by the responsible local ethics committees. EQPERA follows the recommendations of the Declaration of Helsinki. Two main papers are foreseen (apart from the data reporting on the local findings) for peer-reviewed publication.