Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 152
Filtrar
Mais filtros

País/Região como assunto
Tipo de documento
País de afiliação
Intervalo de ano de publicação
1.
J Urol ; 210(2): 290-298, 2023 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-37416955

RESUMO

PURPOSE: Assessments of financial toxicity among patients with metastatic prostate cancer are lacking. Using patient surveys, we sought to identify coping mechanisms and assess characteristics associated with lower financial toxicity. MATERIALS AND METHODS: Surveys were administered to all patients seen at a single center's Advanced Prostate Cancer Clinic over a 3-month period. Surveys included the COST-FACIT (COmprehensive Score for Financial Toxicity) and coping mechanism questionnaires. Patients with metastatic disease (lymph nodes, bone, visceral) were included for analysis. Coping mechanisms were compared between patients experiencing low (COST-FACIT >24) vs high (COST-FACIT ≤24) financial toxicity using Fisher's exact test. Multivariable linear regression was used to evaluate characteristics associated with lower financial toxicity. RESULTS: Overall, 281 patients met inclusion criteria of which 79 reported high financial toxicity. In multivariable analysis, characteristics associated with lower financial toxicity included older age (estimate: 0.36, 95%CI: 0.21-0.52), applying for patient assistance programs (estimate: 4.42, 95%CI: 1.72-7.11), and an annual income of at least $100,000 (estimate: 7.81, 95%CI: 0.97, 14.66). Patients with high financial toxicity were more likely to decrease spending on basic goods (35% vs 2.5%, P < .001) and leisure activities (59% vs 15%, P > .001), as well as use savings (62% vs 17%, P < .001) to pay for their treatment. CONCLUSIONS: In this cross-sectional study, patients with metastatic prostate cancer and high financial toxicity were more likely to decrease spending on basic goods and leisure activities and use savings to pay for care. Understanding the impact of financial toxicity on patients' lives is crucial to inform shared decision-making and interventions designed to mitigate financial toxicity in this population.


Assuntos
Neoplasias , Neoplasias da Próstata , Masculino , Humanos , Efeitos Psicossociais da Doença , Estresse Financeiro , Estudos Transversais , Adaptação Psicológica , Inquéritos e Questionários , Qualidade de Vida
2.
Clin Trials ; 20(5): 559-563, 2023 10.
Artigo em Inglês | MEDLINE | ID: mdl-37050880

RESUMO

INTRODUCTION: Testing healthcare delivery interventions in rigorous clinical trials is a critical step in improving patient care, but conducting multisite randomized clinical trials to test the effect of care delivery interventions has unique challenges and requires foresight and planning. METHODS: We conducted the first care delivery trial (A191402CD) in the Alliance for Clinical Trials in Oncology, a National Cancer Institute Community Oncology Research Program research base, which tested the effectiveness of two different decision aids for supporting shared decision-making about prostate cancer treatment. Our experience illustrates the kind of challenges that confront care delivery researchers as they seek to test interventions to improve the experiences of patients. RESULTS: Lessons learned include the following: cluster-randomized designs introduce complexity; workflow disruption can discourage site participation; evidence-based methods may not always be sufficient. CONCLUSION: We conclude with the following recommendations: assessing feasibility requires special rigor; relationships and interpersonal dynamics must be leveraged. Our experiences may inform future care delivery research.


Assuntos
Oncologia , Neoplasias da Próstata , Humanos , Masculino , Atenção à Saúde , Ensaios Clínicos como Assunto
3.
J Clin Ethics ; 34(4): 328-341, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37991733

RESUMO

AbstractPurpose: to characterize ethics course content, structure, resources, pedagogic methods, and opinions among academic administrators and course directors at U.S. medical schools. METHOD: An online questionnaire addressed to academic deans and ethics course directors identified by medical school websites was emailed to 157 Association of American Medical Colleges member medical schools in two successive waves in early 2022. Descriptive statistics were utilized to summarize responses. RESULTS: Representatives from 61 (39%) schools responded. Thirty-two (52%) respondents were course directors; 26 (43%) were deans of academic affairs, medical education, or curriculum; and 3 with other roles also completed the survey (5%). All 61 schools reported some form of formal ethics education during the first year of medical school, with most (n = 54, 89%) reporting a formal mandatory introductory course during preclinical education. Schools primarily utilized lecture and small-group teaching methods. Knowledge-based examinations, attendance, and participation were most commonly used for assessment. A large majority regarded ethics as equally or more important than other foundational courses, but fewer (n = 37, 60%) provided faculty training for teaching ethics. CONCLUSIONS: Despite a response rate of 39 percent, the authors conclude that medical schools include ethics in their curricula in small-group and lecture formats with heterogeneity regarding content taught. Preclinical curricular redesigns must innovate and implement best practices for ensuring sound delivery of ethics content in future curricula. Additional large-scale research is necessary to determine said best practices.


Assuntos
Currículo , Ética Médica , Faculdades de Medicina , Humanos , Escolaridade , Ética Médica/educação
4.
Cancer ; 128(6): 1242-1251, 2022 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-34890060

RESUMO

BACKGROUND: Decision aids (DAs) can improve knowledge for prostate cancer treatment. However, the relative effects of DAs delivered within the clinical encounter and in more diverse patient populations are unknown. A multicenter cluster randomized controlled trial with a 2×2 factorial design was performed to test the effectiveness of within-visit and previsit DAs for localized prostate cancer, and minority men were oversampled. METHODS: The interventions were delivered in urology practices affiliated with the NCI Community Oncology Research Program Alliance Research Base. The primary outcome was prostate cancer knowledge (percent correct on a 12-item measure) assessed immediately after a urology consultation. RESULTS: Four sites administered the previsit DA (39 patients), 4 sites administered the within-visit DA (44 patients), 3 sites administered both previsit and within-visit DAs (25 patients), and 4 sites provided usual care (50 patients). The median percent correct in prostate cancer knowledge, based on the postvisit knowledge assessment after the intervention delivery, was as follows: 75% for the pre+within-visit DA study arm, 67% for the previsit DA only arm, 58% for the within-visit DA only arm, and 58% for the usual-care arm. Neither the previsit DA nor the within-visit DA had a significant impact on patient knowledge of prostate cancer treatments at the prespecified 2.5% significance level (P = .132 and P = .977, respectively). CONCLUSIONS: DAs for localized prostate cancer treatment provided at 2 different points in the care continuum in a trial that oversampled minority men did not confer measurable gains in prostate cancer knowledge.


Assuntos
Participação do Paciente , Neoplasias da Próstata , Tomada de Decisões , Técnicas de Apoio para a Decisão , Humanos , Masculino , Preferência do Paciente , Neoplasias da Próstata/terapia , Encaminhamento e Consulta
5.
J Urol ; 208(5): 987-996, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-36094864

RESUMO

PURPOSE: Out-of-pocket costs represent an important component of financial toxicity and may impact patients' receipt of care. Herein, we evaluated patient-level factors associated with out-of-pocket costs for contemporary advanced prostate cancer treatment options. MATERIALS AND METHODS: We identified all commercially insured men receiving treatment for advanced prostate cancer between 2007 and 2019 within the OptumLabs Data Warehouse®. Patients were categorized into 3 treatment groups: androgen deprivation monotherapy, novel hormonal therapy, and nonandrogen systemic therapy. The primary outcome was out-of-pocket costs in the first year of treatment. The associations of treatment and patient variables with out-of-pocket costs were assessed using multivariable regression models. All costs were adjusted to reflect 2019 U.S. dollars using the Consumer Price Index. RESULTS: In a cohort of 13,409 men 81% (n = 10,926) received androgen deprivation monotherapy, 6% (n = 832) novel hormonal therapy, and 12% (n = 1,651) nonandrogen systemic therapy. Mean treatment-related out-of-pocket costs in the first year were $165, $4,236, and $994 for androgen deprivation monotherapy, novel hormonal therapy, and nonandrogen systemic therapy, respectively. The adjusted difference in annual treatment-related out-of-pocket costs for novel hormonal therapy and nonandrogen systemic therapy were $2,581 (95% CI: $1,923-$3,240) and $752 (95% CI: $600-$903) higher than androgen deprivation monotherapy, respectively. Patient characteristics associated (P < .05) with higher treatment-related out-of-pocket costs included older age (65-74 years), Black race, lower comorbidity scores, and lower household income. CONCLUSIONS: Patients receiving novel hormonal therapy for advanced prostate cancer had substantially higher treatment-related out-of-pocket costs. In addition to raising awareness among prescribers, these data support the inclusion of treatment associated financial toxicity in shared decision making for advanced prostate cancer and call attention to subgroups of patients particularly vulnerable to financial toxicity.


Assuntos
Gastos em Saúde , Neoplasias da Próstata , Antagonistas de Androgênios/uso terapêutico , Androgênios , Custos e Análise de Custo , Humanos , Masculino , Neoplasias da Próstata/tratamento farmacológico
6.
J Gen Intern Med ; 37(5): 1031-1037, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-35083651

RESUMO

BACKGROUND: Prognostic information is key to shared decision-making, particularly in life-limiting illness like advanced chronic kidney disease (CKD). OBJECTIVE: To understand the prognostic information preferences expressed by older patients with CKD. DESIGN AND PARTICIPANTS: Qualitative study of 28 consecutively enrolled patients over 65 years of age with non-dialysis dependent CKD stages 3b-5, receiving care in a multi-disciplinary CKD clinic. APPROACH: Semi-structured telephone or in-person interviews to explore patients' preference for and perceived value of individualized prognostic information. Interviews were analyzed using inductive content analysis. KEY RESULTS: We completed interviews with 28 patients (77.7 ± SD 6.8 years, 69% men). Patients varied in their preference for prognostic information and more were interested in their risk of progression to end-stage kidney disease (ESKD) than in life expectancy. Many conflated ESKD risk with risk of death, perceiving a binary choice between dialysis and quick decline and death. Patients expressed that prognostic information would allow them to plan, take care of important business, and think about their treatment options. Patients were accepting of prognostic uncertainty and imagined leveraging it to nurture hope or motivate them to better manage risk factors. They endorsed the desire to receive prognosis of life expectancy even though it may be hard to accept or difficult to talk about but worried it could create helplessness for other patients in their situation. CONCLUSION: Most, but not all, patients were interested in prognostic information and could see its value in motivating behavior change and allowing planning. Some patients expressed concern that information on life expectancy might cause depression and hopelessness. Therefore, prognostic information is most appropriate as part of a clinical conversation that fosters shared decision-making and helps patients consider treatment risks, benefits, and burdens in context of their lives.


Assuntos
Falência Renal Crônica , Insuficiência Renal Crônica , Tomada de Decisões , Feminino , Humanos , Falência Renal Crônica/terapia , Masculino , Prognóstico , Pesquisa Qualitativa , Diálise Renal , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/terapia
7.
Eur J Cancer Care (Engl) ; 30(1): e13301, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33112008

RESUMO

OBJECTIVE: The degree decision aids (DAs) can promote active surveillance (AS) for prostate cancer (PCa) remains poorly understood. Herein, we surveyed radiation oncologists (RO) and urologists (URO) about their attitudes towards DAs in counselling patients about AS for low-risk PCa. METHODS: We conducted a national survey of RO (n = 915) and URO (n = 940) to assess their attitudes about DAs for AS for patients with low-risk PCa. Respondents were queried about their attitudes towards DAs and proportion of PCa patients managed with AS. Multivariable logistic regression models were used to examine physician characteristics related to attitudes about DAs. RESULTS: The overall response rate was 37.3% (n = 691). Most respondents strongly agreed or agreed that DAs helped patients with low-risk PCa make informed decisions (93.9%) and also increased patient support for AS (86.6%). Having a high volume of their low-risk PCa patients on AS (>15%) was associated with endorsing the statement that use of DAs increased the likelihood of recommending AS (OR: 1.83; 95% CI: 1.00-4.61; p = .05) and being a URO versus a RO (OR: 3.37; 95% CI: 2.46-5.79; p < .001). CONCLUSIONS: Most specialists view DAs as effective tools to facilitate more informed treatment decisions and facilitate greater use of AS in appropriately selected patients.


Assuntos
Neoplasias da Próstata , Urologistas , Atitude do Pessoal de Saúde , Tomada de Decisões , Técnicas de Apoio para a Decisão , Humanos , Masculino , Padrões de Prática Médica , Neoplasias da Próstata/terapia , Radio-Oncologistas , Conduta Expectante
8.
Support Care Cancer ; 28(3): 1183-1197, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31209630

RESUMO

INTRODUCTION: Chemotherapy-induced peripheral neuropathy (CIPN) is a prominent clinical problem, with limited effective therapies. Preliminary non-randomized clinical trial data support that Scrambler Therapy is helpful in this situation. METHODS: Patients were eligible if they had CIPN symptoms for at least 3 months and CIPN-related tingling or pain at least 4/10 in severity during the week prior to registration. They were randomized to receive Scrambler Therapy versus transcutaneous electrical nerve stimulation (TENS) for 2 weeks. Patient-reported outcomes (PROs) were utilized to measure efficacy and toxicity daily for 2 weeks during therapy and then weekly for 8 additional weeks. RESULTS: This study accrued 50 patients, 25 to each of the 2 study arms; 46 patients were evaluable. There were twice as many Scrambler-treated patients who had at least a 50% documented improvement during the 2 treatment weeks, from their baseline pain, tingling, and numbness scores, when compared with the TENS-treated patients (from 36 to 56% compared with 16-28% for each symptom). Global Impression of Change scores for "neuropathy symptoms," pain, and quality of life were similarly improved during the treatment weeks. Patients in the Scrambler group were more likely than those in the TENS group to recommend their treatment to other patients, during both the 2-week treatment period and the 8-week follow-up period (p < 0.0001). Minimal toxicity was observed. CONCLUSIONS: The results from this pilot trial were positive, supporting the conduct of further investigations regarding the use of Scrambler Therapy for treating CIPN.


Assuntos
Antineoplásicos/efeitos adversos , Neoplasias/tratamento farmacológico , Doenças do Sistema Nervoso Periférico/induzido quimicamente , Doenças do Sistema Nervoso Periférico/terapia , Estimulação Elétrica Nervosa Transcutânea/métodos , Administração Cutânea , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/patologia , Manejo da Dor/métodos , Doenças do Sistema Nervoso Periférico/patologia , Projetos Piloto , Qualidade de Vida
9.
J Clin Ethics ; 31(1): 79-82, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32213696

RESUMO

We reflect on Dr. Iserson's article in this journal, in which he suggests that clinicians must "shove" patients towards appropriate care. While recognizing that overt clinical guidance is part of care, we suggest that its use should be tempered by the guidance's responsiveness to the human and emotional experience of each patient.


Assuntos
Tomada de Decisões , Autonomia Pessoal , Relações Médico-Paciente , Emoções , Humanos , Assistência ao Paciente
11.
Ann Surg Oncol ; 26(2): 660-668, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30311161

RESUMO

PURPOSE: The reasons for low clinical adoption of active surveillance (AS) for low-risk prostate cancer (PCa) remain poorly understood. Thus, we conducted a national survey of radiation oncologists (ROs) and urologists (UROs) to elucidate perceived barriers to AS for low-risk PCa. METHODS: In 2017, we undertook a four-wave mail survey of 1855 ROs and UROs. The survey instrument assessed attitudes about possible barriers towards AS for low-risk PCa. We used Pearson Chi square and multivariable logistic regression analyses to identify physician characteristics associated with attitudes about AS. RESULTS: We received 691 completed surveys for an overall response rate of 37.3%. A majority of respondents indicated that they felt comfortable recommending AS (90.0%), agreed that high-level evidence supports it (82.3%), and considered AS equally effective for survival compared with surgery and radiation therapy (84.4%). UROs were less likely to agree that patients were not interested in AS for low-risk PCa compared with ROs (16.5 vs. 48.9%; adjusted odds ratio [OR] 0.18, p < 0.001). Similarly, UROs were less likely to concur patients avoid AS because of repeat prostate biopsies than ROs (36.3 vs. 55.4%; adjusted OR 0.41, p < 0.001). ROs and UROs were more likely to agree that patients preferred treatments delivered by the respondent's specialty. CONCLUSIONS: Physician perceptions of patient lack of interest in AS, need for repeat prostate biopsies, and biases of patient treatment preferences in favor of their own specialty treatments represent key barriers to AS. Shared decision making may be a meaningful approach to engaging patients in conversations about treatment decisions.


Assuntos
Atitude do Pessoal de Saúde , Padrões de Prática Médica , Neoplasias da Próstata/terapia , Radioterapia (Especialidade)/estatística & dados numéricos , Urologia/estatística & dados numéricos , Conduta Expectante/métodos , Adulto , Idoso , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Percepção , Prognóstico , Inquéritos e Questionários
12.
World J Urol ; 37(10): 2099-2108, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30671637

RESUMO

PURPOSE: Although prediction tools for prostate cancer (PCa) are essential for high-quality treatment decision-making, little is known about the degree of confidence in existing tools and whether they are used in clinical practice from radiation oncologists (RO) and urologists (URO). Herein, we performed a national survey of specialists about perceived attitudes and use of prediction tools. METHODS: In 2017, we invited 940 URO and 911 RO in a national survey to query their confidence in and use of the D'Amico criteria, Kattan Nomogram, and CAPRA score. The statistical analysis involved bivariate association and multivariable logistic regression analyses to identify physician characteristics (age, gender, race, practice affiliation, specialty, access to robotic surgery, ownership of linear accelerator and number of prostate cancer per week) associated with survey responses and use of active surveillance (AS) for low-risk PCa. RESULTS: Overall, 691 (37.3%) specialists completed the surveys. Two-thirds (range 65.6-68.4%) of respondents reported being "somewhat confident", but only a fifth selected "very confident" for each prediction tool (18.0-20.1%). 19.1% of specialists in the survey reported not using any prediction tools in clinical practice, which was higher amongst URO than RO (23.9 vs. 13.4%; p < 0.001). Respondents who reported not using prediction tools were also associated with low utilization of AS in their low-risk PCa patients (adjusted OR 2.47; p = 0.01). CONCLUSIONS: While a majority of RO and URO view existing prediction tools for localized PCa with some degree of confidence, a fifth of specialists reported not using any such tools in clinical practice. Lack of using such tools was associated with low utilization of AS for low-risk PCa.


Assuntos
Atitude do Pessoal de Saúde , Oncologia , Nomogramas , Neoplasias da Próstata/terapia , Radiologia , Urologia , Adulto , Idoso , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
13.
Crit Care Med ; 46(8): 1209-1216, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29498939

RESUMO

OBJECTIVES: To assess the effectiveness of noninvasive ventilation in patients with acute respiratory failure and do-not-intubate or comfort-measures-only orders. DATA SOURCES: MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science from inception to January 1, 2017. STUDY SELECTION: Studies of all design types that enrolled patients in the ICU or hospital ward who received noninvasive ventilation and had preset do-not-intubate or comfort-measures-only orders. DATA EXTRACTION: Data abstraction followed Meta-analysis of Observational Studies in Epidemiology guidelines. Data quality was assessed using a modified Newcastle-Ottawa Scale. DATA SYNTHESIS: Twenty-seven studies evaluating 2,020 patients with do-not-intubate orders and three studies evaluating 200 patients with comfort-measures-only orders were included. In patients with do-not-intubate orders, the pooled survival was 56% (95% CI, 49-64%) at hospital discharge and 32% (95% CI, 21-45%) at 1 year. Hospital survival was 68% for chronic obstructive pulmonary disease, 68% for pulmonary edema, 41% for pneumonia, and 37% for patients with malignancy. Survival was comparable for patients treated in a hospital ward versus an ICU. Quality of life of survivors was not reduced compared with baseline, although few studies evaluated this. No studies evaluated quality of dying in nonsurvivors. In patients with comfort-measures-only orders, a single study showed that noninvasive ventilation was associated with mild reductions in dyspnea and opioid requirements. CONCLUSIONS: A large proportion of patients with do-not-intubate orders who received noninvasive ventilation survived to hospital discharge and at 1 year, with limited data showing no decrease in quality of life in survivors. Provision of noninvasive ventilation in a well-equipped hospital ward may be a viable alternative to the ICU for selected patients. Crucial questions regarding quality of life in survivors, quality of death in nonsurvivors, and the impact of noninvasive ventilation in patients with comfort-measures-only orders remain largely unanswered.


Assuntos
Diretivas Antecipadas/estatística & dados numéricos , Estado Terminal , Ventilação não Invasiva/estatística & dados numéricos , Insuficiência Respiratória/terapia , Doença Aguda , Mortalidade Hospitalar/tendências , Humanos , Estudos Observacionais como Assunto , Alta do Paciente/estatística & dados numéricos , Qualidade de Vida , Análise de Sobrevida
14.
BMC Cancer ; 18(1): 788, 2018 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-30081846

RESUMO

BACKGROUND: Treatments for localized prostate cancer present challenging tradeoffs in the face of uncertain treatment benefits. These options are best weighed in a process of shared decision-making with the patient's healthcare team. Minority men experience disparities in prostate cancer outcomes, possibly due in part to a lack of optimal communication during treatment selection. Decision aids facilitate shared decision-making, improve knowledge of treatment options, may increase satisfaction with treatment choice, and likely facilitate long-term quality of life. METHODS/DESIGN: This study will compare the effect of two evidence-based decision aids on patient knowledge and on quality of life measured one year after treatment, oversampling minority men. One decision aid will be administered prior to specialist consultation, preparing patients for a treatment discussion. The other decision aid will be administered within the consultation to facilitate transparent, preference-sensitive, and evidence-informed deliberations. The study will utilize a four-arm, block-randomized design to test whether each decision aid alone (Arms 1 and 2) or in combination (Arm 3) can improve patient knowledge and quality of life compared to usual care (Arm 4). The study, funded by the National Cancer Institute's Community Oncology Research Program (NCORP), will be deployed within select institutions that have demonstrated capacity to recruit minority populations into urologic oncology trials. DISCUSSION: Upon completion of the trial, we will have 1) tested the effectiveness of two evidence-based decision aids in enhancing patients' knowledge of options for prostate cancer therapy and 2) estimated whether decision aids may improve patient quality of life one year after initial treatment choice. TRIAL REGISTRATION: Clinicaltrials.gov: NCT03103321 . The trial registration date (on ClinicalTrials.gov) was April 6, 2017.


Assuntos
Tomada de Decisão Clínica , Técnicas de Apoio para a Decisão , Participação do Paciente , Neoplasias da Próstata/terapia , Comportamento de Escolha , Pesquisa Comparativa da Efetividade , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Estudos Multicêntricos como Assunto , Gradação de Tumores , Estadiamento de Neoplasias , Educação de Pacientes como Assunto , Valor Preditivo dos Testes , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/patologia , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
15.
Health Expect ; 21(1): 110-117, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28636280

RESUMO

BACKGROUND: Patients and clinicians do not often agree on whether a decision has been made about cancer care. This could be explained by factors related to communication quality and/or the type of decision being made. METHODS: We used a self-developed coding scheme to code a random sample of 128 encounters in which patients and clinicians either agreed (n=64) or disagreed (n=64) that a cancer care decision was made and tested for associations between concordance and key communication behaviours. We also identified and characterized cancer care decisions by topic and level of patient involvement and looked for trends. RESULTS: We identified 378 cancer care decisions across 128 encounters. Explicit decisions were most commonly made about topics wherein decision control could be easily delegated to a clear and present expert (eg either the patient or the clinician). Related to this, level of patient involvement varied significantly by decision topic. Explicit decisions were rarely made in an observable way about social, non-clinical or self-management related topics, although patients and clinicians both reported having made a cancer care decision in encounters where no decisions were observed. We found no association between communication behaviours and concordance in our sample. CONCLUSIONS: What counts as a "decision" in cancer care may be constructed within disparate social roles that leave many agendas unaddressed and decisions unmade. Changing the content of conversations to encourage explicit decisions about self-management and life context-related topics may have greater value in enabling shared understanding than promoting communication behaviours among already high-performing communicators.


Assuntos
Tomada de Decisões , Oncologia , Participação do Paciente , Relações Médico-Paciente , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/terapia
16.
BMC Med Educ ; 18(1): 275, 2018 Nov 22.
Artigo em Inglês | MEDLINE | ID: mdl-30466489

RESUMO

BACKGROUND: The success of initiatives intended to increase the value of health care depends, in part, on the degree to which cost-conscious care is endorsed by current and future physicians. This study aimed to first analyze attitudes of U.S. physicians by age and then compare the attitudes of physicians and medical students. METHODS: A paper survey was mailed in mid-2012 to 3897 practicing physicians randomly selected from the American Medical Association Masterfile. An electronic survey was sent in early 2015 to all 5,992 students at 10 U.S. medical schools. Survey items measured attitudes toward cost-conscious care and perceived responsibility for reducing healthcare costs. Physician responses were first compared across age groups (30-40 years, 41-50 years, 51-60 years, and > 60 years) and then compared to student responses using Chi square tests and logistic regression analyses (controlling for sex). RESULTS: A total of 2,556 physicians (65%) and 3395 students (57%) responded. Physician attitudes generally did not differ by age, but differed significantly from those of students. Specifically, students were more likely than physicians to agree that cost to society should be important in treatment decisions (p < 0.001) and that physicians should sometimes deny beneficial but costly services (p < 0.001). Students were less likely to agree that it is unfair to ask physicians to be cost-conscious while prioritizing patient welfare (p < 0.001). Compared to physicians, students assigned more responsibility for reducing healthcare costs to hospitals and health systems (p < 0.001) and less responsibility to lawyers (p < 0.001) and patients (p < 0.001). Nearly all significant differences persisted after controlling for sex and when only the youngest physicians were compared to students. CONCLUSIONS: Physician attitudes toward cost-conscious care are similar across age groups. However, physician attitudes differ significantly from medical students, even among the youngest physicians most proximate to students in age. Medical student responses suggest they are more accepting of cost-conscious care than physicians and attribute more responsibility for reducing costs to organizations and systems rather than individuals. This may be due to the combined effects of generational differences, new medical school curricula, students' relative inexperience providing cost-conscious care within complex healthcare systems, and the rapidly evolving U.S. healthcare system.


Assuntos
Atitude do Pessoal de Saúde , Controle de Custos/estatística & dados numéricos , Educação Médica/estatística & dados numéricos , Médicos/psicologia , Médicos/estatística & dados numéricos , Estudantes de Medicina/psicologia , Estudantes de Medicina/estatística & dados numéricos , Adulto , Fatores Etários , Animais , Estudos Transversais , Tomada de Decisões , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Camundongos , Pessoa de Meia-Idade , Papel do Médico , Estados Unidos
18.
J Med Ethics ; 43(5): 307-309, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28130386

RESUMO

High-value care (HVC) is en vogue, but the ethics of physicians' roles in the growing number of HVC recommendations demands further attention. In this brief report, we argue that, from the standpoint of individual physicians' primary commitments and duties to individual patients, not all HVC is ethically equal. Our analysis suggests that the ethical case for HVC may be both stronger and weaker than is ordinarily supposed. In some cases, HVC is not merely a 'good thing to do' but is actually ethically obligatory. In others, it is merely permissible-or even ethically suspect. More importantly, we suggest further that understanding HVC as ethically 'obligatory, permissible, or suspect' has implications for the design and implementation of strategies that promote HVC. For example, it questions the use of adherence to certain HVC recommendations as a physician performance metric, which may already be occurring in some contexts. Properly construed, ethics does not threaten HVC but can instead help shape HVC in ways that preserve the fundamental values of the medical profession.


Assuntos
Atenção à Saúde/normas , Fidelidade a Diretrizes/ética , Relações Médico-Paciente/ética , Padrões de Prática Médica/ética , Qualidade da Assistência à Saúde/normas , Atenção à Saúde/ética , Humanos , Obrigações Morais , Papel do Médico , Guias de Prática Clínica como Assunto , Qualidade da Assistência à Saúde/ética
19.
BMC Nephrol ; 18(1): 322, 2017 Oct 25.
Artigo em Inglês | MEDLINE | ID: mdl-29070040

RESUMO

BACKGROUND: Efficient and safe delivery of care to dialysis patients is essential. Concerns have been raised regarding the ability of accountable care organizations to adequately serve this high-risk population. Little is known about primary care involvement in the care of dialysis patients. This study sought to describe the extent of primary care provider (PCP) involvement in the care of hemodialysis patients and the outcomes associated with that involvement. METHODS: In a retrospective cohort study, patients accessing a Midwestern dialysis network from 2001 to 2010 linked to United States Renal Database System and with >90 days follow up were identified (n = 2985). Outpatient visits were identified using Current Procedural Terminology (CPT)-4 codes, provider specialty, and grouped into quartiles-based on proportion of PCP visits per person-year (ppy). Top and bottom quartiles represented patients with high primary care (HPC) or low primary care (LPC), respectively. Patient characteristics and health care utilization were measured and compared across patient groups. RESULTS: Dialysis patients had an overall average of 4.5 PCP visits ppy, ranging from 0.6 in the LPC group to 6.9 in the HPC group. HPC patients were more likely female (43.4% vs. 35.3%), older (64.0 yrs. vs. 60.0 yrs), and with more comorbidities (Charlson 7.0 vs 6.0). HPC patients had higher utilization (hospitalizations 2.2 vs. 1.8 ppy; emergency department visits 1.6 vs 1.2 ppy) and worse survival (3.9 vs 4.3 yrs) and transplant rates (16.3 vs. 31.5). CONCLUSIONS: PCPs are significantly involved in the care of hemodialysis patients. Patients with HPC are older, sicker, and utilize more resources than those managed primarily by nephrologists. After adjusting for confounders, there is no difference in outcomes between the groups. Further studies are needed to better understand whether there is causal impact of primary care involvement on patient survival.


Assuntos
Recursos em Saúde/estatística & dados numéricos , Falência Renal Crônica/terapia , Aceitação pelo Paciente de Cuidados de Saúde , Assistência ao Paciente/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Diálise Renal/estatística & dados numéricos , Adolescente , Adulto , Idoso , Estudos de Coortes , Feminino , Recursos em Saúde/tendências , Humanos , Falência Renal Crônica/epidemiologia , Masculino , Pessoa de Meia-Idade , Meio-Oeste dos Estados Unidos/epidemiologia , Assistência ao Paciente/tendências , Atenção Primária à Saúde/tendências , Diálise Renal/tendências , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
20.
Fetal Diagn Ther ; 42(3): 210-217, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28301843

RESUMO

INTRODUCTION: The Management of Myelomeningocele Study (MOMS) compared prenatal with postnatal surgery for fetal myelomeningocele (MMC). We sought to understand how subspecialists interpreted the trial results and whether their practice has changed. MATERIALS AND METHODS: Cross-sectional, mailed survey of 1,200 randomly selected maternal-fetal medicine (MFM) physicians, neonatologists, and pediatric surgeons. RESULTS: Of 1,176 eligible physicians, 670 (57%) responded. Compared to postnatal closure, 33% viewed prenatal closure as "very favorable" and 60% as "somewhat favorable." Most physicians reported being more likely to recommend prenatal surgery (69%), while 28% were less likely to recommend pregnancy termination. In multivariable analysis, neonatologists were more likely to report prenatal closure as "very favorable" (OR 1.6; 95% CI: 1.03-2.5). Pediatric surgeons and neonatologists were more likely to recommend prenatal closure (OR 2.1; 95% CI: 1.3-3.3, and OR 2.9; 95% CI: 1.8-4.6) and less likely to recommend termination (OR 3.8; 95% CI: 2.2-6.7, and OR 4.7; 95% CI: 2.7-8.1). In addition, physicians with a higher tolerance for prematurity were more likely to report prenatal closure as "very favorable" (OR 1.02; 95% CI: 1.00-1.05). DISCUSSION: In light of the MOMS trial, the vast majority of pediatric subspecialists and MFMs view prenatal MMC closure favorably. These attitudes vary by specialty and risk tolerance.


Assuntos
Atitude do Pessoal de Saúde , Fetoscopia , Meningomielocele/cirurgia , Estudos Transversais , Feminino , Humanos , Médicos/psicologia , Gravidez , Resultado do Tratamento
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA