Co-production of a systematic review on decision coaching: a mixed methods case study within a review.

BACKGROUND: Co-production is a collaborative approach to prepare, plan, conduct, and apply research with those who will use or be impacted by research (knowledge users). Our team of knowledge users and researchers sought to conduct and evaluate co-production of a systematic review on decision coaching. METHODS: We conducted a mixed-methods case study within a review to describe team co-production of a systematic review. We used the Collaborative Research Framework to support an integrated knowledge translation approach to guide a team through the steps in co-production of a systematic review. The team agreed to conduct self-study as a study within a review to learn from belonging to a co-production research team. A core group that includes a patient partner developed and conducted the study within a review. Data sources were surveys and documents. The study coordinator administered surveys to determine participant preferred and actual levels of engagement, experiences, and perceptions. We included frequency counts, content, and document analysis. RESULTS: We describe co-production of a systematic review. Of 17 team members, 14 (82%) agreed to study participation and of those 12 (86%) provided data pre- and post-systematic review. Most participants identified as women (n = 9, 75.0%), researchers (n = 7, 58%), trainees (n = 4, 33%), and/or clinicians (n = 2, 17%) with two patient/caregiver partners (17%). The team self-organized study governance with an executive and Steering Committee and agreed on research co-production actions and strategies. Satisfaction for engagement in the 11 systematic review steps ranged from 75 to 92%, with one participant who did not respond to any of the questions (8%) for all. Participants reported positive experiences with team communication processes (n = 12, 100%), collaboration (n = 12, 100%), and negotiation (n = 10-12, 83-100%). Participants perceived the systematic review as co-produced (n = 12, 100%) with collaborative (n = 8, 67%) and engagement activities to characterize co-production (n = 8, 67%). Participants indicated that they would not change the co-production approach (n = 8, 66%). Five participants (42%) reported team logistics challenges and four (33%) were unaware of challenges. CONCLUSIONS: Our results indicate that it is feasible to use an integrated knowledge translation approach to conduct a systematic review. We demonstrate the importance of a relational approach to research co-production, and that it is essential to plan and actively support team engagement in the research lifecycle.

Evaluation of an integrated knowledge translation approach used for updating the Cochrane Review of Patient Decision Aids: a pre-post mixed methods study.

BACKGROUND: When people who can use or benefit from research findings are engaged as partners on study teams, the quality and impact of findings are better. These people can include patients/consumers and clinicians who do not identify as researchers. They are referred to as "knowledge users". This partnered approach is called integrated knowledge translation (IKT). We know little about knowledge users' involvement in the conduct of systematic reviews. We aimed to evaluate team members' degree of meaningful engagement and their perceptions of having used an IKT approach when updating the Cochrane Review of Patient Decision Aids. METHODS: We conducted a pre-post mixed methods study. We surveyed all team members at two time points. Before systematic review conduct, all participating team members indicated their preferred level of involvement within each of the 12 steps of the systematic review process from "Screen titles/abstracts" to "Provide feedback on draft article". After, they reported on their degree of satisfaction with their achieved level of engagement across each step and the degree of meaningful engagement using the Patient Engagement In Research Scale (PEIRS-22) across 7 domains scored from 100 (extremely meaningful engagement) to 0 (no meaningful engagement). We solicited their experiences with the IKT approach using open-ended questions. We analyzed quantitative data descriptively and qualitative data using content analysis. We triangulated data at the level of study design and interpretation. RESULTS: Of 21 team members, 20 completed the baseline survey (95.2% response rate) and 17/20 (85.0% response rate) the follow-up survey. There were 11 (55%) researchers, 3 (15%) patients/consumers, 5 (25%) clinician-researchers, and 1 (5%) graduate student. At baseline, preferred level of involvement in the 12 systematic review steps varied from n = 3 (15%) (search grey literature sources) to n = 20 (100%) (provide feedback on the systematic review article). At follow-up, 16 (94.1%) participants were totally or very satisfied with the extent to which they were involved in these steps. All (17, 100%) agreed that the process was co-production. Total PEIRS-22 scores revealed most participants reported extremely (13, 76.4%) or very (2, 11.8%) meaningful degree of engagement. Triangulated data revealed that participants indicated benefit to having been engaged in an authentic research process that incorporated diverse perspectives, resulting in better and more relevant outputs. Reported challenges were about time, resources, and the logistics of collaborating with a large group. CONCLUSION: Following the use of an IKT approach during the conduct of a systematic review, team members reported high levels of meaningful engagement. These results contribute to our understanding of ways to co-produce systematic reviews.

When people who can use or benefit from research findings are engaged as partners on study teams, the quality and impact of findings are better. These people can include patients/consumers and clinicians who do not identify as researchers. This partnered approach is called integrated knowledge translation (IKT). This approach is rarely used and there is little information about using it with systematic reviews. A systematic review is a type of study that provides the best available evidence on a given topic by combining data from all existing studies. The aim of this study was to find out how engaged our team members felt when partnering on our systematic review about patient decision aids. Twenty of 21 team members participated in the study, including 11 researchers, 3 patients/consumers, 5 clinician-researchers, and 1 graduate student. We asked our team members to complete a survey about their experience as part of our IKT research process at two time points: before starting the study and after the study was done. Most team members felt extremely or very engaged in the process. All team members felt like partners. They gave examples of how this was achieved. Advantages to using the IKT approach included knowledge sharing, inclusion of more diverse voices, a more authentic research process, better and more relevant results, and personal benefits (e.g. enjoyment from being involved). Disadvantages to using this approach was that it took more time and resources. Three team members said there were no disadvantages. It is possible for patients/consumers and clinicians to partner and feel engaged with research teams doing systematic reviews. Our findings may help researchers engage knowledge users as equal partners on study teams.

Decision aids for people facing health treatment or screening decisions.

BACKGROUND: Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES: To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS: We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA: We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS: Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS: This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS: Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Movement-evoked Pain versus Pain at Rest in Postsurgical Clinical Trials and in Meta-analyses: An Updated Systematic Review.

BACKGROUND: Given the widespread recognition that postsurgical movement-evoked pain is generally more intense, and more functionally relevant, than pain at rest, the authors conducted an update to a previous 2011 review to re-evaluate the assessment of pain at rest and movement-evoked pain in more recent postsurgical analgesic clinical trials. METHODS: The authors searched MEDLINE and Embase for postsurgical pain randomized controlled trials and meta-analyses published between 2014 and 2023 in the setting of thoracotomy, knee arthroplasty, and hysterectomy using methods consistent with the original 2011 review. Included trials and meta-analyses were characterized according to whether they acknowledged the distinction between pain at rest and movement-evoked pain and whether they included pain at rest and/or movement-evoked pain as a pain outcome. For trials measuring movement-evoked pain, pain-evoking maneuvers used to assess movement-evoked pain were tabulated. RESULTS: Among the 944 included trials, 504 (53%) did not measure movement-evoked pain (vs. 61% in 2011), and 428 (45%) did not distinguish between pain at rest and movement-evoked pain when defining the pain outcome (vs. 52% in 2011). Among the 439 trials that measured movement-evoked pain, selection of pain-evoking maneuver was highly variable and, notably, was not even described in 139 (32%) trials (vs. 38% in 2011). Among the 186 included meta-analyses, 94 (51%) did not distinguish between pain at rest and movement-evoked pain (vs. 71% in 2011). CONCLUSIONS: This updated review demonstrates a persistent limited proportion of trials including movement-evoked pain as a pain outcome, a substantial proportion of trials failing to distinguish between pain at rest and movement-evoked pain, and a lack of consistency in the use of pain-evoking maneuvers for movement-evoked pain assessment. Future postsurgical trials need to (1) use common terminology surrounding pain at rest and movement-evoked pain, (2) assess movement-evoked pain in virtually every trial if not contraindicated, and (3) standardize movement-evoked pain assessment with common, procedure-specific pain-evoking maneuvers. More widespread knowledge translation and mobilization are required in order to disseminate this message to current and future investigators.

Decisional Support Needed when Facing Tough Decisions: Survey of Parents with Children having Differences of Sex Development.

Introduction: Parents of infants and young children newly diagnosed with differences of sex development (DSD) commonly face medical and psychosocial management decisions at a time when they are first learning about the condition and cannot consult their child for input. The aim of this study was to identify areas of greatest need for parental decisional support. Methods: 34 parents of children receiving care for DSD at one of three US children's hospitals participated in a survey to learn what clinical and psychosocial decisions needed to be made on behalf of their child. Parents were then asked to identify and focus on a "tough" decision and respond to questions assessing factors affecting decision-making, decision-making preferences, decisional conflict, and decision regret. Descriptive analyses were conducted. Results: Decisions about surgery and aspects of sharing information about their child's condition with others were the two most frequently reported decisions overall, experienced by 97% and 88% of parents, as well as most frequently nominated as tough decisions. Many parents reported mild to moderate levels of decisional conflict (59%) and decision regret (74%). Almost all parents (94%) reported experiencing at least one factor as interfering with decision-making (e.g., "worried too much about choosing the 'wrong' option"). Parents universally reported a desire to be involved in decision-making - preferably making the final decision primarily on their own (79%), or together with their child's healthcare providers (21%). The majority of parents judged healthcare providers (82%) and patient/family organizations (58%) as trustworthy sources of information. Discussion: Parents of children with DSD encounter medical, surgical, and psychosocial management decisions. Despite difficulties including emotional distress and informational concerns (including gaps and overload), parents express strong desires to play key roles in decision-making on behalf of their children. Healthcare providers can help identify family-specific needs through observation and inquiry in the clinical context. Together with families, providers should focus on specific clinical management decisions and support parental involvement in making decisions on behalf of young children with DSD.

Co-creating a suite of patient decision aids for parents of an infant or young child with differences of sex development: A methods roadmap.

Introduction: Parents and guardians of infants and young children with differences of sex development (DSD) often face numerous health and social decisions about their child's condition. While proxy health decisions can be stressful in any circumstance, they are further exacerbated in this clinical context by significant variations in clinical presentation, parental lack of knowledge about DSD, irreversibility of some options (e.g., gonadectomy), a paucity of research available about long-term outcomes, and anticipated decisional regret. This study aimed to engage clinicians, parents, and an adult living with DSD to collaboratively develop a suite of patient decision aids (PDAs) to respond to the decisional needs of parents and guardians of infants and young children diagnosed with DSD. Methods: We used a systematic co-development process guided by the Ottawa Decision Support Framework and the International Patient Decision Aids Standards (IPDAS). The five steps were: literature selection, establish the team, decisional needs assessment, create the PDAs, and alpha testing. Results: We developed four PDAs to support parents/guardians of infants or young children diagnosed with DSD about four priority decisions identified through our decisional needs assessment: genetic testing, gender of rearing, genital surgery and gonadal surgery. All four PDAs include information for parents about DSD, the options, reasons to choose or avoid each option, and opportunities for parents/guardians to rate the importance of features of each option to clarify their values for these features. Qualitative feedback was positive from clinicians, parents and an adult living with DSD. Conclusions: These PDAs are clinical tools designed to support parents/guardians and to promote making an informed and shared DSD-related decision. While these tools are specific to DSD, they contain themes and elements translatable to other pediatric populations.

Evaluation of an educational program for nurses providing cancer symptom management: The pan-Canadian Oncology Symptom Triage and Remote Support Online Tutorial.

Purpose: To evaluate the acceptability of the pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) open-access online tutorial and its impact on nurses' knowledge and perceived confidence in symptom management. Methods: Retrospective pre-/post-test evaluation of nurses who completed the tutorial knowledge test and/or acceptability survey. The tutorial was modeled after the previously evaluated in-person workshop to prepare nurses providing cancer symptom management using COSTaRS practice guides. Results: From 2017-2021, 743 nurses completed the knowledge test, and 749 nurses evaluated the tutorial. Mean knowledge score was 4.4/6 and 83% of participants achieved passing scores. Compared to pre-tutorial, nurses improved their perceived confidence in assessing, triaging, guiding patients in self-care (p<0.001), and ability to use the COSTaRS guides (p<0.001). Nurses rated the tutorial as easy to understand (95%), just the right amount of information (92%), providing new information (75%), overall good to excellent (89%), and would recommend it to others (83%). Conclusions: More than 700 nurses accessed the tutorial. After completion, nurses demonstrated good knowledge and improved perceived confidence in cancer symptom management.

Quality of patient decision aids to support the public making COVID-19 decisions: An online environmental scan.

OBJECTIVE: To identify and appraise the quality of COVID-19 patient decision aids (PtDAs). METHODS: We conducted an environmental scan of online publicly available COVID-19 PtDAs. Two reviewers independently searched and extracted data. We calculated median International Patient Decision Aid Standards (IPDAS) scores and proportion scoring > 70% on Patient Education Materials Information Tool (PEMAT) adequate for understandability and actionability. RESULTS: Of 876 resources identified, 12 were PtDAs. Decisions focused on initial COVID-19 vaccination series (n = 9), location of care for elderly (n = 2), and social distancing (n = 1). All 12 PtDAs were written materials and two had accompanying videos. The median IPDAS score minimizing risk of biased decisions was 4 of 6 items (IQR 1, range 2-4). For PEMAT, 92% had adequate for understandability and none for actionability. CONCLUSIONS: We identified few online publicly available COVID-19 PtDAs and none were about COVID-19 vaccination boosters or treatment. PtDAs scored poorly on actionability and none met all IPDAS criteria for minimizing risk of biased decisions. PRACTICE IMPLICATIONS: PtDA developers for COVID-19 and future pandemics should ensure their PtDAs meet all IPDAS criteria for minimizing risk of bias, have adequate scores for actionability, and are disseminated in the A to Z inventory.

Decisions and Decisional Needs of Canadians From all Provinces and Territories During the COVID-19 Pandemic: Population-Based Cross-sectional Surveys.

BACKGROUND: Never before COVID-19 had Canadians faced making health-related decisions in a context of significant uncertainty. However, little is known about which type of decisions and the types of difficulties that they faced. OBJECTIVE: We sought to identify the health-related decisions and decisional needs of Canadians. METHODS: Our study was codesigned by researchers and knowledge users (eg, patients, clinicians). Informed by the CHERRIES (the Checklist for Reporting Results of Internet E-Surveys) reporting guideline, we conducted 2 online surveys of random samples drawn from the Leger consumer panel of 400,000 Canadians. Eligible participants were adults (≥18 years) who received or were receiving any health services in the past 12 months for themselves (adults) or for their child (parent) or senior with cognitive impairment (caregiver). We assessed decisions and decisional needs using questions informed by the Ottawa Decision Support Framework, including decisional conflict and decision regret using the Decision Conflict Scale (DCS) and the Decision Regret Scale (DRS), respectively. Descriptive statistics were conducted for adults who had decided for themselves or on behalf of someone else. Significant decisional conflict (SDC) was defined as a total DCS score of >37.5 out of 100, and significant decision regret was defined as a total DRS score of >25 out of 100. RESULTS: From May 18 to June 4, 2021, 14,459 adults and 6542 parents/caregivers were invited to participate. The invitation view rate was 15.5% (2236/14,459) and 28.3% (1850/6542); participation rate, 69.3% (1549/2236) and 28.7% (531/1850); and completion rate, 97.3% (1507/1549) and 95.1% (505/531), respectively. The survey was completed by 1454 (97.3%) adults and 438 (95.1%) parents/caregivers in English (1598/1892, 84.5%) or French (294/1892, 15.5%). Respondents from all 10 Canadian provinces and the northern territories represented a range of ages, education levels, civil statuses, ethnicities, and annual household income. Of 1892 respondents, 541 (28.6%) self-identified as members of marginalized groups. The most frequent decisions were (adults vs parents/caregivers) as follows: COVID-19 vaccination (490/1454, 33.7%, vs 87/438, 19.9%), managing a health condition (253/1454, 17.4%, vs 47/438, 10.7%), other COVID-19 decisions (158/1454, 10.9%, vs 85/438, 19.4%), mental health care (128/1454, 8.8%, vs 27/438, 6.2%), and medication treatments (115/1454, 7.9%, vs 23/438, 5.3%). Caregivers also reported decisions about moving family members to/from nursing or retirement homes (48/438, 11.0%). Adults (323/1454, 22.2%) and parents/caregivers (95/438, 21.7%) had SDC. Factors making decisions difficult were worrying about choosing the wrong option (557/1454, 38.3%, vs 184/438, 42.0%), worrying about getting COVID-19 (506/1454, 34.8%, vs 173/438, 39.5%), public health restrictions (427/1454, 29.4%, vs 158/438, 36.1%), information overload (300/1454, 20.6%, vs 77/438, 17.6%), difficulty separating misinformation from scientific evidence (297/1454, 20.4%, vs 77/438, 17.6%), and difficulty discussing decisions with clinicians (224/1454, 15.4%, vs 51/438, 11.6%). For 1318 (90.6%) adults and 366 (83.6%) parents/caregivers who had decided, 353 (26.8%) and 125 (34.2%) had significant decision regret, respectively. In addition, 1028 (50%) respondents made their decision alone without considering the opinions of clinicians. CONCLUSIONS: During COVID-19, Canadians who responded to the survey faced several new health-related decisions. Many reported unmet decision-making needs, resulting in SDC and decision regret. Interventions can be designed to address their decisional needs and support patients facing new health-related decisions.

Combination pharmacotherapy for the treatment of neuropathic pain in adults: systematic review and meta-analysis.

ABSTRACT: Neuropathic pain causes substantial morbidity and healthcare utilization. Monotherapy with antidepressants or anticonvulsants often fails to provide relief. Combining different drugs sometimes provides improved analgesia and/or tolerability. More than half of patients receive 2 or more analgesics, and combination trials continue to emerge. This review comprehensively searched CENTRAL, MEDLINE, and EMBASE for relevant trials. Included studies are double-blind randomized controlled trials evaluating combinations of 2 or more drugs vs placebo or at least one monotherapy in adults with neuropathic pain. Outcomes included measures of efficacy and adverse effects. Risk of bias was assessed. Meta-analyses compared combination to monotherapy wherever 2 or more similar studies were available. Forty studies (4741 participants) were included. Studies were heterogenous with respect to various characteristics, including dose titration methods and administration (ie, simultaneous vs sequential) of the combination. Few combinations involved a nonsedating drug, and several methodological problems were identified. For opioid-antidepressant, opioid-gabapentinoid, and gabapentinoid-antidepressant combinations, meta-analyses failed to demonstrate superiority over both monotherapies. In general, adverse event profiles were not substantially different for combination therapy compared with monotherapy. Despite widespread use and a growing number of trials, convincing evidence has not yet emerged to suggest superiority of any combination over its respective monotherapies. Therefore, implementing combination therapy-as second- or third-line treatment-in situations where monotherapy is insufficient, should involve closely monitored individual dosing trials to confirm safety and overall added benefit. Further research is needed, including trials of combinations involving nonsedating agents, and to identify clinical settings and specific combinations that safely provide added benefit.

A survey of healthcare professionals' perceptions of the decisional needs of parents with an infant born with a disorder/difference of sex development.

INTRODUCTION: Parents of infants born with differences in sex development (DSD) face many difficult decisions. As part of a larger project designed to develop educational interventions to promote shared decision making, this study assessed healthcare professionals' (HCPs) perceptions of parental decision-making needs when an infant is born with a DSD. METHODS: A cross-sectional web-based survey following the Ottawa Decision Support Framework was conducted in two waves, between October 2020 and June 2022. Survey domains included: common DSD decisions, indicators of parents' decisional needs, and resources and approaches to support parental decision making. Eligible participants were HCPs working within interprofessional pediatric DSD centers in the USA. Up to three reminders were sent. Descriptive analysis was conducted. RESULTS: 71 HCPs participated; most (>90%) reported parents experience signs of decisional conflict including feeling unsure, worrying about what could go wrong, and fear of choosing a "wrong," irreversible option. The majority (90%) reported parents experience strong emotions interfering with their receptivity to information or deliberation. The majority (>70%) identified inadequate parental knowledge of the DSD as a barrier to decision making, coupled with information overload (>90%). HCPs rated several factors as "very" important, including: parents having information on benefits, harms, and other features of options (93%), having information about all the available options (87%), and having access to providers to discuss the options (84%). Providers endorsed using a variety of approaches to support parents' decision making; however, access to decision aids was not universally rated as highly important (very, 44%; somewhat, 46%; a little, 10%). IMPLICATIONS: Overall, HCPs expressed favorable attitudes toward supporting active parental participation in medical decision making. Opportunities for enhanced support of shared decision making included: a) recognizing and addressing parental emotional distress and informational overload at a time when parents need to consider complex options for their infant or young child; and b) the need for HCPs to encourage values clarification in decision-making encounters with parents.

Glial-modulating agents for the treatment of pain: protocol for a systematic review.

INTRODUCTION: Evidence suggests a role for Central nervous system glia in pain transmission and in augmenting maladaptive opioid effects. Identification of drugs that modulate glia has guided the evaluation of glial suppression as a pain management strategy. This planned systematic review will describe evidence of the efficacy and adverse effects of glial-modulating drugs in pain management. METHODS AND ANALYSIS: A detailed search will be conducted on the Cochrane Central Register of Controlled Trials, Medline, and Embase from their inception until the date the final searches are run to identify relevant randomised controlled trials. The reference lists of retrieved studies, as well as online trial registries, will also be searched. English language, randomised, double-blind trials comparing various glial-modulating drugs with placebo and/or other comparators, with participant-reported pain assessment, will be included. Two reviewers will independently evaluate studies for eligibility, extract data and assess trial quality and potential bias. Risk of bias will be assessed using criteria outlined in the Cochrane Handbook for Systematic Review of Interventions. Primary outcomes for this review will include any validated measure of pain intensity and/or pain relief. Dichotomous data will be used to calculate risk ratio and number needed to treat or harm. The quality of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation. ETHICS AND DISSEMINATION: This systematic review does not require formal ethics approval. The findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42021262074.

Decision coaching for people making healthcare decisions.

BACKGROUND: Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching. OBJECTIVES: To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects. SEARCH METHODS: We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021. SELECTION CRITERIA: We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions. DATA COLLECTION AND ANALYSIS: Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence. MAIN RESULTS: Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms.  For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low.  For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low. AUTHORS' CONCLUSIONS: Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.

Pharmacotherapy for the Prevention of Chronic Pain after Surgery in Adults: An Updated Systematic Review and Meta-analysis.

BACKGROUND: Chronic postsurgical pain can severely impair patient health and quality of life. This systematic review update evaluated the effectiveness of systemic drugs to prevent chronic postsurgical pain. METHODS: The authors included double-blind, placebo-controlled, randomized controlled trials including adults that evaluated perioperative systemic drugs. Studies that evaluated same drug(s) administered similarly were pooled. The primary outcome was the proportion reporting any pain at 3 or more months postsurgery. RESULTS: The authors identified 70 new studies and 40 from 2013. Most evaluated ketamine, pregabalin, gabapentin, IV lidocaine, nonsteroidal anti-inflammatory drugs, and corticosteroids. Some meta-analyses showed statistically significant-but of unclear clinical relevance-reductions in chronic postsurgical pain prevalence after treatment with pregabalin, IV lidocaine, and nonsteroidal anti-inflammatory drugs. Meta-analyses with more than three studies and more than 500 participants showed no effect of ketamine on prevalence of any pain at 6 months when administered for 24 h or less (risk ratio, 0.62 [95% CI, 0.36 to 1.07]; prevalence, 0 to 88% ketamine; 0 to 94% placebo) or more than 24 h (risk ratio, 0.91 [95% CI, 0.74 to 1.12]; 6 to 71% ketamine; 5 to 78% placebo), no effect of pregabalin on prevalence of any pain at 3 months (risk ratio, 0.88 [95% CI, 0.70 to 1.10]; 4 to 88% pregabalin; 3 to 80% placebo) or 6 months (risk ratio, 0.78 [95% CI, 0.47 to 1.28]; 6 to 68% pregabalin; 4 to 69% placebo) when administered more than 24 h, and an effect of pregabalin on prevalence of moderate/severe pain at 3 months when administered more than 24 h (risk ratio, 0.47 [95% CI, 0.33 to 0.68]; 0 to 20% pregabalin; 4 to 34% placebo). However, the results should be interpreted with caution given small study sizes, variable surgical types, dosages, timing and method of outcome measurements in relation to the acute pain trajectory in question, and preoperative pain status. CONCLUSIONS: Despite agreement that chronic postsurgical pain is an important topic, extremely little progress has been made since 2013, likely due to study designs being insufficient to address the complexities of this multifactorial problem.

Quality of telephone-based cancer symptom management by nurses: a quality improvement project.

PURPOSE: To determine the quality of cancer symptom management when evidence from clinical practice guidelines are used in telephone-based oncology nursing services. METHODS: Guided by the Knowledge to Action Framework, we conducted a quality improvement (QI) project focused on "monitoring knowledge use" (e.g., use of practice guides) and "measuring outcomes." In 2016, 15 Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) practice guides that synthesize evidence from guidelines were implemented with training for all oncology nurses at a regional ambulatory oncology program. Eighteen months post-implementation, Symptom Management Analysis Tool (SMAT) was used to analyze audio-recorded calls and related documentation of cancer symptom management. RESULTS: Of 113 audio-recorded calls, 66 were COSTaRS symptoms (58%), 43 other symptoms (38%), and 4 medically complex situations (4%). Of 66 recorded calls, 63 (95%) were documented. Average SMAT quality score was 71% (range 21-100%) for audio-recordings and 63% (range 19-100%) for documentation of calls. COSTaRS practice guide use was documented in 33% calls. For these calls, average SMAT quality scores were 74% with COSTaRS versus 69% without COSTaRS for audio-recording and 73% (range 33-100%) with COSTaRS versus 58% without COSTaRS for documentation. Patient outcomes indicated symptom was resolved (38%), worse (25%), unchanged (3%), or unknown (33%). Eight patients (13%) had an ED visit within 14 days post that was related to the symptom discussed. CONCLUSIONS: Only a third of nurses indicated use of COSTaRS practice guides. There were higher quality symptom management scores when COSTaRS use was reported. Nurses documented less than what they discussed.

Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) practice guides - What's changed in Version 2020?

The pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) practice guides present evidence on symptom management in user-friendly formats and using plain language. The aim of this work is to summarize changes to the practice guides based on new evidence including management specific to immune checkpoint inhibitors (ICIs). A systematic review of literature was conducted to identify clinical practice guidelines and systematic reviews. For version 2020, there is new evidence from 86 sources (range 2-16; mean 9 per guide), including 14 specific to ICIs, and we removed 21 outdated sources. The 15 COSTaRS practice guides were updated and 2 new guides created for mouth dryness and skin rash. The National Cancer Institute's common terminology criteria for adverse events (NCI-CTCAE) grading was added to the assessment results. "Review self-care strategies" was changed to "Review 3 or more self-care strategies". There were changes based on new evidence and ensuring consistency across practice guides. The 2020 update was validated by oncology nurses from across Canada.

Quality of telephone nursing services for adults with cancer and related non-emergent visits to the emergency department.

A quality improvement project was conducted to determine the quality of telephone nursing for patients with cancer symptoms. Eligible patients were ones who telephoned the nurse about cancer symptom(s) within four weeks prior to an emergency department (ED) visit not requiring hospital admission. Experienced oncology nurses extracting data indicated appropriateness of ED visits and opportunities for improvement. The Symptom Management Analysis Tool was used to analyze nurse documentation. For 77 patients, 87% ED visits occurred within four days of calls about symptoms (e.g., pain, breathlessness, constipation, diarrhea, nausea/vomiting) and 91% could have been managed by more complete telephone assessment and/or an urgent clinic visit. Quality of nurse documentation revealed few patients were assessed adequately (38%), received any symptom-specific medication review (49%), or were guided in self-care strategies (17%). There was low-quality telephone symptom management by nurses and a need for alternative options for patients requiring urgent face-to-face assessments. Our findings highlight a gap in use of guidelines for informing telephone symptom management.