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Objectives: The proposed study aims to assess users' perceptions of a surgical safety checklist (SSC) reimplementation toolkit and its impact on SSC attitudes and operating room (OR) culture, meaningful checklist use, measures of surgical safety, and OR efficiency at 3 different hospital sites. Background: The High-Performance Checklist toolkit (toolkit) assists surgical teams in modifying and implementing or reimplementing the World Health Organization's SSC. Through the explore, prepare, implement, and sustain implementation framework, the toolkit provides a process and set of tools to facilitate surgical teams' modification, implementation, training on, and evaluation of the SSC. Methods: A pre-post intervention design will be used to assess the impact of the modified SSC on surgical processes, team culture, patient experience, and safety. This mixed-methods study includes quantitative and qualitative data derived from surveys, semi-structured interviews, patient focus groups, and SSC performance observations. Additionally, patient outcome and OR efficiency data will be collected from the study sites' health surveillance systems. Data analysis: Statistical data will be analyzed using Statistical Product and Service Solutions, while qualitative data will be analyzed thematically using NVivo. Furthermore, interview data will be analyzed using the Consolidated Framework for Implementation Research and reach, effectiveness, adoption, implementation, maintenance implementation frameworks. Setting: The toolkit will be introduced at 3 diverse surgical sites in Alberta, Canada: an urban hospital, university hospital, and small regional hospital. Anticipated impact: We anticipate the results of this study will optimize SSC usage at the participating surgical sites, help shape and refine the toolkit, and improve its usability and application at future sites.
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Digital phenotyping, the moment-by-moment quantification of human behavior in situ using data from personal digital devices, is a potentially powerful tool for increasing understanding of recovery from surgery. While physical metrics are often emphasized, measures of emotional, cognitive, and psychosocial function are important aspects for the surgeon, a better understanding of which can lead to improved preoperative counseling and optimization, shared decision-making, and monitoring of recovery after surgery. A growing number of studies have begun to characterize these techniques. Ultimately, this tool may provide rich data about the perioperative period that will help surgeons and patients alike.
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Recuperação de Função Fisiológica , Humanos , Fenótipo , Dispositivos Eletrônicos VestíveisRESUMO
Importance: Most of the rapid increase in cutaneous melanoma incidence in the US has been localized disease that is treated surgically and is associated with high survival rates. However, little is known about the psychological well-being of survivors in the US. Objective: To explore the lived experiences and fear of cancer recurrence among survivors of localized cutaneous melanoma. Design, Setting, and Participants: This was a qualitative and survey-based study that used semistructured interviews and the Fear of Cancer Recurrence Inventory short form (FCRI-SF) survey tool with participants recruited from an academic dermatology practice affiliated with the University of Texas, Austin. Interviews were completed via telephone or in person from August 2021 to September 2022. Each of the 9 items in the FCRI-SF was rated on a 5-point Likert scale, scored from 0 to 4, with a maximum possible score of 36 points. Data analyses were performed from February 2022 to June 2023. Main Outcomes and Measures: Semistructured interviews were analyzed for themes and subthemes associated with the lived experiences of survivors of cutaneous melanoma. The FCRI-SF scores were tabulated, with scores of 13 or greater identifying potential cases of clinically significant fear of cancer recurrence. Results: In all, 51 participants (mean [SD] age, 49.5 [11.7] years; 34 [67%] female and 17 [33%] male) with a history of localized melanoma (stage 0-IIA) completed the interview and survey. Among them, 17 (33%) had survived a diagnosis of stage 0 melanoma, and the remainder, at least 1 invasive melanoma diagnosis (stage I-IIA). Semistructured interviews revealed several themes: (1) emotions surrounding follow-up appointments, (2) intensity of melanoma surveillance, (3) lifestyle changes regarding sun exposure, and (4) thoughts about life and death. Thirty-eight of 51 participants had an FCRI-SF score above the threshold for clinical fear of cancer recurrence. Conclusions and Relevance: This qualitative and survey-based study found that despite having an excellent prognosis, some survivors of localized melanoma, even those who had stage 0, have high rates of fear of cancer recurrence and intense survivorship experiences that affect their psychological well-being.
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Sobreviventes de Câncer , Medo , Melanoma , Recidiva Local de Neoplasia , Neoplasias Cutâneas , Humanos , Melanoma/psicologia , Neoplasias Cutâneas/psicologia , Neoplasias Cutâneas/patologia , Masculino , Feminino , Medo/psicologia , Recidiva Local de Neoplasia/psicologia , Recidiva Local de Neoplasia/epidemiologia , Pessoa de Meia-Idade , Sobreviventes de Câncer/psicologia , Adulto , Idoso , Inquéritos e Questionários , Pesquisa Qualitativa , Qualidade de Vida , Melanoma Maligno Cutâneo , Entrevistas como AssuntoRESUMO
Doege-Potter syndrome occurs when incompletely processed insulin-like growth factor 2 (IGF-2), also known as big IGF-2, is produced by a solitary fibrous tumor (SFT) and results in non-islet cell tumor hypoglycemia (NICTH). We discuss here the case of a 66-year-old male who presented with a 2-week history of increasing confusion and a serum glucose of 34â mg/dL. The patient's symptoms immediately improved with dextrose. The patient did not use insulin, serum sulfonylurea screen was negative, and testing for adrenal insufficiency was unremarkable. Outpatient laboratory evaluation revealed a serum glucose of 48â mg/dL along with low insulin, C-peptide, and proinsulin levels. Further work-up showed an IGF-2 to IGF-1 ratio of 38:1. A ratio greater than 10:1 is diagnostic of NICTH. Imaging demonstrated a 21-cm mass in the lower abdomen and pelvis. The patient underwent surgical resection. The hypoglycemia resolved immediately postoperatively. Surgical pathology revealed a malignant SFT. In NICTH, big IGF-2 forms a complex that is biologically active and saturates the insulin and IGF receptors, resulting in refractory hypoglycemia. Although glucocorticoids can mitigate hypoglycemia, complete surgical resection is the only definitive treatment of NICTH. This case highlights the importance of maintaining a broad differential for seemingly simple hypoglycemia.
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This cross-sectional study examines the surgical workforce in all counties across the US from 2010 to 2020.
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Vulnerabilidade Social , Cirurgiões , Humanos , Estados Unidos , Recursos Humanos , População RuralRESUMO
BACKGROUND: Previous studies of hospital-based patients with metastatic melanoma suggest sociodemographic factors, including insurance type, may be associated with the receipt of systemic treatments. OBJECTIVES: To examine whether insurance type is associated with the receipt of systemic treatment among patients with melanoma in a broad cohort of patients in North Carolina. METHODS: We conducted a retrospective cohort study between 2011 and 2017 of patients with stages III-IV melanoma using data from the North Carolina Central Cancer Registry linked to Medicare, Medicaid, and private health insurance claims across the state. The primary outcome was the receipt of any systemic treatment, and the secondary outcome was the receipt of immunotherapy. RESULTS: A total of 372 patients met the inclusion criteria. The average age was 68 years old (interquartile range: 56-76) and 61% were male. Within the cohort 48% had Medicare only, 29% had private insurance, 12% had both Medicare and Medicaid, and 11% had Medicaid only. A total of 186 (50%) patients received systemic treatment for melanoma, 125 (67%) of whom received immunotherapy. The use of systemic therapy, including immunotherapy, increased significantly over time. Having Medicaid-only insurance was independently associated with a 45% lower likelihood of receiving any systemic treatment [0.55 (95% CI: 0.35, 0.85)] and a 43% lower likelihood of receipt of immunotherapy [0.57 (95% CI: 0.34, 0.95)] compared with private insurance. CONCLUSIONS: Stage III-IV melanoma patients with Medicaid-only insurance were less likely to receive systemic therapy or immunotherapy than patients with private insurance or Medicare insurance. This finding raises concerns about insurance-based disparities in treatment access.
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Medicare , Melanoma , Humanos , Masculino , Idoso , Estados Unidos , Feminino , North Carolina , Estudos Retrospectivos , Seguro Saúde , Medicaid , Melanoma/terapia , Melanoma Maligno CutâneoRESUMO
INTRODUCTION: Social media platforms like Twitter are highly utilized for communicating about cancer care. Although surgery is the primary curative treatment for solid malignancies, little is known about online communication behaviors regarding this treatment modality. This study tracked online discussions and characterized participants to better characterize the content of public communication about surgical cancer care. METHODS: Tweets referencing cancer surgery were collected from 2018 to 2021 using Twitter's Application Programming Interface. Metadata (e.g., profile biography, follower count) was used to predict user demographic information. Natural language processing was performed using Latent Dirichlet Allocation to identify common themes of conversation and mentioned cancer sites. RESULTS: There were 442,840 tweets about cancer surgery by 262,168 users, including individuals (65%), influencers (1.5%), surgeons (1%), and oncologists (0.5%). Following the onset of the COVID-19 pandemic, tweets mentioning delays in care increased by 21.7% (1971-57,846 tweets). Individuals commonly mentioned surgical costs (20.3%) and postoperative recovery (21.6%). Surgeons and oncologists frequently mentioned research (52.7%), but infrequently mentioned community support (7.8%) or survivorship (9.3%). Relative to their prevalence, neurologic cancers were most discussed (231 tweets per 1000 operations) while thoracic (29 tweets per 1000 operations) and urologic cancers were least discussed (12 tweets per 1000 operations). CONCLUSIONS: Twitter was utilized by patients to discuss real-time issues such as COVID-19-related surgical delays and the financial burden of cancer surgery. Further efforts to improve community outreach may be optimized by targeting greater discussion of undermentioned cancer types and encouraging clinicians to participate in discussions about community-centered themes.
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COVID-19 , Neoplasias , Mídias Sociais , Humanos , COVID-19/epidemiologia , Pandemias , Comunicação , Neoplasias/cirurgiaRESUMO
PURPOSE: To assess the impact of primary-site surgery plus systemic therapy compared to systemic therapy alone on overall survival in common metastatic cancer types. METHODS: Data sources included Embase, PubMed, and Web of Science (January 1, 1995-March 22, 2023). Randomized controlled trials were included that enrolled patients diagnosed with the 10 most common de novo metastatic cancer types in the Surveillance, Epidemiology, and End Results database and randomized patients to resection of the primary site and systemic therapy versus systemic treatment alone. Random-effects models were used to pool associations by cancer type. RESULTS: Eight studies with 1774 patients evaluating the efficacy of surgery in breast, renal, stomach, and colorectal cancer were included. There was no statistically significant reduction in risk of all-cause mortality associated with surgical intervention for metastatic breast (HR = 0.94, 95% CI 0.63-1.40) or renal cancer (HR = 0.79, 95% CI 0.53-1.20), although results were heterogeneous (I2 = 73.7% and 80.6%, respectively). One study evaluating gastrectomy in metastatic stomach cancer found no benefit (HR = 1.09, 95% CI 0.78-1.52), while a small trial suggested that surgery and hyperthermic intraperitoneal chemotherapy might be beneficial for colorectal cancer with peritoneal metastasis (HR = 0.55, 95% CI 0.32-0.95). CONCLUSIONS: Few randomized trials have evaluated cancer-directed surgery among patients with metastatic solid malignancies.
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Neoplasias Colorretais , Neoplasias Gástricas , Humanos , Neoplasias Gástricas/cirurgiaRESUMO
This cross-sectional study examines trends in the prevalence of functional limitation in cancer survivors using data from the National Health Interview Survey.
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Sobreviventes de Câncer , Neoplasias , Humanos , Estados Unidos/epidemiologia , Prevalência , Fatores de Risco , Sobreviventes , Neoplasias/epidemiologiaRESUMO
This case-control study assesses the prevalence of patient-reported delayed or forgone care due to patient-clinician identity discordance among cancer survivors and factors associated with this barrier to care.
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Sobreviventes de Câncer , Neoplasias , Humanos , Prevalência , Acessibilidade aos Serviços de Saúde , Pesquisas sobre Atenção à Saúde , Neoplasias/epidemiologia , Neoplasias/terapiaRESUMO
BACKGROUND: Musculoskeletal providers are increasingly recognizing the importance of social factors and their association with health outcomes as they aim to develop more comprehensive models of care delivery. Such factors may account for some of the unexplained variation between pathophysiology and level of pain intensity and incapability experienced by people with common conditions, such as persistent nontraumatic knee pain secondary to osteoarthritis (OA). Although the association of one's social position (for example, income, employment, or education) with levels of pain and capability are often assessed in OA research, the relationship between aspects of social context (or unmet social needs) and such symptomatic and functional outcomes in persistent knee pain are less clear. QUESTIONS/PURPOSES: (1) Are unmet social needs associated with the level of capability in patients experiencing persistently painful nontraumatic knee conditions, accounting for sociodemographic factors? (2) Do unmet health-related social needs correlate with self-reported quality of life? METHODS: We performed a prospective, cross-sectional study between January 2021 and August 2021 at a university academic medical center providing comprehensive care for patients with persistent lower extremity joint pain secondary to nontraumatic conditions such as age-related knee OA. A final 125 patients were included (mean age 62 ± 10 years, 65% [81 of 125] women, 47% [59 of 125] identifying as White race, 36% [45 of 125] as Hispanic or Latino, and 48% [60 of 125] with safety-net insurance or Medicaid). We measured patient-reported outcomes of knee capability (Knee injury and Osteoarthritis Outcome Score for Joint Replacement), quality of life (Patient-Reported Outcome Measure Information System [PROMIS] Global Physical Health and PROMIS Global Mental Health), and unmet social needs (Accountable Health Communities Health-Related Social Needs Survey, accounting for insufficiencies related to housing, food, transportation, utilities, and interpersonal violence), as well as demographic factors. RESULTS: After controlling for demographic factors such as insurance status, education attained, and household income, we found that reduced knee-specific capability was moderately associated with experiencing unmet social needs (including food insecurity, housing instability, transportation needs, utility needs, or interpersonal safety) (standardized beta regression coefficient [ß] = -4.8 [95% confidence interval -7.9 to -1.7]; p = 0.002 and substantially associated with unemployment (ß = -13 [95% CI -23 to -3.8]; p = 0.006); better knee-specific capability was substantially associated with having Medicare insurance (ß = 12 [95% CI 0.78 to 23]; p = 0.04). After accounting for factors such as insurance status, education attained, and household income, we found that older age was associated with better general mental health (ß = 0.20 [95% CI 0.0031 to 0.39]; p = 0.047) and with better physical health (ß = 0.004 [95% CI 0.0001 to 0.008]; p = 0.04), but effect sizes were small to negligible, respectively. CONCLUSION: There is an association of unmet social needs with level of capability and unemployment in patients with persistent nontraumatic knee pain. This finding signals a need for comprehensive care delivery for patients with persistent knee pain that screens for and responds to potentially modifiable social risk factors, including those based on one's social circumstances and context, to achieve better outcomes. LEVEL OF EVIDENCE: Level II, prognostic study.
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Osteoartrite do Joelho , Qualidade de Vida , Humanos , Feminino , Idoso , Estados Unidos , Pessoa de Meia-Idade , Estudos Transversais , Estudos Prospectivos , Medicare , Dor , Osteoartrite do Joelho/complicações , Osteoartrite do Joelho/diagnóstico , Osteoartrite do Joelho/psicologiaRESUMO
OBJECTIVES: To explore the surgeon-perceived added value of mobile health technologies (mHealth), and determine facilitators of and barriers to implementing mHealth. BACKGROUND: Despite the growing popularity of mHealth and evidence of meaningful use of patient-generated health data in surgery, implementation remains limited. METHODS: This was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify surgeons across the United States and Canada. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Video-based interviews were conducted (September-November 2020) and interview transcripts were thematically analyzed. RESULTS: Thirty surgeons from 8 specialties and 6 North American regions were interviewed. Surgeons identified opportunities to integrate mHealth data pre- operatively (eg, expectation-setting, decision-making) and during recovery (eg, remote monitoring, earlier detection of adverse events) among higher risk patients. Perceived advantages of mHealth data compared with surgical and patient-reported outcomes included easier data collection, higher interpretability and objectivity of mHealth data, and the potential to develop more patientcentered and functional measures of health. Surgeons identified a variety of implementation facilitators and barriers around surgeon- and patient buy-in, integration with electronic medical records, regulatory/reimbursement concerns, and personnel responsible for mHealth data. Surgeons described similar considerations regarding perceptions of mHealth among patients, including the potential to address or worsen existing disparities in surgical care. CONCLUSIONS: These findings have the potential to inform the effective and equitable implementation of mHealth for the purposes of supporting patients and surgical care teams throughout the delivery of surgical care.
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Grupos Raciais , Telemedicina , Humanos , Tecnologia Biomédica , Canadá , Pesquisa QualitativaRESUMO
From smartphones or wearables to portable physiologic sensors and apps, healthcare is witnessing an exponential growth in mHealth-digital health tools used to support medical and surgical care, as well as public health. In surgery, there is interest in harnessing the capabilities of mHealth to improve the quality of patient-centered care delivery. Digitally delivered surveys have enhanced patient-reported outcome measurement and patient engagement throughout care. Wearable devices and sensors have allowed for the assessment of physical fitness before surgery and during recovery. Smartphone-based digital phenotyping has introduced novel methods of integrating multiple data streams (accelerometer, global positioning system, call and text logs) to create multidimensional digital health footprints for patients following surgery. Yet, with all the technological sophistication and 'big data' mHealth provides, widespread implementation has been elusive. Do clinicians and patients find these data valuable or clinically actionable? How can mHealth become integrated into the day-to-day workflows of surgical systems? Do these data represent opportunities to address disparities of care or worsen them? In this review, we discuss experiences and future opportunities to use mHealth to enhance patient-centered surgical care.
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Aplicativos Móveis , Telemedicina , Envio de Mensagens de Texto , Tecnologia Biomédica , Humanos , Assistência Centrada no Paciente , Smartphone , Telemedicina/métodosRESUMO
AIMS: Daily micro-surveys, or the high-frequency administration of patient-reported outcome measures (PROMs), may provide real-time, unbiased assessments of health-related quality of life (HRQoL). We evaluated the feasibility and accuracy of daily micro-surveys using a smartphone platform among patients recovering from cancer surgery. METHODS: In a prospective study (2017-2019), patients undergoing cancer surgery downloaded a smartphone application that administered daily micro-surveys comprising five randomly selected items from the Short Form-36 (SF-36). Micro-surveys were administered without replacement until the entire SF-36 was administered weekly. The full-length SF-36 was also administered preoperatively and 4, 12, and 24 weeks postoperatively. We assessed response and completion rates between the micro-surveys and full-length SF-36, as well as agreement of responses using Bland-Altman (B&A) analyses. RESULTS: Ninety-five patients downloaded the application and were followed for a mean of 131 days [SD ± 85]. Response rates for the full-length SF-36 and micro-surveys was 76% [95%CI 69, 83], and 34% [95%CI 26, 39]. Despite lower response rates, more SF-36 surveys were collected using the daily micro-surveys compared to the intermittent full-length SF-36 (9.9 [95%CI 8.4, 12.6] vs. 3.0 [95%CI 2.8, 3.3], respectively). B&A analyses demonstrated lack of agreement between micro-surveys and SF-36. However, agreement improved with higher micro-survey completion rate. Eighty-five percent of participants reported that daily micro-surveys were not burdensome. CONCLUSION: This study suggests that collection of daily micro-surveys among patients recovering from cancer surgery is feasible using smartphones in the early postoperative period. Future implementation of daily micro-surveys may more granularly describe momentary HRQoL changes through a greater volume of self-reported survey data.
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Neoplasias , Smartphone , Estudos de Viabilidade , Humanos , Neoplasias/cirurgia , Estudos Prospectivos , Qualidade de Vida/psicologia , Inquéritos e QuestionáriosRESUMO
Merkel cell carcinoma (MCC) is a rare, aggressive primary neuroendocrine carcinoma of the skin that can present in immunocompromised patients. Kaposi sarcoma (KS) is an indolent angioproliferative tumor associated with human herpesvirus 8 (HHV8). The concurrence of both MCC and KS is rare, and there have been limited cases reported in the literature. We present a rare case of concurrent MCC and KS in an immunocompromised patient. To our knowledge, this is the first report of MCC and KS described in the same histopathological specimen. A 37-year-old Black male with a history of recurrent AIDS-related KS involving bilateral lower extremities was evaluated for a tender nodule on the left posterior leg. A punch biopsy was consistent with MCC. Magnetic resonance imaging brain and full-body positron emission tomography/computed tomography (PET/CT) scan were without evidence of distant metastasis. The patient underwent wide local excision with negative margins and completed postoperative radiation therapy. However, he later developed cutaneous metastasis of MCC to the left medial thigh and excision revealed residual MCC with adjacent KS. Treatment is still ongoing with pembrolizumab for both KS and MCC.
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Infecções Oportunistas Relacionadas com a AIDS/patologia , Carcinoma de Célula de Merkel/patologia , Sarcoma de Kaposi/patologia , Neoplasias Cutâneas/patologia , Adulto , Humanos , Masculino , Neoplasias Primárias Múltiplas/patologiaRESUMO
OBJECTIVE: To determine the prevalence of clinically significant decision conflict (CSDC) among patients undergoing cancer surgery and associations with postoperative physical activity, as measured through smartphone accelerometer data. BACKGROUND: Patients with cancer face challenging treatment decisions, which may lead to CSDC. CSDC negatively affects patient-provider relationships, psychosocial functioning, and health-related quality of life; however, physical manifestations of CSDC remain poorly characterized. METHODS: Adult smartphone-owners undergoing surgery for breast, skin-soft-tissue, head-and-neck, or abdominal cancer (July 2017-2019) were approached. Patients downloaded the Beiwe application that delivered the Decision Conflict Scale (DCS) preoperatively and collected smartphone accelerometer data continuously from enrollment through 6âmonths postop-eratively. Restricted-cubic-spline regression, adjusting for a priori potential confounders (age, type of surgery, support status, and postoperative complications) was used to determine trends in postoperative daily physical activity among patients with and without CSDC (DCS score >25/100). RESULTS: Among 99 patients who downloaded the application, 85 completed the DCS (86% participation rate). Twenty-three (27%) reported CSDC. These patients were younger (mean age 48.3âyears [standard deviation 14.2]-vs-55.0 [13.3], P = 0.047) and more frequently lived alone (22%-vs-6%, P = 0.042). There were no differences in preoperative physical activity (115.4âminutes [95%CI 90.9, 139.9]-vs-110.8 [95%CI 95.7, 126.0], P = 0.753). Adjusted postoperative physical activity was lower among patients reporting CSDC at 30âdays (difference 33.1 minutes [95%CI 5.93,60.2], P = 0.017), 60âdays 35.5 [95%CI 8.50, 62.5], P = 0.010 and 90âdays 31.8 [95%CI 5.44, 58.1], P = 0.018 postoperatively. CONCLUSIONS: CSDC was prevalent among patients who underwent cancer surgery and associated with lower postoperatively daily physical activity. These data highlight the importance of addressing modifiable decisional needs of patients through enhanced shared decision-making.
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Neoplasias , Smartphone , Adulto , Exercício Físico , Humanos , Pessoa de Meia-Idade , Neoplasias/cirurgia , Estudos Prospectivos , Qualidade de VidaRESUMO
Patient expectations of the impact of surgery on postoperative health-related quality of life (HRQL) may reflect the effectiveness of patient-provider communication. We sought to compare expected versus experienced HRQL among patients undergoing cancer surgery. METHODS: Adults undergoing cancer surgery were eligible for inclusion (2017-2019). Preoperatively, patients completed a smartphone-based survey assessing expectations for HRQL 1 week and 1, 3, and 6 months postoperatively based on the 8 short-form 36 (SF36) domains (physical functioning, physical role limitations, pain, general health, vitality, social functioning, emotional role limitations, and mental health). Experienced HRQL was then assessed through smartphone-based SF36 surveys 1, 3, and 6 months postoperatively. Correlations between 1- and 6-month trends in expected versus experienced HRQL were determined. RESULTS: Among 101 consenting patients, 74 completed preoperative expectations and SF36 surveys (73%). The mean age was 54 years (SD 14), 49 (66%) were female, and the most common operations were for breast (34%) and abdominal (31%) tumors. Patients expected HRQL to worsen 1 week after surgery and improve toward minimal disability over 6 months. There was poor correlation (≤±0.4) between 1- and 6-month trends in expected versus experienced HRQL in all SF36 domains except for moderate correlation in physical functioning (0.50, 95% confidence interval [0.22-0.78], P < 0.001) and physical role limitations (0.41, 95% confidence interval [0.05-0.77], P = 0.024). Patients expected better HRQL than they experienced. CONCLUSIONS: Preoperative expectations of postoperative HRQL correlated poorly with lived experiences except in physical health domains. Surgeons should evaluate factors which inform expectations around physical and psychosocial health and use these data to enhance shared decision-making.