Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 151
Filtrar
Filtros adicionais











Intervalo de ano
1.
Breast J ; 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31478585

RESUMO

While radiotherapy can be safely omitted in many older women with early-stage breast cancer after lumpectomy, approximately two-thirds of eligible women still undergo this treatment. We surveyed 63 older women with stage I (T1N0M0), estrogen-receptor-positive breast cancer who underwent lumpectomy, and were considering/receiving radiotherapy. Participants perceived that radiotherapy would reduce their 10-year risk of local recurrence by an average of 18.7%, which is significantly higher than the 8% risk reduction reported in literature. Multivariate analyses demonstrated that participants who reported a large perceived benefit were significantly more likely to undergo radiotherapy treatment (odds ratio 10.34; 95% confidence interval: 1.66-66.35).

2.
AIDS Care ; : 1-6, 2019 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-31288547

RESUMO

ABSTRACT The Dual Motivational Model of pre-exposure prophylaxis (PrEP) use intention (DMM) is a new theoretical model recently tested among men who have sex with men (MSM) in the United States. The model posits that there are two main motivational pathways to use PrEP: the Protection Motivation Pathway and the Expectancy Motivation Pathway. The Protection Motivation Pathway suggests that the intention to use PrEP is triggered by the desire to protect oneself from HIV, while the Expectancy Motivation Pathway suggests that PrEP use intention is triggered by the expectation to have better sexual experiences on PrEP. Although both motivators have been tested separately, only the DMM of PrEP use intention suggests that both pathways simultaneously influence an individual's intention to use PrEP. We used data from 1078 MSM in Ukraine to test the DMM. Results show that the relationship of the pathways is similar among Ukrainian and American MSM. Potential explanations for minor differences may be related to cultural and contextual differences, and the different trajectories for PrEP roll-out. Successful validation of the DMM for PrEP use intention as a theoretical model suggests that it may be applied to other cultures contemplating PrEP use delivery to target health promotion among high risk MSM.

3.
J Gen Intern Med ; 34(8): 1530-1537, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31161566

RESUMO

BACKGROUND: Patient care ownership is essential to delivering high-quality medical care but appears to be eroding among trainees. The lack of an objective measure has limited the study of ownership in physicians. OBJECTIVE: To develop an instrument to measure psychological ownership of patient care. DESIGN: Cross-sectional study. PARTICIPANTS: Internal medicine trainees in a large, academic hospital completing an inpatient rotation. MAIN MEASURES: Our scale prototype adapted an existing ownership scale (developed in the non-medical setting) based on themes identified in qualitative studies of patient care ownership. We conducted cognitive interviews to determine face validity of the scale items. Our finalized scale measures ownership's key constructs: advocacy, responsibility, accountability, follow-through, knowledge, communication, initiative, continuity of care, autonomy, and perceived ownership. We distributed an online, anonymous, 46-question survey to 219 residents; 192 residents completed the survey; and 166 responses were included in the analysis. We calculated Cronbach's α to determine the scale's internal consistency. Exploratory factor analysis was used to explore possible subscales. We examined construct validity using bivariate and correlational analysis. KEY RESULTS: The 15-item ownership scale demonstrated good internal consistency (Cronbach's α = 0.89). We identified three possible subscales corresponding to assertiveness, being the "go-to" person, and diligence. Training level and prior intensive care unit experience significantly predicted ownership (p < 0.01). There was no significant relationship between ownership and age, gender, inpatient service type, call schedule, patient turnover, or supervisory experience of the attending physician. We found a significant negative correlation between ownership and perceived degree of burnout (r = - 0.33), depression (r = - 0.24), detachment (r = - 0.35), and frustration (r = - 0.31) and a significant positive association between ownership and fulfillment (r = 0.37) and happiness (r = 0.36). CONCLUSION: We developed an instrument to quantify patient care ownership in residents. Our scale demonstrates good internal consistency and preliminary evidence of validity. With further validation, we expect this to be a valuable tool to evaluate interventions aimed at improving ownership.

4.
Hosp Pediatr ; 9(6): 405-414, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31113814

RESUMO

OBJECTIVES: There is wide variation in the decision of whether to perform lumbar punctures (LPs) on well-appearing febrile infants ≤8 weeks old. Our objectives were to identify factors that influence that decision and the barriers and facilitators to shared decision-making about LP with parents of febrile infants. METHODS: We conducted semistructured interviews with 15 pediatric and general emergency medicine physicians and 8 pediatric emergency medicine nurses at an urban, academic medical center. Through interviews, we assessed physicians' practices and physicians' and nurses' perspectives about communication and decision-making with parents of febrile infants. Two researchers independently reviewed the transcripts, coded the data using the constant comparative method, and identified themes. RESULTS: Five themes emerged for factors that influence physicians' decisions about whether to perform an LP: (1) the age of the infant; (2) the physician's clinical experience; (3) the physician's use of research findings; (4) the physician's values, particularly risk aversion; and (5) the role of the primary care pediatrician. Barriers and facilitators to shared decision-making identified by physicians and by nurses included factors related to their perceptions of parents' understanding and acceptance of risks, parents' emotions, physicians' assessment of whether there is clinical equipoise, and availability of follow-up with the primary care pediatrician. CONCLUSIONS: Differences in physicians' values, use of research findings, and clinical experience likely contribute to decisions of whether to perform an LP on well-appearing febrile infants. Incorporation of parents' preferences through shared decision-making may be indicated, although there are barriers that would need to be overcome.

5.
PLoS Med ; 16(5): e1002800, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31067237

RESUMO

BACKGROUND: Treatment decision-making regarding immunosuppressive therapy is challenging for individuals with lupus. We assessed the effectiveness of a decision aid for immunosuppressive therapy in lupus nephritis. METHODS AND FINDINGS: In a United States multicenter, open-label, randomized controlled trial (RCT), adult women with lupus nephritis, mostly from racial/ethnic minority backgrounds with low socioeconomic status (SES), seen in in- or outpatient settings, were randomized to an individualized, culturally tailored, computerized decision aid versus American College of Rheumatology (ACR) lupus pamphlet (1:1 ratio), using computer-generated randomization. We hypothesized that the co-primary outcomes of decisional conflict and informed choice regarding immunosuppressive medications would improve more in the decision aid group. Of 301 randomized women, 298 were analyzed; 47% were African-American, 26% Hispanic, and 15% white. Mean age (standard deviation [SD]) was 37 (12) years, 57% had annual income of <$40,000, and 36% had a high school education or less. Compared with the provision of the ACR lupus pamphlet (n = 147), participants randomized to the decision aid (n = 151) had (1) a clinically meaningful and statistically significant reduction in decisional conflict, 21.8 (standard error [SE], 2.5) versus 12.7 (SE, 2.0; p = 0.005) and (2) no difference in informed choice in the main analysis, 41% versus 31% (p = 0.08), but clinically meaningful and statistically significant difference in sensitivity analysis (net values for immunosuppressives positive [in favor] versus negative [against]), 50% versus 35% (p = 0.006). Unresolved decisional conflict was lower in the decision aid versus pamphlet groups, 22% versus 44% (p < 0.001). Significantly more patients in the decision aid versus pamphlet group rated information to be excellent for understanding lupus nephritis (49% versus 33%), risk factors (43% versus 27%), medication options (50% versus 33%; p ≤ 0.003 for all); and the ease of use of materials was higher in the decision aid versus pamphlet groups (51% versus 38%; p = 0.006). Key study limitations were the exclusion of men, short follow-up, and the lack of clinical outcomes, including medication adherence. CONCLUSIONS: An individualized decision aid was more effective than usual care in reducing decisional conflict for choice of immunosuppressive medications in women with lupus nephritis. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02319525.

6.
Curr Opin Rheumatol ; 31(3): 256-263, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30747733

RESUMO

PURPOSE OF REVIEW: To provide an overview of recent articles discussing patient preferences for rheumatoid arthritis (RA) treatment. RECENT FINDINGS: Recent studies examined patient preferences for RA treatment in several populations, finding that most participants were willing to accept certain risks of adverse effects to gain potential benefits. Perspectives regarding cannabis were studied, with patients describing medical marijuana as an alternative therapy to be used with prescription medications or as means of tapering off these medications. Treatment preferences for different RA therapies were explored using a conjoint analysis survey and five distinct preference phenotypes emerged, with members of the largest group most concerned with the cost of medications. Other discrete choice studies demonstrated route of administration as an important attribute influencing treatment preferences, with patients expressing preference for various modes in different studies. Patient preferences for route of administration have demonstrated preference for newer autoinjectors over prefilled syringes as well as currently marketed autoinjectors. Incorporating patient preferences in clinical practice recommendations was described in the development of the 2015 American College of Rheumatology (ACR) RA treatment guidelines as well as the 2017 ACR/American Association of Hip and Knee Surgeons guidelines for perioperative management of antirheumatic medications. In addition, other studies explored preferences with regard to predictive testing, medication intensification and tapering, treatment goals, and psychological support. SUMMARY: Our review of recent studies show variability in patient preferences for RA treatment, highlighting the importance of incorporating patient input into the treatment approach.

7.
J Rheumatol ; 2019 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-30709963

RESUMO

OBJECTIVE: The Outcome Measures in Rheumatology (OMERACT) Shared Decision Making (SDM) Working Group aims to determine the core outcome domain set for measuring the effectiveness of SDM interventions in rheumatology trials. METHODS: A white paper was developed to clarify the draft core domain set. It was then used to prepare for interviews to investigate reasons for lack of consensus on it and to suggest further improvements. RESULTS: OMERACT scientists/clinicians (n = 13) and patients (n = 10) suggested limiting the core domain set to outcome domains, removing process domains, and clarifying remaining domains. CONCLUSION: A revised core domain set will undergo further consensus-building.

8.
AIDS Care ; 31(5): 545-553, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30554519

RESUMO

INTRODUCTION: Despite documented effectiveness of pre-exposure prophylaxis (PrEP), PrEP uptake remains low among men who have sex with men (MSM), the population bearing the highest HIV burden in the U.S. OBJECTIVES: To elicit MSM stakeholder preferences in order to inform program development aimed at improving uptake of PrEP. METHODS: 554 MSM were recruited through social networking applications to complete a stated preference [choice-based conjoint (CBC)] survey. Respondents completed 14 choice tasks presenting experimentally varied combinations of five attributes related to PrEP administration (dosing frequency, dispensing venue, prescription practices, adherence support, and costs). Latent class analysis was used to estimate the relative importance of each attribute and preferences across seven possible PrEP delivery programs. RESULTS: Preferences clustered into five groups. PrEP affordability was the most influential attribute across groups, followed by dosing strategy. Only one group liked daily and on-demand PrEP equally (n = 74) while the other four groups disliked the on-demand intermittent option. Monthly injectable PrEP is preferred by two (n = 210) out of the five groups, including young MSM. Two groups (n = 267) were willing to take PrEP across all the hypothetical programs. One group (n = 183) almost exclusively considered costs in their decision-making. Participants in the most racially diverse among groups (n = 88) had a very low level of interest in PrEP initiation. CONCLUSION: Our data suggest that PrEP uptake will be maximized by making daily PrEP affordable to MSM and streamlining PrEP consultation visits for young MSM. Young MSM should be prioritized for injectable PrEP when it becomes available. A successful PrEP program will spend resources on removing structural barriers to PrEP access and educating MSM of color, and will emphasize protection of privacy to maximize uptake among rural/suburban MSM.

9.
Artigo em Inglês | MEDLINE | ID: mdl-30414353

RESUMO

OBJECTIVE: To determine the proportion of primary lipid screening among patients with rheumatoid arthritis (RA) and compare it with patients with diabetes mellitus (DM) and patients with neither RA nor DM. To determine whether primary lipid screening varied according to the healthcare provider (rheumatologist vs. non-rheumatologist). METHODS: We analyzed claims data from United States' private and public health plans from 2006-2010. Eligibility requirements included: 1) continuous medical and pharmacy coverage for ≥12 months (baseline period), and 2) >2 physician diagnoses and relevant medications to define 4 disease categories: RA, DM, RA and DM, or neither condition. Among the 330,695 eligible participants, we calculated the proportion with a lipid profile ordered during the 2 years following baseline. Time-varying Cox proportional hazard models were used to determine the probability of hyperlipidemia screening in participants with RA according to provider specialty. RESULTS: Over half the patients were 41-71 years old. Among patients with RA (n=12,182), DM (n=62,834), RA and DM (n=1,082), and neither condition (n=167,811), the proportion screened for hyperlipidemia was 37%, 60%, 55%, and 41%, respectively. Patients with RA who visited a rheumatologist and a non-rheumatology clinician during follow-up had a 55% (95% CI [1.36, 1.78]) higher screening probability than those who only visited a rheumatologist. CONCLUSION: Primary lipid screening was suboptimal among RA patients. It was also lower than patients with DM and minimally different from the general population. Screening was higher for RA patients receiving care from both a rheumatologist and a non-rheumatologist (e.g. primary care physician). This article is protected by copyright. All rights reserved.

10.
Patient Educ Couns ; 101(11): 1900-1905, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30305252

RESUMO

OBJECTIVE: To examine whether visual aids (a graphic representation and/or conceptual illustrations) influence patients' risk perceptions for rare and very rare risks. METHODS: Participants were randomized to a scenario which varied by probability of infection (2% or 0.2%) and visual aid: numbers only, numbers + graphic representation, numbers + conceptual illustrations, or numbers + graphic representation + conceptual illustrations. Risk perceptions and likelihood of starting the medication were examined across the four formats, separately, in participants with and without a college education. RESULTS: Adding a graphic representation and/or conceptual illustrations did not affect risk perceptions among those with a higher level of education. Adding both a graphic representation + conceptual illustrations decreased risk perceptions and increased likelihood of starting the medication among participants randomized to the 2%, but not 0.2% scenario, among participants with lower levels of education. CONCLUSION: Adding a graphic representation + conceptual illustrations to numbers may influence perceptions for rare, but not very rare, risks among patients with lower education. PRACTICE IMPLICATIONS: Clinicians should be aware of the differential effects of visual aids developed to facilitate risk communication. Patients with higher levels of education may be less responsive to visual aids than those with lower education.

11.
Artigo em Inglês | MEDLINE | ID: mdl-30295422

RESUMO

OBJECTIVE: To evaluate SLE patients who persistently frequent the ED to identify opportunities to improve outpatient care. METHODS: We conducted a retrospective study of SLE patients who frequented the ED for ≥3 visits in a calendar year from 2013-2016. Persistent users met criteria for frequent use for at least 2 out of the 4 years, and limited users for 1 out of the 4 years. Each ED encounter was categorized as; SLE-, infection-, pain- related, or "other". We compared ED use between persistent and limited users, and analyzed factors associated with pain-related encounters among persistent users through multivariate logistic regression. RESULTS: We identified 77 participants having 1143 encounters as persistent users, and 52 participants having 335 encounters as limited users. Persistent users accounted for 77% of ED use by SLE patients who frequented the ED. Pain-related ED visits were more common among persistent users (32%) than limited users (18%). Among persistent users, most pain-related encounters were discharged from the ED (69%) or within 48 hours of admission (20%). Persistent users with pain-related encounters accounting for >10% of ED use, were more likely to be obese, have fewer comorbid conditions, and be on LTOT. CONCLUSION: Pain is major cause of ED use. SLE patients persistently utilizing the ED for pain are likely to be non-critically ill, as evidenced by frequent discharges from the ED and short stay admissions. SLE patients who persistently frequent the ED for pain represent a viable target for interventions to improve outpatient quality of care. This article is protected by copyright. All rights reserved.

12.
Artigo em Inglês | MEDLINE | ID: mdl-30369071

RESUMO

OBJECTIVE: Treat-to-target implementation in rheumatoid arthritis (RA) requires a shared decision making (SDM) process. However, ability to pay is a major determinant of patient choice, but how this factor affects SDM is under explored. METHODS: Visits at four RA clinics during which patients faced a decision to change their treatment were audiotaped between May 2016 and June 2017. Audiotapes were transcribed verbatim and analyzed using qualitative Framework Analysis. RESULTS: 156 visits were analyzed. Most RA patients, except those with effective insurance coverage, had deliberations disrupted or sidelined by third-party insurance providers having power to authorize the preferred DMARD choice. This triangulated SDM complicated efficiency in deliberations and timely treatment, and was a barrier to shared engagement about health risks and symptom improvement typically found in patient-provider dyads. CONCLUSION: Rheumatology care providers should aim to incorporate treatment costs and ability to pay into their deliberations so individualized out-of-pocket estimates can be considered during triangulated SDM at point-of-care. This article is protected by copyright. All rights reserved.

13.
Artigo em Inglês | MEDLINE | ID: mdl-30221841

RESUMO

INTRODUCTION: Treat to target (TTT) is an accepted paradigm for care of patients with rheumatoid arthritis (RA). Since TTT can be associated with more medication switches, concerns arise whether implementing TTT may increase adverse events and/or resource use. METHODS: We used data from six practices enrolled in an 18-month cluster-randomized controlled trial to compare adverse events and resource use before (months 1-9) and during (months 10-18) a TTT intervention. The outcomes of interest, adverse events and resource use, were based on medical record review of all rheumatology visits for RA patients before and during the intervention. RESULTS: We examined records for 321 patients before the intervention and 315 during the intervention. An adverse event was recorded in 10.2% of visits before the intervention and 8.8% during the intervention (P = 0.41). Biologic DMARDs were used in 53.6% of patients before the intervention and 49.8% during the intervention (p = 0.73). Rheumatology visits were more frequent before the intervention (mean 4.0 ± 1.4) than during the intervention (mean 3.6 ± 1.2; p = 0.02). More visits were accompanied by monitoring laboratory tests before the intervention (90.0%) compared with during the intervention (52.7%; p <0.001). A greater percentage of visits before the intervention included diagnostic imaging (15.4%) versus during the intervention (8.9%; p<0.001). CONCLUSIONS: We observed similar rates of adverse events before and during the implementation of TTT for RA. Rheumatology visits, use of laboratory monitoring, and diagnostic imaging did not increase during the TTT intervention. This article is protected by copyright. All rights reserved.

14.
Am J Mens Health ; 12(6): 1843-1854, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30160195

RESUMO

Pre-exposure prophylaxis (PrEP) uptake has been extremely low among key groups. PrEP-related stigma and shaming are potential barriers to uptake and retention in PrEP programs. There is a lack of literature describing PrEP stigma. In order to fill this gap, we recruited online 43 HIV-negative Men who have Sex with Men (MSM) who use PrEP. Semistructured interviews were conducted to explore their perceptions and experience of stigma related to PrEP use. Data were analyzed using Strauss and Corbin's grounded theory and constant comparison techniques to enhance understanding of the lived experiences of MSM who use PrEP. The participants experienced PrEP stigma as rejection by potential/actual partners, stereotypes of promiscuity or chemsex, and labeling of both the user and the medication. They connected PrEP stigma with HIV stigma, generational differences, moralization of condom use, and inability to embrace one's own sexuality. These findings point to a need to develop tailored interventions to address PrEP-related stigma and shaming for individuals, health-care professionals, and the MSM community-at-large.

15.
Rheumatology (Oxford) ; 57(11): 1933-1937, 2018 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-29982720

RESUMO

Objectives: Adherence to a treat to target (TTT) strategy is a recommended paradigm for RA; however, research shows there are many barriers to implementation. We conducted a trial to improve TTT implementation, and herein examine barriers to treatment adjustment within TTT among patient visits not in agreement with the TTT paradigm. Methods: Chart review assessed TTT implementation based on documentation of four items: designation of a treatment target, recording a disease activity measure, shared-decision making when applicable and adjusting treatment when disease activity was not at target. A treatment decision not in agreement with the TTT paradigm was defined as lack of treatment adjustment when disease activity was not at the pre-determined treatment target. Providers were encouraged to report the barriers to treatment change; these were categorized and analysed by study staff. Multiple barriers were possible for one visit. Results: Eighty-three visits not in agreement with the TTT strategy were observed in 74 patients, during which 90 reported barriers to treatment adjustment were noted. Common barriers to adjusting treatment included patient preference in 37.1% of visits and elevated disease activity measure despite no objective evidence of active RA in 38.6% of visits. Conclusion: An elevated disease activity measure not reflective of RA disease activity and patient preference are the two leading barriers to treatment adjustment to TTT in RA. Understanding barriers to adherence should guide interventions aimed at using better markers of disease activity and improving alignment with patient preference, with the overarching goal of enhancing TTT adherence.

16.
Soc Sci Med ; 212: 17-25, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29990671

RESUMO

RATIONALE: Do culturally targeted patient decision aids (DAs) better prepare lower-middle and middle-class Hispanic American women for medical decision making compared to DAs designed for the general population? Health promotion evidence indicates that inclusion of cultural values, imagery, linguistics, and health data in a DA will improve ethnic patients' preparation relative to a generic DA; yet, this hypothesis remains untested. METHOD: Four experiments examined consultation preparation effects of culturally targeted versus generic DAs for Hispanic women living in the United States. Drawing on highly rated online DAs, an experienced Hispanic content developer and Hispanic focus groups worked with researchers to develop culturally targeted digital DAs. Online panels of self-identified Hispanic women in the U.S. were randomly assigned to a targeted or generic DA as part of a scenario-based physician consultation for advanced diabetes (Study 1) or early stage breast cancer (Studies 2-4). RESULTS: Manipulation checks showed high awareness of cultural information in the targeted DA group. Despite efforts to rule out confounds that could account for null effects, DA cultural targeting did not increase knowledge, decision preparedness, or empowerment or reduce decision conflict in the four randomized experiments. Only individual difference variables (e.g., group interdependence) consistently predicted enhanced DA consultation preparation effects. Related research indicates that culture at the group level may exert less influence when individuals think deliberatively, feel less constrained by limited resources such as time, understand processing objectives, and/or are primed with task-specific schema/norms. CONCLUSION: Given deeper deliberation and clearly primed processing objectives, personal experiences and task-related schema/norms may have significantly reduced the effects of cultural targeting. Consistent findings from four studies suggest that culturally targeted DAs may not better prepare Hispanic women in the U.S. for medical decision making than generic versions designed for the broader population.

17.
AIDS Behav ; 2018 Jul 06.
Artigo em Inglês | MEDLINE | ID: mdl-29980993

RESUMO

Men who have sex with men (MSM) account for most new HIV infections in the United States. Despite representing a fraction of the population, MSM make up an estimated 65% of new infections. To address this epidemic, pre-exposure prophylaxis (PrEP) is recommended to supplement condom use. Despite its effectiveness, PrEP uptake among MSM is low. Few studies have employed theoretical approaches to understand PrEP use intention. Incorporating factors like safe sex fatigue, expectation of better sexual experiences, and perceived risk are proposed in this dual motivational path model of PrEP use intention. This model hypothesized that PrEP use intention is influenced by two key pathways: (1) protection motivation pathway, and (2) sexual expectancy pathway. Data were collected using social networking applications from 402 MSM. The model was tested using structural equation modeling. We elaborate the complex decision-making process proposed by this novel theoretical model and discuss its practical implications.

18.
Artigo em Inglês | MEDLINE | ID: mdl-29953733

RESUMO

OBJECTIVE: In this proof-of-concept study, we sought to evaluate whether a value clarification tool enabling patients to view a set of rheumatoid arthritis (RA) treatment preference phenotypes could be used to support shared decision-making (SDM) at the point-of-care. METHODS: We conducted a pre-post test study. All English-speaking RA patients presenting to their scheduled outpatient visits were asked to participate. Visits for patients with active RA were transcribed. SDM components were measured using a quantitative coding scheme based on an established model of SDM. RESULTS: Forty-six visits were included in the pre-test and 40 in the post-test phase. Providers offered more DMARDs (two or more) in the post-test visits (60%) compared to the pre-test visits (47.8%). Overall, more patients vocalized their values and/or preferences in the post-test visits compared to the pre-test visits for treatment escalation decisions including choice of one new DMARD (90.9% versus 56.3%), two or more new DMARDs (95.8% versus 86.4%), as well as prednisone (87.5% versus 66.7%). Providers were also more likely to base their recommendations on patients' values and/or preferences in the post-test (100% of six visits) than pre-test (64.3% of 14 visits) phase during visits in which a recommendation was made. The average (SD) length of the visit was 29.9 (11.6) minutes and 25.1 (10.7) minutes in the pre- and post-test phases respectively. CONCLUSION: This study provides an early indication that a value clarification tool allowing patients to consider a set of preference phenotypes can support SDM at the point-of-care without extending visit time. This article is protected by copyright. All rights reserved.

19.
BMC Med Inform Decis Mak ; 18(1): 40, 2018 06 20.
Artigo em Inglês | MEDLINE | ID: mdl-29925368

RESUMO

BACKGROUND: As patients become more engaged in decisions regarding their medical care, they must weigh the potential benefits and harms of different treatments. Patients who are low in numeracy may be at a disadvantage when making these decisions, as low numeracy is correlated with less precise representations of numerical magnitude. The current study looks at the feasibility of improving number representations. The aim of this study was to evaluate whether providing a small amount of feedback to adult subjects could improve performance on a number line placement task and to determine characteristics of those individuals who respond best to this feedback. METHODS: Subjects from two outpatient clinic waiting rooms participated in a three phase number line task. Participants were asked to place numbers on a computerized number line ranging from 0 to 1000 in pre-test, feedback, and post-test phases. Generalized estimating equations were used to model log-transformed scores and to test whether 1) performance improved after feedback, and 2) the degree of improvement was associated with age, education level or subjective numeracy. RESULTS: There was an overall improvement in task performance following the feedback. The average percent absolute error was 7.32% (SD: 6.00) for the pre-test and 5.63% (SD: 3.71) for the post-test. There was a significant interaction between college education and post-test improvement. Only subjects without some college education improved with feedback. CONCLUSIONS: Adults who do not have higher levels of education improve significantly on a number line task when given feedback.

20.
Artigo em Inglês | MEDLINE | ID: mdl-29799668

RESUMO

BACKGROUND: Patients have a poor understanding of outcomes related to total knee replacement (TKR) surgery, with most underestimating the potential benefits and overestimating the risk of complications. In this study, we sought to compare the impacts of descriptive information alone or in combination with an icon array (IA), experience condition (images), or spinner on participants' preference for TKR. METHODS: 648 members of an online arthritis network were randomized to one of four outcome presentation formats: numeric only, numeric with an IA, numeric with a set of 50 images, and numeric with a functional spinner. Preferences for TKR were measured before and immediately after viewing the outcome information using an 11-point numeric rating scale. Knowledge was assessed by asking participants to report the frequency of each outcome. RESULTS: Participants randomized to the IA, images and spinner had stronger preferences for TKR (after controlling for baseline preferences) compared to those viewing the numbers only format (mean differences all p < 0.05). Knowledge scores were highest in participants randomized to the IA; however, knowledge did not mediate the association between format and change in preference for TKR. CONCLUSIONS: Decision support at the point-of-care is being increasingly recognized as a vital component of care. Our findings suggest that adding graphical information to descriptive statistics strengthens preferences for TKR. Although experience formats using images may be too complex to use in clinical practice, IAs and spinners may be a viable and easily adaptable decision aid to support communication of probabilistic information. This article is protected by copyright. All rights reserved.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA