Osteoarthritis is a leading cause of pain and disability. Knee osteoarthritis accounts for nearly four-fifths of the burden of osteoarthritis internationally, and 10% of adults in the United Kingdom ...have the condition. Shared decision-making (SDM) supports patients to make more informed choices about treatment and care while reducing inequities in access to treatment. We evaluated the experience of a team adapting an SDM tool for knee osteoarthritis and the tool's implementation potential within a local clinical commissioning group (CCG) area in southwest England. The tool aims to prepare patients and clinicians for SDM by providing evidence-based information about treatment options relevant to disease stage.
This study aimed to explore the experiences of a team adapting an SDM tool from one health context to another and the implementation potential of the tool in the local CCG area.
A partnership approach using mixed methods was used to respond to recruitment challenges and ensure that study aims could be addressed within time restrictions. A web-based survey was used to obtain clinicians' feedback on experiences of using the SDM tool. Qualitative interviews were conducted by telephone or video call with a sample of stakeholders involved in adapting and implementing the tool in the local CCG area. Survey findings were summarized as frequencies and percentages. Content analysis was conducted on qualitative data using framework analysis, and data were mapped directly to the Theoretical Domains Framework (TDF).
Overall, 23 clinicians completed the survey, including first-contact physiotherapists (11/23, 48%), physiotherapists (7/23, 30%), specialist physiotherapists (4/23, 17%), and a general practitioner (1/23, 4%). Eight stakeholders involved in commissioning, adapting, and implementing the SDM tool were interviewed. Participants described barriers and facilitators to the adaptation, implementation, and use of the tool. Barriers included a lack of organizational culture that supported and resourced SDM, lack of clinician buy-in and awareness of the tool, challenges with accessibility and usability, and lack of adaptation for underserved communities. Facilitators included the influence of clinical leaders' belief that SDM tools can improve patient outcomes and National Health Service resource use, clinicians' positive experiences of using the tool, and improving awareness of the tool. Themes were mapped to 13 of the 14 TDF domains. Usability issues were described, which did not map to the TDF domains.
This study highlights barriers and facilitators to adapting and implementing tools from one health context to another. We recommend that tools selected for adaptation should have a strong evidence base, including evidence of effectiveness and acceptability in the original context. Legal advice should be sought regarding intellectual property early in the project. Existing guidance for developing and adapting interventions should be used. Co-design methods should be applied to improve adapted tools' accessibility and acceptability.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Shared decision-making provides an approach to discuss advance care planning in a participative and informed manner, embodying the principles of person-centered care. A number of guided approaches to ...achieve shared decision-making already exist, such as the three-talk model. However, it is uncertain whether daily practice methods in nursing home wards for persons with dementia comply with the underpinnings of this model. It is also uncertain whether professionals consider shared decision-making to be important in this context, and whether they perceive themselves sufficiently competent to practice this approach frequently.
The study has a cross-sectional design, with 65 wards (46 Belgian nursing homes) participating in the study. We compared nursing home professionals' and residents' perspectives on the level of shared decision-making during advance care planning conversations with ratings from external raters. Residents and professionals rated the level of shared decision-making by means of a questionnaire, which included the topic of the conversation. External raters assessed audio recordings of the conversations. Professionals filled in an additional self-report questionnaire on the importance of shared decision-making, their competence in practicing the approach, and with what frequency.
At ward level, professionals and residents rated the average achieved level of shared decision-making 71.53/100 (σ = 16.09) and 81.11/100 (σ = 19.18) respectively. Meanwhile, raters gave average scores of 26.97/100 (σ = 10.45). Only 23.8% of residents referred to advance care planning as the topic of the conversation. Professionals considered shared decision-making to be important (x̄=4.48/5, σ = 0.26). This result contrasted significantly with the frequency (x̄=3.48/5, σ = 0.51) and competence (x̄=3.76/5, σ = 0.27) with which these skills were practiced (P < 0.001).
Residents with dementia are grateful when involved in discussing their care, but find it difficult to report what is discussed during these conversations. Receiving more information about advance care planning could provide them with the knowledge needed to prepare for such a conversation. External raters observe a discrepancy between the three-talk model and daily practice methods. Training programs should focus on providing professionals with better knowledge of and skills for shared decision-making. They should also promote team-based collaboration to increase the level of person-centered care in nursing home wards for persons with dementia.
The methods and results of systematic reviews should be reported in sufficient detail to allow users to assess the trustworthiness and applicability of the review findings. The Preferred Reporting ...Items for Systematic reviews and Meta-Analyses (PRISMA) statement was developed to facilitate transparent and complete reporting of systematic reviews and has been updated (to PRISMA 2020) to reflect recent advances in systematic review methodology and terminology. Here, we present the explanation and elaboration paper for PRISMA 2020, where we explain why reporting of each item is recommended, present bullet points that detail the reporting recommendations, and present examples from published reviews. We hope that changes to the content and structure of PRISMA 2020 will facilitate uptake of the guideline and lead to more transparent, complete, and accurate reporting of systematic reviews.
Recent work has suggested that the prefrontal cortex (PFC) plays a key role in context-dependent perceptual decision-making. In this study, we addressed that role using a new method for identifying ...task-relevant dimensions of neural population activity. Specifically, we show that the PFC has a multidimensional code for context, decisions and both relevant and irrelevant sensory information. Moreover, these representations evolve in time, with an early linear accumulation phase followed by a phase with rotational dynamics. We identify the dimensions of neural activity associated with these phases and show that they do not arise from distinct populations but from a single population with broad tuning characteristics. Finally, we use model-based decoding to show that the transition from linear to rotational dynamics coincides with a plateau in decoding accuracy, revealing that rotational dynamics in the PFC preserve sensory choice information for the duration of the stimulus integration period.
The mental health recovery model is based on shared decision making, in which patients' preferences and perceptions of the care received are taken into account. However, persons with psychosis ...usually have very few opportunities to participate in this process. The present study explores the experiences and perceptions of a group of patients with psychosis-in some cases longstanding, in others more recently diagnosed-concerning their participation in the decisions taken about the approach to their condition and about the attention received from healthcare professionals and services. For this purpose, we performed a qualitative analysis of the outcomes derived from five focus groups and six in-depth interviews (36 participants). Two major themes, with five sub-themes, were identified: shared decision-making (drug-centred approach, negotiation process, and lack of information) and the care environment and styles of clinical practice as determinants (aggressive versus person-centred environments, and styles of professional practice). The main conclusions drawn are that users want to participate more in decision making, they want to be offered a range of psychosocial options from the outset and that their treatment should be based on accessibility, humanity and respect. These findings are in line with the guidelines for clinical practice and should be taken into account in the design of care programmes and the organisation of services for persons with psychosis.
Acute behavioural disturbance (ABD), sometimes called 'excited delirium', is a medical emergency. In the UK, some patients presenting with ABD are managed by advanced paramedics (APs), however little ...is known about how APs make restraint decisions. The aim of this research is to explore the decisions made by APs when managing restraint in the context of ABD, in the UK pre-hospital ambulance setting. Seven semi-structured interviews were undertaken with APs. All participants were experienced APs with post-registration, post-graduate advanced practice education and qualifications. The resulting data were analysed using reflexive thematic analysis, informed by critical realism. We identified four interconnected themes from the interview data. Firstly, managing complexity and ambiguity in relation to identifying ABD patients and determining appropriate treatment plans. Secondly, feeling vulnerable to professional consequences from patients deteriorating whilst in the care of APs. Thirdly, negotiating with other professionals who have different roles and priorities. Finally, establishing primacy of care in relation to incidents which involve police officers and other professionals. A key influence was the need to characterise incidents as medical, as an enabler to establishing clinical leadership and decision-making control. APs focused on de-escalation techniques and sought to reduce physical restraint, intervening with pharmacological interventions if necessary to achieve this. The social relationships and interactions with patients and other professionals at the scene were key to success. Decisions are a source of anxiety, with fears of professional detriment accompanying poor patient outcomes. Our results indicate that APs would benefit from education and development specifically in relation to making ABD decisions, acknowledging the context of inter-professional relationships and the potential for competing and conflicting priorities. A focus on joint, high-fidelity training with the police may be a helpful intervention.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective
To describe the perspectives of healthcare professionals regarding the implementation of Shared decision‐making (SDM) in primary healthcare centres (PHCCs) in Saudi Arabia.
Methods
...Qualitative semi‐structured interviews were conducted with a purposive and snowball sample of healthcare professionals in PHCCs. Interviews have been recorded, transcribed, translated and thematically analysed. Themes were mapped to the COM‐B model.
Results
Sixteen healthcare professionals were interviewed. The data analysis identified six themes and 14 sub‐themes. The six themes are patient related factors, health professional related factors, environmental context and resources, patient–physician communication, patient–physician preferences toward SDM and physicians' perceived value and benefits of SDM. Physicians are unlikely to practice SDM in the context of time pressures, shortage of physicians, lack of treatment options, and decision‐making aids. The findings also underscored the importance of building a trustworthy physician‐patient relationship through the use of effective conversation techniques.
Conclusions
There are multiple barriers to SDM in primary care. Unless these barriers are addressed, it is unlikely that physicians will effectively or fully engage in SDM with patients.
Background
Personalised care planning is a collaborative process used in chronic condition management in which patients and clinicians identify and discuss problems caused by or related to the ...patient's condition, and develop a plan for tackling these. In essence it is a conversation, or series of conversations, in which they jointly agree goals and actions for managing the patient's condition.
Objectives
To assess the effects of personalised care planning for adults with long‐term health conditions compared to usual care (i.e. forms of care in which active involvement of patients in treatment and management decisions is not explicitly attempted or achieved).
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, ProQuest, clinicaltrials.gov and WHO International Clinical Trials Registry Platform to July 2013.
Selection criteria
We included randomised controlled trials and cluster‐randomised trials involving adults with long‐term conditions where the intervention included collaborative (between individual patients and clinicians) goal setting and action planning. We excluded studies where there was little or no opportunity for the patient to have meaningful influence on goal selection, choice of treatment or support package, or both.
Data collection and analysis
Two of three review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes were effects on physical health, psychological health, subjective health status, and capabilities for self management. Secondary outcomes included effects on health‐related behaviours, resource use and costs, and type of intervention. A patient advisory group of people with experience of living with long‐term conditions advised on various aspects of the review, including the protocol, selection of outcome measures and emerging findings.
Main results
We included 19 studies involving a total of 10,856 participants. Twelve of these studies focused on diabetes, three on mental health, one on heart failure, one on end‐stage renal disease, one on asthma, and one on various chronic conditions. All 19 studies included components that were intended to support behaviour change among patients, involving either face‐to‐face or telephone support. All but three of the personalised care planning interventions took place in primary care or community settings; the remaining three were located in hospital clinics. There was some concern about risk of bias for each of the included studies in respect of one or more criteria, usually due to inadequate or unclear descriptions of research methods.
Physical health
Nine studies measured glycated haemoglobin (HbA1c), giving a combined mean difference (MD) between intervention and control of ‐0.24% (95% confidence interval (CI) ‐0.35 to ‐0.14), a small positive effect in favour of personalised care planning compared to usual care (moderate quality evidence).
Six studies measured systolic blood pressure, a combined mean difference of ‐2.64 mm/Hg (95% CI ‐4.47 to ‐0.82) favouring personalised care (moderate quality evidence). The pooled results from four studies showed no significant effect on diastolic blood pressure, MD ‐0.71 mm/Hg (95% CI ‐2.26 to 0.84).
We found no evidence of an effect on cholesterol (LDL‐C), standardised mean difference (SMD) 0.01 (95% CI ‐0.09 to 0.11) (five studies) or body mass index, MD ‐0.11 (95% CI ‐0.35 to 0.13) (four studies).
A single study of people with asthma reported that personalised care planning led to improvements in lung function and asthma control.
Psychological health
Six studies measured depression. We were able to pool results from five of these, giving an SMD of ‐0.36 (95% CI ‐0.52 to ‐0.20), a small effect in favour of personalised care (moderate quality evidence). The remaining study found greater improvement in the control group than the intervention group.
Four other studies used a variety of psychological measures that were conceptually different so could not be pooled. Of these, three found greater improvement for the personalised care group than the usual care group and one was too small to detect differences in outcomes.
Subjective health status
Ten studies used various patient‐reported measures of health status (or health‐related quality of life), including both generic health status measures and condition‐specific ones. We were able to pool data from three studies that used the SF‐36 or SF‐12, but found no effect on the physical component summary score SMD 0.16 (95% CI ‐0.05 to 0.38) or the mental component summary score SMD 0.07 (95% CI ‐0.15 to 0.28) (moderate quality evidence). Of the three other studies that measured generic health status, two found improvements related to personalised care and one did not.
Four studies measured condition‐specific health status. The combined results showed no difference between the intervention and control groups, SMD ‐0.01 (95% CI ‐0.11 to 0.10) (moderate quality evidence).
Self‐management capabilities
Nine studies looked at the effect of personalised care on self‐management capabilities using a variety of outcome measures, but they focused primarily on self efficacy. We were able to pool results from five studies that measured self efficacy, giving a small positive result in favour of personalised care planning: SMD 0.25 (95% CI 0.07 to 0.43) (moderate quality evidence).
A further five studies measured other attributes that contribute to self‐management capabilities. The results from these were mixed: two studies found evidence of an effect on patient activation, one found an effect on empowerment, and one found improvements in perceived interpersonal support.
Other outcomes
Pooled data from five studies on exercise levels showed no effect due to personalised care planning, but there was a positive effect on people's self‐reported ability to carry out self‐care activities: SMD 0.35 (95% CI 0.17 to 0.52).
We found no evidence of adverse effects due to personalised care planning.
The effects of personalised care planning were greater when more stages of the care planning cycle were completed, when contacts between patients and health professionals were more frequent, and when the patient's usual clinician was involved in the process.
Authors' conclusions
Personalised care planning leads to improvements in certain indicators of physical and psychological health status, and people's capability to self‐manage their condition when compared to usual care. The effects are not large, but they appear greater when the intervention is more comprehensive, more intensive, and better integrated into routine care.
Multi-criteria decision-making (MCDM) methods are commonly used in many fields of research, e.g., engineering and manufacturing systems, water resources studies , medicine, and etc. However, there is ...no effective approach of selecting a MCDM method to problem, which is solved. The formal requirements of each MCDM method are not sufficient because most methods would seem to be appropriate for most problems. Therefore, the main purpose of the paper is a comparison of accuracy selected MCDM methods. Proposed approach is presented on the example of mortality in patients with acute coronary syndrome. Additionally, the paper presents characteristic objects method (COMET) as a potential decision making method for use in medical problems, which accuracy is compared with TOPSIS and AHP. In the experimental study, the average and standard deviation of the root mean square error of evaluations are examined for groups of randomly selected patients, each described by age, blood pressure, and heart rate. Then, the correctness of choosing the patient in the best and worst condition is also examined among randomly selected pairs. As a result of the experimental study, rankings obtained by the COMET method are distinctly more accurate than those obtained by TOPSIS or AHP techniques. The COMET method, in the opposite of others method, is completely free of the rank reversal phenomenon, which is identified as a main source of problems with evaluations accuracy.
The world currently faces several severe social and environmental crises, including economic under-development, widespread poverty and hunger, lack of safe drinking water for one-sixth of the world's ...population, deforestation, rapidly increasing levels of pollution and waste, dramatic declines in soil fertility and biodiversity, and global warming.Inequality, Democracy, and the Environmentsheds light on the structural causes of these and other social and environmental crises, highlighting in particular the key role that elite-controlled organizations, institutions, and networks play in creating these crises.
Liam Downey focuses on four topics-globalization, agriculture, mining, and U.S. energy and military policy-to show how organizational and institutional inequality and elite-controlled organizational networks produce environmental degradation and social harm. He focuses on key institutions like the World Bank, the International Monetary Fund, the U.S. Military and the World Trade Organization to show how specific policies are conceived and enacted in order to further elite goals. Ultimately, Downey lays out a path for environmental social scientists and environmentalists to better understand and help solve the world's myriad social and environmental crises.Inequality, Democracy and the Environmentpresents a passionate exposé of the true role inequality, undemocratic institutions and organizational power play in harming people and the environment.
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