Ana Castaneda-Guarderas

Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.

Objective To compare the effectiveness of shared decision making with usual care in choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome. Design Multicenter pragmatic parallel randomized controlled trial. Setting Six emergency departments in the United States. Participants 898 adults (aged >17 years) with a primary complaint of chest pain who were being considered for admission to an observation unit for cardiac testing (451 were allocated to the decision aid and 447 to usual care), and 361 emergency clinicians (emergency physicians, nurse practitioners, and physician assistants) caring for patients with chest pain. Interventions Patients were randomly assigned (1:1) by an electronic, web based system to shared decision making facilitated by a decision aid or to usual care. The primary outcome, selected by patient and caregiver advisers, was patient knowledge of their risk for acute coronary syndrome and options for care; secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, and the 30 day rate of major adverse cardiac events. Results Compared with the usual care arm, patients in the decision aid arm had greater knowledge of their risk for acute coronary syndrome and options for care (questions correct: decision aid, 4.2 v usual care, 3.6; mean difference 0.66, 95% confidence interval 0.46 to 0.86), were more involved in the decision (observing patient involvement scores: decision aid, 18.3 v usual care, 7.9; 10.3, 9.1 to 11.5), and less frequently decided with their clinician to be admitted for cardiac testing (decision aid, 37% v usual care, 52%; absolute difference 15%; P<0.001). There were no major adverse cardiac events due to the intervention. Conclusions Use of a decision aid in patients at low risk for acute coronary syndrome increased patient knowledge about their risk, increased engagement, and safely decreased the rate of admission to an observation unit for cardiac testing. Trial registration ClinicalTrials.gov NCT01969240.

What Is Shared Decision Making? (and What It Is Not).

Both the practice of medicine and the expectations of patients regarding their care are changing. A point of confluence is in the need for medicine to be more patient centered, and in the need for patients to be more involved in their care.1,2 This confluence is particularly pertinent when more than one reasonable approach is available to manage the patients situation, and when those approaches differ in ways that matter to patients.3 In shared decision-making (SDM), clinicians and patients work together to understand the patients situation and to determine how best to address it. Emergency medicine is not exempt from these trends. In this paper we seek to define SDM and its role in contemporary healthcare. Our goal is to set the stage for the active exploration of SDM in the care of patients in the emergency department. This article is protected by copyright. All rights reserved.

Patient capacity and constraints in the experience of chronic disease: A qualitative systematic review and thematic synthesis

BackgroundLife and healthcare demand work from patients, more so from patients living with multimorbidity. Patients must respond by mobilizing available abilities and resources, their so-called capacity. We sought to summarize accounts of challenges that reduce patient capacity to access or use healthcare or to enact self-care while carrying out their lives.MethodsWe conducted a systematic review and synthesis of the qualitative literature published since 2000 identifying from MEDLINE, EMBASE, Psychinfo, and CINAHL and retrieving selected abstracts for full text assessment for inclusion. After assessing their methodological rigor, we coded their results using a thematic synthesis approach.ResultsThe 110 reports selected, when synthesized, showed that patient capacity is an accomplishment of interaction with (1) the process of rewriting their biographies and making meaningful lives in the face of chronic condition(s); (2) the mobilization of resources; (3) healthcare and self-care tasks, particularly, the cognitive, emotional, and experiential results of accomplishing these tasks despite competing priorities; (4) their social networks; and (5) their environment, particularly when they encountered kindness or empathy about their condition and a feasible treatment plan.ConclusionPatient capacity is a complex and dynamic construct that exceeds “resources” alone. Additional work needs to translate this emerging theory into useful practice for which we propose a clinical mnemonic (BREWS) and the ICAN Discussion Aid.

Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis ☆ ☆☆ ★ ★★

BACKGROUND Scribes offer a potential solution to the clerical burden and time constraints felt by health care providers. OBJECTIVES This is a systematic review and meta-analysis to evaluate scribe effect on patient throughput, revenue, and patient and provider satisfaction. METHODS Six electronic databases were systematically searched from inception until May 2015. We included studies where clinicians used a scribe. We collected throughput metrics, billing data, and patient/provider satisfaction data. Meta-analyses were conducted using a random effects model and mean differences (MDs) with 95% confidence intervals (CIs) with adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. RESULTS From a total of 210 titles, 17 studies were eligible and included. Qualitative analysis suggests improvement in provider/patient satisfaction. Meta-analysis on throughput data was derived from 3 to 5 studies depending on the metric; meta-analysis revealed no impact of scribes on length of stay (346 minutes for scribes, 344 minutes for nonscribed; MD -1.6 minutes, 95% CI -22.3 to 19.2 minutes) or provider-to-disposition time (235 minutes for scribes, 216 for nonscribed; MD -18.8 minutes, 95% CI -22.3 to 19.2) with an increase in patients seen per hour (0.17 more patient per hour; 95% CI 0.02-32). Two studies reported relative value units, which increased 0.21 (95% CI 0-0.42) per patient with scribe use. CONCLUSION We found no difference in length of stay or time to disposition with a small increase in the number of patients per hour seen when using scribes. Potential benefits include revenue and patient/provider satisfaction.

Stepping down inhaled corticosteroids from scheduled to as needed in stable asthma: Systematic review and meta-analysis.

BACKGROUND Many patients with asthma are potentially overtreated, which results in unnecessary cost and unnecessary exposure to drugs that may result in adverse events. Step down helps reduce overtreatment, may mitigate these harms, and is advocated by major guidelines. Unfortunately, data that support step down are sparse. OBJECTIVES This systematic review aimed to examine the effect of stepping down from scheduled inhaled corticosteroids (ICS) to as-needed ICS in patients with stable asthma. METHODS Several electronic databases were systematically searched in April 2014. Articles were screened independently in duplicate. Studies were required to have at least a 12-week follow-up duration and to have compared stepping down from scheduled ICS to as-needed ICS and maintenance of scheduled ICS. Patients were required to have stable asthma as evidenced by at least 4 weeks without asthma exacerbation before intervention. RESULTS A total of 3025 abstracts were retrieved initially, 77 of which were retrieved for full-text screening. Of these, only two articles were found to be eligible for inclusion, both were randomized controlled trials. By using random effects meta-analysis, it was determined that, after a follow-up of 6-10 months, the relative risk of exacerbation of stepping down from scheduled to as-needed ICS was 1.32 (95% confidence interval [CI], 0.81-2.16; p = 0.27, I(2) = 0%). Those who did not step down had more symptom-free days (standard mean difference 0.26 [95% CI, 0.02-0.49; p = 0.03; I(2) = 22%]). CONCLUSION There is currently insufficient evidence to associate stepping down from scheduled to as-needed ICS with a change in exacerbations, although it may lead to fewer symptom-free days.

Non-pharmacological treatment of depression: a systematic review and evidence map

Background The comparative effectiveness of non-pharmacological treatments of depression remains unclear. Methods We conducted an overview of systematic reviews to identify randomised controlled trials (RCTs) that compared the efficacy and adverse effects of non-pharmacological treatments of depression. We searched multiple electronic databases through February 2016 without language restrictions. Pairs of reviewers determined eligibility, extracted data and assessed risk of bias. Meta-analyses were conducted when appropriate. Result We included 367 RCTs enrolling ∼20 000 patients treated with 11 treatments leading to 17 unique head-to-head comparisons. Cognitive behavioural therapy, naturopathic therapy, biological interventions and physical activity interventions reduced depression severity as measured using standardised scales. However, the relative efficacy among these non-pharmacological interventions was lacking. The effect of these interventions on clinical response and remission was unclear. Adverse events were lower than antidepressants. Limitation The quality of evidence was low to moderate due to inconsistency and unclear or high risk of bias, limiting our confidence in findings. Conclusions Non-pharmacological therapies of depression reduce depression symptoms and should be considered along with antidepressant therapy for the treatment of mild-to-severe depression. A shared decision-making approach is needed to choose between non-pharmacological therapies based on values, preferences, clinical and social context.

Uptake and Documentation of the Use of an Encounter Decision Aid in Usual Practice: A Retrospective Analysis of the Use of the Statin/Aspirin Choice Decision Aid

Shared decision making, a key feature of patientcentered care, is a process through which patients and their clinicians work together in a collaborative environment to deliberate about reasonable options for patient care. In the United States, under the Affordable Care Act, in which shared decision making is to become a prominent quality metric, clinicians will need to find ways to practice it and document its usage in patient medical records. Decision aids are evidence-based tools designed to engage patients in a shared decision-making process. One such decision aid, Statin Choice, has been found in randomized trials to improve the quality of the decision-making process and increase patient understanding and accurate estimation of their cardiovascular risk and risk reduction with statins. To facilitate integration into clinical practice, in 2010, Statin/Aspirin Choice was incorporated into the electronic medical record (EMR) at Mayo Clinic, Rochester, Minnesota, placing the tool right in the middle of the workflow (https://statindecisionaid .mayoclinic.org/). Since the completion of the original Statin Choice trial, members of our team have had discussions with primary care key opinion leaders, as well as given medical grand rounds and division-specific academic presentations (i.e., passive dissemination). We aimed to determine the use and uptake by clinicians of the electronic Statin/Aspirin Choice in clinical encounters and how they documented its use in primary care practices.

Shared Decision Making in the Emergency Department among patients with Limited Health Literacy: Beyond Slower and Louder

Although studies suggest that patients with limited health literacy and/or low numeracy skills may stand to gain the most from shared decision making (SDM), the impact of these conditions on the effective implementation of SDM in the emergency department (ED) is not well understood. In this article from the proceedings of the 2016 Academic Emergency Medicine Consensus Conference on Shared Decision Making in the Emergency Department we discuss knowledge gaps identified and propose consensus-driven research priorities to help guide future work to improve SDM for this patient population in the ED.

Weight changes after thyroid surgery for patients with benign thyroid nodules and thyroid cancer: population based study and systematic review and meta-analysis

BACKGROUND A key concern among patients who undergo thyroid surgery is postoperative weight gain. Yet, the impact of thyroid surgery on weight is unclear. METHODS The population-based Rochester Epidemiology Project was used to examine weight and body mass index (BMI) changes at one, two, and three years of follow-up in (i) patients with thyroid cancer and benign thyroid nodules after thyroid surgery, and (ii) patients with thyroid nodules who did not have surgery. A comprehensive systematic review of the published literature from inception to February 2016 was also conducted. The results were pooled across studies using a random effects model. RESULTS A total of 435 patients were identified: 181 patients with thyroid cancer who underwent surgery (group A), 226 patients with benign thyroid nodules without surgery (group B), and 28 patients with benign thyroid nodules undergoing surgery (group C). Small changes in mean weight, BMI, and the number of patients whose weight increased between 5 and 10 kg were similar during each year of follow-up between patients in groups A and B. Furthermore, age >50 years, female sex, baseline BMI >25 kg/m2, and thyrotropin value at one to two years were not predictors of a 5% weight change. In the meta-analysis, 11 studies were included. One to two years after surgery for thyroid cancer or thyroid nodules, patients gained on average 0.94 kg [confidence interval (CI) 0.58-1.33] and 1.07 kg [CI 0.26-1.87], respectively. Patients with benign thyroid nodules who did not have surgery gained 1.50 kg [CI 0.60-2.4] at the longest follow-up. CONCLUSIONS On average, patients receiving care for thyroid nodules or cancer gain weight, but existing evidence suggests that surgery for these conditions does not contribute significantly to further weight gain. Clinicians and patients can use this information to discuss what to expect after thyroid surgery.

Humor During Clinical Practice: Analysis of Recorded Clinical Encounters

Objective: Little is known about humors use in clinical encounters, despite its many potential benefits. We aimed to describe humor during clinical encounters. Design: We analyzed 112 recorded clinical encounters. Two reviewers working independently identified instances of humor, as well as information surrounding the logistics of its use. Results: Of the 112 encounters, 66 (59%) contained 131 instances of humor. Humor was similarly frequent in primary care (36/61, 59%) and in specialty care (30/51, 59%), was more common in gender-concordant interactions (43/63, 68%), and was most common during counseling (81/112, 62%). Patients and clinicians introduced humor similarly (63 vs 66 instances). Typically, humor was about the patients medical condition (40/131, 31%). Discussion and Conclusion: Humor is used commonly during counseling to discuss the patients medical condition and to relate to general life events bringing warmth to the medical encounter. The timing and topic of humor and its use by all parties suggests humor plays a role in the social connection between patients and physicians and allows easier discussion of difficult topics. Further research is necessary to establish its impact on clinicians, patients, and outcomes.