Anouk M. Knops

Decision aids for patients facing a surgical treatment decision: a systematic review and meta-analysis.

Objective:To summarize the evidence available on the effects of decision aids in surgery. Background:When consenting to treatment, few patients adequately understand their treatment options. To help patients make deliberate treatment choices, decision aids provide evidence-based information on the disease, treatment options, and their associated benefits and harms. Although decision aids are not designed to direct patients toward a particular treatment option, it is possible that their introduction will change the proportion of patients that opt for surgery. Methods:We searched electronic databases for studies that evaluated a decision aid in patients offered both surgery and alternative treatment options, regarding the effect on the actual treatment choices made. In addition, we documented effects on knowledge, decisional conflict, anxiety, quality of life, patient involvement, satisfaction, mortality, morbidity, and costs. Results:Seventeen studies were included. Overall, methodological study quality was good. Patients in the decision aid group less often chose to undergo invasive treatment [risk ratio = 0.80; 95% confidence interval, 0.67–0.95), had more knowledge about treatment options [mean difference = 8.99; 95% confidence interval, 3.20–14.78), and experienced less decisional conflict (mean difference = −5.04; 95% confidence interval, −7.10 to −2.99). Levels of anxiety and quality of life were similar. Conclusions:Offering a decision aid increases the number of patients who prefer conservative or less invasive treatment options. As decision aids improve patient knowledge and lower decisional conflict without raising anxiety levels, they have a place in surgery to help surgeons and patients achieve well-considered and shared treatment decisions.

Attitudes, Awareness, and Barriers Regarding Evidence-Based Surgery Among Surgeons and Surgical Nurses

BackgroundEvidence-based surgery (EBS) is stressed to increase efficiency and health care quality, but not all surgeons and surgical nurses use EBS in clinical practice. To define future tailor-made interventions to improve evidence-based behavior, the aim of this study was to determine the attitude and awareness among surgeons and surgical nurses as to the paradigm of EBS and the barriers experienced when practicing EBS.MethodsIn this cross-sectional study, surgeons and surgical nurses at a university hospital in Amsterdam were invited to complete the BARRIERS scale and McColl et al. questionnaire. An evidence quiz was composed for the surgeons.ResultsResponse rates were 67% (29/43) for surgeons and 60% (73/122) for nurses. Attitudes toward EBS were positive. Among the surgeons, 90% were familiar with EBS terms, whereas only 40% of the nurses were. Common barriers for surgeons were conflicting results (79%, 23/29) and the methodologic inadequacy of research reports (73%, 21/29); and for nurses they were unawareness of EBS (67%, 49/73) and unclear reported research (59%, 43/73). Only about half of the convincing evidence presented in the quiz was actually applied.ConclusionsSurgeons have a positive attitude toward EBS and are familiar with EBS terminology, but conflicting results and methodologic shortcomings of research reports are major barriers to practicing EBS. Continual confrontations with available evidence through frequent critical appraisal meetings or grand rounds and using more aggregate sources of evidence are advocated. Nurses can probably benefit from EBS training focusing on basic skills. Finally, collaboration is needed among surgeons and nurses with the same zest about EBS.

Interpreting Patient Decisional Conflict Scores Behavior and Emotions in Decisions about Treatment

Background. Patient decision aids facilitate treatment decisions. They are often evaluated in terms of their effect on decisional conflict, as measured by the Decisional Conflict Scale (DCS). It is unclear to what extent lower DCS scores are accompanied by observable patient behavior or emotions. Objective. To help interpret DCS scores. Design. In a Dutch university hospital, statements on behaviors or emotions during decision making were collected from asymptomatic aneurysm patients and healthy employees. Subsequently, they rated the intensity of decisional conflict that each statement expresses on a 1 to 10 scale. Selected statements were prospectively tested in aneurysm patients and cancer patients facing treatment dilemmas. Measurements. Associations between patients’ DCS scores and reported behavior and emotions were analyzed using logistic regression analysis. Results. Participants provided 363 statements on behaviors and emotions during decision making, of which 28 were mentioned more than 4 times. Nine forms of behavior and emotions were selected as they were graded with the least variable median ratings of intensity of decisional conflict. Among 100 patients facing a treatment dilemma, each point increase in DCS lowered their odds for “immediately making the decision” (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93–0.98), whereas the odds of “fretting regularly” (OR, 1.05; 95% CI, 1.02–1.08) and “feeling nervous when thinking of the decision” (OR, 1.04; 95% CI, 1.01–1.06) where higher. Conclusions. A decrease in decisional conflict scores leads to less decision postponing behavior, fretting, and nervousness. Research should focus on which DCS scores are needed to make deliberate decisions and which scores hinder patients in decision making.

Evidence-Based Practice: A Survey Among Pediatric Nurses and Pediatricians

This survey compared the attitude, awareness, and knowledge of pediatric nurses and pediatricians regarding evidence-based practice (EBP). Potential barriers were also investigated. Both nurses and pediatricians welcomed EBP (mean scores are 73.3 and 75.4 out of 100). Overall, 52% of the nurses and 36% of the pediatricians did not know relevant sources of information, and 62% of the nurses versus 19% of the pediatricians did not know common EBP terms. Time constraints and lack of knowledge were considered as major barriers. Recommendations include multilevel training and continuous exchange of information.

A Decision Aid Regarding Treatment Options for Patients with an Asymptomatic Abdominal Aortic Aneurysm: A Randomised Clinical Trial

OBJECTIVE Abdominal aortic aneurysm patients tend to be informed inconsistently and incompletely about their disorder and the treatment options open to them. The objective of this trial was to evaluate whether these patients are better informed and experience less decisional conflict regarding their treatment options after viewing a decision aid. DESIGN A six-centre, randomised clinical trial comparing a decision aid plus regular information versus regular information from the surgeon. METHODS Included patients had recently been diagnosed with an asymptomatic abdominal aortic aneurysm at least 4 cm in diameter. The decision aid consisted of a one-time viewing of an interactive CD-ROM elaborating on elective surgery versus watchful waiting. Generally, the decision aid advised patients with aneurysms less than 5.5 cm to agree to watchful waiting, for larger aneurysms the decision aid provided insight into the balance of benefit and harm of surgical and conservative approaches, taking into account age, co-morbidity and size of the aneurysm. The primary outcome was patient decisional conflict measured at 1 month follow-up (Decisional Conflict Scale). Secondary outcomes were patient knowledge, anxiety and satisfaction. RESULTS In 178 aneurysm patients, decisional conflict scores did not differ significantly between the decision aid and the regular information groups (22 vs. 24 on the 0-100 Decisional Conflict Scale; p = .33). Patients in the decision aid group had significantly better knowledge (10.0 vs. 9.4 out of 13 points; p = .04), whereas anxiety levels (4.4 and 5.0 on a 0-21 scale; p = .73) and satisfaction scores (74 and 73 on a 0-100 scale; p = .81) were similar in both groups. CONCLUSION In addition to regular patient-surgeon communication, a decision aid helps to share treatment decisions with abdominal aortic aneurysm patients by increasing their knowledge about the disorder and available treatment options without raising anxiety levels; however, it does not reduce decisional conflict, nor does it improve satisfaction.

Design and development of a decision aid to enhance shared decision making by patients with an asymptomatic abdominal aortic aneurysm

Objective To design, develop, and evaluate an evidence-based decision aid (DA) for patients with an asymptomatic abdominal aortic aneurysm (AAA) to inform them about the pros and cons of their treatment options (ie, surgery or watchful observation) and to help them make a shared decision. Methods A multidisciplinary team defined criteria for the desired DA as to design, medical content and functionality, particularly for elderly users. Development was according to the international standard (IPDAS). Fifteen patients with an AAA, who were either treated or not yet treated, evaluated the tool. Results A DA was developed to offer information about the disease, the risks and benefits of surgical treatment and watchful observation, and the individual possibilities and threats based on the patient’s aneurysm diameter and risk profile. The DA was improved and judged favorably by physicians and patients. Conclusion This evidence-based DA for AAA patients, developed according to IPDAS criteria, is likely to be a simple, user-friendly tool to offer patients evidence-based information about the pros and cons of treatment options for AAA, to improve patients’ understanding of the disease and treatment options, and may support decision making based on individual values.

Long-term adherence to a local guideline on postoperative body temperature measurement: mixed methods analysis.

AIM To find out whether a successful multifaceted implementation approach of a local evidence-based guideline on postoperative body temperature measurements (BTM) was persistent over time, and which factors influenced long-term adherence. METHODS Mixed methods analysis. Patient records were retrospectively examined to measure guideline adherence. Data on influencing factors were collected in focus group meetings for nurses and a plenary meeting with an interactive questionnaire for doctors. RESULTS Records from 102 surgical patients were studied, totalling 1226 BTM. According to the guideline, an indication for BTM was present in 55% (679/1226). Actually, BTM were taken in 60% (736/1226), of which 55% (403/736) was in accordance with the guideline. The overall adherence rate to the guideline was 50% (617/1226). Belief in the advantages of the guideline and strong staff support appeared to facilitate long-term adherence. Barriers were, the controversial nature of the guideline, the lack of self-efficacy among nurses and doctors as to clinical judgement to identify an infection when refraining from BTM, and a lack of management and staff doctor support. Furthermore, newly appointed nurses and doctors were trained to measure BTM during their initial medical or nursing education, which was in contradiction with the guideline. CONCLUSIONS A multifaceted implementation strategy is not sufficient to maintain long-term adherence. To ensure long-term adherence, especially of controversial guidelines, adherence should be monitored and reported regularly over time. Strong staff support and leadership on all wards is crucial to maintain awareness. Medical and nursing curricula should include the pros and cons of taking BTM, combined with enhancing self-efficacy.

A tool to balance benefit and harm when deciding about adjuvant therapy

Adjuvant therapy aims to prevent outgrowth of residual disease but can induce serious side effects. Weighing conflicting treatment effects and communicating this information with patients is not elementary. This study presents a scheme balancing benefit and harm of adjuvant therapy vs no adjuvant therapy. It is illustrated by the available evidence on adjuvant pelvic external beam radiotherapy (RT) for intermediate-risk stage I endometrial carcinoma patients. The scheme comprises five outcome possibilities of adjuvant therapy: patients who benefit from adjuvant therapy (some at the cost of complications) vs those who neither benefit nor contract complications, those who do not benefit but contract severe complications, or those who die. Using absolute risk differences, a fictive cohort of 1000 patients receiving adjuvant RT is categorised. Three large randomised clinical trials were included. Recurrences will be prevented by adjuvant RT in 60 patients, a majority of 908 patients will neither benefit nor suffer severe radiation-induced harm but 28 patients will suffer severe complications due to adjuvant RT and an expected four patients will die. This scheme readily summarises the different possible treatment outcomes and can be of practical value for clinicians and patients in decision making about adjuvant therapies.

Regarding "Pilot testing of a decision support tool for patients with abdominal aortic aneurysms"

We have read with interest the article by Berman et al reporting the evaluation of a decision support tool for patients with an abdominal aortic aneurysm (AAA). This article is of particular importance because AAA patient preferences should be taken into account when weighing a patient’s risk of aneurysm rupture against the risk of surgical complications. In current clinical practice, however, patient preferences are insufficiently explored. The content of the developed tool was based on a national survey of vascular surgeons and the input of postoperative AAA patients. A health literacy expert was involved as well. Two years ago, we developed a decision aid for newly diagnosed AAA patients in the Netherlands. In addition to the input of vascular surgeons and AAA patients, we followed the International Patient Decision Aids Standards criteria, which provide an international consensus-based framework for high-quality decision aids. We also included input from patients who did not consent to surgery, because their ideas about what information should be included in a decision aid may well differ from patients who have undergone aneurysm repair. In the study by Berman et al, 12 surgical candidates with an AAA reported the decision support tool to be feasible. Before and after tool measurements showed increased patient knowledge and decreased decisional conflict. From our point of view, it would be interesting to monitor final treatment decisions as well. Providing comprehensive information, such as in decision aids, may reassure AAA patients who are not surgical candidates. This could reduce unnecessary surgical treatment. The issues mentioned here are currently being addressed in our ongoing randomized clinical trial on the effectiveness of a patient decision aid in treatment decision making with AAA patients. Final results are expected to be published in 2012.

Verpleegkundigen verslaafd aan EBP

SamenvattingHet is belangrijk om het bewustzijn, de kennis en de houding ten opzichte van Evidence Based Practice (EBP) onder verpleegkundigen in kaart te brengen. Niet alleen nu, om de huidige stand van zaken te meten, maar ook in de toekomst, om de EBP-groei te kunnen meten. In het Academisch Medisch Centrum (AMC) heeft zo’n eerste inventarisatie plaatsgevonden. Hiervoor is niet alleen de Barriers Scale maar ook de McColl-vragenlijst gebruikt. Voor de implementatie van EBP zijn een paar duidelijke belemmerende en bevorderende factoren aan te wijzen.