Carissa Bonner

Too much medicine in older people? Deprescribing through shared decision making

Jansen and colleagues explore the role of shared decision making in tackling inappropriate polypharmacy in older adults

Improving decision making about clinical trial participation – a randomised controlled trial of a decision aid for women considering participation in the IBIS-II breast cancer prevention trial

Background:Decision aids may improve informed consent in clinical trial recruitment, but have not been evaluated in this context. This study investigated whether decision aids (DAs) can reduce decisional difficulties among women considering participation in the International Breast Cancer Intervention Study-II (IBIS-II) trial.Methods:The IBIS-II trial investigated breast cancer prevention with anastrazole in two cohorts: women with increased risk (Prevention), and women treated for ductal carcinoma in situ (DCIS). Australia, New Zealand and United Kingdom participants were randomised to receive a DA (DA group) or standard trial consent materials (control group). Questionnaires were completed after deciding about participation in IBIS-II (post decision) and 3 months later (follow-up).Results:Data from 112 Prevention and 34 DCIS participants were analysed post decision (73 DA; 73 control); 95 Prevention and 24 DCIS participants were analysed at follow-up (58 DA; 61 control). There was no effect on the primary outcome of decisional conflict. The DCIS–DA group had higher knowledge post decision, and the Prevention-DA group had lower decisional regret at follow-up.Conclusions:This was the first study to evaluate a DA in the clinical trial setting. The results suggest DAs can potentially increase knowledge and reduce decisional regret about clinical trial participation.

General practitioners' use of different cardiovascular risk assessment strategies: A qualitative study

Objectives: To identify factors that influence the extent to which general practitioners use absolute risk (AR) assessment in cardiovascular disease (CVD) risk assessment.

I don't believe it, but I'd better do something about it: Patient experiences of online heart age risk calculators

Background Health risk calculators are widely available on the Internet, including cardiovascular disease (CVD) risk calculators that estimate the probability of a heart attack, stroke, or death over a 5- or 10-year period. Some calculators convert this probability to “heart age”, where a heart age older than current age indicates modifiable risk factors. These calculators may impact patient decision making about CVD risk management with or without clinician involvement, but little is known about how patients use them. Previous studies have not investigated patient understanding of heart age compared to 5-year percentage risk, or the best way to present heart age. Objective This study aimed to investigate patient experiences and understanding of online heart age calculators that use different verbal, numerical, and graphical formats, based on 5- and 10-year Framingham risk equations used in clinical practice guidelines around the world. Methods General practitioners in New South Wales, Australia, recruited 26 patients with CVD/lifestyle risk factors who were not taking cholesterol or blood pressure-lowering medication in 2012. Participants were asked to “think aloud” while using two heart age calculators in random order, with semi-structured interviews before and after. Transcribed audio recordings were coded and a framework analysis method was used. Results Risk factor questions were often misinterpreted, reducing the accuracy of the calculators. Participants perceived older heart age as confronting and younger heart age as positive but unrealistic. Unexpected or contradictory results (eg, low percentage risk but older heart age) led participants to question the credibility of the calculators. Reasons to discredit the results included the absence of relevant lifestyle questions and impact of corporate sponsorship. However, the calculators prompted participants to consider lifestyle changes irrespective of whether they received younger, same, or older heart age results. Conclusions Online heart age calculators can be misunderstood and disregarded if they produce unexpected or contradictory results, but they may still motivate lifestyle changes. Future research should investigate both the benefits and harms of communicating risk in this way, and how to increase the reliability and credibility of online health risk calculators.

Quantity vs. Quality: An Exploration of the Predictors of Posttreatment Sexual Adjustment for Women Affected by Early Stage Cervical and Endometrial Cancer

INTRODUCTION Women with early stage cervical and endometrial cancer may experience complex posttreatment changes to their sexual function, but clinical practice and past research have focused more on the quantity than the perceived quality of sexual life. AIM The aims of this prospective study were to explore the following: (i) the relative importance of quantity vs. quality of sexual life over the first year posttreatment; (ii) the psychological and sexual predictors of overall sexual function; and (iii) the relationship between sexual function and quality of life (QoL). METHODS Fifty-three cancer patients completed standardized measures at baseline, with follow-up at 6 and 12 months posttreatment. Analyses were based on prespecified linear mixed models with overall sexual function and QoL as outcomes, and quality and quantity of sexual life, anxiety, and depression as the main predictors of interest. Radiotherapy, age, and relationship satisfaction were controlled for as potential confounders. MAIN OUTCOME MEASURES Derogatis Sexual Functioning Inventory subscales to assess quantity (Drive) and quality (Satisfaction) of sexual life, and overall sexual function (Global Sexual Satisfaction Index); Functional Assessment of Cancer Therapy--General to assess QoL; Hospital Anxiety and Depression Scale to assess psychological distress; and Relationship Satisfaction Interaction Scale to assess relationship satisfaction. RESULTS The models demonstrated that: (i) overall sexual function was predicted more strongly by the perceived quality than the quantity of sexual interactions, (ii) a small change in perceived quality had a large impact on overall sexual function, and (iii) overall sexual function was a predictor of QoL. CONCLUSION This study found that quality rather than quantity of sexual life is the best predictor of overall sexual function among women treated for early stage cervical and endometrial cancer, indicating the importance of including quality indices in posttreatment sexual assessment in clinical practice and research studies.

Communicating cardiovascular disease risk: An interview study of general practitioners' use of absolute risk within tailored communication strategies

BackgroundCardiovascular disease (CVD) prevention guidelines encourage assessment of absolute CVD risk - the probability of a CVD event within a fixed time period, based on the most predictive risk factors. However, few General Practitioners (GPs) use absolute CVD risk consistently, and communication difficulties have been identified as a barrier to changing practice. This study aimed to explore GPs’ descriptions of their CVD risk communication strategies, including the role of absolute risk.MethodsSemi-structured interviews were conducted with a purposive sample of 25 GPs in New South Wales, Australia. Transcribed audio-recordings were thematically coded, using the Framework Analysis method to ensure rigour.ResultsGPs used absolute CVD risk within three different communication strategies: ‘positive’, ‘scare tactic’, and ‘indirect’. A ‘positive’ strategy, which aimed to reassure and motivate, was used for patients with low risk, determination to change lifestyle, and some concern about CVD risk. Absolute risk was used to show how they could reduce risk. A ‘scare tactic’ strategy was used for patients with high risk, lack of motivation, and a dismissive attitude. Absolute risk was used to ‘scare’ them into taking action. An ‘indirect’ strategy, where CVD risk was not the main focus, was used for patients with low risk but some lifestyle risk factors, high anxiety, high resistance to change, or difficulty understanding probabilities. Non-quantitative absolute risk formats were found to be helpful in these situations.ConclusionsThis study demonstrated how GPs use three different communication strategies to address the issue of CVD risk, depending on their perception of patient risk, motivation and anxiety. Absolute risk played a different role within each strategy. Providing GPs with alternative ways of explaining absolute risk, in order to achieve different communication aims, may improve their use of absolute CVD risk assessment in practice.

General practitioners’ use of absolute risk versus individual risk factors in cardiovascular disease prevention: an experimental study

Objective To understand general practitioners’ (GPs) use of individual risk factors (blood pressure and cholesterol levels) versus absolute risk in cardiovascular disease (CVD) risk management decision-making. Design Randomised experiment. Absolute risk, systolic blood pressure (SBP), cholesterol ratio (total cholesterol/high-density lipoprotein (TC/HDL)) and age were systematically varied in hypothetical cases. High absolute risk was defined as 5-year risk of a cardiovascular event >15%, high blood pressure levels varied between SBP 147 and 179 mm Hg and high cholesterol (TC/HDL ratio) between 6.5 and 7.2 mmol/L. Setting 4 GP conferences in Australia. Participants 144 Australian GPs. Outcomes GPs indicated whether they would prescribe cholesterol and/or blood pressure lowering medication. Analyses involved logistic regression. Results For patients with high blood pressure: 93% (95% CI 86% to 96%) of high absolute risk patients and 83% (95% CI 76% to 88%) of lower absolute risk patients were prescribed blood pressure medication. Conversely, 30% (95% CI 25% to 36%) of lower blood pressure patients were prescribed blood pressure medication if absolute risk was high and 4% (95% CI 3% to 5%) if lower. 69% of high cholesterol/high absolute risk patients were prescribed cholesterol medication (95% CI 61% to 77%) versus 34% of high cholesterol/lower absolute risk patients (95% CI 28% to 41%). 36% of patients with lower cholesterol (95% CI 30% to 43%) were prescribed cholesterol medication if absolute risk was high versus 10% if lower (95% CI 8% to 13%). Conclusions GPs’ decision-making was more consistent with the management of individual risk factors than an absolute risk approach, especially when prescribing blood pressure medication. The results suggest medical treatment of lower risk patients (5-year risk of CVD event <15%) with mildly elevated blood pressure or cholesterol levels is likely to occur even when an absolute risk assessment is specifically provided. The results indicate a need for improving uptake of absolute risk guidelines and GP understanding of the rationale for using absolute risk.

Sexual adjustment following early stage cervical and endometrial cancer: prospective controlled multi‐centre study

The primary aim of this study was to investigate objective and subjective aspects of sexual adjustment for women with early stage cervical and endometrial cancer during the first 6 months post‐treatment, compared to women with benign and pre‐invasive gynaecological conditions. ‘Objective’ aspects of sexual function were operationalised as the frequency of sexual activity and ‘subjective’ aspects as the perceived quality of sexual interactions.

Factors influencing intention to undergo whole genome screening in future healthcare: A single-blind parallel-group randomised trial

OBJECTIVE This study investigated the effect of biased information on beliefs about, and intention to undergo, whole genome sequencing (WGS) screening; and predictors of intention. METHODS A single-blind parallel-group randomised trial was conducted in Australia, in 2011. Using Excel, 216 participants with English proficiency and no genetic testing experience were randomly allocated (1:1): a neutral information pamphlet or a biased version omitting screening limitations. Measures included: screening intention; Protection Motivation Theory (PMT) constructs; consideration of future consequences (CFC); uncertainty avoidance (UA); anticipated regret (AR). RESULTS Intention decreased from pre to post-manipulation (p<.001, η(2)=.07, 95% CIs [4.41, 4.86], [3.99, 4.44], respectively). Biased participants (n=106) had higher response efficacy beliefs than neutral participants (n=102) (p<.001, η(2)=.04, 95% CIs [4.80, 5.10], [4.49, 4.79] respectively), but equal intention. The model explained 36.2% of the variance in intention; response efficacy (p<.001), response costs (p<.001), self-efficacy (p=.024), and UA (p=.019) were predictors. CONCLUSION This is the first study investigating factors influencing anticipated WGS screening uptake. Omitting screening limitations may bias beliefs about screening efficacy and benefits. Uptake may be driven by perceived benefits and costs, self-efficacy beliefs, and uncertainty avoidance. PMT appears to be an appropriate psychosocial model for this setting.

Shared decision making in Australia in 2017

Shared decision making (SDM) is now firmly established within national clinical standards for accrediting hospitals, day procedure services, public dental services and medical education in Australia, with plans to align general practice, aged care and disability service. Implementation of these standards and training of health professionals is a key challenge for the Australian health sector at this time. Consumer involvement in health research, policy and clinical service governance has also increased, with a major focus on encouraging patients to ask questions during their clinical care. Tools to support shared decision making are increasingly used but there is a need for more systemic approaches to their development, cultural adaptation and implementation. Sustainable solutions to ensure tools are kept up-to-date with the best available evidence will be important for the future.