Hubert Robitaille

Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument.

We have no clear overview of the extent to which health‐care providers involve patients in the decision‐making process during consultations. The Observing Patient Involvement in Decision Making instrument (OPTION) was designed to assess this.

Training health professionals in shared decision-making: An international environmental scan

OBJECTIVE To update an environmental scan of training programs in SDM for health professionals. METHODS We searched two systematic reviews for SDM training programs targeting health professionals produced from 2011 to 2015, and also in Google and social networks. With a standardized data extraction sheet, one reviewer extracted program characteristics. All completed extraction forms were validated by a second reviewer. RESULTS We found 94 new eligible programs in four new countries and two new languages, for a total of 148 programs produced from 1996 to 2015-an increase of 174% in four years. The largest percentage appeared since 2012 (45.27%). Of the 94 newprograms, 42.55% targeted licensed health professionals (n=40), 8.51% targeted pre-licensure (n=8), 28.72% targeted both (n=27), 20.21% did not specify (n=19), and 5.32% targeted also patients (n=5). Only 23.40% of the new programs were reported as evaluated, and 21.28% had published evaluations. CONCLUSIONS Production of SDM training programs is growing fast worldwide. Like the original scan, this update indicates that SDM training programs still vary widely. Most still focus on the single provider/patient dyad and few are evaluated. PRACTICE IMPLICATIONS This update highlights the need to adapt training programs to interprofessional practice and to evaluate them.

Tissue engineering of skin and cornea : Development of new models for in vitro studies

Human beings are greatly preoccupied with the unavoidable nature of aging. While the biological processes of senescence and aging are the subjects of intense investigations, the molecular mechanisms linking aging with disease and death are yet to be elucidated. Tissue engineering offers new models to study the various processes associated with aging. Using keratin 19 as a stem cell marker, our studies have revealed that stem cells are preserved in human skin reconstructed by tissue engineering and that the number of epithelial stem cells varies according to the donors age. As with skin, human corneas can also be engineered in vitro. Among the epithelial cells used for reconstructing skin and corneas, significant age‐dependent variations in the expression of the transcription factor Sp1 were observed. Culturing skin epithelial cells with a feeder layer extended their life span in culture, likely by preventing Sp1 degradation in epithelial cells, therefore demonstrating the pivotal role played by this transcription factor in cell proliferation. Finally, using the human tissue‐engineered skin as a model, we linked Hsp27 activation with skin differentiation.

The Small Heat-Shock Protein Hsp27 Undergoes ERK-Dependent Phosphorylation and Redistribution to the Cytoskeleton in Response to Dual Leucine Zipper-Bearing Kinase Expression

Hsp27, a small heat-shock protein, has important roles in many cellular processes, including cytoskeleton dynamics, cell differentiation, and apoptosis. Its expression in normal epidermis correlates with differentiation; however, little is known about the regulatory mechanisms involved. In this study, we report that Hsp27 undergoes upregulation, phosphorylation, and redistribution to the cytoskeleton during the late phase of epidermal keratinocyte differentiation. Our results also show that the expression of the dual leucine zipper-bearing kinase (DLK), an upstream activator of the MAP kinase pathways, is sufficient by itself to induce Hsp27 phosphorylation, cell periphery localization, and redistribution to the insoluble protein fraction (cytoskeleton) in poorly differentiated keratinocytes. This redistribution correlates with the insolubilization of cornified envelope-associated proteins such as involucrin. Interestingly, the effects of DLK on Hsp27 were blocked by PD98059, a selective inhibitor of the extracellular signal-regulated protein kinase (ERK) pathway. Moreover, downregulation of Hsp27 by small interfering RNA in epithelial cells expressing DLK was accompanied by attenuated expression of involucrin in the cytoskeleton. Thus, these observations suggest that the DLK-ERK signaling pathway may act as a regulator of the interaction that occurs between Hsp27 and the cytoskeleton during the formation of the cornified cell envelope, a process conferring to the skin its crucial barrier function.

The decisional conflict scale: moving from the individual to the dyad level

Decisional conflict is a central determinant of decision making, particularly in the context of uncertainty. It is also one of the most frequently reported outcomes in studies on decision support interventions. Decisional conflict is defined as personal uncertainty about which option to choose. The Decisional Conflict Scale (DCS) is a self-administered questionnaire that was originally designed to assess decisional conflict in patients. The scale has since been adapted to and tested among health professionals, since decisional conflict as seen by doctors, nurses and other healthcare providers has proven useful in evaluating the quality of the shared decision making (SDM) process. In recent years, however, more and more researchers have found that evaluating the perspectives of the patient and the health professional as interdependent members of a dyad, rather than as two autonomous individuals, offers exciting avenues for developing interventions to improve decision making in the clinical setting. For that reason, the SDM community has increasingly turned its attention to a dyadic approach to SDM. In this paper, we briefly review the history of the Dyadic Decisional Conflict Scale (D-DCS), update its psychometrics based on published work, and propose a research agenda for refining it further.

Some but not all dyadic measures in shared decision making research have satisfactory psychometric properties

OBJECTIVE To assess the psychometric properties of dyadic measures for shared decision making (SDM) research. STUDY DESIGN AND SETTING We conducted an observational cross-sectional study in 17 primary care clinics with physician-patient dyads. We used seven subscales to measure six elements of SDM: (1) defining the problem, presenting options, and discussing pros and cons; (2) clarifying the patients values and preferences; (3) discussing the patients self-efficacy; (4) drawing on the doctors knowledge; (5) verifying the patients understanding; and (6) assessing the patients uncertainty. We assessed the reliability and invariance of the factorial structure and considered a measure to be dyadic if the factorial structure of the patient version was similar to that of the physician version and if there was equality of loading (no significant chi-square). RESULTS We analyzed data for 264 physicians and 269 patients. All measures except one showed adequate reliability (Cronbach alpha, 0.70-0.93) and factorial validity (root mean square error of approximation, 0.000-0.06). However, we found only four measures to be dyadic (P>0.05): the values clarification subscale, perceived behavioral subscale, information-verifying subscale, and uncertainty subscale. CONCLUSION The subscales for values clarification, perceived behavioral control, information verifying, and uncertainty are appropriate dyadic measures for SDM research and can be used to derive dyadic indices.

A systematic process for creating and appraising clinical vignettes to illustrate interprofessional shared decision making

Abstract Vignettes and written case simulations have been widely used by educators and health services researchers to illustrate plausible situations and measure processes in a wide range of practice settings. We devised a systematic process to create and appraise theory-based vignettes for illustrating an interprofessional approach to shared decision making (IP-SDM) for health professionals. A vignette was developed in six stages: (1) determine IP-SDM content elements; (2) choose true-to-life clinical scenario; (3) draft script; (4) appraise IP-SDM concepts illustrated using two evaluation instruments and an interprofessional concept grid; (5) peer review script for content validity; and (6) retrospective pre-/post-test evaluation of video vignette by health professionals. The vignette contained six scenes demonstrating the asynchronous involvement of five health professionals with an elderly woman and her daughter facing a decision about location of care. The script scored highly on both evaluation scales. Twenty-nine health professionals working in home care watched the vignette during IP-SDM workshops in English or French and rated it as excellent (n = 6), good (n = 20), fair (n = 0) or weak (n = 3). Participants reported higher knowledge of IP-SDM after the workshops compared to before (p < 0.0001). Our video vignette development process resulted in a product that was true-to-life and as part of a multifaceted workshop it appears to improve knowledge among health professionals. This could be used to create and appraise vignettes targeting IP-SDM in other contexts.

An interprofessional approach to shared decision making: an exploratory case study with family caregivers of one IP home care team.

BackgroundWithin the context of an exploratory case study, the authors assessed the perceptions of family caregivers about the decision-making process regarding relocating their relative and about the applicability of an interprofessional approach to shared decision making (IP-SDM). They also assessed perceptions of health professionals and health managers about IP-SDM.MethodsFrom November 2010 to October 2011, we worked with one IP home care team dedicated to older adults (the case) from a large primary health care organization in Quebec City, Canada. We identified six of their clients who had faced a decision about whether to stay at home or move to a long-term care facility in the past year and interviewed their family caregivers. We explored the decision-making process they had experienced regarding relocating their relative and their perceptions about the applicability of IP-SDM in this context. Attitudes towards IP-SDM and potential barriers to this approach were explored using a focus group with the participating IP home care team, individual interviews with 8 managers and a survey of 272 health professionals from the primary care organization. A hybrid process of inductive and deductive thematic analysis was used and data were triangulated across all sources.ResultsFamily caregivers reported lack of agreement on the nature of the decision to be made, a disconnection between home care services and relatives’ needs, and high cost of long-term care alternatives. Factors influencing their decision included their ability to provide care for their relative. While they felt somewhat supported by the IP home care team, they also felt pressured in the decision. Overall, they did not perceive they had been exposed to IP-SDM but agreed that it was applicable in this context. Results from the survey, focus group and interviews with health professionals and managers indicated they all had a favourable attitude towards IP-SDM but many barriers hampered its implementation in their practice.ConclusionsThe family caregivers in this study did not experience IP-SDM when relocating their relative. Added to results obtained with health professionals and managers, this highlights the need for an effective intervention targeting identified barriers to implementing IP-SDM in this context.

Decision aids that support decisions about prenatal testing for Down syndrome: an environmental scan

BackgroundPrenatal screening tests for Down syndrome (DS) are routine in many developed countries and new tests are rapidly becoming available. Decisions about prenatal screening are increasingly complex with each successive test, and pregnant women need information about risks and benefits as well as clarity about their values. Decision aids (DAs) can help healthcare providers support women in this decision. Using an environmental scan, we aimed to identify publicly available DAs focusing on prenatal screening/diagnosis for Down syndrome that provide effective support for decision making.MethodsData sources searched were the Decision Aids Library Inventory (DALI) of the Ottawa Patient Decision Aids Research Group at the Ottawa Health Research Institute; Google searches on the internet; professional organizations, academic institutions and other experts in the field; and references in existing systematic reviews on DAs. Eligible DAs targeted pregnant women, focused on prenatal screening and/or diagnosis, applied to tests for fetal abnormalities or aneuploidies, and were in French, English, Spanish or Portuguese. Pairs of reviewers independently identified eligible DAs and extracted characteristics including the presence of practical decision support tools and features to aid comprehension. They then performed quality assessment using the 16 minimum standards established by the International Patient Decision Aids Standards (IPDASi v4.0).ResultsOf 543 potentially eligible DAs (512 in DALI, 27 from experts, and four on the internet), 23 were eligible and 20 were available for data extraction. DAs were developed from 1996 to 2013 in six countries (UK, USA, Canada, Australia, Sweden, and France). Five DAs were for prenatal screening, three for prenatal diagnosis and 12 for both). Eight contained values clarification methods (personal worksheets). The 20 DAs scored a median of 10/16 (range 6–15) on the 16 IPDAS minimum standards.DiscussionNone of the 20 included DAs met all 16 IPDAS minimum standards, and few included practical decision support tools or aids to comprehension.ConclusionsOur results indicate there is a need for DAs that effectively support decision making regarding prenatal testing for Down syndrome, especially in light of the recently available non-invasive prenatal screening tests.

Applications of Human Tissue-Engineered Blood Vessel Models to Study the Effects of Shed Membrane Microparticles from T-Lymphocytes on Vascular Function

Microparticles (MPs) are membrane vesicles harboring cell surface proteins and containing cytoplasmic components of the original cell. High levels of circulating MPs have been detected in pathological states associated with vascular dysfunction. We took advantage of the self-assembly method of tissue engineering to produce in vitro three vascular constructs from human vascular smooth muscle cells and fibroblasts to investigate the role of the adventitia in the modulation of vascular tone by MPs, comparing the contractile response of each of these constructs to histamine. The first two were composed of an adventitia (tissue-engineered vascular adventitia (TEVA)) or a media (tissue-engineered vascular media (TEVM)) solely, and the third one contained a media and an adventitia (tissue-engineered vascular media and adventitia (TEVMA)). In the three constructs, the results show that histamine induces contraction insensitive to blockade of inducible nitric oxide (NO) synthase (iNOS) and cyclooxygenase-2 (COX-2) and not affected by MP treatment. MPs decreased NO production and nuclear factor (NF)-kappaB expression but did not affect superoxide anion (O(2)(-)) release in TEVA. MPs enhanced NF-kappaB expression but did not affect iNOS and COX-2 expression or NO or O(2)(-) release in TEVM. In TEVMA, MPs did not enhance NF-kappaB expression, but COX-2 expression was higher, and O(2)(-) release was lower. Thus, MPs affected NO, O(2)(-), NF-kappaB, and COX-2 in a subtle fashion to maintain the contractile response to histamine. The use of tissue-engineered vascular constructs results in a better understanding of the effect of MPs on human adventitia and media.