Marie-Odile Carrère

Shared decision-making in the medical encounter: are we all talking about the same thing?

Objective. This article aims to explore 1) whether after all the research done on shared decision making (SDM) in the medical encounter, a clear definition (or definitions) of SDM exists; 2) whether authors provide a definition of SDM when they use the term; 3) and whether authors are consistent, throughout a given paper, with respect to the research described and the definition they propose or cite. Methods. The authors searched different databases (Medline, HealthStar, Cinahl, Cancerlit, Sociological Abstracts, and Econlit) from 1997 to December 2004. The keywords used were informed decision making and shared decision making as these are the keywords more often encountered in the literature. The languages selected were English and French. Results. The 76 reported papers show that 1) several authors clearly define what they mean by SDM or by another closely related phrase, such as informed shared decision making. 2) About a third of the papers reviewed (25/76) cite these authors although 8 of them do not use the term in a manner consistent with the definition cited. 3) Certain authors use the term SDM inconsistently with the definition they propose, and some use the terms informed decision making and SDM as if they were synonymous. 4) Twenty-one papers do not provide or cite any definition, or their use of the term (i.e., SDM) is not consistent with the definition they provide. Conclusion. Although several clear definitions of shared decision making have been proposed, they are cited by only about a third of the papers reviewed. In the other papers, authors refer to the term without specifying or citing a definition or use the term inconsistently with their definition. This is a problem because having a clear definition of the concept and following this definition are essential to guide and focus research. Authors should use the term consistently with the identified definition.

Respiratory gating techniques for optimization of lung cancer radiotherapy

Purpose: The primary objective of the STIC 2003 project was to compare the clinical and economic aspects of respiratory-gated conformal radiotherapy (RGRT), an innovative technique proposed to limit the impact of respiratory movements during irradiation, versus conventional conformal radiotherapy, the reference radiation therapy for lung cancer. Methods and Materials: A comparative, nonrandomized, multicenter, and prospective cost toxicity analysis was performed in the context of this project between April 2004 and June 2008 in 20 French centers. Only the results of the clinical study are presented here, as the results of the economic assessment have been published previously. Results: The final results based on 401 evaluable patients confirm the feasibility and good reproducibility of the various RGRT systems. The results of this study demonstrated a marked reduction of dosimetric parameters predictive of pulmonary, cardiac and esophageal toxicity as a result of the various respiratory gating techniques. These dosimetric benefits were mainly observed with deep inspiration breath-hold (DIBH) techniques (ABC and SDX systems), which markedly increased the total lung volume compared with the inspiration-synchronized system based on tidal volume (Real-time Position Management). These theoretical dosimetric benefits were correlated clinically with a significant reduction of pulmonary acute toxicity, and the pulmonary, cardiac, and esophageal late toxicities, especially with DIBH techniques. Pulmonary function parameters, although more heterogeneous, especially DLCO, showed a tendency to reduction of pulmonary toxicity in the RGRT group. Conclusions: RGRT seems to be essential to reduce toxicities, especially the pulmonary, cardiac, and esophageal late toxicities with the DIBH methods.

Economic Impact of Harmonizing Medical Practices: Compliance With Clinical Practice Guidelines in the Follow-Up of Breast Cancer in a French Comprehensive Cancer Center

PURPOSE The introduction of clinical practice guidelines (CPGs) and the increasing desire to harmonize clinical practices draw attention to the economic impact of these trends. In 1994, CPGs were introduced in a French Comprehensive Cancer Center (Centre Régional Léon Bérard, Lyon). We evaluated the application of these CPGs in addition to the consequences of harmonizing clinical practices with respect to the distribution of resources by specifically analyzing the posttherapeutic follow-up of patients with localized breast cancer. METHODS A before-and-after analysis of the records of patients who received posttherapeutic follow-up for localized breast cancer as of either 1993 or 1995 was performed. Two hundred records were chosen at random, 100 from 1993 and 100 from 1995. Follow-up was continued for as long as possible and CPG compliance was studied for each year of the follow-up periods. RESULTS Follow-up that was not CPG-compliant required a significantly greater amount of resources. This difference was due to neither consultations nor mammographies, but was due to other examinations that were systematically performed without any warning signs to justify them. Depending on the follow-up year, noncompliant follow-up cost the Social Security from 2.2 to 3.6 times more than compliant follow-up. A noticeable change in medical practices was observed after the introduction of CPGs in 1994. This was confirmed by a sharp decrease in mean Social Security expenditure per patient of more than one third between 1993 and 1995, regardless of the follow-up year considered. CONCLUSION In the follow-up of patients with localized breast cancer, a large decrease in costs has been observed along with the evolution of medical practices toward CPG compliance. This finding is probably generalizable to other settings, but there is nothing that proves that it is applicable to other treatment strategies.

Analysis of the eligibility of published economic evaluations for transfer to a given health care system Methodological approach and application to the French health care system

CONTEXT Economic evaluations are costly and cannot always be carried out locally. Therefore, decision-makers may wish to use studies already performed in other settings. OBJECTIVE To define a method for assessing the eligibility of published economic evaluations for transfer to a given health care system and apply it to the french health care system in the clinical situation of adjuvant therapy for women with breast cancer. METHODS (1) Literature search in six databases from 1982 to 1996; (2) critical appraisal of articles based on four inclusion criteria; and (3) assessment of the eligibility of the studies for transfer based on five indicators. RESULTS We identified 26 published economic evaluations concerning adjuvant therapy in women with breast cancer. Six (23%) met all four criteria used to select studies, but none of these studies were eligible for transfer to the french health care system. The main reason was that cost data was not reported in a transparent way. CONCLUSIONS To improve the transferability of economic evaluations, we recommend that requirements for data provision in publications be standardized and international collaboration strengthened.

Clinical issues in shared decision-making applied to breast cancer

Objectives  To assess (1) the clinical issues addressed during the medical encounter; (2) the feasibility of the process of shared decision‐making in clinical practice and (3) patients’ desires concerning the question of ‘who should take the decision in breast cancer treatments?’

Eliciting patients’ preferences for adjuvant chemotherapy in breast cancer: development and validation of a bedside decision‐making instrument in a French Regional Cancer Centre

In developed countries, the physician‐patient relationship is moving from a paternalistic model to new decision‐making models that take patient preferences into account.

Cost comparison of two surgical strategies in the treatment of breast cancer: Sentinel lymph node biopsy versus axillary lymph node dissection

OBJECTIVES The feasibility and accuracy of sentinel lymph node biopsy (SLNB) in the treatment of breast cancer is widely acknowledged today. The aim of our study was to compare the hospital-related costs of this strategy with those of conventional axillary lymph node dissection (ALND). METHODS A retrospective study was carried out to determine the total direct medical costs for each of the two medical strategies. Two patient samples (n = 43 for ALND; n = 48 for SLNB) were selected at random among breast cancer patients at the Centre Leon Bérard, a comprehensive cancer treatment center in Lyon, France. Costs related to ALND carried out after SLNB (either immediately or at a later date) were included in SLNB costs (n = 18 of 48 patients). RESULTS Total direct medical costs were significantly different in the two groups (median 1965.86 Euro versus 1429.93 Euro, p = 0.0076, Mann-Whitney U-test). The total cost for SLNB decreased even further for patients who underwent SLNB alone (median, 1,301Euro). Despite the high cost of anatomic pathology examinations and nuclear medicine (both favorable to ALND), the difference in direct medical costs for the two strategies was primarily due to the length of hospitalization, which differs significantly depending on the technique used (9-day median for ALND versus 3 days for SLNB, p < 0.0001). CONCLUSIONS A lower morbidity rate is favorable to the generalization of SLNB, when the patients clinical state allows for it. From an economic point of view, SLNB also seems to be preferred, particularly because our results confirm those found in two published studies concerning the cost of SLNB.

From information to shared decision-making in medicine

As stated by Angela Coulter in one of her leading articles, Most readers of Health Expectations will be familiar with the now extensive body of research into shared decision-making, including patients information needs, the evaluation and use of patient decision aids, and strategies for training health professionals to elicit patients values and preferences and engage them in decisions about their care. 1 Indeed, this journal has now been engaged for over 5 years in making shared decision-making studies known internationally. We are grateful to the editorial board of the journal for agreeing to publish this special issue on work presented at the international meeting From information to shared decision-making in medicine that was organized in Lyons (France) in December 2002, as part of the 15th Entretiens Jacques Cartier. From the early nineties, publications dealing with information and shared decision-making in the context of the doctor–patient relationship, as well as in medicine in general, have reported studies conducted by multidisciplinary teams including physicians, sociologists, ethicists, psychologists and economists, mostly from Northern America, Australia and Northern Europe. Although French researchers have been less involved in this domain of research, a number of publications have emerged from France since the end of the nineties, dealing either with legal or administrative aspects, or with scientific information. In this context, we were keen to invite international and French specialists involved in the domain from the very beginning to participate in the meeting. The occasion gave us an opportunity to discuss current advances and future prospects, and also to promote the theme of patient information and shared decision-making in our country. Several very exciting communications were made. A list of the different contributions is given below (in alphabetical order of authors): Janine Barbot and Emmanuelle Fillion: How is medical decision-making shared? The case of haemophilia patients and doctors: the aftermath of the infected blood affair in France. Carlos Brailowsky: Competence certification in family medicine: impact of shared decisionmaking. Alain Brémond: Clinical issues in shared decision-making applied to breast cancer. Dominique Broclain: Observed roles of hospitalized patients in medical decision-making. Marie-FranceCallu: Shared decision-making in medicine:acentral issue intheFrenchlegal system. Angela Coulter: Shared decision-making: the next steps. Hanneke De Haes: Does patient-centred medicine represent the ideal world? Adrian Edwards: The contribution of risk communication to medical decision-making: what does it achieve and how should we do? France Légaré: Clinical decision-making in hormone replacement therapy: agreement of women and their doctor. Amiram Gafni: The physician–patient encounter: an economic perspective. Andrew Kennedy: Information is not enough: the information and preferences in Menorrhagia (IPMEN study).