Does a decision aid help physicians to detect chronic obstructive pulmonary disease?

Background

Numerous decision aids have been developed recently, but the value they add above that of the initial clinical assessment is not well known.

Aim

To quantify whethera formal decision aid for chronic obstructive pulmonary disease (COPD) adds diagnostic information, above the physician''s clinical assessment.

Design and setting

Subanalysis of a diagnostic study in Dutch primary care.

Method

Sixty-five primary care physicians included 357 patients who attended for persistent cough and were not known to have COPD. The physicians estimated the probability of COPD after short history taking and physical examination. After this, the presence or absence of COPD was determined using results of extensive diagnostic work-up. The extent to which an 8-item decision aid for COPD, which included only symptoms and signs, added diagnostic value above the physician''s estimation was quantified by the increase of the area under the receiver operating characteristic curve (ROC area), and the improvement in diagnostic risk classification across two classes: ‘low probability of COPD’ (<20%) and ‘possible COPD’ (≥20%).

Results

One hundred and four patients (29%) had COPD. Adding the decision aid to the clinical assessment increased the ROC area from 0.75 (95% confidence interval [CI] = 0.70 to 0.81) to 0.84 (95% CI = 0.80 to 0.89) (P<0.005), and improved the diagnostic risk classification of the patients, such that 35 fewer patients needed spirometry testing and eight fewer COPD cases were missed.

Conclusion

A short decision aid for COPD added diagnostic value to the physician''s clinical assessment.     

Animated graphics for comparing two risks: a cautionary tale

Background

The increasing use of computer-administered risk communications affords the potential to replace static risk graphics with animations that use motion cues to reinforce key risk messages. Research on the use of animated graphics, however, has yielded mixed findings, and little research exists to identify the specific animations that might improve risk knowledge and patients’ decision making.

Objective

To test whether viewing animated forms of standard pictograph (icon array) risk graphics displaying risks of side effects would improve people’s ability to select the treatment with the lowest risk profile, as compared with viewing static images of the same risks.

Methods

A total of 4198 members of a demographically diverse Internet panel read a scenario about two hypothetical treatments for thyroid cancer. Each treatment was described as equally effective but varied in side effects (with one option slightly better than the other). Participants were randomly assigned to receive all risk information in 1 of 10 pictograph formats in a quasi-factorial design. We compared a control condition of static grouped icons with a static scattered icon display and with 8 Flash-based animated versions that incorporated different combinations of (1) building the risk 1 icon at a time, (2) having scattered risk icons settle into a group, or (3) having scattered risk icons shuffle themselves (either automatically or by user control). We assessed participants’ ability to choose the better treatment (choice accuracy), their gist knowledge of side effects (knowledge accuracy), and their graph evaluation ratings, controlling for subjective numeracy and need for cognition.

Results

When compared against static grouped-icon arrays, no animations significantly improved any outcomes, and most showed significant performance degradations. However, participants who received animations of grouped icons in which at-risk icons appeared 1 at a time performed as well on all outcomes as the static grouped-icon control group. Displays with scattered icons (static or animated) performed particularly poorly unless they included the settle animation that allowed users to view event icons grouped.

Conclusions

Many combinations of animation, especially those with scattered icons that shuffle randomly, appear to inhibit knowledge accuracy in this context. Static pictographs that group risk icons, however, perform very well on measures of knowledge and choice accuracy. These findings parallel recent evidence in other data communication contexts that less can be more—that is, that simpler, more focused information presentation can result in improved understanding. Decision aid designers and health educators should proceed with caution when considering the use of animated risk graphics to compare two risks, given that evidence-based, static risk graphics appear optimal.     

Risk communication methods in hip fracture prevention: a randomised trial in primary care

Background

Treatment acceptance by patients is influenced by the way treatment effects are presented. Presentation of benefits using relative risk increases treatment acceptance compared to the use of absolute risk. It is not known whether this effect is modified by prior presentation of a patient''s individualised risk estimate or how presentation of treatment harms by relative or absolute risk affects acceptance.

Aim

To compare acceptance of a hypothetical treatment to prevent hip fracture after presentation of the treatment''s benefit in relative or absolute terms in the context of a personal fracture risk estimate, and to reassess acceptance following subsequent presentation of harm in relative orabsolute terms.

Design and setting

Randomised controlled trial of patients recruited from 10 GPs'' lists in Christchurch, New Zealand.

Method

Women aged ≥50 years were invited to participate. Participants were given a personal 10-year hip fracture risk estimate and randomised to receive information on a hypothetical treatment''s benefit and harm in relative orabsolute terms.

Results

Of the 1140 women invited to participate 393 (34%) took part. Treatment acceptance was greater following presentation of benefit using absolute terms than relative terms after adjustment forage, education, previous osteoporosis diagnosis, and self-reported risk (OR 1.73, 95% confidence interval [CI] = 1.10 to 2.73, P = 0.018). Presentation of the treatment''s harmful effect in relative terms led to a greater proportion of participants declining treatment than did presentation in absolute terms (OR 4.89, 95% CI = 2.3 to 11.0, P<0.001).

Conclusion

Presentation of treatment benefit and harm using absolute risk estimates led to greater treatment acceptance than presentation of the same information in relative terms.     

Patients' views of antidepressants: from first experiences to becoming expert

Background

The majority of patients discontinue antidepressant treatment earlier than prescribed. The factors behind this and the influences on patients'' choices about whether to take medication remain poorly understood.

Aim

To explore factors that influence patients'' decisions about taking antidepressant medication.

Design of study

Qualitative interview study.

Setting

Interviews were conducted across three sites: London, East Lancashire, and North East England.

Method

Semi-structured interviews were conducted with a purposive sample of 65 primary care patients who were prescribed antidepressants in the past year for depression or mixed anxiety/depression.

Results

Participants described their first course of antidepressants as typically occurring when they had ‘hit rock bottom’, having exhausted all other possibilities; therefore, there was little sense of a positive choice at this stage. There would typically follow a period of experimentation where it was usual to stop and restart medication, often several times. Ultimately, these recurring cycles lead to participants becoming more expert about their condition and better able to make an informed decision about medication. For younger participants, recovery typically remained a goal, although for older people there was often an acceptance that their condition, and medication use, would be long term.

Conclusion

Participants'' accounts demonstrated how they could become expert at managing their condition through a process of trial and error.     

Assessing the acceptability and usability of an interactive serious game in aiding treatment decisions for patients with localized prostate cancer

Background

Men diagnosed with localized prostate cancer face a potentially life-altering treatment decision that can be overwhelming. Enhancing patient knowledge through education can significantly reduce feelings of uncertainty while simultaneously increasing confidence in decision making. Serious games have been shown in other populations to increase health knowledge and assist with the health decision-making process. We developed an interactive serious game, Time After Time, which translates evidence-based treatment outcome data into an accessible and understandable format that men can utilize in their prostate cancer treatment decision-making process. The game specifically aims to raise men’s awareness and understanding of the impact of health-related quality of life issues associated with the major treatment options and to enrich their conversations with their health care providers.

Objective

This study determined the acceptability and usability of the alpha version of Time After Time, an interactive decision aid for men diagnosed with localized prostate cancer, in order to inform future iterations of the serious game.

Methods

The study employed a mixed methods approach to assess the acceptability and usability of the Time After Time serious game using qualitative focus groups and a quantitative Likert scale survey.

Results

A total of 13 men who had already completed treatment for localized prostate cancer completed the survey and participated in focus group meetings. The majority of the study participants rated Time After Time as an appropriate decision tool for localized prostate cancer and verified that it meets its goals of increasing focus on side effects and generating questions for the patient’s health care team. However, participants also expressed concerns about game usability and the diversity of information covered regarding treatment options and potential treatment outcomes.

Conclusions

Serious games are a promising approach to health education and decision support for older men. Participants were receptive to the idea of a serious game as a decision aid in localized prostate cancer. However, usability issues are a major concern for this demographic, as is clarity and transparency of data sources.     

Direct contact in inviting high-risk members of hereditary colon cancer families to genetic counselling and DNA testing

Background

Identification of hereditary predisposition to cancer has limited significance if not followed by efficient cancer prevention in the family. Probands are traditionally left to inform their relatives about the increased risk, but distant relatives may remain uninformed. An approach to contacting directly at‐risk persons assumed to be unaware of their increased cancer risk was taken. With cancer prevention as the ultimate goal, the study was aimed at investigating attitudes towards and psychosocial consequences of this novel strategy.

Methods

In families with hereditary non‐polyposis colorectal cancer (Lynch syndrome), 286 healthy adult relatives with a 50% risk of a predisposing mutation were contacted by letter. Of these, 112 participated in counselling and predictive testing. Baseline information and information obtained 1 month after the test for 73 respondents were compared with 299 corresponding subjects, approached via the proband (family‐mediated approach in our previous study) in these families.

Results

After the contact letter, 51% consented to the study. Of these, 92% approved of the direct contact and 33% had tried to seek information. In 34% of the mutation carriers, neoplasia was identified in the first post‐test colonoscopy. Although post‐test fear of cancer increased among the mutation carriers and decreased among noncarriers, almost all participants were satisfied with their decision to participate, independently of their test results, parallel to the family‐mediated approach.

Conclusion

In this large‐scale study, relatives in cancer families were actively contacted to inform them of the condition and genetic counselling. Their attitudes were encouraging, and the psychosocial consequences were similar to the family‐mediated approach. Our results suggest the appropriateness of direct contact as an alternative method of contact in cases of life‐threatening treatable disease.     

Rate and risk of anterior cruciate ligament injury among sportswomen in Slovenia

Context:

Anterior cruciate ligament (ACL)-injury rate is greater among female athletes than among male athletes.

Objective:

To investigate the rate and risk of ACL injury among Slovenian sportswomen playing professional basketball, team handball, or volleyball.

Design:

Prospective cohort study.

Setting:

The Slovenian National Organizations of basketball, team handball, and volleyball.

Patients or Other Participants:

During the 2003–2004 season, we prospectively followed 585 Slovenian sportswomen registered in the Slovenian National Organizations of basketball, team handball, and volleyball.

Main Outcome Measure(s):

We asked sportswomen and coaches to document the occurrence of every significant traumatic knee injury requiring medical attention. Injury rate and injury risk were calculated for sportswomen in each sport group. To calculate injury rate, we estimated the average exposure of each sportswoman during the research period.

Results:

During the 2003–2004 season, 585 Slovenian sportswomen sustained 12 ACL injuries. The ACL-injury risk was different in athletes participating in the various sports, with basketball players having the greatest ACL-injury risk and volleyball players having the lowest ACL-injury risk (P  =  .04). The risk of ACL injury among Slovenian sportswomen was 2.1 per 100 athletes (95% confidence interval  =  0.9, 3.2), whereas the rate of ACL injury was 0.037 per 1000 exposure hours (95% confidence interval  =  0.016, 0.06).

Conclusions:

Overall differences in injury risk were found among sports, but no differences were noted among divisions within sports. No differences for injury rate were observed between or within sports. The rate and risk of ACL injury among Slovenian sportswomen are high, with basketball players having the greatest ACL-injury risk.     

Risk factors for placenta praevia presenting with severe vaginal bleeding in Mulago hospital, Kampala, Uganda

Objective

To determine the risk factors for placenta praevia presenting with severe vaginal bleeding in Mulago hospital, Kampala, Uganda.

Design

A case control study.

Setting

Mulago hospital labour suite

Participants

Between 15^th November 2001 and 30^th November 2002 we identified and recruited thirty six parturients with placenta previa who developed severe bleeding and 180 women with normal delivery. The risk factors were studied.

Variables of interest

Socio demographic characteristics, social and family history, gynaecological operations, blood transfusion, medical conditions, past and present obstetric performance and HIV status.

Results

Significant predictors for severe bleeding in parturients with placenta praevia were: previous history of evacuation of the uterus or dilation and curettage (O.R. 3.6, CI: 1.1–12.5), delivery by caesarean section in previous pregnancy (O.R. 19.9, CI: 6.4–61.7), residing more than ten kilometres from Mulago hospital (O.R. 2.4, CI: 1.0–5.7) and recurrent vaginal bleeding during the current pregnancy (O.R. 7.3, CI 2.4–63.7).

Conclusion

Severe bleeding in placenta praevia is associated with high maternal morbidity and mortality. The determinants of severe bleeding in placenta praevia can be used in the antenatal period to identify mothers at risk. These, with prompt interventions to deliver the women can be used to reduce the maternal morbidity associated with this condition.     

Acceptability and preliminary feasibility of an internet/CD-ROM-based education and decision program for early-stage prostate cancer patients: randomized pilot study

Background

Prostate cancer is the most common cancer affecting men in the United States. Management options for localized disease exist, yet an evidence-based criterion standard for treatment still has to emerge. Although 5-year survival rates approach 98%, all treatment options carry the possibility for significant side effects, such as erectile dysfunction and urinary incontinence. It is therefore recommended that patients be actively involved in the treatment decision process. We have developed an Internet/CD-ROM-based multimedia Prostate Interactive Educational System (PIES) to enhance patients’ treatment decision making. PIES virtually mirrors a health center to provide patients with information about prostate cancer and its treatment through an intuitive interface, using videos, animations, graphics, and texts.

Objectives

(1) To examine the acceptability and feasibility of the PIES intervention and to report preliminary outcomes of the program in a pilot trial among patients with a new prostate cancer diagnosis, and (2) to explore the potential impact of tailoring PIES treatment information to participants’ information-seeking styles on study outcomes.

Methods

Participants (n = 72) were patients with newly diagnosed localized prostate cancer who had not made a treatment decision. Patients were randomly assigned to 3 experimental conditions: (1) control condition (providing information through standard National Cancer Institute brochures; 26%), and PIES (2) with tailoring (43%) and (3) without tailoring to a patient’s information-seeking style (31%). Questionnaires were administrated before (t1) and immediately after the intervention (t2). Measurements include evaluation and acceptability of the PIES intervention, monitoring/blunting information-seeking style, psychological distress, and decision-related variables (eg, decisional confidence, feeling informed about prostate cancer and treatment, and treatment preference).

Results

The PIES program was well accepted by patients and did not interfere with the clinical routine. About 79% of eligible patients (72/91) completed the pre- and post-PIES intervention assessments. Patients in the PIES groups compared with those in the control condition were significantly more likely to report higher levels of confidence in their treatment choices, higher levels of helpfulness of the information they received in making a treatment decision, and that the information they received was emotionally reassuring. Patients in the PIES groups compared with those in the control condition were significantly less likely to need more information about treatment options, were less anxious about their treatment choices, and thought the information they received was clear (P < .05). Tailoring PIES information to information-seeking style was not related to decision-making variables.

Conclusions

This pilot study confirms that the implementation of PIES within a clinical practice is feasible and acceptable to patients with a recent diagnosis of prostate cancer. PIES improved key decision-making process variables and reduced the emotional impact of a difficult medical decision.     

Quality of life in patients with chronic kidney disease

AIM:

To compare the dimensions of quality of life in the stages of chronic kidney disease and the influence of sociodemographic, clinical and laboratory data.

INTRODUCTION:

The information available on the quality of life of patients on conservative treatment and the relationship between the quality of life and glomerular filtration rate is limited.

METHODS:

155 patients in stages 1–5 of chronic kidney disease and 36 in hemodialysis were studied. Quality of life was rated by the Medical Outcomes Study Short Form 36-Item (SF-36) and functional status by the Karnofsky Performance Scale. Clinical, laboratory and sociodemographic variables were investigated.

RESULTS:

Quality of life decreased in all stages of kidney disease. A reduction in physical functioning, physical role functioning and in the physical component summary was observed progressively in the different stages of kidney disease. Individuals with higher educational level who were professionally active displayed higher physical component summary values, whereas men and those with a higher income presented better mental component summary values. Older patients performed worse on the physical component summary and better on the mental component summary. Hemoglobin levels correlated with higher physical component summary values and the Karnofsky scale. Three or more comorbidities had an impact on the physical dimension.

CONCLUSION:

Quality of life is decreased in renal patients in the early stages of disease. No association was detected between the stages of the disease and the quality of life. It was possible to establish sociodemographic, clinical and laboratory risk factors for a worse quality of life in this population.     

Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance

Context:

Evidence suggests that athletes engaging in high-intensity activities after concussion have more difficulties with cognitive recovery.

Objective:

To examine the role postinjury activity level plays in postconcussive symptoms and performance on neurocognitive tests in a population of student-athletes.

Design:

Retrospective cohort study with repeated measures of neurocognitive performance and symptom reporting.

Setting:

University-based sports concussion clinic.

Patients or Other Participants:

Ninety-five student-athletes (80 males, 15 females: age  =  15.88 ± 1.35 years) were retrospectively assigned to 1 of 5 groups based on a postinjury activity intensity scale.

Main Outcome Measure(s):

We employed a regression analysis for repeated measures to evaluate the relationship of activity intensity to symptoms and neurocognitive outcome up to 33 days after concussion. Postconcussion symptom scores and neurocognitive (verbal memory, visual memory, visual motor speed, and reaction time) scores served as the primary outcome measures.

Results:

Level of exertion was significantly related to all outcome variables (P < .02 for all comparisons). With multivariate analysis, activity intensity remained significant with respect to visual memory (P  =  .003) and reaction time (P < .001).

Conclusions:

Activity level after concussion affected symptoms and neurocognitive recovery. Athletes engaging in high levels of activity after concussion demonstrated worse neurocognitive performance. For these tasks, those engaging in moderate levels of activity demonstrated the best performance.     

Concordance between PHQ-9 scores and patients�� experiences of depression: a mixed methods study

Background

In 2009, a new indicator (DEP 3) was introduced into the Quality and Outcomes Framework. GPs are now encouraged to assess response to antidepressant treatment 5–12 weeks after the initial assessment, to guide clinical decision making. The Patient Health Questionnaire (PHQ-9) is one of the validated instruments that GPs can use to assess the patient''s clinical state.

Aims

To explore the extent to which changes in PHQ-9 score over time reflect patients’ accounts of their experiences of depression during the same period; and to explore patients’ experiences of using the PHQ-9 within primary care consultations.

Design of study

Mixed methods.

Setting

Primary care.

Method

Patients were recruited through six GP practices. The PHQ-9 and in-depth interviews were used at the same three time points over a 6-month period during a new or first episode of depression.

Results

Patterns in the total PHQ-9 score broadly reflected patients’ accounts of the severity of their depression over time. However, the PHQ-9 was inaccurate in its assessment of the presence and intensity of thoughts of self-harm, and missed symptoms that are meaningful to patients. At the diagnostic primary care consultation, patients viewed their score as a ‘tangible’ measure of their condition. Some patients requested the PHQ-9 subsequently as a way to measure their own treatment response and recovery process.

Conclusion

The potential therapeutic value of the PHQ-9 may be dependent upon the GP''s willingness to openly discuss the results and what they may mean for the patient.     

Skin diseases among children attending the out patient clinic of the University of Nigeria teaching hospital, Enug

Background

The prevalence of skin diseases varies worldwide and information regarding local prevalence of its various causes may help the development of policies towards better management.

Objective

To document the types of skin disorders seen among children attending the University of Nigeria Teaching Hospital, Enugu( UNTH).

Methods

The medical register from the children out patient clinic was used to obtain information on pattern and outcome of skin diseases seen from January 1996 to December 2005.

Results

Of the 16,337 children seen in children.s out patient clinic (CHOP), 1506 (1.3%) had a skin disease. Age range was one week to 16 years with a mean ± SD of 3.89 ± 3.8 years. Children aged 0 – 5 years constituted 70.24% of patients with skin diseases. The commonest skin condition was pyoderma (29.81%) seen mainly in those below 5 years, followed by scabies (13.55%). Approximately 1/3 (33.3%) of the patients were referred to the dermatology clinic.

Conclusion

Infectious skin diseases constitute a high percentage of skin disorders encountered in paediatrics. Almost half (48.4%) of the skin problems were diagnosed as non-specific dermatitis suggesting the need of better dermatological training of the paediatric residents.     

Self-monitoring and other non-pharmacological interventions to improve the management of hypertension in primary care: a systematic review

Background

Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals: a condition labelled as ‘uncontrolled’ hypertension. The optimal way to organise and deliver care to hypertensive patients has not been clearly identified.

Aim

To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension.

Design of study

Systematic review of randomised controlled trials.

Setting

Primary and ambulatory care.

Method

Interventions were categorised as following: self-monitoring; educational interventions directed to the patient; educational interventions directed to the health professional; health professional- (nurse or pharmacist) led care; organisational interventions that aimed to improve the delivery of care; and appointment reminder systems. Outcomes assessed were mean systolic and diastolic blood pressure, control of blood pressure and proportion of patients followed up at clinic.

Results

Seventy-two RCTs met the inclusion criteria. The trials showed a wide variety of methodological quality. Self-monitoring was associated with net reductions in systolic blood pressure (weighted mean difference [WMD] −2.5mmHg, 95%CI = −3.7 to −1.3 mmHg) and diastolic blood pressure (WMD −1.8mmHg, 95%CI = −2.4 to −1.2 mmHg). An organised system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure and all-cause mortality in a single large randomised controlled trial.

Conclusion

Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring is a useful adjunct to care while reminder systems and nurse/pharmacist -led care require further evaluation.     

Limb blood flow after class 4 laser therapy

Context:

Laser therapy is purported to improve blood flow in soft tissues. Modulating circulation would promote healing by controlling postinjury ischemia, hypoxia, edema, and secondary tissue damage. However, no studies have quantified these responses to laser therapy.

Objective:

To determine a therapeutic dose range for laser therapy for increasing blood flow to the forearm.

Design:

Crossover study.

Setting:

Controlled laboratory setting.

Patients or Other Participants:

Ten healthy, college-aged men (age = 20.80 ± 2.16 years, height = 177.93 ± 3.38 cm, weight = 73.64 ± 9.10 kg) with no current history of injury to the upper extremity or cardiovascular conditions.

Intervention(s):

A class 4 laser device was used to treat the biceps brachii muscle. Each grid point was treated for 3 to 4 seconds, for a total of 4 minutes. Each participant received 4 doses of laser therapy: sham, 1 W, 3 W, and 6 W.

Main Outcome Measure(s):

The dependent variables were changes in blood flow, measured using venous occlusion plethysmography. We used a repeated-measures analysis of variance to analyze changes in blood flow for each dose at 2, 3, and 4 minutes and at 1, 2, 3, 4, and 5 minutes after treatment. The Huynh-Feldt test was conducted to examine differences over time.

Results:

Compared with baseline, blood flow increased over time with the 3-W treatment (F_3,9 = 3.468, P < .011) at minute 4 of treatment (2.417 ± 0.342 versus 2.794 ± 0.351 mL/min per 100 mL tissue, P = .032), and at 1 minute (2.767 ± 0.358 mL/min per 100 mL tissue, P < .01) and 2 minutes (2.657 ± 0.369 mL/min per 100 mL tissue, P = .022) after treatment. The sham, 1-W, and 6-W treatment doses did not change blood flow from baseline at any time point.

Conclusions:

Laser therapy at the 3-W (360-J) dose level was an effective treatment modality to increase blood flow in the soft tissues.