Is there shared decision making when the provider makes a recommendation?

Objective

To compare the amount of shared decision making in breast cancer surgery interactions when providers do and do not make a treatment recommendation.

Methods

We surveyed breast cancer survivors who were eligible for mastectomy and lumpectomy. Patients reported whether the provider made a recommendation and the recommendation given. They completed items about their interaction including discussion of options, pros, cons, and treatment preference. A total involvement score was calculated with higher scores indicating more shared decision making.

Results

Most patients (85%) reported that their provider made a recommendation. Patients who did not receive a recommendation had higher involvement scores compared to those who did (52% vs. 39.1%, p = 0.004). Type of recommendation was associated with involvement. Patients given different recommendations had the highest total involvement scores followed by those who received mastectomy and lumpectomy recommendations (65.5% vs. 42.5% vs. 33.2%, respectively, p < 0.001).

Conclusion

Providers were less likely to present a balanced view of the options when they gave a recommendation for surgery. Patients who received a recommendation for lumpectomy had the lowest involvement score.

Practice implications

Providers need to discuss both mastectomy and lumpectomy and elicit patients’ goals and treatment preferences regardless of whether or not a recommendation is given.     

End‐of‐life decisions: an important theme in the care for people with intellectual disabilities

Background While end‐of‐life decisions in the general population have received attention in several countries, not much is known about this in people with intellectual disabilities (IDs). Therefore, the prevalence and nature of end‐of‐life decisions were investigated in a Dutch centre providing residential care for 335 people with IDs. Method A retrospective study of medical files of people who died between January 2002 and July 2007. Results One or more end‐of‐life decisions were taken in 27 out of 47 cases. A non‐treatment decision was taken for seven residents, possibly shortening life expectancy in some cases. The family was involved in decision making in half of the 27 cases. No information was found about the process of end‐of‐life decision making. There was no evidence in the notes that any of the people with IDs was asked for his or her own opinion in taking an end‐of‐life decision. Conclusion This study demonstrates that medical end‐of‐life decisions played a part in significant numbers of people with IDs who have died within this centre, but further studies are needed to establish decision‐making processes.     

Outcome of palliative total gastrectomy for stage IV proximal gastric cancer

Background

Minor burns represent .96% to 1.5% of emergency department visits, yet burn center referral is common. Analysis of the Grady Memorial Hospital Burn Center was conducted to examine the feasibility and savings if burns were managed locally with consultation as needed.

Methods

Data on 776 consecutive admissions to Grady Memorial Hospital Burn Center between November 2005 and July 2007 were prospectively reviewed. National and international cohorts were compared.

Results

Patients' mean age was 31 years, 69.8% were male, and 87% were insured. Thirty-nine percent were transfers. Seventy-six percent of transfers (51% of air transfers) and 70% of all admissions were for ≤10% total body surface area burns. Helicopter transport cost $12,500 and averaged 48 miles. Eighty percent of burns were hot water (scald), grease, or flame burns, and 31% required skin grafting.

Conclusions

Most burns require assessment, debridement, and dressing changes. Grafting is rarely necessary. Patients are transferred because of a lack of training, and patients suffer economic burden and treatment delay. Savings could be realized were patients treated locally with select burn center referral. Video consultation and mentoring can help with triage and care of minor burns. Major burns require burn center referral. International practice reinforces these results.     

Quality differences in multifragmentary pertrochanteric fractures [OTA 31A2.2 and 31A2.3] treated with short and long cephalomedullary nails

ObjectivesThis study compares demographics, outcomes, and costs of patients with similar multifragmentary pertrochanteric (MP) fracture patterns treated with either a short or long cephalomedullary nail (CMN) to determine treatment efficacy and value during hospital admission.DesignRetrospective cohort study.SettingLevel-1 trauma center.Patients384 patients who presented with a MP fracture [AO/OTA 31A2.2 and 31A2.3] at 1 of 3 hospitals within a single academic medical center.InterventionSurgical treatment with either short or long CMNMain outcome measurements: Operative time, in-hospital complications, discharge disposition, procedural and total costs of admission.ResultsSixty-nine (18.0%) patients were treated with long CMNs compared to 315 patients treated with short CMNs. Patients treated with long CMNs had increased rates of transfusions of allogenic packed red blood cells (52.2% vs 34.0%, p = 0.005), discharge to rehabilitation facilities (91.3% vs 80.3%, p = 0.030), and had costlier hospital stays ($28,632.50 vs $23,024.86, p = 0.014) with longer (74.9 vs 52.3 min, p <0.001), costlier procedures and implants ($12,090.31 vs $9,647.41, p = 0.014) compared to patients treated with short CMNs. There were no differences in timing of radiographic healing, rates of readmission, nonunion, screw cut out, fixation failure, or peri?implant fracture.ConclusionsShort and long CMNs are equally suitable implants for the most unstable intertrochanteric fracture patterns. Short CMNs correlate with reduced operative time and costs with non-inferior in-hospital complication rates, hospital quality measures, and less frequent rehabilitation facility discharges. Given the similar long-term outcomes demonstrated here and in the literature, this data suggests nail length selection should be driven more by cost and discharge considerations for MP fractures.Level of evidencelevel III.     

Association of Prehospital Step 1 Vital Sign Criteria and Vital Sign Decline with Increased Emergency Department and Hospital Death

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Mass casualty incidents with multiple burn victims: Rationale for a Swiss burn plan

Introduction

Mass casualty incidents involving victims with severe burns pose difficult and unique problems for both rescue teams and hospitals. This paper presents an analysis of the published reports with the aim of proposing a rational model for burn rescue and hospital referral for Switzerland.

Methods

Literature review including systematic searches of PubMed/Medline, reference textbooks and journals as well as landmark articles.

Results

Since hospitals have limited surge capacities in the event of burn disasters, a special approach to both prehospital and hospital management of these victims is required. Specialized rescue and care can be adequately met and at all levels of needs by deploying mobile burn teams to the scene. These burn teams can bring needed skills and enhance the efficiency of the classical disaster response teams. Burn teams assist with both primary and secondary triage, contribute to initial patient management and offer advice to non-specialized designated hospitals that provide acute care for burn patients with Total Burn Surface Area (TBSA) <20–30%. The main components required for successful deployments of mobile burn teams include socio-economic feasibility, streamlined logistical implementation as well as partnership coordination with other agencies including subsidiary military resources.

Conclusions

Disaster preparedness plans involving burn specialists dispatched from a referral burn center can upgrade and significantly improve prehospital rescue outcome, initial resuscitation care and help prevent an overload to hospital surge capacities in case of multiple burn victims. This is the rationale behind the ongoing development and implementation of the Swiss burn plan.     

便携低功耗军用分检心电图机

便携低功耗军用分检心电图机是为救护人员在战场上进行火线抢救而设计的一款微型生命信息检测设备。利用该设备能够准确迅速地获得伤员生命的状态,从而加快伤员分检的速度,减少人员伤亡。系统以C8051F310微处理器为控制核心,采用高精度、低温漂放大器AD620和超低功耗图形点阵液晶显示模块LMS019对采集到的心电信号进行实时和准确的显示。该设备使用方便,价格低廉,能够符合我军野战部队大量装备的要求。     

Preliminary investigation into the validity of dentists' decisions to restore occlusal surfaces of permanent teeth

Abstract – This study investigates the validity of the treatment decisions made by 10 hospital dentists, who examined the fissures of extracted teeth using a visual-only technique. The study shows that 8 of the 10 dentists were more likely to leave carious teeth unrestored than unnecessarily treat sound teeth. The authors suggest that this system of diagnosing occlusal caries is a satisfactory one in terms of its sensitivity and specificity.     

Treatment decisions in older patients with colorectal cancer: the role of age and multidimensional function

The aim of the study was to investigate the role of age and multidimensional functional status in treatment decisions in older patients with colorectal cancer. Three hundred and thirty-seven patients aged 58–95 years with adenocarcinoma of the colon or rectum were interviewed before and after treatment using the OARS Multidimensional Functional Assessment Questionnaire (OMFAQ), a self-reported severity of morbidity scale, and the Rotterdam Symptom Checklist (RSCL). The OMFAQ rates five dimensions of function: social resources, economic resources, mental and physical health and self-care capacity. The likelihood of patients with Duke's C colorectal cancer receiving adjuvant chemotherapy decreased significantly with age ( P  = 0.001, trend). Differences in treatment received were not explained by differences in morbidity, economic, mental or physical function, self-care capacity, or any of the RSCL measures. After controlling for age, Duke's C patients who received adjuvant chemotherapy were less impaired in social resources than Duke's C patients who did not ( P  = 0.06). No other significant pre-treatment differences in functional status were found. Differences in age and social resources exist between patients who do and do not receive adjuvant chemotherapy. Care should be taken to ensure that patients are not excluded from treatment with known survival benefits because of their age, and the question of providing appropriate social support during adjuvant chemotherapy should be re-examined.