Effectiveness of a web-based, individually tailored decision aid for depression or acute low back pain: a randomized controlled trial

Objective

To evaluate the effectiveness of a web-based, individually tailored decision aid (Patient Dialogue) on depression or acute low back pain for insurees of a German sickness fund.

Methods

Patient Dialogue (PD) was compared to the non-tailored Static Patient Information (SPI) in an online randomized controlled trial (RCT). The primary outcome was decisional conflict; secondary outcomes included knowledge, preparation for decision-making, preference for participation, involvement in decision-making, decision regret, and adherence.

Results

Out of 2480 randomized participants, 657 (26.5%) provided analyzable data immediately after using the system. Three months later, data from 131 (5.3%) participants could be included in the analysis. The PD group reported a significantly lower overall decisional conflict than the SPI group (38.7 vs. 45.1; p = 0.028 via multiple imputation estimator). The largest standardized effect (Cohen's d 0.56) resulted from the preparation for decision-making (PD 59.4 vs. SPI 46.8; p < 0.001).

Conclusion

PD may be an effective tool to reduce decisional conflict and prepare participants for treatment decision-making. However, the large dropout rate needs to be taken into account.

Practice implications

This study shows how a health insurance fund can support shared decision-making and how a decision aid can be evaluated in a RCT under routine care conditions.     

Do the public share practitioners’ views about the best evidence?

Objective

To investigate whether general practitioners (GPs) and patients agree on what constitutes the best evidence for the effectiveness of treatments.

Methods

GPs and members of the public aged 18–83 read five scenarios describing comparisons between hypothetical treatments for common ailments. Each scenario reported that one treatment was the more effective, as determined by randomised controlled trial (RCT), audit of treatment outcomes from many doctors’ patients, a single doctor's clinical experience, a friend's experience, or a web-based sales site. Participants rated how confident they would be that the treatment reported to be more effective would work for them.

Results

All participants had least confidence in the web-based sales site, more confidence in a friend's experience and more still in one doctor's experience. For doctor's experience, audit and RCT, amongst the public there were some differences by age but, importantly, only GPs had most confidence in evidence from an RCT.

Conclusion

GPs may treat evidence from RCTs as the gold standard while members of the public (their patients) may not afford it that same respect.

Practice implications

GPs engaged in shared decision-making should be alert to possible differences from their patients in the weight given to different types of evidence.     

Computerised decision aids: a systematic review of their effectiveness in facilitating high-quality decision-making in various health-related contexts

Objective

To systematically review existing empirical evidence regarding the effectiveness of computerised decision aids (CDAs) in enabling high-quality decision-making in preference-sensitive health-related contexts.

Methods

Relevant studies were identified via Medline, CINAHL, and PsycINFO databases (1990–October 2010). Only randomised controlled trials with at least one decision quality or decision process variable outcome were included.

Results

Of 1467 identified articles, 28 studies met all inclusion criteria, evaluating 26 unique CDAs. CDAs performed better than standard consultations/education regarding improved knowledge and lower decisional conflict, and were found not to increase anxiety. CDAs facilitated greater satisfaction with the decision-making process than standard education. The effects on risk perceptions, value congruence with the chosen option, preferred roles in decision-making and decisional self-efficacy need further evaluation. A paucity of CDAs adhered to decision theories.

Conclusions

CDAs showed similar effects as non-computerised DAs on various outcomes. Further research into the potentially superior effects of CDAs on feeling informed, values-clarity, and decisional conflict is required.

Practice implications

The more remarkable effects on knowledge and risk perceptions were reported when unique features of interactive computerised media were used. The potential benefit of tailored information, values-clarification, and integration of CDAs into shared decision-making consultations remains unresolved.     

北京协和医院分级护理制度考察报告

考察了北京协和医院护士决策分级护理的情况,并对分级护理实施的依据、下达方式和流程以及医护间的协调进行叙述。建议编制分级护理决策护士的岗位描述,制订具体工作流程,完善相关管理制度,为护士决策分级护理的研究和实践提供有益的借鉴。     

Moral decision-making, ToM, empathy and the default mode network

Automatic intuitions and deliberate reasoning, sourcing internal representations of our personal norms and values, contribute to our beliefs of what is right and wrong. We used fMRI to directly compare moral (M) and non-moral (NM) decision-making processes using scenarios requiring conscious deliberation, whereby the main character declared an intention to take a course of action. Furthermore, we examined the relationship between BOLD signal, associated with M>NM decision-making, and moral judgment competence, psychopathy, and empathy. We observed greater activity in various parts of Theory of Mind, empathy and default mode networks during M>NM decision-making. There was a trend for high scores on primary psychopathy to correlate with decreased M>NM BOLD activation in an area extending from dorsolateral prefrontal cortex to medial prefrontal cortex. We suggest that moral decision-making entails a greater degree of internally directed processing, such as self-referential mental processing and the representation of intentions and feelings, than non-moral decision-making.     

Evidence-based practice: a framework for clinical practice and research design

The evidence-based practice (EBP) framework emerged in the early 1970s as a means of improving clinical practice. This shift towards EBP allowed health professionals to move from a culture of delivering care based on tradition, intuition and authority, to a situation where decisions were guided and justified by the best available evidence. Despite the many advantages of EBP, many practitioners remain cautious about embracing the model. Part of this opposition is due to a misunderstanding of EBP, which this paper aims to address.     

Decision making and counseling around mammography screening for women aged 80 or older

BACKGROUND: Despite uncertain benefit, many women over age 80 (oldest-old) receive screening mammography. OBJECTIVE: To explore decision-making and physician counseling of oldest-old women around mammography screening. DESIGN: Qualitative research using in-depth semi-structured interviews. PARTICIPANTS: Twenty-three women aged 80 or older who received care at a large academic primary care practice (13 had undergone mammography screening in the past 2 years) and 16 physicians at the same center. APPROACH: We asked patients and physicians to describe factors influencing mammography screening decisions of oldest-old women. We asked physicians to describe their counseling about screening to the oldest-old. RESULTS: Patients and/or physicians identified the importance of physician influence, patient preferences, system factors, and social influences on screening decisions. Although physicians felt that patient’s health affected screening decisions, few patients felt that health mattered. Three types of elderly patients were identified: (1) women enthusiastic about screening mammography; (2) women opposed to screening mammography; and (3) women without a preference who followed their physician’s recommendation. However, physician counseling about mammography screening to elderly women varies; some individualize discussions; others encourage screening; few discourage screening. Physicians report that discussions about stopping screening can be uncomfortable and time consuming. Physicians suggest that more data could facilitate these discussions. CONCLUSIONS: Some oldest-old women have strong opinions about screening mammography while others are influenced by physicians. Discussions about stopping screening are challenging for physicians. More data about the benefits and risks of mammography screening for women aged 80 or older could inform patients and improve provider counseling to lead to more rational use of mammography. The authors have no conflicts of interest to declare. This paper was presented in part at the 2005 National Meeting of the Society of General Internal Medicine, May 13, 2005, New Orleans, LA. Grant support was obtained from the National Research Service Award from the National Cancer Institute (1 F32 CA110424-01).     

医学伦理的临床实践

[摘要]针对医学伦理的实践问题 从医学伦理观、伦理决策、伦理实践以及伦理审查与监督等角度 阐述了医学伦理临床 实践的意义和如何进行医学伦理临床实践的问题。