Method: This is a 2-armed randomized controlled trial (target: 300 patients per arm). Intervention Arm features DATES Web, the interactive DA that elicits patient risk for CRC and clarifies preference for a specific CRC screening test option. Control Arm features a web-based DA with the same information but without the interactive features. Setting is 10 community and 1 university-based primary care practices in Metro Detroit. Participants are adults aged 50 to 75 years, not current on CRC screening, and scheduled for a regular visit with their physicians. In the clinic before the patient-physician encounter, participants complete a Patient Baseline Survey before being randomized. Data are collected after the patient reviews the respective website (Post-Intervention Survey), during the patient-physician encounter (digital audio recording) and after it (Post-Encounter Survey). A 6-month chart audit is performed to determine whether the patient underwent CRC screening. Primary outcomes are: patient uptake of CRC screening, patient decision quality (knowledge, preference clarification, intent), degree of shared decision making, and patient-physician agreement regarding test preference. Independent samples t-tests and Pearson's Chi-squared tests were used to compare the baseline demographic and web usage data between the arms.
Result: So far, 258 participants have been recruited. Mean age + standard deviation 58.9 (6.9) years; racial distribution 44.1% Caucasian and 48.0% African American; gender distribution 52.5% women and 47.5% men, difference between the 2 arms statistically not significant (NS). Differences in knowledge, attitude, perceived self-efficacy, decision-making preference, and test preference at baseline are statistically NS between the 2 arms. Average duration of website usage is 23.9 minutes in the Control Arm vs. 25.6 minutes in the Intervention Arm (NS).
Conclusion: The recruitment and randomization process have been successful. The results of our study will be among the first to examine the effect of a real-time preference assessment exercise on CRC screening and mediators, and, in doing so, will shed light on the patient-physician communication and shared decision making "black box" that currently exists between the delivery of DAs to patients and the subsequent patient behavior.
Method: 1015 men were recruited from 4 VA hospitals immediately after receiving a biopsy for suspicion of prostate cancer. Men received an education intervention and completed 3 surveys: at their biopsy, immediately before receiving their cancer diagnosis, and one week following diagnosis. Only patients with a positive biopsy result indicating localized prostate cancer (PSA<20, Gleason score of 6-7) were eligible to complete Time 2 and 3 surveys (N = 335). Key measures included the COMRADE (combined outcome measure for risk communication and treatment decision making effectiveness), the PICS (Perceived Involvement Scale), perceptions of physician recommendations, and treatment preferences and treatment received.
Result: Overall, patients reported high satisfaction with their physician and their communication with their physician (Ms=4.25 and 4.43 on COMRADE Subscales and M=0.73 on PIC doctor facilitation subscale). Neither race, education, literacy, nor numeracy predicted patients’ satisfaction with their physician. Higher scores on PICS predicted more desire for a strong physician role in decision making (and thus less patient role in decision making; B=-0.14, p=0.03).
Patients indicated that they believed that it is very important to undergo the treatment that their doctor thinks is best for them (M=8.6 on a 10-point scale). 73.8% of patients received a treatment recommendation from their urologist (45.0% of the recommendations were for surgery, 3.3% for radiation, and 32.8% for active surveillance). Patients indicated that the recommendations were moderately strong (M=3.8 on 5-point scale) and were moderately influential on their treatment decision (M=3.7 on 5-point scale).
After talking to their doctor about their treatment choices, the only factors that influenced the treatment patients’ received was their physicians’ recommendations (factors not influential included race, numeracy, literacy, patients’ own treatment preferences, knowledge).
Conclusion: Physicians play an important role in patients’ decisions, both by self-report and as reflected in the patients’ actual treatment decisions. Patients’ reported high satisfaction with their interaction with their urologists and believe that their recommendations play a role in their decision making process. However, there is concern that patients’ values may not be reflected in decisions given the strong impact of physicians’ recommendations.
Method: Focus group discussions with 62 peer educators and members of SHGs in three villages of the KV Kuppam block, Tamil Nadu. Discussions about barriers and facilitators to screening and women’s information needs were audio-recorded, translated and transcribed from Tamil to English. One foreign and one local researcher independently analysed the data and identified key themes. The VoiceSite design was informed by this data.
Result: Seven core themes were found. 1) Competing priorities were a challenge for some women. 2) Information needs were the greatest barrier to cervical cancer prevention and treatment. 3) Women wanted to make an informed choice, understand the advantages and disadvantages of screening, along with available treatment options.4) Stigma was a major barrier to information-seeking. 5) Most households had at least one mobile phone; audio-information using female voices via mobile phones would provide some anonymity and be acceptable for most women. 6) Women preferred cervical cancer to be discussed in the broader context of women’s health. 7) Most household mobile phones were controlled by husbands and the VoiceSite should be clearly associated with the well-respected local hospital. The VoiceSite design has four sections 1) A story of two villages 2) A dialogue answering ten questions 3) Clinic schedules 4) An opportunity to ‘post’ questions. Uptake, patterns of use and acceptability are being tested in two villages (n=2,000).
Conclusion: Disadvantaged, rural women want to make informed choices about cervical cancer screening and treatment. Stigma, low literacy and spouse roles are major barriers to information access. A mobile phone delivered VoiceSite is being developed and pilot tested to address these needs.
Nosocomial infections are one of significant causes of morbidity and mortality. Evaluating risk factors to predict nosocomial infection is important to improve clinical outcomes. We aimed to evaluate the accuracy of risk factors to predict nosocomial infections in children.
Method:
A prospective cohort study was conducted during 28 months at a teaching hospital in Yogyakarta, Indonesia. All consecutive patients admitted to the Pediatric ICU and pediatric wards >48 hours were eligible. Those eligible patients were observed daily to identify the presence of nosocomial infection based on Centers for Disease Control and Prevention (CDC) criteria. The risk factors of nosocomial infections were identified. Logistic regression was used to identify independent predictors and assigned the risk score (value). We then computed the score for each patient and chose the cutoff value of score. We finally performed a receiver operating characteristic (ROC) curve analysis and computed the area under the curve (AUC).
Result:
Total of 2646 patients were recruited. Of 400 were diagnosed as nosocomial infections. The cumulative incidence of nosocomial infection was 15.1%. In multivariate analysis; length of stay >7 days, suffered from syndrome, use of central venous line (CVL), urine catheter, mechanical ventilation, and exposed to irrational antibiotics were independently associated with increased risk of nosocomial infections with adjusted OR (95%CI): 22.46(14.73-34.26), 1.98(1.33-2.93), 2.45(1.18-5.08), 3.56(2.34-5.40), 2.50(1.57-3.99), and 2.13(1.58-2.87), respectively. A score of these risk factors accurately predicts nosocomial infections with the area under ROC curve of 0.86.
Conclusion:
This study proves that length of stay >7 days, syndrome, use of CVL, urine catheter, mechanical ventilation, and irrational antibiotics increased risk of nosocomial infections in children. The score of these risk factors accurately predicts nosocomial infections.
Key words: risk factor, nosocomial infection, children, developing countries, Indonesia
To derive and compare relative preferences of physicians and patients for selecting oral antithrombotics in atrial fibrillation (AF).
Method:
Elicitation task: Best worst scaling (BWS) choice experiments were constructed from literature review and expert opinion, reflecting four attributes relevant to oral antithrombotics selection in the setting of stroke prevention in AF – frequency of laboratory monitoring, annual risk of stroke, annual risk of major bleed, availability of reversible agent.
Main survey. BWS experimental design was developed using Sawtooth Software. Each physician respondent answered 20 questions and patient respondent answered 16 questions. Patients were recruited through the Atrial Fibrillation Clinic at Vancouver General Hospital and physicians were invited to participate through the local health authority’s email listserv and research broadcast.
Analysis. Relative utilities based on the BWS choice data were derived using the latent class analysis. To determine the difference in preference for each attribute level between physician and patient respondents, the Wilcoxon signed-rank test was performed to assess the difference between the best-worst score for the two groups.
Result:
The survey was completed by 33 physicians and 58 patients. Both groups favoured “annual stroke risk of 0%” as the most valued attribute-level with mean utility estimates of 4.58 (p-value <0.001) and 6.5032 (p-value <0.001), respectively. In comparison, “annual stroke risk of 10%” was chosen as the least favourable attribute-level for both physicians and patients with mean utility estimates of -3.66 (p-value <0.001) and -4.86 (p-value <0.001), respectively. Patients preferred “having reversibility agent available” over “laboratory monitoring every year” and deemed “annual stroke risk of 6%” to be a better attribute level than “annual major bleeding risk of 6%”. The reverse was found for the physician respondents in both cases. Wilcoxon signed-rank results revealed significant preference differences between the two perspectives for several of the attribute levels including: “laboratory monitoring every month”, “annual stroke risk of 10%”, “annual bleeding risk of 2%”, and “reversibility agent not available”.
Conclusion:
Preferences for stroke prophylaxis differ between physicians and AF patients. This is the first study known to compare valuation between the two perspectives using a BWS choice experiment and provides important insights to clinical decision-making in a patient-centered care model.
Method: A 27 question web-based questionnaire was developed and administered to a panel of Norwegian women aged 25- 69. Respondents were randomized into 3 groups based on when in the screening process information regarding overtreatment and the potential impact of surgical treatment on future pregnancy was first introduced: 1) when a Pap test is first suggested, 2) when a second test is recommended following the detection of abnormal cells, and 3) when surgical treatment is recommended. A fourth group served as a control group and was not provided information about overtreatment or side effects during all three points. This project is part of a larger international comparative study.
Results: 1,060 women responded to the survey. Additional information about overtreatment and side effects made no significant difference on women’s stated intentions at the first two time points; however it appears to create uncertainty when surgery becomes an option, χ 2(DF=6, N=1060, p=.014). Of the women surveyed, 945 (89.2%) believed that cervical cancer is among the three most common types of cancer among Norwegians. This overestimation is reflected in estimations of incidence, where 302 women (28.5%) correctly identified cervical cancer incidence rates in Norway at approximately 300 cases per year, while 71 (6.7%) underestimated the incidence rate, and 422 (39.8%) placed incidence rates at over 1000 cases a year. Over 80% of women state a preference for receiving information about all potential side effects.
Conclusions: Norwegian women overestimate the risk of cervical cancer. Their intention to undergo Pap tests is largely unaffected by the presence of additional information; however, this information may result in greater uncertainty when surgical intervention is suggested.