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At least 469 records · Page 26Linked to original sources
PubMed1998

Breast cancer advocacy in clinical care.

Although still in a continual state of evolution, breast cancer advocacy has come of age in the last few years. Advocacy is a very broad term that can be defined as the viewpoint of a breast cancer patient or survivor, or a viewpoint that is fully patient centered. In the area of clinical care and research, a cooperative atmosphere has developed that has required a close working relationship and understanding of cultures between advocates and those in the professional medical care and research communities. Interaction with patients and decision makers, which reflects individual values and preferences, requires a firm knowledge of medical outcomes; in this way, the advantages and disadvantages of a screening, diagnostic, or treatment plan can be analyzed. Moreover, a clear communication strategy needs to be in place to convey these concepts to patients and to elicit their individual choices and concerns. The development of optimal, shared decision making will require ongoing innovations in all these areas, and some are now being piloted and tested in the areas of screening, prevention, and treatment. The role of advocacy in research has likewise involved a sharp learning curve from both sides. Multiple models of mutual education, exchange of ideas, and the conversion of this interaction into research strategies are now in place in many settings. The intent of such interaction is to move forward with discovery and clinical application in a way that forces a rethinking and innovation of approaches but emphasizes proper scientific methodology. Patient-focused themes of relevance to patients with breast cancer, timely translation to the clinic, and a broader scope of research and ideas are all being integrated into the scientific review process. An emphasis on advocacy issues, along with stepwise scientific progress, will be essential in the new era of rapid technology development, clinical testing, and adoption into the standard of patient care.

Journal Article↗
PubMedDate not supplied

HPV communication: review of existing research and recommendations for patient education.

The potential for human papillomavirus (HPV) DNA testing in cervical cancer prevention programs has been a topic at the forefront of cervical cancer policy discussions in recent years. To prevent some of the anxiety and psychological distress often experienced on HPV diagnosis and during the period of management, mass patient education must accompany the incorporation of HPV DNA testing into screening protocols. To contribute to a growing body of work that provides an empiric basis for development of effective counseling messages about HPV and HPV testing, this paper highlights women's most common information gaps and psychosocial concerns and describes the different perspectives offered by women's usual sources of information about HPV, including the crucial role of the clinical community in creating a shared decision making environment in which screening decisions and results can be discussed.

Carcinoma, Squamous Cell↗
PubMed2003

Prostate cancer intervention. Involving the patient in early detection and treatment.

Cancer screening by PSA testing is widespread in the United States, and treatment recommendations encourage early therapy. Yet controversy about patient care persists because evidence demonstrating that these approaches improve the length and quality of a man's life is lacking. Physicians can assist their patients by first providing a balanced presentation of the known risks and benefits of prostate cancer detection and treatment and then incorporating patient preferences into medical decisions. Success in shared decision making may increase with use of patient education materials to convey most of the time-consuming and challenging information. At least two of the many materials developed can be easily administered with very few resources and independent of primary care encounters.

Aged↗
PubMed2005

Patient preferences in prostate cancer: a clinician's guide to understanding health utilities.

Prostate cancer treatments have positive and negative outcomes that must be taken into account when deciding how to proceed with a patient's care. One way to quickly determine a patient's preferences in this situation is to ascertain their health utilities for various health states. Health utilities are underutilized but powerful tools in aiding shared decision making between patients and physicians. This review is intended to inform physicians about the different techniques available, help the physician choose among them, and aid initial development of utilities for use in the clinic by way of the tables' references. A brief history, summary of applications and current directions of health utilities, and collection of references are provided to increase the reader's overall knowledge of health utilities and encourage their use in the clinic. Ultimately, the use and choice of one of these direct preference-based measures depends on the needs of the physician.

Decision Making↗
PubMed1986

The case of Claire Conroy: will administrative review safeguard incompetent patients?

The emotional issue of withdrawing feeding tubes from incompetent patients was reviewed recently by the New Jersey Supreme Court in the case of Claire Conroy. The court ruled that artificial feedings do not differ from other life-sustaining treatments and may be withdrawn or withheld if they are against the patient's wishes or best interests. The ruling rejected the tradition of shared decision making by physicians and families of incompetent patients. Instead, the court required the State Ombudsman to investigate cases like that of Claire Conroy as possible cases of elder abuse. Although such review was intended to safeguard vulnerable patients, it may have detrimental effects and impede humane decisions to withhold care. To minimize cumbersome decision-making procedures, physicians should discuss life-sustaining treatment in advance with patients who are still competent. Such discussions should be more specific than is now customary.

Aged↗
PubMed1988

Minimizing malpractice risks by role clarification. The confusing transition from tort to contract.

The purposes and applications of informed consent are the subject of confusion and controversy according to a President's Commission report. The Commission suggests shared decision making as the new ideal for physician-patient relationships, but notes that such a changed ideal will not be initiated by court action. The four models of decision making are the traditional model, informed consent, collaboration, and patient choice. Misunderstandings about these and other terms arise when they are implied; therefore, they should be defined expressly. Mutual expectations should be ascertained and common misunderstandings that erode relationships and lead to litigation should be clarified. Without agreements, different models may be selected and expectations about responsibility may differ. Such agreements may be documented by notes in patients' charts, supported by intake procedures that teach patients about defining responsibility, and questionnaires that elicit values, needs, and preferences. The literature on the evolution of contract principles in health care is reviewed, with informed consent viewed as a judicial stepping stone from tort to contract. A framework for defining mutual expectations is presented. Physicians' patterns of allocating responsibility by express and implied agreements should be evaluated and changes made where needed.

Consent Forms↗
PubMed1996

What is accountability in health care?

Accountability has become a major issue in health care. Accountability entails the procedures and processes by which one party justifies and takes responsibility for its activities. The concept of accountability contains three essential components: 1) the loci of accountability--health care consists of at least 11 different parties that can be held accountable or hold others accountable; 2) the domains of accountability--in health care, parties can be held accountable for as many as six activities: professional competence, legal and ethical conduct, financial performance, adequacy of access, public health promotion, and community benefit; and 3) the procedures of accountability, including formal and informal procedures for evaluating compliance with domains and for disseminating the evaluation and responses by the accountable parties. Different models of accountability stress different domains, evaluative criteria, loci, and procedures. We characterize and compare three dominant models of accountability: 1) the professional model, in which the individual physician and patient participate in shared decision making and physicians are held accountable to professional colleagues and to patients; 2) the economic model, in which the market is brought to bear in health care and accountability is mediated through consumer choice of providers; and 3) the political model, in which physicians and patients interact as citizen-members within a community and in which physicians are accountable to a governing board elected from the members of the community, such as the board of a managed care plan. We argue that no single model of accountability is appropriate to health care. Instead, we advocate a stratified model of accountability in which the professional model guides the physician-patient relationship, the political model operates within managed care plans and other integrated health delivery networks, and the economic and political models operate in the relations between managed care plans and other groups such as employers, government, and professional associations.

Delivery of Health Care, Integrated↗
PubMed1997

Advising patients who seek alternative medical therapies.

Alternative medical therapies, such as chiropractic, acupuncture, homeopathy, and herbal remedies, are in great public demand. Some managed care organizations now offer these therapies as an "expanded benefit." Because the safety and efficacy of these practices remain largely unknown, advising patients who use or seek alternative treatments presents a professional challenge. A step-by-step strategy is proposed whereby conventionally trained medical providers and their patients can proactively discuss the use or avoidance of alternative therapies. This strategy involves a formal discussion of patients' preferences and expectations, the maintenance of symptom diaries, and follow-up visits to monitor for potentially harmful situations. In the absence of professional medical and legal guidelines, the proposed management plan emphasizes patient safety, the need for documentation in the patient record, and the importance of shared decision making.

Complementary Therapies↗
PubMed2004

Health care system chaos should spur innovation: summary of a report of the Society of General Internal Medicine Task Force on the Domain of General Internal Medicine.

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The Society believes that the chaos and dysfunction that characterize today's medical care and the challenges facing general internal medicine should spur innovation. The task force proposed the following recommendations. Remaining true to its core values and competencies, general internal medicine should stay both broad and deep, ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care given by their teams, embrace changes in information systems, and aim to provide most of the care required by their patients. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency and provide comprehensive, ongoing care. General internal medicine residency training should provide both broad and deep medical knowledge as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification in generalist fields. Research should expand to include practice and operations management, developing more effective shared decision making and transparent medical records and promoting the close personal connection that both doctors and patients want. The task force believes that these changes will benefit patients and the public and reenergize general internal medicine.

Biomedical Research↗
PubMed1999

Patient-centered communication.

The term patient-centered communication (PCC) has been used to describe a group of communication strategies and behaviors that promote mutuality, shared understandings, and shared decision making in health care encounters. There is evidence to suggest that advanced practice nurse and patients use these strategies to co-produce highly individualized clinical discourse. Although the communication behaviors associated with PCC have been studied separately, their impact as an integrated communications strategy has not been studied. Suggestions for developing PCC as a mid-range theory of health care communication encompassing other more specific communication concepts are offered.

Communication↗
PubMed2000

Clinicians' use of a palm-top based system to elicit patient preferences at the bedside: a feasible technique to improve patient outcomes.

While there is an increased emphasis on shared decision making between patients and clinicians, there has been little research on decision support systems (DSSs) to assist clinicians in eliciting and integrating patient preferences in clinical care and evaluating their effect on patient outcomes. This paper presents the results of nurses' use of CHOICE, a palm-top based DSS for preference-based care planning that assists nurses in eliciting patient preferences for functional performance at the bedside and to select care priorities consistent with patient preferences. Nurses' use of CHOICE changed nursing care to be more consistent with patient preferences and improved patients' preference achievement. The study demonstrated that the use of computer-based decision support for preference-based care planning can improve patient-centered care and patient outcomes.

Aged↗
PubMedDate not supplied

Breast cancer risk reduction: what do we know and where should we go?

Clinicians should be aware of the advances in breast cancer risk assessment and risk-reduction therapy. The modified Gail model is appropriate for predicting the risk of developing breast cancer within the next 5 years for most women between ages 35 and 75. Tamoxifen has been approved by the U.S. Food and Drug Administration (FDA) for reduction of breast cancer risk in women aged 35 and older who meet the threshold risk for breast cancer. Raloxifene is being compared with tamoxifen in the clinical trial, STAR (a Study of Tamoxifen and Raloxifene), which is now enrolling postmenopausal women aged 35 or older. The risks and benefits of therapy to reduce breast cancer risk are reviewed here. Processes for comparison of risks and benefits and for shared decision making are outlined.

Breast Neoplasms↗
PubMed2000

A school-based asthma clinic: a partnership model for managing childhood asthma.

Childhood asthma is a major public health problem. It is the leading cause of childhood hospitalizations and school absences despite recent advances in management. Current standards of care call for client education as partners in disease management. In pediatrics, this calls for shared decision making between health care provider, parent, and child. Traditional care delivery systems often fall short of meeting this standard. This article describes a nurse practitioner-run school-based asthma clinic, designed as a pilot study, to fill these gaps. Characteristics of the community that affected outcomes are described.

Asthma↗
PubMed2001

What does family practice need to do next? A cross-generational view.

BACKGROUND AND OBJECTIVES: This paper presents a 60-year view of family practice, including its first 30 years and best projections for its next 30 years as a discipline and field of practice. METHODS: An objective cross-generational approach was taken based on available evidence. RESULTS: Five lessons are drawn from the past 30 years: (1) Neither medical education, medical practice, nor the health care system have been reformed by family medicine. (2) Family practice remains but one of several options for primary care. (3) The generalist-specialist ratio has shifted farther to specialists since 1970. (4) The United States is unique among Western industrialized nations in having multiple generalist specialties. (5) The three primary care specialties are on parallel but separate courses. The health care system is now very different from that of 1970, as a result of managed care; increased burden of chronic illness in an aging population; de-emphasis of hospital care; proliferation of primary care providers; increased emphasis on shared decision making with patients, cost-effectiveness, and value of health care services; and advances in information and communication technology. CONCLUSIONS: The following course changes are recommended for family practice: (1) Embrace new paradigms of care (eg, evidence-based medicine, population-based care, chronic disease management). (2) Modify practice style and redesign systems of care. (3) Embrace further differentiation within family practice. (4) Reassess and revise educational programs at all levels. (5) Increase emphasis on practice-based research and expansion of clinical electronic databases. (6) Explore feasibility of a unified generalist discipline through new alliances with other primary care specialties. (7) Build organizational and political strength through alliances in advocating for structural change of the health care system to include universal coverage and a generalist primary care physician for all Americans.

Delivery of Health Care↗
PubMed2001

[Recommendations for writing patient information statements].

With Evidence-Based Medicine, shared decision making is attracting considerable interest as a means by which patient preferences can be incorporated into clinical decisions. Patients cannot express informed preferences unless they are given sufficient and appropriate information, including a detailed explanation concerning their condition, the different therapeutic options and the likely outcomes with and without treatment. A patient education leaflet is a potentially powerful tool for communicating information to patients, who will be able to participate in the process of decision making. The present article is a review of available guides for the writing of patient information materials. It also includes criteria for evaluating their quality.

Decision Making↗
PubMed2002

Using a collaborative weaning plan to decrease duration of mechanical ventilation and length of stay in the intensive care unit for patients receiving long-term ventilation.

BACKGROUND: Patients requiring mechanical ventilation for prolonged periods typically are sicker and have more comorbid illnesses than do patients who can be weaned more rapidly. As a result, the weaning process is often complex, requiring shared decision making by a skilled, multidisciplinary team. Unfortunately, many of the structures used in critical care units to plan and evaluate care do not lend themselves to collaborative management of patients. OBJECTIVE: To evaluate the effect of a collaborative weaning plan on outcomes, including duration of mechanical ventilation, for patients treated with mechanical ventilation for 7 days or more. METHODS: A collaborative weaning plan (weaning board and flow sheet) was introduced into the medical intensive care unit at the University of California Los Angeles, Medical Center. A historical design was used to compare outcomes before and after the plan was used. The primary outcome variable was duration of mechanical ventilation. Other outcomes studied included length of stay in the unit, cost, prevalence of complications (ie, reventilation, readmission to the intensive care unit), and mortality rate. RESULTS: The collaborative weaning plan decreased duration of ventilation by 4.9 days (P=.02) and decreased median length of stay in the unit by 4.5 days (P=.004). The median cost per stay in the unit decreased from $50462 to $37330 (P=.004). The prevalence of complications did not differ significantly between groups. CONCLUSIONS: Collaborative structures (eg, weaning boards, flow sheets) are useful in decreasing duration of mechanical ventilation for patients receiving long-term ventilation.

APACHE↗
PubMed2002

[Extended trachelectomy relapse: plea for patient involvement in the medical decision].

A series of 96 radical trachelectomies performed between April 1987 and May 2002 at Hospital Edouard Herriot in Lyon is reported. One second cancer (bilateral suprarenal glands cancer) and four recurrences were observed. The retrospective unifactorial analysis demonstrated that the maximal tumoral diameter (2 cm or more) and the depth of infiltration (1 cm or more) were the two only significant factors of risk (p = 0.001 et p = 0.002 respectively). Age less than 30 years and presence of lymphovascular spaces involvement were likely to be factors of risk as well but the level of statistical significance was not reached (p = 0.006). Histotype other than squamous, infiltration of the parametrium and infiltration of the vaginal cuff had no prognosis impact. Adjuvant radiotherapy did not seem to lessen the risk. The chances for recurrence were 19% for the patients affected by a tumor 2 cm or more and 25% for the patients affected by a tumor 2 cm or more with a depth of infiltration 1 cm or more. Should these patients be excluded from the indications of radical trachelectomy? The chances for failure do not seem lower if the radical option is chosen rather than the conservative one. The authors play for a shared decision making.

Adult↗
PubMedDate not supplied

Relationship-centered administration: transferring effective communication skills from the exam room to the conference room.

Medical researchers have shown that relationship-centered healthcare increases patient satisfaction and improves health outcomes. The components of relationship-centered healthcare--listening, sharing decision making, and respecting others--improve patient motivation and commitment to a plan of action. Currently, no data are available on the extent to which medical administrative settings adhere to relationship-centered principles. To begin to answer this question, we observed a convenience sample of 45 meetings in healthcare settings to assess the frequency and types of relationship-centered behaviors shown by group leaders. Our results provide preliminary data that leaders, especially female leaders, praised the value of group member efforts and encouraged members to provide input. Less frequently employed relationship-centered behaviors included providing a verbal summary of a discussion, responding to feelings expressed by members, and setting explicit agendas. Finally, we found some provocative associations. Female leaders received higher satisfaction ratings, and male leaders were more verbally dominant. Similar to physician-patient interaction, new topics for discussion are less likely to arise spontaneously late in a meeting if early agenda setting is utilized. To our knowledge, this is the first such study in a medical setting. Our findings encourage those who chair meetings to reflect on the extent to which they use a collaborative approach and offer specific content areas on which to focus. Further research on the concept and outcomes of relationship-centered administrative approach is warranted.

Colorado↗