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PubMed2003

[Disease management from the economic point of view].

The introduction of disease management programs for chronic diseases aims to achieve a permanent improvement of care. Such an improvement cannot be reached without effective incentives. However, the incentives set in the German Health Care System may cause reactions on the micro level that do not correspond to the aims on the macro level. In the long term, patient empowerment will be needed in order to enable a shared-decision-making of patients and physicians. A market-oriented solution consists of quality competition allowing for various delivery systems and the search for new models that lead to an improvement of care. However, quality competition will have to respect the traditional principle of solidarity underlying the German health care system. Disease management will contribute to an integrated, incentive-oriented delivery system but only if it allows for a variety of care.

Costs and Cost Analysis↗
PubMed2003

Prostate specific antigen: an updated review.

Since its discovery in 1979, serum PSA has revolutionized how physicians manage men with prostate cancer. PSA screening, although currently under much debate, has been recommended by most North American medical bodies, including the Canadian Urological Association, to be performed as a shared-decision making process after discussing with patients the pros and cons of treatment. Although most commonly thought of as a screening tool, serum PSA has also been used to predict tumor volume, stage and prognosis in patients before and after treatment. In this review, we examine PSA testing and its effectiveness in the diagnosis and management of prostate cancer. Further, we also evaluate recent literature regarding the use of PSA derivatives and other prostate cancer markers, such as proPSA, bPSA, and hk2

Humans↗
PubMed2004

Cardiology.

This article describes recent developments in cardiology and cardiovascular disease that are likely to be relevant to primary healthcare professionals and their patients. The following subject areas are covered: Primary prevention: recent developments in pharmaco-logical interventions, drug interactions, and drugs that are likely to cause harm; cardiovascular risk estimation and shared decision making with patients; and new developments in 24-hour ambulatory blood pressure monitoring. Secondary prevention: new models of care, including nurse-led care for the provision of hypertension and secondary prevention clinics; new drugs for the treatment of angina and myocardial infarction; ambulatory electrocardiography for the diagnosis of arrhythmias in primary care; and new developments in the treatment of atrial fibrillation - direct thrombin inhibitors and implantable devices. Tertiary prevention: recent developments in cardiac rehabilitation; recent evidence concerning revascularisation procedures and appropriateness criteria for referral; and implantable defibrillators.

Cardiology↗
PubMed2005

Evidence-based prenatal care: Part I. General prenatal care and counseling issues.

Effective prenatal care should integrate the best available evidence into a model of shared decision making. Pregnant women should be counseled about the risks of smoking and alcohol and drug use. Structured educational programs to promote breastfeeding are effective. Routine fetal heart auscultation, urinalysis, and assessment of maternal weight, blood pressure, and fundal height generally are recommended, although the evidence for these interventions is variable. Women should be offered ABO and Rh blood typing and screening for anemia during the first prenatal visit. Genetic counseling and testing should be offered to couples with a family history of genetic disorders, a previously affected fetus or child, or a history of recurrent miscarriage. All women should be offered prenatal serum marker screening for neural tube defects and aneuploidy. Women at increased risk for aneuploidy should be offered amniocentesis or chorionic villus sampling. Counseling about the limitations and risks of these tests, as well as their psychologic implications, is necessary. Folic acid supplementation beginning in the preconception period reduces the incidence of neural tube defects. There is limited evidence that routine use of other dietary supplements may improve outcomes for the mother and infant.

Blood Grouping and Crossmatching↗
PubMed1992

Ethical issues.

The HIV virus and the associated worldwide pandemic pose enormous biomedical, clinical, and social dilemmas for health care providers, biomedical researchers, policy analysts, and the public at large 10 years after its discovery. Many of these dilemmas and challenges are captured in the difficult ethical issues the HIV epidemic has highlighted for primary care physicians. Given the vanishingly small risk to primary care providers of acquiring HIV infection in office practice and the rapidly increasing prevalence of the virus, a clear ethical obligation to care for HIV-infected patients exists for primary care physicians. Primary care providers should be sensitive to the potentially sensitive nature of patient risk status and HIV testing results and balance confidentiality in the medical record with the "need to know" the patient's clinical status by other health care professionals. Every attempt should be made by the primary care provider to encourage HIV-infected patients to act responsibly toward their intimate sexual partners and inform them of their HIV status to take appropriate precautions against acquiring the virus. Primary care providers should also model responsible shared decision making and goal setting with HIV-infected patients early in the course of the disease, laying the foundation for subsequent decision making later in the course of the illness. Finally, considerable controversy exists about the responsibilities of HIV-infected providers to inform patients of their status; professional and public policy in this area is in rapid flux. Undoubtedly, the HIV epidemic will continue to challenge us and force careful examination of many of the critical dilemmas in modern biomedical ethics.

Acquired Immunodeficiency Syndrome↗
PubMed2005

Screening for prostate cancer: who and how often?

Engage patients in shared decision making by discussing the benefits and risks of prostate cancer screening. Patients who review educational pamphlets before an office visit engage more fully in the decision-making process. If performing prostate cancer screening, limit to men with greater than 10 years life expectancy. Because the lead time of a diagnosis based on PSA screening is estimated to be 5 to 7 years, PSA screening every other year is unlikely to cause a loss of sensitivity. Men with tumors with a Gleason score less than 5 are the best candidates for "watchful waiting," having a favorable 20-year survival.

Biopsy↗
PubMed2005

[Dissertations 25 years after the date 5. The dentist and patient education: 25 years later].

In 1979 the thesis 'The dentist and patient education' was published. Based on theory and research, it was the aim of the thesis to provide physicians, dentists, dental students, and dental hygienists theoretical and practical tools to be of assistance in daily patient education. During the last 25 years the insights in patient education and shared decision making were further developed. Two literature studies were published in books. Some research projects were carried out and published in articles. Nowadays, individual based patient education is an essential part of dentists' and dental hygienists' daily work. When compared with the period 1970-1985, at present, multimedia campaigns on oral disease prevention are extremely scarce. Communication skills of dentists appeared to be strongly related to patients' satisfaction of oral care delivery. In the Netherlands, the ethical principle of informed consent has been legislated in 1995 and, as a consequence, activities in the field of patient education are more juridically characterized.

Dentistry↗
PubMed2006

A review of studies examining stated preferences for cancer screening.

INTRODUCTION: Stated preference studies for cancer screening programs are used to understand how the programs can be improved to maximize usage. Our objectives were to conduct a systematic review of stated preference studies for cancer screening, identify gaps in the literature, and determine which types of research should be conducted in the future. METHODS: We considered all studies in the PubMed database through May 2005 that measured utility-based stated preferences for cancer screening using contingent valuation or conjoint analysis. We abstracted data on 1) study characteristics and 2) study results and policy implications. RESULTS: We found eight (of 84 identified) preference studies for cancer screening. The most commonly studied cancer was breast cancer, and the most commonly used method was contingent valuation. We found no studies for prostate cancer or physician preferences. Studies demonstrated that although individuals are able to state their preferences for cancer screening, they do not weigh test benefits and harms, and a significant percentage would choose to have no screening at all. Several studies found that test accuracy and reduction in mortality risk were important for determining preferences. CONCLUSION: Few studies of cancer screening preferences exist. The available studies examine only a few types of cancer and do not explore practice and policy implications in depth. The results of this review will be useful in identifying the focus of future research, identifying which screening methods may be more preferred to increase use of the programs, and developing interventions and policies that could facilitate informed and shared decision making for screening.

Humans↗
PubMed2006

Epidemiology, clinical consequences, and psychosocial treatment of nonadherence in schizophrenia.

Partial adherence and nonadherence to medication continue to be problems in the treatment of patients with schizophrenia. Nonadherence to medication has a negative impact on the course of illness for these patients as is shown by data on relapse, rehospitalization, time to remission, and attempted suicide. Several factors that contribute to poor adherence have been identified and need to be taken into account when attempting to address the problem of nonadherence. These risk factors relate to the patient, his or her illness and social situation, and the physician. Among the measures that have the potential to improve adherence to medication are psychosocial interventions, psychoeducation in the form of professional, peer-to-peer or family-to-family interventions, and shared decision making.

Antipsychotic Agents↗
PubMed2006

[EbM and patient perspective--a 5-step approach].

OBJECTIVES: Shared decision making describes a way of involving patients in the planning and management of their individual healing process. Doing this effectively seems to be quite a challenge for both physicians and patients. The mutual transfer of information appears to be one of the main steps of this process. Clinical patient information or patient guidelines can help to explain complex medical processes in a non-specialist way and thus improve communication and self-management. In order to develop an "evidence-based asthma patient guideline" we tried to focus on both evidence-based recommendations and patients' perspectives. Patients were asked about their individual needs and knowledge and took part in the subsequent review. METHODS: In order to explore patients' perspectives and needs we implemented two additional steps to our existing concept of guideline development: (1) a questionnaire for asthma patients with 10 items dealing with patients' knowledge about asthma and a personal grading of 16 "asthma-related questions", and (2) patients joining the actual guideline review panel. RESULTS: By evaluating the results of the questionnaire we discovered a gap between what patients consider to be interesting and/or important and what is necessary from the point of view of medicine and health policy. Although the patients showed a great interest in an autonomous approach to life with asthma [important items: "what can I do by myself" (68%); "how can I prevent an asthma attack" (86%); "how can I live a better life with asthma" (77%)], they were less interested in topics that would give them more autonomy ["structured educational programs" (41%); "how to use inhaling devices" (64%) or "peak flow measurement" (36%)]. Patients participating in the review panel emphasized the need for more or better information about pollution (i.e. ozone), complementary/alternative methods and the administration of cortisone during the asthma attack--topics that were not mentioned in the physicians' guideline. CONCLUSIONS: To acquire an "implementable" evidence-based patient guideline it is not sufficient to "translate" existing asthma guidelines into lay language. We should focus on the needs of individual asthma patients and the problems they encounter every day. Therefore patients should be asked what they want to know and what they do not know, and they should review the results and include their own views into the guideline. We applied this concept to the above mentioned evidence-based patient guideline and received a thematic ranking focused on patients' daily needs as well as a to-do list of topics that require increased attention (like peak flow measurement and structured education programs). The patients' perspectives changed our perspective on our patient guideline more than we expected.

Evidence-Based Medicine↗
PubMed2006

[Is there more than one "true" theory of cognition in medicine?].

Alternative approaches such as Traditional Chinese Medicine are very popular with patients. Often, however, there is a lack of high quality studies to prove their efficacy. The question will be discussed whether different theories of cognition may coexist in medicine which are all true. Not only biological, but also psychological and social factors contribute to health and well-being. Integrative medicine should bridge the gap between mainstream evidence-based medicine and complementary methods. Shared decision making between patient and physician can help to find the optimum, often multimodal treatment strategy for each patient.

Complementary Therapies↗
PubMed1989

Psychiatric aspects of basketball.

This article presents a theory of the psychology of basketball from three perspectives: individual psychodynamics, family systems interactions and athlete-community relationships. It focuses on the differences between functional and dysfunctional individual and team performance. Maximal individual performance usually requires relatively high levels of cognitive and physical skills, while team performance depends on having individuals with the interpersonal skills necessary to create the chemistry mandatory for the shared decision making called teamwork.

Basketball↗
PubMed1986

The ballad of Baby Doe: parental discretion or medical neglect?

The Baby Doe legislation generated, over a 3-year period, a "large-scale national seminar" on the rights and interests of handicapped newborns and their parents. In this article, the background for the Baby Doe legislation is provided, the details of what the law says are presented, and the implications of the legislation for medical practice are discussed, including the creation of infant bioethics committees. The overall effect of the Baby Doe law will be to protect the legitimate interests of a few children who would otherwise be mistreated. It will cause some resentment among parents whose interests conflict with their children's survival, among doctors who dislike shared decision making, and among others who resist the intrusion of the state into "private affairs." Yet subjecting life-and-death medical decisions to more professional scrutiny will probably yield better treatment rather than worse treatment in a majority of cases. In addition, it may have further spin-offs that benefit both the professions and society in times to come.

Child Abuse↗
PubMedDate not supplied

Staff development: an alternative to inservice education.

Continuing education may be viewed from two perspectives. Inservice programs are often perceived as externally mandated activities oriented toward the correction of deficiencies. In contrast, the staff development approach involves the shared decision making of the participant and supervisor in the planning, implementation, and evaluation stages of the learning process. Research indicates that the philosophical and managerial perspectives associated with staff development enhance efforts at implementing change.

Education, Medical, Continuing↗
PubMed1995

Position of the American Dietetic Association: legal and ethical issues in feeding permanently unconscious patients.

Health care team members, including the dietitian, must set patient-centered treatment goals that are handled individually and that respect the unique values and personal decision of the patient. The patient's expressed desire is the primary guide for determining the extent of nutrition and hydration once the patient is diagnosed as being in a PVS. Within the extent of the law, the family should share decision making when the patient's preference is not stated and the family is in agreement about medical care. The health care team will need to discuss with the family as needed the issues of ethics, values, religious guidelines, and pastoral advice. If the patient's choice is feeding, the dietitian will ensure that the composition of the feeding promotes nutritional health. If the patient's choice is cessation of feeding, the dietitian should explain what is known about the duration of time between cessation of feeding and death. Sensitivity to the family's needs and responsiveness to their questions are imperative in both scenarios. Within institutions, the ethics committee should help establish and implement defined written guidelines for care of the permanently unconscious. The dietitian should be required to be a member of or consultant to such a committee and should serve an integral role in development of institutional policy. The dietitian must provide education about nutrition and hydration issues, serve as a patient advocate, and participate in the legal and ethical issues regarding feeding. The dietetics community is involved in the legislative arena at the state and local level to promote the use of advanced directives and to affect legislative and societal changes that result in appropriate care for patients in a PVS.

Dietetics↗
PubMed1994

Health care reform and professionalism.

With its emphasis on consumer choice of health plans, the current health care debate neglects a more fundamental crisis: changes in the traditional physician-patient relationship. This paper discusses how this relationship is being redefined and what it means for professionals in the future, particularly in the context of managed competition. The paper asserts that the final health reform plan must address flaws in the scientific and ethical basis of clinical practice. It calls for a flexible workforce policy that promotes shared decision making, lifetime learning, professional commitment to improved quality of care, a national evaluation program, and organizations to coordinate these efforts.

Decision Making, Organizational↗
PubMed1994

Psychosocial issues. Unanswered questions in the use of bone marrow transplantation for treatment of hemoglobinopathies.

PURPOSE: This article addresses some of the psychosocial issues of bone marrow transplantation for treatment of hemoglobinopathies. The central focus is on the importance of attending to the experiences of minority patients and their families. Findings of recent studies relative to issues of bone marrow donation provide some framework for this analysis. PATIENTS AND METHODS: Unanswered questions are posed by hypothetical parents to raise critical questions and to highlight the importance of truly informed consent in shared decision making. CONCLUSIONS: Recommendations for researchers and care-givers are for more personal contacts and dialogues with patients and families. There should also be involvement in grass roots activities, with attention to assessing the efficacy of bone marrow transplantation, as well as emphasizing minority representation in the process.

Adaptation, Psychological↗
PubMedDate not supplied

Overcoming parochialism: interdisciplinary training of the generalist team.

The work force that will staff most health care systems of the future will include a complex array of professionals working together in teams. The traditional inpatient model of patient care has been only multidisciplinary--nurses, medical social workers, dietitians, pharmacists, and physicians, all interested in each patient, but with divided responsibilities, training formats, and faculties--whereas interdisciplinary teams openly share decision making, expectations for care, goals for the team, and mutual respect.

Decision Making, Organizational↗