The virtual ear, nose and throat follow-up clinic: a 10-year quality improvement project

Background/Aims Ear, nose and throat services have seen one of the greatest increases in service demand over the last 6 years. This study aimed to determine if a virtual clinic system could reduce the volume of patients who need to be seen in person in an ear, nose and throat outpatient clinic. Methods Clinical outcome data for one consultant's team in a single ear, nose and throat department between 2009–19 were analysed. Data were prospectively collected on all patients who used the virtual clinic in this 10-year period and the outcomes analysed. Results A total of 3071 patients entered the virtual clinic during the 10-year period. Of these, 61% were discharged from the clinic via virtual follow-up and 39% required an in-person review appointment. On average, 187 patients per year did not have to attend an in-person follow-up appointment, with estimated cost savings of £27 000 per year. Conclusions The virtual ear, nose and throat clinic service has clear benefits for patients and services, delivering healthcare without unnecessary in-person appointments through a shared, clinician–patient decision process.

Study protocols for the development and randomized controlled pilot trial of a patient decision aid to facilitate women's choice between oral and LAI ART for HIV (Preprint)

BACKGROUND Many women with HIV (WWH) have suboptimal adherence to oral antiretroviral therapy (ART) due to multilevel barriers to HIV care access and retention. A long-acting injectable (LAI) version of ART was approved by the Food and Drug Administration in January 2021 and has the potential to overcome many of these barriers by eliminating the need for daily pill-taking. However, it may not be optimal for all WWH. It is critical to develop tools that facilitate patient-provider shared decision making about oral versus LAI ART modalities to promote women’s adherence and long-term HIV outcomes. OBJECTIVE This study will develop and pilot test a web-based patient decision aid, called i.ART+support (iARTs). This decision aid aims to support shared decision-making between WWH and their providers, and help women choose between oral and LAI HIV treatment. METHODS The study will occur in three phases. In Phase 1, we will utilize a mixed-methods approach to collect data from WWH and medical and social service providers to inform i.ARTs content. During Phase 2, we will conduct focus groups with WWH and providers to refine i.ARTs content and develop the web-based decision aid. In Phase 3, i.ARTs will be tested in a randomized controlled trial (RCT) with n=180 women in Miami, FL and assessed for feasibility, usability and acceptability, as well as to evaluate the associations between receiving i.ARTs and viral suppression, ART refills, and clinic attendance. RESULTS Phase 1 participant recruitment began in September 2021. CONCLUSIONS This study is the first to develop a web-based patient decision aid to support WWH choices between oral and LAI ART. Its strengths include the incorporation of both patient and provider perspectives, a mixed-methods design, and implementation in a real-world clinical setting. CLINICALTRIAL We will apply for Clinicaltrials.gov registration prior to Phase 3 when we enroll our first participant in the RCT. This is anticipated to occur in April 2023.

Abstract 12789: Development of the Tool to EMPOwer Surrogate Decision Makers of Comatose Survivors of Cardiac Arrest

Introduction: Surrogate decision makers (SDMs) for comatose survivors of cardiac arrest are often charged with making time-sensitive complex decisions with regard to life-sustaining therapies in a sudden critical illness. We describe the development of a decision aid for SDMs of comatose survivors of cardiac arrest. Methods: Applying recommendations from the International Patient Decision Aid Standards, we developed this decision aid iteratively with the purpose to educate families on post-arrest care and evidence based decision-making. We obtained feedback from stakeholders, including surrogate decision makers, patients, caregivers, nurses and physicians, in focus groups and semi-structured interviews. Results: Informed by interviews with SDMs and the AHA Guidelines, we designed a prototype of the decision aid. Each iteration resulted in a refined version of the aid (Figure). Step 1 included feedback from the Shared Decision-Making Core at the Adult and Child Consortium on Outcomes Research and Delivery Science (ACCORDS). Step 2 incorporated feedback from the ACCORDS Community Engagement Stakeholder group. Step 3 consisted of 10 semi-structured interviews with informal caregivers and patient pairs within the Advanced Heart Failure or Seniors clinics. The document was then reviewed by a team of expert cardiac arrest stakeholders. The aid includes key definitions, a timeline of post-arrest care, factors that support decisions to discontinue or pursue life sustaining therapies, commonly asked questions and an illustration of a patient undergoing post-arrest treatment. The decision aid, entitled T ool to EMPO wer (TEMPO) Surrogate Decision Makers, is written at a 7 th grade reading level. Conclusions: Through a robust iterative process, we designed a decision aid for SDMs of comatose survivors of cardiac arrest. The aid is intended to support the decision to pursue or forego further life-sustaining therapy and to be informative about post-arrest care.

Using a patient decision aid about insulin treatment in type 2 diabetes clinics

The Candlin Researcher AwardThe low uptake of insulin leaves many Malaysians with type 2 diabetes at risk of developing complications. To improve decision making about insulin treatment, a patient decision aid (PDA) was developed for use with patients. However, although it is generally accepted that PDAs can support informed and shared decision making, there is limited discursive data showing how they are used in doctor–patient consultations. This paper reports on activity analysis of clinic consultations in which a PDA about insulin treatment was used. Eleven consultations with diverse participants conducted in three healthcare settings in Malaysia were systematically mapped to identify structural, interactional and thematic patterns. Two main phases of Assessment and Treatment were identified, with doctors generally participating more than patients. Mapping of the Treatment phase showed that structural patterns depended on two main factors: whether patients had read the PDA and whether they responded negatively or positively towards insulin. While mapping is only a preliminary stage of activity analysis, the findings offer insights into structural, interactional and thematic patterns in PDA use at the level of the whole consultation. They also point towards key areas for closer analysis of discursive practices.

Practitioners’ views on shared decision-making implementation: A qualitative study

Introduction Shared decision-making (SDM) refers to the collaboration between patients and their healthcare providers to make clinical decisions based on evidence and patient preferences, often supported by patient decision aids (PDAs). This study explored practitioner experiences of SDM in a context where SDM has been successfully implemented. Specifically, we focused on practitioners’ perceptions of SDM as a paradigm, factors influencing implementation success, and outcomes. Methods We used a qualitative approach to examine the experiences and perceptions of 10 Danish practitioners at a cancer hospital experienced in SDM implementation. A semi-structured interview format was used and interviews were audio-recorded and transcribed. Data was analyzed through thematic analysis. Results Prior to SDM implementation, participants had a range of attitudes from skeptical to receptive. Those with more direct long-term contact with patients (such as nurses) were more positive about the need for SDM. We identified four main factors that influenced SDM implementation success: raising awareness of SDM behaviors among clinicians through concrete measurements, supporting the formation of new habits through reinforcement mechanisms, increasing the flexibility of PDA delivery, and strong leadership. According to our participants, these factors were instrumental in overcoming initial skepticism and solidifying new SDM behaviors. Improvements to the clinical process were reported. Sustaining and transferring the knowledge gained to other contexts will require adapting measurement tools. Conclusions Applying SDM in clinical practice represents a major shift in mindset for clinicians. Designing SDM initiatives with an understanding of the underlying behavioral mechanisms may increase the probability of successful and sustained implementation.

Results of watchful waiting of unruptured intracranial aneurysms in a Western patient population: a single-center cohort

BackgroundThe natural history of unruptured intracranial aneurysms (UIAs) in Western populations is still debated, especially for those <7 mm. Reporting data of a large single-center cohort managed with watchful waiting is therefore interesting.MethodsFrom January 2011 to June 2019, 662 UIAs were followed up by yearly MR angiography. Morphologically stable UIAs were managed conservatively while unstable UIAs were offered treatment. The patients’ clinical and radiological data were analyzed retrospectively.ResultsUIAs were ≤4 mm in 60%, 4.1–7.0 mm in 33%, and >7 mm in 7%. They were located on the anterior circulation in 90% of cases. The mean follow-up duration was 51.32 months for a total of 2831 aneurysm-years. During follow-up, 37 UIAs (5.5%) were treated because of an increase in size, and 8 UIAs were treated because of patient decision. Three aneurysms ruptured during follow-up for an annual risk of rupture of 0.1% (95% CI 0% to 0.24%). No risk factors for rupture were identified. The three ruptured cases made an excellent recovery. During follow-up, annual mortality from unrelated causes was 0.8% (95% CI 0.51% to 1.18%).ConclusionsThis single-center cohort evaluated our watchful waiting policy applied in two-thirds of all incidental UIAs. Morphological change of UIAs during follow-up led to treatment in 5.5% of cases. With such a management paradigm, we found a low rupture rate in these selected UIAs and the mortality was unrelated to aneurysms.

INNV-13. UNDERSTANDING FACTORS THAT INFLUENCE THE DECISION OF ACCEPTING TUMOR TREATING FIELDS (TTF) THERAPY

BACKGROUND Tumor Treating Fields (TTF) Therapy is an FDA-approved therapy in the first line and recurrent setting for glioblastoma. Despite Phase 3 evidence showing improved survival, it is not uniformly utilized despite its availability. This qualitative prospective study interviewed glioblastoma patients to better understand key driving factors for decision making. METHODS Adult glioblastoma patients who were offered TTF and who signed IRB approved consent were included. Patients participated in a one-time recorded interview with the researchers from the Northwestern University Department of Medical Social Sciences and were asked about factors shaping their decision to use or not use TTF. RESULTS 40 patients were enrolled with a mean age of 53 years, 92.5% were white and 60% were male. Of the 33 (82.5%) participants who accepted TTF, 23 (69.7%) reported their physician recommending TTF, 8 (24.2%) reported physician neutrality toward TTF, and 2 (6.1%) said their physician advised against TTF. Among the 7 (17.5%) participants who did not choose TTF, 4 (57.1%) reported physician neutrality, 2 (28.6%) reported that their physician advised against TTF, and 1 (14.3%) reported that their physician recommended TTF. Participants who decided against TTF stated that head shaving, appearing sick, and inconvenience of wearing/carrying the device most influenced their decision. For those choosing to use TTF, the most influential factors were extending life and following their doctor's opinion; other factors included level of familial support and the clinical evidence supporting TTF. DISCUSSION This clinical study was a collaboration with the Medical Social Sciences team to better understand the key factors that drive patient decision making with TTF. Findings suggest that physician support and positive Phase 3 results are among the key decision-making factors. Properly understanding the path to patients’ decision making is crucial in optimizing use of TTF and other therapeutic decisions for glioblastoma patients.