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Barr P.J.,Dartmouth Institute for Health Policy and Clinical Practice | Forcino R.C.,Dartmouth Institute for Health Policy and Clinical Practice | Mishra M.,Dartmouth Center for Health Care Delivery Science | Elwyn G.,Dartmouth Institute for Health Policy and Clinical Practice | Elwyn G.,Dartmouth Center for Health Care Delivery Science
BMJ Open | Year: 2016

Objective: To identify information priorities for consumers and clinicians making depression treatment decisions and assess shared decision-making (SDM) in routine depression care. Design:20 questions related to common features of depression treatments were provided. Participants were initially asked to select which features were important, and in a second stage they were asked to rank their top 5 'important features' in order of importance. Clinicians were asked to provide rankings according to both consumer and clinician perspectives. Consumers completed CollaboRATE, a measure of SDM. Multiple logistic regression analysis identified consumer characteristics associated with CollaboRATE scores. Setting: Online cross-sectional surveys fielded in September to December 2014. Participants: We administered surveys to convenience samples of US adults with depression and clinicians who treat depression. Consumer sampling was targeted to reflect age, gender and educational attainment of adults with depression in the USA. Primary outcome measures: Information priority rankings; CollaboRATE, a 3-item consumer-reported measure of SDM. Results:972 consumers and 244 clinicians completed the surveys. The highest ranked question for both consumers and clinicians was 'Will the treatment work?' Clinicians were aware of consumers' priorities, yet did not always prioritise that information themselves, particularly insurance coverage and cost of treatment. Only 18% of consumers reported high levels of SDM. Working with a psychiatrist (OR 1.87; 95% CI 1.07 to 3.26) and female gender (OR 2.04; 95% CI 1.25 to 3.34) were associated with top CollaboRATE scores. Conclusions: While clinicians know what information is important to consumers making depression treatment decisions, they do not always address these concerns. This mismatch, coupled with low SDM, adversely affects the quality of depression care. Development of a decision support intervention based on our findings can improve levels of SDM and provide clinicians and consumers with a tool to address the existing misalignment in information priorities.


Danford N.,Dartmouth Center for Health Care Delivery Science | Zaha R.,Dartmouth Center for Health Care Delivery Science | Freile C.,National Tuberculosis Program of Ecuador
International Journal of Tuberculosis and Lung Disease | Year: 2014

BACKGROUND: Non-adherence to tuberculosis (TB) treatment jeopardizes patient health and promotes disease transmission. In July 2011, Ecuador's National Tuberculosis Program (NTP) enacted a monetary incentive program giving adherent drug-resistant TB (DR-TB) patients a US$240 bonus each month. OBJECTIVE: To describe patients' experiences with the program qualitatively, and to assess its effects on treatment adherence. METHODS: We interviewed 92 current and five default patients about their treatment experience. NTP data on DR-TB patients receiving treatment were used to compare 12-month default rates among the incentive program group and non-program controls. RESULTS: Our interviews found that patients are financially challenged and use the bonus for a variety of expenses, most commonly food. The most common complaint was that bonus payments were frequently delayed. The 1-year default rate among program patients (9.5%) was significantly lower than the rate among pre-program patients (26.7%). CONCLUSION: Ecuador's monetary incentive program alleviates the economic burden placed by treatment on patients. The bonus does not, however, directly address other treatment barriers, including psychological distress and side effects. The program could benefit from timely delivery of payments. Further research is necessary to assess the program's effect on default rates. © 2014 The Union.


Durand M.-A.,Dartmouth Institute for Health Policy and Clinical Practice | Durand M.-A.,University of Hertfordshire | Moulton B.,Informed Medical Decisions Foundation | Moulton B.,Boston University | And 4 more authors.
BMC Health Services Research | Year: 2015

Background: To explore the likely influence and impact of shared decision-making on medical malpractice litigation and patients' intentions to initiate litigation. Methods: We included all observational, interventional and qualitative studies published in all languages, which assessed the effect or likely influence of shared decision-making or shared decision-making interventions on medical malpractice litigation or on patients' intentions to litigate. The following databases were searched from inception until January 2014: CINAHL, Cochrane Register of Controlled Trials, Cochrane Database of Systematic Reviews, EMBASE, HMIC, Lexis library, MEDLINE, NHS Economic Evaluation Database, Open SIGLE, PsycINFO and Web of Knowledge. We also hand searched reference lists of included studies and contacted experts in the field. Downs & Black quality assessment checklist, the Critical Appraisal Skill Programme qualitative tool, and the Critical Appraisal Guidelines for single case study research were used to assess the quality of included studies. Results: 6562 records were screened and 19 articles were retrieved for full-text review. Five studies wee included in the review. Due to the number and heterogeneity of included studies, we conducted a narrative synthesis adapted from the ESRC guidance for narrative synthesis. Four themes emerged. The analysis confirms the absence of empirical data necessary to determine whether or not shared decision-making promoted in the clinical encounter can reduce litigation. Three out of five included studies provide retrospective and simulated data suggesting that ignoring or failing to diagnose patient preferences, particularly when no effort has been made to inform and support understanding of possible harms and benefits, puts clinicians at a higher risk of litigation. Simulated scenarios suggest that documenting the use of decision support interventions in patients' notes could offer some level of medico-legal protection. Our analysis also indicated that a sizeable proportion of clinicians prefer ordering more tests and procedures, irrespective of patient informed preferences, as protection against litigation. Conclusions: Given the lack of empirical data, there is insufficient evidence to determine whether or not shared decision-making and the use of decision support interventions can reduce medical malpractice litigation. Further investigation is required. Trial registration: This review was registered on PROSPERO. Registration number: CRD42012002367. © 2015 Durand et al.; licensee BioMed Central.


Binagwaho A.,Ministry of Health | Wagner C.M.,Harvard University | Gatera M.,Rwanda Biomedical Center | Karema C.,Rwanda Biomedical Center | And 2 more authors.
Bulletin of the World Health Organization | Year: 2012

Problem Virtually all women who have cervical cancer are infected with the human papillomavirus (HPV). Of the 275 000 women who die from cervical cancer every year, 88% live in developing countries. Two vaccines against the HPV have been approved. However, vaccine implementation in low-income countries tends to lag behind implementation in high-income countries by 15 to 20 years. Approach In 2011, Rwanda's Ministry of Health partnered with Merck to offer the Gardasil HPV vaccine to all girls of appropriate age. The Ministry formed a "public-private community partnership" to ensure effective and equitable delivery. Local setting Thanks to a strong national focus on health systems strengthening, more than 90% of all Rwandan infants aged 12-23 months receive all basic immunizations recommended by the World Health Organization. Relevant changes In 2011, Rwanda's HPV vaccination programme achieved 93.23% coverage after the first three-dose course of vaccination among girls in grade six. This was made possible through school-based vaccination and community involvement in identifying girls absent from or not enrolled in school. A nationwide sensitization campaign preceded delivery of the first dose. Lessons learnt Through a series of innovative partnerships, Rwanda reduced the historical two-decade gap in vaccine introduction between high- and low-income countries to just five years. High coverage rates were achieved due to a delivery strategy that built on Rwanda's strong vaccination system and human resources framework. Following the GAVI Alliance's decision to begin financing HPV vaccination, Rwanda's example should motivate other countries to explore universal HPV vaccine coverage, although implementation must be tailored to the local context.


De Assis A.M.,University of Sao Paulo | Moreira A.M.,University of Sao Paulo | De Paula Rodrigues V.C.,University of Sao Paulo | Yoshinaga E.M.,University of Sao Paulo | And 4 more authors.
Journal of Vascular and Interventional Radiology | Year: 2015

Purpose To describe the safety and efficacy of prostatic artery embolization (PAE) with spherical microparticles to treat lower urinary tract symptoms associated with benign prostatic hyperplasia in patients with prostate volume > 90 g.Materials and Methods This prospective, single-center, single-arm study was conducted in 35 patients with prostate volumes ranging from 90-252 g. Mean patient age was 64.8 years (range, 53-77 y). Magnetic resonance imaging, uroflowmetry, and the International Prostate Symptom Score (IPSS) were used to assess clinical and functional outcomes.Results Mean prostate size decreased significantly from 135.1 g before PAE to 91.9 g at 3 months of follow-up (P <.0001). Mean IPSS and quality-of-life index improved from 18.3 to 2.7 and 4.8 to 0.9 (P <.0001 for both), respectively. A significant negative correlation was observed between prostate-specific antigen at 24 hours after PAE and IPSS 3 months after PAE (P =.0057).Conclusions PAE is a safe and effective treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia in patients with prostate volume > 90 g. Excessively elevated prostate-specific antigen within 24 hours of PAE is associated with lower symptom burden in short-term follow-up. © 2015 SIR.


Han P.K.J.,Center for Outcomes Research and Evaluation | Han P.K.J.,Tufts University | Joekes K.,St George's, University of London | Elwyn G.,Dartmouth Center for Health Care Delivery Science | And 6 more authors.
Patient Education and Counseling | Year: 2014

Objective: To develop, pilot, and evaluate a curriculum for teaching clinical risk communication skills to medical students. Methods: A new experience-based curriculum, "Risk Talk," was developed and piloted over a 1-year period among students at Tufts University School of Medicine. An experimental study of 2nd-year students exposed vs. unexposed to the curriculum was conducted to evaluate the curriculum's efficacy. Primary outcome measures were students' objective (observed) and subjective (self-reported) risk communication competence; the latter was assessed using an Observed Structured Clinical Examination (OSCE) employing new measures. Results: Twenty-eight 2nd-year students completed the curriculum, and exhibited significantly greater (p < .001) objective and subjective risk communication competence than a convenience sample of 24 unexposed students. New observational measures of objective competence in risk communication showed promising evidence of reliability and validity. The curriculum was resource-intensive. Conclusion: The new experience-based clinical risk communication curriculum was efficacious, although resource-intensive. More work is needed to develop the feasibility of curriculum delivery, and to improve the measurement of competence in clinical risk communication. Practice implications: Risk communication is an important advanced communication skill, and the Risk Talk curriculum provides a model educational intervention and new assessment tools to guide future efforts to teach and evaluate this skill. © 2013 Elsevier Ireland Ltd.


Tai-Seale M.,View Medical | Elwyn G.,Dartmouth Center for Health Care Delivery Science | Wilson C.J.,Palo Alto Medical Foundation Research Institute | Stults C.,Palo Alto Medical Foundation Research Institute | And 5 more authors.
Health Affairs | Year: 2016

Patient-provider communication and shared decision making are essential for primary care delivery and are vital contributors to patient experience and health outcomes. To alleviate communication shortfalls, we designed a novel, multidimensional intervention aimed at nudging both patients and primary care providers to communicate more openly. The intervention was tested against an existing intervention, which focused mainly on changing patients' behaviors, in four primary care clinics involving 26 primary care providers and 300 patients. Study results suggest that compared to usual care, both the novel and existing interventions were associated with better patient reports of how well primary care providers engaged them in shared decision making. Future research should build on the work in this pilot to rigorously examine the comparative effectiveness and scalability of these interventions to improve shared decision making at the point of care. © 2016 Project HOPE- The People-to-People Health Foundation, Inc.


PubMed | Rwanda Ministry of Health, Brown University, Dartmouth Center for Health Care Delivery Science, Rwanda Biomedical Center and 2 more.
Type: Journal Article | Journal: Global health, science and practice | Year: 2014

Between 2008 and 2011, Rwanda introduced integrated community case management (iCCM) of childhood illness nationwide. Community health workers in each of Rwandas nearly 15,000 villages were trained in iCCM and equipped for empirical diagnosis and treatment of pneumonia, diarrhea, and malaria; for malnutrition surveillance; and for comprehensive reporting and referral services.We used data from the Rwanda health management information system (HMIS) to calculate monthly all-cause under-5 mortality rates, health facility use rates, and community-based treatment rates for childhood illness in each district. We then compared a 3-month baseline period prior to iCCM implementation with a seasonally matched comparison period 1 year after iCCM implementation. Finally, we compared the actual changes in all-cause child mortality and health facility use over this time period with the changes that would have been expected based on baseline trends in Rwanda.The number of children receiving community-based treatment for diarrhea and pneumonia increased significantly in the 1-year period after iCCM implementation, from 0.83 cases/1,000 child-months to 3.80 cases/1,000 child-months (P=.01) and 0.25 cases/1,000 child-months to 5.28 cases/1,000 child-months (P<.001), respectively. On average, total under-5 mortality rates declined significantly by 38% (P<.001), and health facility use declined significantly by 15% (P=.006). These decreases were significantly greater than would have been expected based on baseline trends.This is the first study to demonstrate decreases in both child mortality and health facility use after implementing iCCM of childhood illness at a national level. While our study design does not allow for direct attribution of these changes to implementation of iCCM, these results are in line with those of prior studies conducted at the sub-national level in other low-income countries.


Tsulukidze M.,Dartmouth Center for Health Care Delivery Science | Grande S.W.,Dartmouth Center for Health Care Delivery Science | Thompson R.,Dartmouth Institute for Health Policy and Clinical Practice | Rudd K.,Dartmouth Center for Health Care Delivery Science | And 3 more authors.
PLoS ONE | Year: 2015

Background: The phenomenon of patients covertly recording clinical encounters has generated controversial media reports. This study aims to examine the phenomenon and analyze the underlying issues. Methods and Findings: We conducted a qualitative analysis of online posts, articles, blogs, and forums (texts) discussing patients covertly recording clinical encounters. Using Google and Google Blog search engines, we identified and analyzed 62 eligible texts published in multiple countries between 2006 and 2013. Thematic analysis revealed four key themes: 1) a new behavior that elicits strong reactions, both positive and negative, 2) an erosion of trust, 3) shifting patient-clinician roles and relationships, and 4) the existence of confused and conflicting responses. When patients covertly record clinical encounters - a behavior made possible by various digital recording technologies - strong reactions are evoked among a range of stakeholders. The behavior represents one consequence of an erosion of trust between patients and clinicians, and when discovered, leads to further deterioration of trust. Confused and conflicting responses to the phenomenon by patients and clinicians highlight the need for policy guidance. Conclusions: This study describes strong reactions, both positive and negative, to the phenomenon of patients covertly recording clinical encounters. The availability of smartphones capable of digital recording, and shifting attitudes to patient-clinician relationships, seems to have led to this behavior, mostly viewed as a threat by clinicians but as a welcome and helpful innovation by some patients, possibly indicating a perception of subordination and a lack of empowerment. Further examination of this tension and its implications is needed. © 2015 Tsulukidze et al.


Binagwaho A.,Ministry of Health of Rwanda | Ngabo F.,Ministry of Health of Rwanda | Wagner C.M.,Global Health Delivery Partnership | Mugeni C.,Ministry of Health of Rwanda | And 3 more authors.
Bulletin of the World Health Organization | Year: 2013

Problem Although it is highly preventable and treatable, cervical cancer is the most common and most deadly cancer among women in Rwanda. Approach By mobilizing a diverse coalition of partnerships, Rwanda became the first country in Africa to develop and implement a national strategic plan for cervical cancer prevention, screening and treatment. Local setting Rwanda - a small, landlocked nation in East Africa with a population of 10.4 million - is well positioned to tackle a number of "high-burden" noncommunicable diseases. The country's integrated response to infectious diseases has resulted in steep declines in premature mortality over the past decade. Relevant changes In 2011-2012, Rwanda vaccinated 227 246 girls with all three doses of the human papillomavirus (HPV) vaccine. Among eligible girls, three-dose coverage rates of 93.2% and 96.6% were achieved in 2011 and 2012, respectively. The country has also initiated nationwide screening and treatment programmes that are based on visual inspection of the cervix with acetic acid, testing for HPV DNA, cryotherapy, the loop electrosurgical excision procedure and various advanced treatment options. Lessons learnt Low-income countries should begin to address cervical cancer by integrating prevention, screening and treatment into routine women's health services. This requires political will, cross-sectoral collaboration and planning, innovative partnerships and robust monitoring and evaluation. With external support and adequate planning, high nationwide coverage rates for HPV vaccination and screening for cervical cancer can be achieved within a few years.

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