Attitude toward second opinions in Germany – a survey of the general population

Background Second medical opinions (SOs) can assist patients in making informed treatment decisions and improve the understanding of their diagnosis. In Germany, there are different approaches to obtain a structured SO procedure: SO programs by health insurers and SOs according to the SO Directive. Through a direct survey of the population, we aimed to assess how structured SOs should be provided to fulfil patients’ needs. Methods A stratified sample of 9990 adults (≥18 years) living in the federal states of Berlin and Brandenburg (Germany) were initially contacted by post in April and sent a reminder in May 2020. The survey results were analyzed descriptively. Results Among 1349 participants (response rate 14%), 56% were female and the median age was 58 years (interquartile range (IQR) 44–69). Participants wanted to be informed directly and personally about the possibility of obtaining an SO (89%; 1201/1349). They preferred to be informed by their physician (93%; 1249/1349). A majority of participants would consider it important to obtain an SO for oncological indications (78%; 1049/1349). Only a subset of the participants would seek an SO via their health insurer or via an online portal (43%; 577/1349 and 16%; 221/1349). A personally delivered SO was the preferred route of SO delivery, as 97% (1305/1349) would (tend to) consider this way of obtaining an SO. Participants were asked to imagine having moderate knee pain for years, resulting in a treatment recommendation for knee joint replacement. They were requested to rate potential qualification criteria for a physician providing the SO. The criteria rated to be most important were experience with the recommended diagnosis/treatment (criterion (very) important for 93%; 1257/1349) and knowledge of the current state of research (criterion (very) important for 86%; 1158/1349). Participants were willing to travel 60 min (median; IQR 60–120) and wait 4 weeks (median; IQR 2–4) for their SO in the hypothetical case of knee pain. Conclusion In general, SOs were viewed positively. We found that participants have clear preferences regarding SOs. We propose that these preferences should be taken into account in the future design and development of SO programs.

Implementing the cancer and aging research group (CARG) tool in the ambulatory oncology setting to drive informed treatment selection.

209 Background: Smilow Cancer Hospital is a NCI designated cancer center in Connecticut that has built a network of 15 community-based oncology (CBO) clinics. Older patients present with unique clinical challenges including multiple comorbidities, decreased functional status, and cognitive impairment. ASCO Geriatric Oncology guidelines recommend completing both a comprehensive geriatric assessment and a chemotherapy toxicity risk assessment on all oncology patients ≥65 years old for informed treatment selection. The CARG calculator is a simple, validated tool to assess chemotherapy toxicity risk in older patients with solid tumors. Despite ASCO guidelines, the existence of validated tools, and literature confirming improved patient outcomes, oncologists’ utilization of risk calculators is limited; therefore, we conducted a pilot CARG quality improvement initiative throughout our CBO network. Methods: 36 CBO physicians agreed to complete five CARG tools, document toxicity scores in the EMR, and complete a post-survey between March and June 2021. PDSA cycles included interventions of a hyperlink to the CARG tool incorporated in the EMR and creating a dot phrase built to simplify documentation. Education was provided on both the CARG and the survey. The survey captured perceived clinical value, time commitment, and barriers to implementation. Baseline data was collected during February 2021 and included geriatric patients receiving a new chemotherapy regimen for a solid tumor. Results: 180 consecutive new chemotherapy starts in geriatric patients were monitored. The CARG score utilization in new chemotherapy starts increased from 6.5% of new cases during the first month, to 26.4% in the third month. 82% of providers found the CARG score helpful in discussing chemotherapy risks with patients. In 32% of cases, the CARG score led to a decision to dose attenuate, and in 15% of cases, the CARG score led to a different treatment regimen. Most oncologists (65%) reported spending ≤5 minutes calculating toxicity, and 88% spent ≤10 minutes. 89% of oncologists reported the CARG score was worth the added time. Conclusions: This QI initiative demonstrates feasibility and increased use of the CARG geriatric chemotherapy toxicity tool in accordance with ASCO geriatric guideline-based care. Physician education and EMR workflow modification were utilized. In the CBO setting, oncologists found the CARG tool to be quick and helpful in discussing treatment risks with patients. Use of the CARG tool led to meaningful changes in treatment, including chemotherapy dose attenuation. Further study metrics such as palliative and supportive care referrals, ED visits, and hospitalizations will fuel sustainability.

Predicting fracture outcomes from clinical registry data using artificial intelligence supplemented models for evidence-informed treatment (PRAISE) study protocol

Background Distal radius (wrist) fractures are the second most common fracture admitted to hospital. The anatomical pattern of these types of injuries is diverse, with variation in clinical management, guidelines for management remain inconclusive, and the uptake of findings from clinical trials into routine practice limited. Robust predictive modelling, which considers both the characteristics of the fracture and patient, provides the best opportunity to reduce variation in care and improve patient outcomes. This type of data is housed in unstructured data sources with no particular format or schema. The “Predicting fracture outcomes from clinical Registry data using Artificial Intelligence (AI) Supplemented models for Evidence-informed treatment (PRAISE)” study aims to use AI methods on unstructured data to describe the fracture characteristics and test if using this information improves identification of key fracture characteristics and prediction of patient-reported outcome measures and clinical outcomes following wrist fractures compared to prediction models based on standard registry data. Methods and design Adult (16+ years) patients presenting to the emergency department, treated in a short stay unit, or admitted to hospital for >24h for management of a wrist fracture in four Victorian hospitals will be included in this study. The study will use routine registry data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), and electronic medical record (EMR) information (e.g. X-rays, surgical reports, radiology reports, images). A multimodal deep learning fracture reasoning system (DLFRS) will be developed that reasons on EMR information. Machine learning prediction models will test the performance with/without output from the DLFRS. Discussion The PRAISE study will establish the use of AI techniques to provide enhanced information about fracture characteristics in people with wrist fractures. Prediction models using AI derived characteristics are expected to provide better prediction of clinical and patient-reported outcomes following distal radius fracture.

Choice, voice and collaboration: using preference accommodation and feedback in trauma therapy

Purpose Organisations are increasingly understanding the need to be trauma informed. However, how trauma therapies in such organisations apply the principles of choice and collaboration is less understood. The present paper applies two trans-theoretical methods for involving clients in their therapy through preference accommodation and feedback-informed treatment (FIT). A case vignette is provided demonstrating how to involve clients in trauma therapy by listening to their preferences, needs and by providing them with a voice on their experience of the process and outcome of care. Design/methodology/approach A focused review of the literature was conducted, with relevant randomised control trials, systematic reviews and meta-analyses sourced. The resulting information informed the design and this model for working with those in trauma therapy. Findings The research regarding trauma-specific therapies being more effective is far from conclusive. At the same time, early attrition and negative outcomes make up a large percentage of those seeking therapy. Using preference accommodation and FIT is one possibly way to mitigate against these experiences in therapy and to provide choice, preference and collaboration consisting with the principles of trauma-informed approaches. Research limitations/implications Methods to improve the experiences of those seeking trauma therapy have been identified and discussed. According to the author’s knowledge, this is the first known paper aligning trauma therapy and trauma-informed approaches with preference accommodation and FIT. Future empirical studies may wish to examine the relative effectiveness of this approach. Practical implications Methods to improve outcomes for those seeking trauma therapy are at the disposal of practitioners. Improving outcomes, while also providing choice, voice and collaboration is a clinical setting. Originality/value This is a novel paper adding to value and extending how practitioners can use principles of trauma-informed approaches within trauma therapy.

Development of a patient decision aid on subacromial decompression surgery and rotator cuff repair surgery: an international mixed-methods study

ObjectiveTo develop and user test a patient decision aid for people with subacromial pain syndrome that presents evidence-based information on the benefits and harms of subacromial decompression surgery and rotator cuff repair surgery.DesignMixed-methods study outlining the development of a patient decision aid.SettingWe assembled a multidisciplinary steering group, and used existing decision aids and decision science to draft the decision aid. Participants were recruited through social media (not restricted by country nor setting), local hospitals and the authors’ collaboration network.ParticipantsPeople with shoulder pain and health professionals who manage people with shoulder pain.Primary and secondary outcomesWe interviewed participants to gather feedback on the decision aid, assessed useability and acceptability (using qualitative and quantitative methods) and performed iterative cycles of redrafting the decision aid and reinterviewing participants as necessary. Interview data were analysed using thematic analysis. Quantitative data were summarised descriptively.ResultsWe interviewed 26 health professionals (11 physiotherapists, 7 orthopaedic surgeons, 4 general practitioners, 3 chiropractors and 1 osteopath) and 14 people with shoulder pain. Most health professionals and people with shoulder pain rated all aspects of decision aid acceptability as adequate-to-excellent (eg, length, presentation, comprehensibility). Interviews highlighted agreement among health professionals and people with shoulder pain on most aspects of the decision aid (eg, treatment options, summary of benefits, harms and practical issues, questions to ask a health professional, graphics, formatting). However, some aspects of the decision aid elicited divergent views among health professionals (eg, causes and symptoms of shoulder pain, evidence on benefits and harms).ConclusionThis decision aid could be an acceptable and valuable tool for helping people with subacromial pain syndrome make informed treatment choices. A randomised controlled trial evaluating whether this decision aid reduces people’s intentions to undergo shoulder surgery and facilitates informed treatment choices is underway.Trial registration number ACTRN12621000992808

THE IMPORTANCE OF ACCURATE IMAGING DIAGNOSIS OF A VASCULAR ANOMALY PRIOR TO THE SURGICAL PROCEDURE

The diagnosis of vascular tumors and malformations is usually achieved with clinical history and physical examination. The imaging of these patients has been sufficiently refined to answer pertinent questions when trying to make an accurate differential diagnosis in order to establish an informed treatment plan. The imaging modalities at hand include ultrasound, doppler sonography, magnetic resonance imaging and contrast material enhanced magnetic resonance angiography. We present two cases of different vascular anomalies that were managed according to the clinical aspect, natural history and imaging performed. Moreover, with better understanding of the imaging features, the radiologist has become a key player in the diagnosis and management plan of the vascular anomalies. This is crucial in avoiding misdiagnosis and improper treatment.

Collective Trauma and Mental Health in Adolescents: A Retrospective Cohort Study of the Effects of Retraumatization

In the wake of the massive Canadian wildfire of May 2016 in the area of Fort McMurray Alberta, we observed increased rates of mental health problems, particularly post-traumatic stress disorder (PTSD), in school-aged adolescents (ages 11–19). Surprisingly, we did not see these rates decline over the 3.5-year follow-up period. Additionally, our research suggested that the impact of this mass incident resulted in other unanticipated effects, including the finding that children who were not present for and relatively unaffected by the wildfire showed a similar PTSD symptom profile to children more directly involved, suggesting some degree of spillover or stress contagion. A potential explanation for these high rates in individuals who were not present could be undiagnosed retraumatization in some of the students. To investigate this possibility, we compared two groups of students: those who reported the wildfire as their most significant trauma (n = 740) and those who had their most significant trauma prior to the wildfire (n = 295). Those with significant pre-existing trauma had significantly higher rates of both depression and PTSD symptoms, although, unexpectedly the groups exhibited no differences in anxiety level. Taken together, this evidence suggests retraumatization is both longer-lasting and more widespread than might be predicted on a case-by-case basis, suggesting the need to reconceptualize the role of past trauma history in present symptomatology. These findings point to the need to recognize that crises instigated by natural disasters are mass phenomena which expose those involved to numerous unanticipated risks. New trauma-informed treatment approaches are required that incorporate sensitivity to the collective impact of mass crises, and recognize the risk of poorer long-term mental health outcomes for those who experienced trauma in the past.