Shared Decision-Making in Drug Selection for Improving Effectiveness of Smoking Cessation

BackgroundA patient decision aid (PDA) is a tool for shared decision making (SDM), which emphasises patient empowerment. It is useful in chronic diseases and when there are multiple, no best...

<h3>Background</h3> A patient decision aid (PDA) is a tool for shared decision making (SDM), which emphasises patient empowerment. It is useful in chronic diseases and when there are multiple, no...

BackgroundAlthough the number of medical institutions running a smoking cessation clinic is on the rise, there remains a paucity of research on the long- and short-term success rates of smoking cessation programs, as well as on smoking relapse rates, before and after project implementation. This study assessed the general characteristics of patients visiting the smoking cessation clinic, success rate of smoking cessation in the short term, and risks of relapse.MethodsMedical records from March 2015 to April 2017 were analyzed and telephone surveys were conducted with 151 smokers who visited a hospital smoking cessation clinic from March 2015 to April 2017.ResultsOf the 139 smokers who were eligible for follow-up, 22 (15.8%) failed to quit smoking initially. The clinic’s 6-month success rate of smoking cessation was 64.83%. Those with higher medication compliance had a lower risk of primary failure (odds ratio, 0.056; 95% confidence interval, 0.005–0.609), whereas those with higher age (hazard ratio [HR], 0.128; P=0.0252) and a greater number of visits to the clinic (HR, 0.274; P=0.0124) had a lower risk of relapsing.ConclusionThe risk of primary failure to quit was higher with low medication compliance, and that of relapsing was higher with lower age and fewer number of clinic visits. Various evaluation and analysis methods can be carried out in the future based on the accumulated data for maintenance of smoking cessation and relapse prevention.

BackgroundMen with localized prostate cancer often have unrealistic expectations. Practitioners are poor judges of men’s preferences, contributing to preference misdiagnosis and unwarranted practice variation. Patient decision aids (PtDAs) can support men with decisions about localized prostate cancer. This is a comparative case study of two strategies for implementing PtDAs in clinical pathways for men with localized prostate cancer, evaluating (a) PtDA use; (b) impact on men, practitioners, and health system outcomes; and (c) factors influencing sustained use.Methods/designGuided by the Knowledge to Action Framework, this comparative case study will be conducted using administrative data, interviews, and surveys. Cases will be bound by geographic location (one hospital in Ontario; province of Saskatchewan) and time. Eligible participants will be all men newly diagnosed with localized prostate cancer, with outcomes assessed using administrative data and interviews. Nurses, urologists, radiation oncologists, and managers will be surveyed and a smaller sample interviewed. Cases will be established for each setting with findings compared across cases. Changes in the proportions of men given the PtDA over 2 years will be determined from administrative data. Factors associated with receiving the PtDA will be explored using multivariable logistic regression analysis. To assess the impact of the PtDA, outcomes will be described using mean and standard deviation (men’s decisional conflict) and frequency and proportions (practitioners consulted, uptake of treatment). To estimate the effect of the PtDA on these outcomes, adjusted mean differences and odds ratios will be calculated using exploratory multivariable general linear regression and binary or multinomial logistic regression. Factors influencing sustained PtDA use will be assessed using descriptive analysis of survey findings and thematic analysis of interview transcripts.DiscussionDetermining how to embed PtDAs effectively within clinical pathways for men with localized prostate cancer is essential. PtDAs have the potential to strengthen men’s active role in making prostate cancer decisions, enhance uptake of shared decision-making by practitioners, and reduce practice variation. Our team of researchers and knowledge users will use findings to improve current PtDA use and consider scaling-up implementation.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0451-1) contains supplementary material, which is available to authorized users.

Patient decision aids (PDAs) are evidence-based tools that facilitate shared decision-making (SDM) between patients and healthcare professionals. These tools are used when multiple treatment options exist, no clear choice prevails regarding risks versus benefits, and the best option may vary depending on patient values. A 2024 Cochrane review of 209 randomized controlled trials involving over 107,000 participants identified the substantial benefits of PDAs,1 including improved patient knowledge, increased SDM and enhanced accuracy of risk perceptions and alignment of decisions with patient values. Given these benefits, SDM tools are more widely used. However, their quality remains inconsistent, potentially limiting their benefit.2-4 Dermatology is particularly suited to SDM, given the wide-ranging and ever-evolving treatment options for conditions that often convey a significant psychological burden. A literature review was conducted to assess dermatologic PDAs for adherence with reporting the development process according to the International Patient Decision Aids Standards (IPDAS) Collaboration.5-8 A comprehensive search using MEDLINE (via PubMed) and EMBASE identified articles on dermatological PDA development from 2014 to 2024. After screening 509 publications, 11 studies describing 14 PDAs across eight conditions, psoriasis (2), acne (1), superficial, low and high-risk basal cell carcinoma (4), vitiligo (1), actinic keratoses (3), metastatic malignant melanoma (1), lentigo maligna (1) and hidradenitis suppurativa (1), were included. Data extraction followed Coulter et al.'s9 template for documenting PDA development, focusing on adherence to IPDAS reporting standards. Most studies (10/11) were published in the last 5 years (2020–2024). All PDAs aimed to support patients with a treatment decision (Table 1). Clinical guidelines (5/14) and literature reviews (4/14) were the most common information sources. Five studies did not report this step. Digital PDAs were most common (6/14), although 4 studies only provided images of the PDA, without stating the format. While most PDAs (10/14) reported adhering to the IPDAS framework with an iterative process, only three included all the required development steps (Figure 1). Clinician needs assessments were infrequently conducted (4/14), with just three specifying numbers involved. In contrast, patient needs assessments were more consistently reported (9/14), although only six provided details on patient numbers. Alpha testing with patients was reported in nearly all studies (12/14), reflecting strong patient engagement, but 4 of these did not provide participant numbers, limiting insight into testing scope. Across the PDAs, patient involvement was nearly double that of clinicians, with a median of 20 (IQR = 33) versus 13 (IQR = 38). Patient participation ranged widely from 7 to 322 individuals, while clinician numbers ranged from 8 to 51. Notably, no patient or clinician numbers were reported for any step in the development of PDAs that did not use the IPDAS development framework. This review of dermatologic PDAs reveals that many lack key elements of the IPDAS development process, such as expert panel involvement, needs assessments and usability testing. While most PDAs were reported to align with the IPDAS framework, a substantial number lacked transparency in their development process which may explain the previously reported variations in dermatologic PDA quality.4 For PDAs to effectively support patient-centred SDM, they must undergo a thorough development process with broad user engagement as demonstrated by our research group's development of a PDA for multiple AKs.10 We suggest developers follow the streamlined IPDAS development framework outlined by Witteman et al.7 and Coulter et al.9 which emphasizes iterative development, evidence-based content and stakeholder engagement through minimal, medium and maximal approaches. These approaches ensure both patients and clinicians are included in all development phases and define a minimum required number for user involvement. Future research should prioritize adherence to these standardized development frameworks. The study was completed in partial fulfillment of a doctorate of medicine funded by a research grant from The City of Dublin Skin and Cancer Hospital Charity. The funders were not involved in the study design, data collection, data analysis or manuscript preparation. The authors declare no conflicts of interest. Not applicable. Not applicable. The data that support the findings of this study are available from the corresponding author upon reasonable request.

NRT, bupropion, varenicline and cytisine have been shown to improve the chances of quitting. Combination NRT and varenicline are equally effective as quitting aids. Nortriptyline also improves the chances of quitting. On current evidence, none of the treatments appear to have an incidence of adverse events that would mitigate their use. Further research is warranted into the safety of varenicline and into cytisine's potential as an effective and affordable treatment, but not into the efficacy and safety of NRT.

The purpose of this article is to review clinical computed tomography (CT) lung screening program elements essential to safely and effectively manage the millions of Americans at high risk for lung cancer expected to enroll in lung cancer screening programs over the next 3 to 5 years. To optimize the potential net benefit of CT lung screening and facilitate medical audits benchmarked to national quality standards, radiologists should interpret these examinations using a validated structured reporting system such as Lung-RADS. Patient and physician educational outreach should be enacted to support an informed and shared decision-making process without creating barriers to screening access. Programs must integrate smoking cessation interventions to maximize the clinical efficacy and cost-effectiveness of screening. At an institutional level, budgets should account for the necessary expense of hiring and/or training qualified support staff and equipping them with information technology resources adequate to enroll and track patients accurately over decades of future screening evaluation. At a national level, planning should begin on ways to accommodate the upcoming increased demand for physician services in fields critical to the success of CT lung screening such as diagnostic radiology and thoracic surgery. Institutions with programs that follow these specifications will be well equipped to meet the significant oncoming demand for CT lung screening services and bestow clinical benefits on their patients equal to or beyond what was observed in the National Lung Screening Trial.

Patient decision aids in knee replacement surgery

Patient decision aids (PDAs) are increasingly used to support treatment decision making in type 2 diabetes. However, research on PDAs generally involves quantitative analysis or focuses on physicians’ communicative practices, with limited data on how PDAs are used collaboratively in doctor-patient consultations. We apply discourse analytic methods to 11 recorded consultations during which a PDA on starting insulin was used. Purposive sampling was used to select participants from different healthcare settings and demographic profiles. Our analysis first addresses general questions on PDA use in the consultations, such as when it was used or mentioned in the consultation and by whom, before categorising the turns in which the PDA is mentioned or used by doctors and patients, according to the actions being performed. Next, we focus on consultations in which the patients have already read the PDA, and analyse the sequences of talk that occur after the doctor brings the PDA into the conversation. Our analysis shows that doctor talk on the PDA not only facilitated information provision, but also allowed doctors to elicit and explore the patient’s knowledge and perspectives. However, the kinds of questions that doctors asked tend to limit patient participation, and their focus on the PDA at times overshadowed patient contributions. More attention to doctors’ discursive choices can facilitate more patient-centred practices in using PDAs.

The aim of nicotine replacement therapy (NRT) is to replace nicotine from cigarettes. This reduces withdrawal symptoms associated with smoking cessation thus helping resist the urge to smoke cigarettes. The aims of this review were to determine the effectiveness of the different forms of nicotine replacement therapy (chewing gum, transdermal patches, nasal spray, inhalers and tablets) in achieving abstinence from cigarettes, or a sustained reduction in amount smoked; to determine whether the effect is influenced by the clinical setting in which the smoker is recruited and treated, the dosage and form of the NRT used, or the intensity of additional advice and support offered to the smoker; to determine whether combinations of NRT are more effective than one type alone; and to determine its effectiveness compared to other pharmacotherapies. We searched the Cochrane Tobacco Addiction Group trials register in April 2001. Randomized trials in which NRT was compared to placebo or no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow-up of less than six months. We extracted data in duplicate on the type of subjects, the dose and duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measures was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed effects model (Peto). We identified 108 trials; 94 with a non NRT control group. The odds ratio for abstinence with NRT compared to control was 1.73 (95% confidence interval 1.62-1.85), The odds ratios for the different forms of NRT were 1.66 for gum, 1.76 for patches, 2.27 for nasal spray, 2.08 for inhaled nicotine and 1.73 for nicotine sublingual tablet. These odds were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2mg gum (odds ratio 2.67, 95% confidence interval 1.69 to 4.22). There was weak evidence that combinations of forms of NRT are more effective. Higher doses of nicotine patch may produce small increases in quit rates. Only one study directly compared NRT to another pharmacotherapy, in which bupropion was significantly more effective than nicotine patch or placebo. All of the commercially available forms of NRT (nicotine gum, transdermal patch, the nicotine nasal spray, nicotine inhaler and nicotine sublingual tablets) are effective as part of a strategy to promote smoking cessation. They increase quit rates approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. There is promising evidence that bupropion may be more effective than NRT (either alone or in combination). However, its most appropriate place in the therapeutic armamentarium requires further study and consideration.

Background: Pharmacologic therapies have an important role in the success of interventions for smoking cessation. This study aims to determine the efficacy of several pharmacologic treatments in patients who applied to a smoking cessation clinic. Methods: This retrospective study includes 422 patients who presented to our smoking cessation clinic between January 2010 and June 2013, used the pharmacologic treatment as prescribed and completed the one-year follow-up period. All patients were assessed using the Fagerström Test for Nicotine Dependence (FTND) and received both behavioral therapy and pharmacotherapy. Patients’ smoking status at one year was assessed by telephone interview. Results: The patients were 24.3% female (103/422) and 75.7% male (319/422) with a mean age of 38 ± 10 years. Patients were divided into three groups: varenicline (166 patients), bupropion (148 patients) and nicotine replacement therapy (108 patients). The smoking cessation rates of these groups were 32.5%, 23% and 52.8%, respectively, and were statistically significant (p &lt; 0.001). The overall success rate was 35%. Further analysis revealed that pharmacologic therapy (p &lt; 0.001) and gender (p = 0.01) were factors that showed statistically significant effects on smoking cessation rates. Males had higher success rates than females. The overall relapse rate was 21.6% and the bupropion group showed the highest relapse rate among treatment groups. Lack of determination emerged as the most important factor leading to relapse. Conclusion: Nicotine replacement therapy was found to be more effective at promoting abstinence from smoking than other pharmacologic therapies.

Background: Opportunistic prostate-specific antigen (PSA) screening may reduce prostate cancer mortality risk but is associated with false positive results, biopsy complications and overdiagnosis. Although different organisations have emphasised the importance of shared decision making (SDM) to assist men in deciding whether to undergo prostate cancer screening, recent evaluations show that the available decision aids fail to facilitate SDM, mainly because they do not consider the patients’ perspective in their design. We aim to systematically develop and test a patient decision aid to promote SDM in prostate cancer screening, following the Knowledge to Action framework. Methods: (1) Feasibility study: a quantitative survey evaluating the population and clinician (urologists and general practitioners) knowledge of the benefits and risks derived from PSA determination and the awareness of the available recommendations. Focus groups to explore the challenges patients and clinicians face when discussing prostate cancer screening, the relevance of a decision aid and how best to integrate it into practice. (2) Patient decision aid development: Based on this data, an evidence-based multicomponent SDM patient decision aid will be developed. (3) User-testing: an assessment of the prototype of the initial patient decision aid through a user-testing design based on mix-methods (questionnaire and semi-structured review). The decision aid will be refined through several iterative cycles of feedback and redesign. (4) Validation: an evaluation of the patient decision aid through a cluster-randomised controlled trial. Discussion: The designed patient decision aid will provide balanced information on screening benefits and risks and should help patients to consider their personal preferences and to take a more active role in decision making. Conclusions: The well-designed patient decision aid (PDA) will provide balanced information on screening benefits and risks and help patients consider their personal preferences.

A prospective cohort study of shared decision making in lung cancer diagnostics: Impact of using a patient decision aid

Shared decision-making in Canada: update, challenges and where next!

Evaluation of Implementation Outcomes After Initiation of a Shared Decision-making Program for Men With Prostate Cancer