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What moves the rheumatologist? Unravelling decision making in the referral of systemic sclerosis patients to health professionals: a qualitative study.

ABSTRACT: Objectives:Well-coordinated multidisciplinary non-pharmacological care is considered to be a cornerstone in the management of patients with systemic sclerosis. However, it has been discovered that unmet information and health care needs are common in patients with SSc. In addition, referrals by rheumatologists do not always correspond with potential treatment goals as identified by health professionals. The aim of this study was to gain insight into the current referral routine of rheumatologists in SSc patients and to identify and explore factors influencing rheumatologists' decisions about referral of SSc patients to health professionals. Methods:Qualitative semi-structured interviews were held with 13 rheumatologists specializing in SSc management from different hospitals in The Netherlands. Results:Our study identified rheumatologists' beliefs and local policy as influencing factors for referral to health professionals and a clear need for a better referral policy. Furthermore, a lack of knowledge about and low confidence in the competence of other disciplines were identified as barriers for referral to health professionals, which may possibly lead to undertreatment. Conclusion:In the opinion of the majority of rheumatologists, adequate referral to health professionals requires an active role for the patient and increased visibility from health professionals.

SUBMITTER: Stocker JK

PROVIDER: S-EPMC6649894 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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What moves the rheumatologist? Unravelling decision making in the referral of systemic sclerosis patients to health professionals: a qualitative study.

Stöcker Juliane K JK Cup Edith H C EHC Vonk Madelon C MC van den Hoogen Frank H J FHJ Nijhuis-van der Sanden Maria W G MWG Staal J Bart JB van den Ende Cornelia H M CHM

Rheumatology advances in practice 20180822 2

<h4>Objectives</h4>Well-coordinated multidisciplinary non-pharmacological care is considered to be a cornerstone in the management of patients with systemic sclerosis. However, it has been discovered that unmet information and health care needs are common in patients with SSc. In addition, referrals by rheumatologists do not always correspond with potential treatment goals as identified by health professionals. The aim of this study was to gain insight into the current referral routine of rheuma ...[more]

PMID: 31431973

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Project description:ObjectivesThis study uses the diffusion of innovations (DOI) theory to comprehensively understand the adoption of shared decision-making (SDM) in clinical practice, specifically focusing on the 'knowledge' and 'persuasion' stages within DOI. We aim to understand the challenges and dynamics associated with SDM adoption, offering insights for more patient-centred decision-making in healthcare.DesignThis qualitative study employs a modified framework analysis approach, integrating ethnographic and interview data from prior research, along with additional interviews. The framework used is based on the DOI theory.Study setting and participantsThis study was conducted in the obstetrics and gynaecology department of a tertiary teaching hospital in the Eastern region of the Netherlands. It included interviews with 20 participants, including gynaecologists, obstetrics registrars and junior doctors currently practising in the department. Additionally, data from prior research conducted within the same department were incorporated, ensuring the maintenance of contextual consistency.ResultsFindings reveal a complex interplay between SDM's benefits and challenges. Clinicians value SDM for upholding patient autonomy and enhancing medical practice, viewing it as valuable for medical decision-making. Decision aids are seen as advantageous in supporting treatment decisions. Challenges include compatibility issues between patient and clinician preferences, perceptions of SDM as time-consuming and difficult and limitations imposed by the rapid pace of healthcare and its swift decisions. Additionally, perceived complexity varies by situation, influenced by colleagues' attitudes, with limited trialability and sparsely observed instances of SDM.ConclusionsClinicians' decision to adopt or reject SDM is multifaceted, shaped by beliefs, cognitive processes and contextual challenges. Cognitive dissonance is critical as clinicians reconcile their existing practices with the adoption of SDM. Practical strategies such as practice assessments, open discussions about SDM's utility and reflective practice through professional development initiatives empower clinicians to make the best informed decision to adopt or reject SDM.

Project description:BackgroundWork participation is an important determinant of public health; being unemployed leads to a decrease in an individual's health. In the Netherlands, people with a work disability can apply for disability benefits, in which people also receive support to return to work (RTW). A method, currently used in the medical sector, that can include both the perspective of the reintegration professional and of the individual in the process of RTW, is shared decision making (SDM). In this article we explore to what extent reintegration professionals currently use SDM, and to what extent they prefer to use SDM in their ideal interaction with clients.MethodsWe performed semi-structured interviews with fourteen reintegration professionals from four different municipalities. The transcripts were coded according to content analysis, applying open and axial coding.ResultsReintegration professionals emphasised the importance of having a good relationship with clients, of building trust and collaborating as a team. They did not inform their clients that they could be part of the decision-making process, or discussed a shared goal. Although professionals did emphasise the importance of aligning their approach with the preferences of the client and though they tried to offer some choice options, they did not mention available options, discussed the pros and cons of these options or evaluated decisions with their clients. Furthermore, they did not mention any of these aspects in their ideal interaction with clients.ConclusionsSDM has a potential value, because all professionals underline the importance of having an alliance with clients, collaborating as a team, and striving to align their approach with the preferences of the client. However, professionals currently perform a limited set of SDM steps. Additional knowledge and skills are needed for both reintegration professionals and municipalities so that professionals can consider and reflect on the value of using SDM, or SDM steps, in supporting RTW. Providing clients with knowledge and skills seems necessary to facilitate both self-management and SDM.

Project description:BackgroundGastrostomy is recommended in amyotrophic lateral sclerosis for long-term nutritional support, however, people with amyotrophic lateral sclerosis and healthcare professionals perceive decision-making as complex.MethodTo explore their perspectives on decision-making regarding gastrostomy, we used semi-structured interviews with people with amyotrophic lateral sclerosis, who had made a decision, and their caregivers; healthcare professionals were interviewed separately. Interviews were transcribed and analyzed thematically.ResultsIn 14 cases, 13 people with amyotrophic lateral sclerosis and 12 caregivers were interviewed; and in 10 of these cases, 5 healthcare professionals. Participants described decision-making on gastrostomy as a continuous process of weighing (future) clinical need against their values and beliefs in coming to a decision to accept or reject gastrostomy, or to postpone decision-making, while being supported by loved ones and healthcare professionals. Participants described gastrostomy as inevitable, but retained agency through control over the timing of decision-making. They said physical necessity, experiences of loss and identity, and expectations about gastrostomy placement were important factors in decision-making. Decision-making was described as a family affair, with caregivers supporting patient choice. healthcare professionals supported people with amyotrophic lateral sclerosis during the decision-making process and respected their autonomy and values. People with amyotrophic lateral sclerosis stressed the importance of adequate information on the procedure and the benefits.ConclusionPeople with amyotrophic lateral sclerosis feel in control of decision-making on gastrostomy if they are able to make their own choice at their own pace, supported by loved ones and healthcare professionals. Person-centered decision-making on gastrostomy requires early information exchange and repeated discussions with people with amyotrophic lateral sclerosis and their caregivers, incorporating their values and respecting patient choice.

Project description:BackgroundShared decision-making (SDM) is a process whereby clinicians and patients work together to select treatments based on both the patient's preferences and clinical evidence. Although patients with psychotic disorders want to participate more in decisions regarding their care, they have limited opportunities to do so because of various barriers. Knowing about health professionals' experiences with SDM is important toward achieving successful implementation. The study aim was to describe and explore health professionals' SDM experiences with patients with psychotic disorders.MethodsThree focus group interviews were conducted, with a total of 18 health professionals who work at one of three Norwegian community mental health centres where patients with psychotic disorders are treated. We applied a descriptive and exploratory approach using qualitative content analysis.ResultsHealth professionals primarily understand the SDM concept to mean giving patients information and presenting them with a choice between different antipsychotic medications. Among the barriers to SDM, they emphasized that patients with psychosis have a limited understanding of their health situation and that time is needed to build trust and alliances. Health professionals mainly understand patients with psychotic disorders as a group with limited abilities to make their own decisions. They also described the concept of SDM with little consideration of presenting different treatment options. Psychological or social interventions were often presented as complementary to antipsychotic medications, rather than as an alternative to them.ConclusionHealth professionals' understanding of SDM is inconsistent with the definition commonly used in the literature. They consider patients with psychotic disorders to have limited abilities to participate in decisions regarding their own treatment. These findings suggest that health professionals need more theoretical and practical training in SDM.

Project description:BackgroundBreastfeeding is recognized as the gold standard of infant feeding and nutrition. The World Health Organization recommends exclusive breastfeeding (EBF) of infants for the first 6 months of life. A variety of factors may impact breastfeeding practices in-hospital which may continue after hospital discharge, such as the use of breastmilk substitutes (BMS). The Baby-Friendly Initiative (BFI), which aims to promote and support breastfeeding practices, established a target rate of 75% for EBF from birth to hospital discharge. Currently, this target is not being met at The Ottawa Hospital (TOH), indicating there is room for improvement in EBF rates. The purpose of this study is to explore health care professionals (HCP) decision-making around use of BMS and identify factors that drive the use of BMS with and without medical indications.MethodsIn this qualitative study, semi-structured interviews were conducted with HCPs within TOH from January to June 2022. All participants had experience in maternity or postpartum care and were probed on factors influencing use of BMS at this institution. Interview transcripts were coded using an inductive approach.ResultsA total of 18 HCPs were interviewed including physicians, midwives, lactation consultants, and registered nurses. Multilevel barriers influencing the use of BMS were categorized into patient, HCP, and institution-level factors. Subthemes that emerged ranged from parental preferences, training differences amongst HCPs, to budget and staffing issues. Over half of HCPs were prepared to answer questions on EBF and were familiar with the BFI. Although most were supportive of this institution receiving BFI designation, a few providers raised concerns of its impact on parents who would like to supplement.ConclusionsSeveral modifiable factors influencing decision-making for use of BMS were identified. These findings will be used to inform unit leads, help identify effective strategies to address modifiable barriers, and develop tailored breastfeeding supports to improve EBF rates.

Project description:BackgroundThe general paediatricians and primary care physicians sometimes face immense difficulty in referral judgements regarding which infantile hemangiomas (IHs) require referrals and when is the appropriate time to refer IHs for treatment. This resulted in the treatment being delayed beyond IHs' critical timeframe. The Infantile Hemangioma Referral Score (IHReS) has been recently developed, with the aim to solve this problem.ObjectivesThe objective of the present study is to evaluate the reliability of IHReS and to assess the possibility of using this instrument in our country where a similar problem of delaying treatment of IHs is currently existing.MethodsThe present study was a prospective, cross-sectional study. Thirteen selected clinical cases were used to assess the reliability of IHReS among physicians who may have had the chance to deal with patients with IHs. The target physicians across the country were asked to participate in the study via an online platform (Google Forms) to decide whether to refer patients with IHs for treatment or observe. There were 3 steps of assessment: step 1, usual practice evaluation; step 2, using IHReS; step 3, retesting by using IHReS.ResultsSubstantial agreement was observed after using IHReS (step 2) for interrater reliability, with Fleiss' Kappa values of 0.80 and 0.78 among IH experts and non-expert physicians, respectively. Regarding repeatability, in the test-retest assessments, Cohen's Kappa coefficient values revealed almost perfect agreement in intrarater repeatability for both experts and non-expert physicians (1.00).ConclusionIHReS is a simple, easy-to-assess tool for non-expert physicians. The benefit in the increase of interrater agreement was found in both IH experts and non-expert physicians. It has had the reliability to be used in making referral decisions regarding patients with IH for treatment among Thai physicians. Using IHReS can improve clinical outcomes by identifying which patient needs early intervention to minimise the possible complications.

Dataset Information

What moves the rheumatologist? Unravelling decision making in the referral of systemic sclerosis patients to health professionals: a qualitative study.

Publications

What moves the rheumatologist? Unravelling decision making in the referral of systemic sclerosis patients to health professionals: a qualitative study.

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