The Use of a Decision Board to Elicit Brazilian Patients' and Physicians' Preferences for Treatment: the Case of Lupus Nephritis

Objectives: To find preferences for treatment expressed by lupus patients and physicians (who were asked to assume they have lupus) and to explore if certain variables explain these preferences. Methods: One hundred seventy-two patients and 202 physicians were interviewed using a lupus nephritis decision board that describes the treatment options and their potential benefits and risks. Clinical and sociodemographic variables were collected. Participants were asked to indicate their preferred treatment and provide justification for their choice. Descriptive statistics, t tests, and Pearson's chi-square tests were used to determine the significance of differences in the decisions made by the two groups. A logistic regression model determined which factors contributed to treatment decisions. Results: the average age of study participants was 34 +/- 8 years for patients and 31 +/- 7 years for physicians. Sixty-eight percent of patients and 96% of physicians (P < 0.001) selected the oral option. Patients and physicians justified their choice of treatment using different arguments (P < 0.001 in each case). Logistic regression showed that risk potential (P < 0.001) and a history of joint involvement (P = 0.011) were the arguments used most often to explain a patient's decision and the risk of side effects was most relevant among physicians (P < 0.001). Conclusions: Using a decision board, patients and physicians were found to have different preferences for treatment when faced with the same treatment options. Further, the variables that influence their preferences are different.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Univ Fed Sao Carlos, Dept Med, BR-13565905 Sao Carlos, SP, BrazilMcMaster Univ, Hamilton, ON, CanadaUniversidade Federal de São Paulo, São Paulo, BrazilUniversidade Federal de São Paulo, São Paulo, BrazilWeb of Scienc

Development and Testing of a Decision Board to Help Clinicians Present Treatment Options to Lupus Nephritis Patients in Brazil

Objective. Decision boards (DBs) help clinicians present options and include patients in the decision-making process. Our objective was to describe the steps to develop a DB to support shared decision making and assess reliability and construct validity.Methods. Systemic lupus erythematosus (SLE) scenarios were designed with the support of experts for disease severity, potential side effects, and outcomes. the DB comprised clinical information, 2 different treatment options (oral and intravenous), a description of the potential to control SLE within 5 years, and a list of potential side effects. Patients selected what they thought would be the 3 worst side effects and were informed of the probability that these would occur. We presented the DB to 172 patients who were asked to select and justify 1 treatment option. Reliability was assessed by kappa statistics. Construct validity was tested by an a priori hypothesis, analyzing the correlation between treatment decision and side effects selected, self-assessment score, educational level, and clinical aspects.Results. Patients favored oral medication, and side effects most often listed were iatrogenic cancer (44.2%), hair loss (21.6%), and severe infection (19.1%). justifications were risk (48.9%), practicality (36.6%), effectiveness (12.2%), and risk-benefit tradeoff (2.3%). Reliability was similar to that found in the test phase (kappa = 0.689, P < 0.001). Validity was tested by prediction of treatment decision based on the undesirable side effects selected (P = 0.047). DB content was clear and easy for all patients to understand (P = 0.05). Immunosuppressive drugs influenced patient decisions (P = 0.006).Conclusion. DB is a reliable and valid instrument to assess SLE patient preference.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Universidade Federal de São Paulo, São Paulo, BrazilMcMaster Univ, Hamilton, ON, CanadaUniversidade Federal de São Paulo, São Paulo, BrazilWeb of Scienc

Chemotherapy Waste Reduction Through Shelf-Life Extension

ABSTRACTMinimization of total drug expenditures within the health care system, without affecting patient outcome has become a rational goal in today's economic, environment. The objective of this study was to observe the effect of extending the shelf-life for three chemotherapy medications, [doxorubicin, epirubicin and mitoxantrone] on wastage of these medications. Prior to and following the introduction of new, longer, shelf-lives for these three medications, prospective, non-randomized, unblinded four-month chemotherapy wastage audits for all chemotherapy medications were completed at 18 institutional sites within Ontario (six Ontario Cancer Treatment and Research Foundation clinics, ten Ontario hospitals and two preparation sites in a large cancer treatment centre).Data were provided by 18 sites in 1989 but from only 12 sites in 1990. Ten of the 12 sites extended their shelf-lives for each of doxorubicin, epirubicin and mitoxantrone, and on average, waste at these sites was reduced to less than 1% of the 1989 total for epirubicin, less than 15% for doxorubicin and 35% for mitoxantrone. Many sites eliminated waste entirely for these drugs. For sites which did not extend their shelf-lives, the waste remained unchanged.We conclude that appropriate extension of the shelf-life for chemotherapy medications can reduce waste, and is a relatively simple method of reducing expenditures without affecting health outcomes or adding additional complications to IV chemotherapy.RÉSUMÉFace à la situation économique que nous connaissons aujourd'hui, réduire les dépenses totales de médicaments au minimum sans pour autant nuire aux patients est devenu un objectif rationnel pour le système des soins de santé. L'étude avait pour but d'examiner l'effet d'une prolongation de la date de péremption de trois médicaments utilisés en chimiothérapie (doxorubicine, épirubicine et mitoxantrone) sur le gaspillage. On a vérifié la quantité de trois médicaments gaspillée grâce à une étude prospective de quatre mois, non randomisée et sans inconnue sur les produits en question, dans 18 établissements de l'Ontario, avant et après l'introduction de nouvelles dates de péremption plus longues (six cliniques de l'Ontario Cancer Treatment and Research Foundation, dix hôpitaux et deux services de préparation d'un grand centre de traitement du cancer).Les dix-huit établissements ont fourni des données en 1989, mais seulement 12 l'ont fait en 1990. Dix des 12 établissements avaient prolongé la date de péremption pour la doxorubicine, l'épirubicine et la mitoxantrone et, en moyenne, avaient réduit le gaspillage à moins de 1 p. 100 du volume enregistré en 1989 pour l'épirubicine, à moins de 15 p. 100 pour la doxorubicine et à 35 p. 100 pour le mitoxantrone. À de nombreux endroits, on a totalement mis fin au gaspillage. Là où on n'a pas prolongé la date de péremption, le gaspillage demeurait le même. On en conclut que prolonger de la façon appropriée la date de péremption des médicaments utilisés en chimiothérapie peut réduire le gaspillage. Cette méthode relativement simple permet de diminuer les dépenses sans compromettre l'issue du traitement ni compliquer la chimiothérapie par perfusion

Outcomes at 3 Months After Planned Cesarean vs Planned Vaginal Delivery for Breech Presentation at Term

Caroline Crowther is listed as a member of the Term Breech Trial 3-Month Follow-up Collaborative Group in the article.Mary E. Hannah; Walter J. Hannah; Ellen D. Hodnett; Beverley Chalmers; Rose Kung; Andrew Willan; Kofi Amankwah; Mary Cheng; Michael Helewa; Sheila Hewson; Saroj Saigal; Hilary Whyte; Amiram Gafni; for the Term Breech Trial 3-Month Follow-up Collaborative Grou