Decision making preferences in the medical encounter – a factorial survey design

<p>Abstract</p> <p>Background</p> <p>Up to now it has not been systematically investigated in which kind of clinical situations a consultation style based on shared decision making (SDM) is preferred by patients and physicians. We suggest the factorial survey design to address this problem.</p> <p>This method, which so far has hardly been used in health service research, allows to vary relevant factors describing clinical situations as variables systematically in an experimental random design and to investigate their importance in large samples.</p> <p>Methods/Design</p> <p>To identify situational factors for the survey we first performed a literature search which was followed by a qualitative interview study with patients, physicians and health care experts. As a result, 7 factors (e.g. "Reason for consultation" and "Number of therapeutic options") with 2 to 3 levels (e.g. "One therapeutic option" and "More than one therapeutic option") will be included in the study. For the survey the factor levels will be randomly combined to short stories describing different treatment situations.</p> <p>A randomized sample of all possible short stories will be given to at least 300 subjects (100 GPs, 100 patients and 100 members of self-help groups) who will be asked to rate how the decision should be made. Main outcome measure is the preference for participation in the decision making process in the given clinical situation.</p> <p>Data analysis will estimate the effects of the factors on the rating and also examine differences between groups.</p> <p>Discussion</p> <p>The results will reveal the effects of situational variations on participation preferences. Thus, our findings will contribute to the understanding of normative values in the medical decision making process and will improve future implementation of SDM and decision aids.</p

Intravascular tissue factor initiates coagulation via circulating microvesicles and platelets

Although tissue factor (TF), the principial initiator of physiological coagulation and pathological thrombosis, has recently been proposed to be present in human blood, the functional significance and location of the intravascular TF is unknown. In the plasma portion of blood, we found TF to be mainly associated with circulating microvesicles. By cell sorting with the specific marker CD42b, platelet-derived microvesicles were identified as a major location of the plasma TF. This was confirmed by the presence of full-length TF in microvesicles acutely shedded from the activated platelets. TF was observed to be stored in the α-granules and the open canalicular system of resting platelets and to be exposed on the cell surface after platelet activation. Functional competence of the blood-based TF was enabled when the microvesicles and platelets adhered to neutrophils, as mediated by P-selectin and neutrophil counterreceptor (PSGL-1, CD18 integrins) interactions. Moreover, neutrophil-secreted oxygen radical species supported the intravascular TF activity. The pools of platelet and microvesicle TF contributed additively and to a comparable extent to the overall blood TF activity, indicating a substantial participation of the microvesicle TF. Our results introduce a new concept of TF-mediated coagulation crucially dependent on TF associated with microvesicles and activated platelets, which principally enables the entire coagulation system to proceed on a restricted cell surface

Life within a limited radius: Investigating activity space in women with a history of child abuse using global positioning system tracking

Early experiences of childhood sexual or physical abuse are often associated with functional impairments, reduced well-being and interpersonal problems in adulthood. Prior studies have addressed whether the traumatic experience itself or adult psychopathology is linked to these limitations. To approach this question, individuals with posttraumatic stress disorder (PTSD) and healthy individuals with and without a history of child abuse were investigated. We used global positioning system (GPS) tracking to study temporal and spatial limitations in the participants’ real-life activity space over the course of one week. The sample consisted of 228 female participants: 150 women with PTSD and emotional instability with a history of child abuse, 35 mentally healthy women with a history of child abuse (healthy trauma controls, HTC) and 43 mentally healthy women without any traumatic experiences in their past (healthy controls, HC). Both traumatized groups—i.e. the PTSD and the HTC group—had smaller movement radii than the HC group on the weekends, but neither spent significantly less time away from home than HC. Some differences between PTSD and HC in movement radius seem to be related to correlates of PTSD psychopathology, like depression and physical health. Yet group differences between HTC and HC in movement radius remained even when contextual and individual health variables were included in the model, indicating specific effects of traumatic experiences on activity space. Experiences of child abuse could limit activity space later in life, regardless of whether PTSD develops.Peer Reviewe

A research programme to evaluate DBT-PTSD, a modular treatment approach for Complex PTSD after childhood abuse

Background: Posttraumatic stress disorder (PTSD) after childhood abuse (CA) is often related to severe co-occurring psychopathology, such as symptoms of borderline personality disorder (BPD). The ICD-11 has included Complex PTSD as a new diagnosis, which is defined by PTSD symptoms plus disturbances in emotion regulation, self-concept, and interpersonal relationships. Unfortunately, the empirical database on psychosocial treatments for survivors of CA is quite limited. Furthermore, the few existing studies often have either excluded subjects with self-harm behaviour and suicidal ideation — which is common behaviour in subjects suffering from Complex PTSD. Thus, researchers are still trying to identify efficacious treatment programmes for this group of patients. We have designed DBT-PTSD to meet the specific needs of patients with Complex PTSD. The treatment programme is based on the rules and principles of dialectical behavioural therapy (DBT), and adds interventions derived from cognitive behavioural therapy, acceptance and commitment therapy and compassion-focused therapy. DBT-PTSD can be provided as a comprehensive residential programme or as an outpatient programme. The effects of the residential programme were evaluated in a randomised controlled trial. Data revealed significant reduction of posttraumatic symptoms, with large between-group effect sizes when compared to a treatment-as-usual wait list condition (Cohen’s d = 1.5). The first aim of this project on hand is to evaluate the efficacy of the outpatient DBT-PTSD programme. The second aim is to identify the major therapeutic variables mediating treatment efficacy. The third aim is to study neural mechanisms and treatment sensitivity of two frequent sequelae of PTSD after CA: intrusions and dissociation. Methods: To address these questions, we include female patients who experienced CA and who fulfil DSM-5 criteria for PTSD plus borderline features, including criteria for severe emotion dysregulation. The study is funded by the German Federal Ministry of Education and Research, and started in 2014. Participants are randomised to outpatient psychotherapy with either DBT-PTSD or Cognitive Processing Therapy. Formal power analysis revealed a minimum of 180 patients to be recruited. The primary outcome is the change on the Clinician-Administered PTSD Scale for DSM-5. Discussion: The expected results will be a major step forward in establishing empirically supported psychological treatments for survivors of CA suffering from Complex PTSD. Trial registration: German Clinical Trials Register, registration number DRKS00005578, date of registration 19 December 2013

Die Gestaltung der Arzt-Patienten-Beziehung in Abhängigkeit von der Behandlungssituation

Da die Gestaltung der Arzt-Patienten-Beziehung den Behandlungserfolg wesentlich mit be-stimmt, stellt sich die Frage, wie medizinische Entscheidungen getroffen werden sollten. Im Wesentlichen lassen sich drei Formen der medizinischen Entscheidungsfindung voneinander abgrenzen: die gemeinsame Entscheidungsfindung („shared decision making“ (SDM)), die ärztliche Entscheidung und die informierte Patientenentscheidung. Die gemeinsame Entschei-dungsfindung wird dabei in der Medizinethik häufig als Ideal betrachtet, da sie gewährleistet, dass die Meinung des Patienten ausreichend berücksichtigt wird. Es wurden vielfältige positi-ve Effekte einer gemeinsamen Entscheidungsfindung nachgewiesen, dennoch ist SDM in der medizinischen Alltagsversorgung bisher noch nicht breit implementiert. Fraglich ist, ob SDM überhaupt für alle Behandlungssituationen geeignet ist, oder ob Grenzen einer gemeinsamen Entscheidungsfindung definiert werden sollten, wie dies theoretische Modelle nahe legen. Die vorliegende Dissertation hatte das Ziel, soziale Normen bezüglich der medizinischen Ent-scheidungsfindung in verschiedenen Behandlungssituationen durch die Befragung von Mit-gliedern unterschiedlicher Interessengruppen systematisch zu untersuchen. In einem ersten Schritt wurden dazu qualitative Interviews mit Patienten, Ärzten und Experten des Gesundheitssystems geführt. In diesen Interviews wurden insgesamt 19 Faktoren identifi-ziert, die nach Ansicht von mindestens fünf befragten Personen einen Einfluss auf die Gestal-tung des medizinischen Entscheidungsfindungsprozesses haben sollten. Basierend auf den identifizierten Faktoren wurde im nächsten Schritt ein faktorieller Survey entwickelt. Dieser besteht aus den Beschreibungen verschiedener Behandlungssituationen, für die sieben rele-vante situative Merkmalen miteinander kombiniert wurden (der Anlass des Arztbesuchs, der Zeitpunkt negativer Konsequenzen, die verbleibende Zeit bis zum erforderlichen Behand-lungsbeginn, die Anzahl der Therapiemöglichkeiten, die Existenz von Nebenwirkungen, das Vorliegen wissenschaftlicher Belege für die Wirksamkeit der Behandlung sowie der Beteili-gungswunsch des Patienten). Mit dem faktoriellen Survey wurden im Rahmen einer größeren quantitativen Studie Allgemeinmediziner, Patienten und Mitglieder von Selbsthilfegruppen befragt. Diese wurden gebeten die ihnen vorgelegten Situationsbeschreibungen bezüglich der Frage, in welcher Form jeweils über die Behandlung entschieden werden sollte, einzuschät-zen. Die statistische Auswertung ergab, dass in den meisten Situationen eine gemeinsame Entscheidungsfindung als angemessen betrachtet wurde. Darüber hinaus zeigte sich, dass alle sieben untersuchten situativen Faktoren einen signifikanten Einfluss darauf haben, wie medi-zinische Entscheidungen getroffen werden sollten. Als besonders wichtig wurde hierbei be-wertet, den Beteiligungswunsch des jeweiligen Patienten zu berücksichtigen. Die stärkste Auswirkung auf die Beurteilung der Fallgeschichten hatte jedoch der persönliche Beteili-gungswunsch der Befragten im Falle einer eigenen Erkrankung. Basierend auf den durchgeführten Studien wurden Situationen beschrieben, in denen SDM als besonders wichtig angesehen wurde, und solche, in denen die Entscheidung nach Ansicht der Befragten am ehesten dem Arzt oder am ehesten dem Patienten überlassen werden könnte. Die Ergebnisse der vorliegenden Studien sollen Ärzten ermöglichen, die Gestaltung der Arzt-Patienten-Beziehung den situativen Erfordernissen anzupassen. Darüber hinaus zeigen sie, wann eine patientenorientierte medizinische Versorgung als besonders wichtig zu betrachten ist, was vor allem vor dem Hintergrund vielfältiger Barrieren, die einer breiten Umsetzung einer gemeinsamen Entscheidungsfindung bisher im Weg stehen, relevant ist

Die Gestaltung der Arzt-Patienten-Beziehung in Abhängigkeit von der Behandlungssituation

Da die Gestaltung der Arzt-Patienten-Beziehung den Behandlungserfolg wesentlich mit be-stimmt, stellt sich die Frage, wie medizinische Entscheidungen getroffen werden sollten. Im Wesentlichen lassen sich drei Formen der medizinischen Entscheidungsfindung voneinander abgrenzen: die gemeinsame Entscheidungsfindung („shared decision making“ (SDM)), die ärztliche Entscheidung und die informierte Patientenentscheidung. Die gemeinsame Entschei-dungsfindung wird dabei in der Medizinethik häufig als Ideal betrachtet, da sie gewährleistet, dass die Meinung des Patienten ausreichend berücksichtigt wird. Es wurden vielfältige positi-ve Effekte einer gemeinsamen Entscheidungsfindung nachgewiesen, dennoch ist SDM in der medizinischen Alltagsversorgung bisher noch nicht breit implementiert. Fraglich ist, ob SDM überhaupt für alle Behandlungssituationen geeignet ist, oder ob Grenzen einer gemeinsamen Entscheidungsfindung definiert werden sollten, wie dies theoretische Modelle nahe legen. Die vorliegende Dissertation hatte das Ziel, soziale Normen bezüglich der medizinischen Ent-scheidungsfindung in verschiedenen Behandlungssituationen durch die Befragung von Mit-gliedern unterschiedlicher Interessengruppen systematisch zu untersuchen. In einem ersten Schritt wurden dazu qualitative Interviews mit Patienten, Ärzten und Experten des Gesundheitssystems geführt. In diesen Interviews wurden insgesamt 19 Faktoren identifi-ziert, die nach Ansicht von mindestens fünf befragten Personen einen Einfluss auf die Gestal-tung des medizinischen Entscheidungsfindungsprozesses haben sollten. Basierend auf den identifizierten Faktoren wurde im nächsten Schritt ein faktorieller Survey entwickelt. Dieser besteht aus den Beschreibungen verschiedener Behandlungssituationen, für die sieben rele-vante situative Merkmalen miteinander kombiniert wurden (der Anlass des Arztbesuchs, der Zeitpunkt negativer Konsequenzen, die verbleibende Zeit bis zum erforderlichen Behand-lungsbeginn, die Anzahl der Therapiemöglichkeiten, die Existenz von Nebenwirkungen, das Vorliegen wissenschaftlicher Belege für die Wirksamkeit der Behandlung sowie der Beteili-gungswunsch des Patienten). Mit dem faktoriellen Survey wurden im Rahmen einer größeren quantitativen Studie Allgemeinmediziner, Patienten und Mitglieder von Selbsthilfegruppen befragt. Diese wurden gebeten die ihnen vorgelegten Situationsbeschreibungen bezüglich der Frage, in welcher Form jeweils über die Behandlung entschieden werden sollte, einzuschät-zen. Die statistische Auswertung ergab, dass in den meisten Situationen eine gemeinsame Entscheidungsfindung als angemessen betrachtet wurde. Darüber hinaus zeigte sich, dass alle sieben untersuchten situativen Faktoren einen signifikanten Einfluss darauf haben, wie medi-zinische Entscheidungen getroffen werden sollten. Als besonders wichtig wurde hierbei be-wertet, den Beteiligungswunsch des jeweiligen Patienten zu berücksichtigen. Die stärkste Auswirkung auf die Beurteilung der Fallgeschichten hatte jedoch der persönliche Beteili-gungswunsch der Befragten im Falle einer eigenen Erkrankung. Basierend auf den durchgeführten Studien wurden Situationen beschrieben, in denen SDM als besonders wichtig angesehen wurde, und solche, in denen die Entscheidung nach Ansicht der Befragten am ehesten dem Arzt oder am ehesten dem Patienten überlassen werden könnte. Die Ergebnisse der vorliegenden Studien sollen Ärzten ermöglichen, die Gestaltung der Arzt-Patienten-Beziehung den situativen Erfordernissen anzupassen. Darüber hinaus zeigen sie, wann eine patientenorientierte medizinische Versorgung als besonders wichtig zu betrachten ist, was vor allem vor dem Hintergrund vielfältiger Barrieren, die einer breiten Umsetzung einer gemeinsamen Entscheidungsfindung bisher im Weg stehen, relevant ist

Mindfulness-Based Stress Reduction (MBSR) as a Standalone Intervention for Posttraumatic Stress Disorder after Mixed Traumatic Events: A Mixed-Methods Feasibility Study

Objectives: There is promising evidence that mindfulness-based interventions are effective in reducing the symptoms of posttraumatic stress disorder (PTSD). However, until now, studies have often lacked a full clinical PTSD assessment, and interventions are often administered in addition to other interventions. This study examined the feasibility of mindfulness-based stress reduction (MBSR) as a standalone intervention in patients with PTSD who have experienced mixed traumatic events.Method: Fourteen patients participated in 8 weeks of MBSR. The patients were assessed prior to treatment, post-treatment and at a 1-month follow-up through self-ratings (e.g., the Davidson Trauma Scale) and the Clinician-Administered PTSD Scale to determine the effects of the intervention. Furthermore, after the intervention, the patients participated in qualitative interviews regarding their experiences with MBSR and their ideas for future improvements.Results: Nine patients finished the program, and these patients considered the exercises to be applicable and helpful. In the Clinician-Administered PTSD Scale, we found large effects regarding the reduction of PTSD symptoms among completers (Cohen's d = 1.2). In the Davidson Trauma Scale, the effect sizes were somewhat lower (Cohen's d = 0.6) but nevertheless confirmed the efficacy of MBSR in reducing PTSD symptoms. In the qualitative interviews, the patients reported an augmentation of wellbeing and improvement regarding the handling of difficult situations and more distance from the traumatic event.Conclusion: Despite the large effects, the high dropout rates and the results of the post-treatment interviews suggest that the intervention should be better adapted to the needs of PTSD patients, e.g., by giving more information regarding the exercises and by including shorter exercises to manage acute distress

Which trauma treatment suits me? Identification of patients' treatment preferences for posttraumatic stress disorder (PTSD)

Several psychotherapy treatments exist for posttraumatic stress disorder. This study examines the treatment preferences of treatment-seeking traumatized adults in Germany and investigates the reasons for their treatment choices. Preferences for prolonged exposure, cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), psychodynamic psychotherapy and stabilization were assessed via an online survey. Reasons for preferences were analyzed by means of thematic coding by two independent rates. 104 traumatized adults completed the survey. Prolonged exposure and CBT were each preferred by nearly 30%, and EMDR and psychodynamic psychotherapy were preferred by nearly 20%. Stabilization was significantly less preferred than all other options, by only 4%. Significantly higher proportions of patients were disinclined to choose EMDR and stabilization. Patients who preferred psychodynamic psychotherapy were significantly older than those who preferred CBT. Reasons underlying preferences included the perceived treatment mechanisms and treatment efficacy. Traumatized patients vary in their treatment preferences. Preference assessments may help clinicians comprehensively address patients' individual needs and thus improve therapy outcomes

Mindfulness-based stress reduction (MBSR) as a standalone intervention for posttraumatic stress disorder after mixed traumatic events: A mixed-methods feasibility study

Objectives: There is promising evidence that mindfulness-based interventions are effective in reducing the symptoms of posttraumatic stress disorder (PTSD). However, until now, studies have often lacked a full clinical PTSD assessment, and interventions are often administered in addition to other interventions. This study examined the feasibility of mindfulness-based stress reduction (MBSR) as a standalone intervention in patients with PTSD who have experienced mixed traumatic events. Method: Fourteen patients participated in 8 weeks of MBSR. The patients were assessed prior to treatment, post-treatment and at a 1-month follow-up through self-ratings (e.g., the Davidson Trauma Scale) and the Clinician-Administered PTSD Scale to determine the effects of the intervention. Furthermore, after the intervention, the patients participated in qualitative interviews regarding their experiences with MBSR and their ideas for future improvements. Results: Nine patients finished the program, and these patients considered the exercises to be applicable and helpful. In the Clinician-Administered PTSD Scale, we found large effects regarding the reduction of PTSD symptoms among completers (Cohen's d = 1.2). In the Davidson Trauma Scale, the effect sizes were somewhat lower (Cohen's d = 0.6) but nevertheless confirmed the efficacy of MBSR in reducing PTSD symptoms. In the qualitative interviews, the patients reported an augmentation of wellbeing and improvement regarding the handling of difficult situations and more distance from the traumatic event. Conclusion: Despite the large effects, the high dropout rates and the results of the post-treatment interviews suggest that the intervention should be better adapted to the needs of PTSD patients, e.g., by giving more information regarding the exercises and by including shorter exercises to manage acute distress

The effects of a combination of cognitive interventions and loving-kindness meditations (C-METTA) on guilt, shame and PTSD symptoms: results from a pilot randomized controlled trial

Background: Trauma-related guilt and shame are crucial for the development and maintenance of PTSD (posttraumatic stress disorder). We developed an intervention combining cognitive techniques with loving-kindness meditations (C-METTA) that specifically target these emotions. C-METTA is an intervention of six weekly individual treatment sessions followed by a four-week practice phase. Objective: This study examined C-METTA in a proof-of-concept study within a randomized wait-list controlled trial. Method: We randomly assigned 32 trauma-exposed patients with a DSM-5 diagnosis to C-METTA or a wait-list condition (WL). Primary outcomes were clinician-rated PTSD symptoms (CAPS-5) and trauma-related guilt and shame. Secondary outcomes included psychopathology, self-criticism, well-being, and self-compassion. Outcomes were assessed before the intervention phase and after the practice phase. Results: Mixed-design analyses showed greater reductions in C-METTA versus WL in clinician-rated PTSD symptoms (d = −1.09), guilt (d = −2.85), shame (d = −2.14), psychopathology and self-criticism. Conclusion: Our findings support positive outcomes of C-METTA and might contribute to improved care for patients with stress-related disorders. The study was registered in the German Clinical Trials Register (DRKS00023470). C-METTA is an intervention that addresses trauma-related guilt and shame and combines cognitive interventions with loving-kindness meditations.A proof-of-concept study was conducted examining C-METTA in a wait-list randomized controlled trialC-METTA led to reductions in trauma-related guilt and shame and PTSD symptoms. C-METTA is an intervention that addresses trauma-related guilt and shame and combines cognitive interventions with loving-kindness meditations. A proof-of-concept study was conducted examining C-METTA in a wait-list randomized controlled trial C-METTA led to reductions in trauma-related guilt and shame and PTSD symptoms.</p