Representation of Racial and Ethnic Minorities and Their Preferences for Mood Stabilizing Treatment Selection for Bipolar Disorder: A Systematic Review

Background: The use of second-generation antipsychotics for bipolar disorder (BD) has increased in the past years1Concerns on potential serious medical side effects and need for blood level monitoring of some traditional mood stabilizers along with other factors have influenced this change. Shared decision-making (SDM) strategies have been implemented in clinical settings due to their ability to engage patients in the process of treatment selection.2 Within minority groups with mental illnesses, socioeconomic factors, individual concerns, and cultural variations in clinical presentations, are often overlooked or misrepresented when assessing the patient’s treatment preferences. Although several studies evaluating the effectiveness of SDM interventions in BD, the representation of patients that belong to minority groups and how their preferences and outcomes differ from those belonging to non-minority groups is unknown. The primary aim of this is to assess the inclusion of minority patients in studies assessing SDM strategies in patients with BD. Methods: After the systematic search, screening and data extraction will be conducted in a duplicate and independent manner. We will include interventional studies implementing strategies for SDM in patients diagnosed with bipolar disorder. Data on the proportion of minorities included in the studies, as well as on quality indicators for the clinical encounter regarding SDM, treatment adherence, and clinical outcomes will be extracted. Results and Conclusion: We have no results yet, but the relevance of the expected results is discussed. Compared to non-Hispanic white patients, patients from minority racial/ethnic groups have lower odds of receiving classic mood stabilizers and higher rates of antipsychotic prescription.3 Patients that belong to minority groups are also at higher risk of misdiagnosis -with subsequent delay in the diagnosis-, and of mistreatment.4 These disparities have been associated with potential cognitive biases that lead to symptom misattribution, inadequate treatment regimens and omission of patient’s sociocultural background.5 Patient-centered care could also benefit the assessment of risk factors that are common to specific groups (e.g., metabolic risk in Hispanic patients).6,7 Moreover, SDM can help understand better the values, preferences for treatment choices and help evaluate if patient engagement can be translated into clinical benefits and an improved quality of life

Women's values and preferences on low-molecular-weight heparin and pregnancy : a mixed-methods systematic review

Venous thromboembolism (VTE) in pregnancy is an important cause of maternal morbidity and mortality. Low-molecular-weight heparin (LMWH) is the cornerstone of prophylaxis and treatment of thrombotic events during pregnancy. LMWH has fewer adverse effects than other anticoagulants, does not cross the placenta, and is safe for the fetus. However, the use of LMWH during pregnancy is sensitive to womens' underlying preferences. The objective of this review is to systematically assess women's values and preferences research evidence on this topic. We searched four electronic databases from inception to March 2022, and included studies examining values and preferences of using LMWH among pregnant women at risk of VTE. We followed a convergent integrated mixed-methods design to compare and contrast quantitative outcomes (utility and non-utility measures) and qualitative findings. We assessed the certainty of the values and preferences evidence with the GRADE approach for quantitative findings, and with GRADE-CERqual for qualitative evidence. Results were presented in a conjoint display. We screened 3,393 references and identified seven eligible studies. The mixed methods analysis resulted in four themes. Datasets confirmed each other in that: 1) the majority of women consider that benefits of treatment outweigh the inconveniences of daily injections; and 2) main concerns around medication are safety and injections administration. Quantitative outcomes expanded on the qualitative findings in that: 3) participants who perceived a higher risk of VTE were more willing to take LMWH. Finally, we found a discrepancy between the datasets around: 4) the amount of information preferred to make the decision; however, qualitative data expanded to clarify that women prefer making informed decisions and receive support from their clinician in their decision-making process. We are moderately confident that in the context of pregnancy, using LMWH is preferred by women given its net beneficial balance. Integrating data from different sources of evidence, and representing them in a jointly manner helps to identify patient's values and preferences. Our results may inform clinical practice guidelines and support shared decision-making process in the clinical encounter for the management of VTE in the context of pregnancy. The online version contains supplementary material available at 10.1186/s12884-022-05042-x

Financial Toxicity in the Clinical Encounter: A Paired Survey of Patient and Clinician Perceptions

Objective: To compare the agreement between patient and clinician perceptions of care-related financial issues. Patients and Methods: We surveyed patient-clinician dyads immediately after an outpatient medical encounter between September 2019 and May 2021. They were asked to separately rate (1-10) patient’s level of difficulty in paying medical bills and the importance of discussing cost issues with that patient during clinical encounters. We calculated agreement between patient-clinician ratings using the intraclass correlation coefficient and used random effects regression models to identify patient predictors of paired score differences in difficulty and importance of ratings. Results: 58 pairs of patients (n=58) and clinicians (n=40) completed the survey. Patient-clinician agreement was poor for both measures, but higher for difficulty in paying medical bills (intraclass correlation coefficient=0.375; 95% CI, 0.13-0.57) than for the importance of discussing cost (−0.051; 95% CI, −0.31 to 0.21). Agreement on difficulty in paying medical bills was not lower in encounters with conversations about the cost of care. In adjusted models, poor patient-clinician agreement on difficulty in paying medical bills was associated with lower patient socioeconomic status and education level, whereas poor agreement on patient-perceived importance of discussing cost was significant for patients who were White, married, reported 1 or more long-term conditions, and had higher education and income levels. Conclusion: Even in encounters where cost conversations occurred, there was poor patient-clinician agreement on ratings of the patient’s difficulty in paying medical bills and perceived importance of discussing cost issues. Clinicians need more training and support in detecting the level of financial burden and tailoring cost conversations to the needs of individual patients

Clinical impact of heparin kinetics during catheter ablation of atrial fibrillation: Meta-analysis and meta-regression

Anticoagulation for Ablation of Atrial Fibrillation Introduction Appropriate activated clotting time (ACT) during catheter ablation of atrial fibrillation (CA-AF) is essential to minimize periprocedural complications. Methods and Results An electronic search was performed using major databases. Outcomes were thromboembolic (TE) and bleeding complications according to ACT levels (seconds). Heparin dose (U/kg) and time (minutes) to achieve the target ACT was compared among patients receiving vitamin K antagonist (VKA) versus non-VKA oral anticoagulants (NOAC). Nineteen studies involving 7,150 patients were identified. Patients with ACT > 300 had less TE (OR, 0.51; 95% CI 0.35-0.74) and bleeding (OR, 0.70; 95% CI 0.60-0.83) compared to ACT 300 decreases the risk of TE without increasing the risk of bleeding. Patients receiving VKAs required less heparin and reached the target ACT faster compared to NOACs