What Does This Mean Review of Hhs Decision (Diwc)
Otolaryngol Head Cervix Surg. Author manuscript; available in PMC 2017 Mar ane.
Published in terminal edited course equally:
PMCID: PMC4857133
NIHMSID: NIHMS782367
Shared controlling and choice for elective surgical intendance: A systematic review
Emily F. Dominate
1Department of Otolaryngology–Caput and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Doc
Nishchay Mehta
2evidENT, Ear Institute, University College London
Neeraja Nagarajan
threeSection of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
Anne Links
1Section of Otolaryngology–Caput and Neck Surgery, Johns Hopkins Academy School of Medicine, Baltimore, MD
James R. Benke
1Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Academy Schoolhouse of Medicine, Baltimore, MD
Zackary Berger
4Division of General Internal Medicine, Johns Hopkins Schoolhouse of Medicine, Baltimore, MD, Department of Health, Behavior, and Guild, Johns Hopkins University School of Public Wellness, Baltimore, MD, Johns Hopkins Berman Institute of Bioethics, Baltimore, Dr.
Ali Espinel
vSection of Otolaryngology, Children'southward National Health System, Washington, DC
Jeremy Meier
vDepartment of Otolaryngology, Children'due south National Health Arrangement, Washington, DC
Ellen A. Lipstein
sixDivision of Otolaryngology-Head and Neck Surgery, Academy of Utah School of Medicine, Table salt Lake City, UT
Abstract
Objective
Shared Controlling (SDM), an integrative patient-provider communication procedure emphasizing word of scientific evidence and patient/family unit values, may better quality care delivery, promote evidence-based practice, and reduce overuse of surgical intendance. Fiddling is known nevertheless regarding SDM in constituent surgical exercise. The purpose of this systematic review is to synthesize findings of studies evaluating employ and outcomes of SDM in elective surgery.
Data Sources
Pubmed, CochraneCENTRAL, EMBASE, CINAHL, and SCOPUS electronic databases
Review Methods
We searched for English language-linguistic communication studies (1/1/1990 to eight/9/2015) evaluating utilize of SDM in constituent surgical care. Identified studies were independently screened by two reviewers in stages of championship/abstract and full-text review. Nosotros abstracted information related to population, written report pattern, clinical dilemma, use of SDM, outcomes, treatment choice, and bias.
Results
Of 10,929 identified manufactures, 24 met inclusion criteria. The most common area studied was spine (7/24) followed by joint (five/24) and gynecological surgery (four/24). Twenty studies used decision aids/back up tools, including modalities that were multimedia/video (13/xx), written (3/20), or personal coaching (iv/20). Outcome of SDM on preference for surgery were mixed across studies, showing a decrease in surgery (9/24), no difference (8/24), or increase (1/24). SDM tended to improve decision quality (iii/3) as well as cognition/training (4/6), while decreasing decision conflict (4/6).
Conclusion
SDM reduces determination conflict and improves decision quality for patients making choices nigh constituent surgery. While net findings prove that SDM may influence patients to choose surgery less often, the impact of SDM on surgical utilization cannot be clearly ascertained.
Keywords: Shared Decision-making, preference-sensitive surgery, overuse, Informed Decision-Making, Constituent Surgery, Determination Aid, Conclusion Support Tool, Elective Surgery, Systematic Review, appropriate utilise
INTRODUCTION
Shared decision-making is a collaborative process in which patients and providers work together to find a mutually agreed upon treatment plan.1 SDM may reduce indiscriminate employ of medical interventions and unwanted variation of care by promoting patients' involvement in their own treatmentone. Key components of the SDM procedure include patients' developing and expressing their personal values as well as treatment goals and preferences, the provider sharing data about clinical context and medical evidence, and a collaborative conversation to make a joint conclusion that is testify-based and consequent with best practices. The practice tin can exist standardized through use of a decision assistance, which is a tool (eastward.thousand., videodisc, booklet) that educates the patient, improves their knowledge of the risks and benefits of treatment options, and provides them with evidence regarding factors of their condition. Many determination aids likewise include some sort of patient values clarification, which is one of the characteristics that distinguish these tools from typical educational materials.2
Although the goals of SDM are broadly applicable across health conditions, SDM may exist a peculiarly key strategy for elective, or "preference-sensitive," treatment decisions3. A preference-sensitive decision is one in which at that place is a lack of clear scientific evidence showing superiority of one treatment, and treatment choices vary in ways that may matter to patients2, 3. In such cases, surgery may be recommended according to local norms or practise patterns, rather than patient preferences, leading to overuse or inappropriate surgical utilization.4, 5 SDM has been shown to ameliorate these patient reactions.6 In essence, past applying SDM and actively including the patient in the decision through elicitation of their preferences and values, contributors to unwarranted variation, such as surgeon preference, financial incentives and local practise patterns, may be overcome, and quality of intendance may be increased. SDM is considered to be a potential solution for improving quality of care7 and guideline-based practice in surgical care.
SDM has likewise been lauded and incorporated into wellness policy and clinical practice initiatives worldwide.8 Within the U.S. solitary, the Patient Protection and Affordable Care Act (PPACA) defines and proposes SDM equally one method to reform healthcare delivery and payment by the newly established Center for Medicare and Medicaid Innovation.9 Moreover, several states accept implemented SDM and conclusion support tools into policy via legislation, demonstration projects, or incorporation into standards set by alternative payment systems (due east.g. answerable intendance organizations).10
Despite the emphasis on SDM to amend quality of treatment decisions and reduce overuse and unwarranted care variation, piddling is known about how SDM actually influences patients' choice for constituent surgery in everyday practice. The aim of this newspaper is to systematically review the published literature evaluating the impact of SDM on patient choice for constituent surgery. We further seek to evaluate how SDM and determination aids are applied in elective surgical do, and what upshot measures are used to assess the touch on of SDM.
METHODS
Data sources and searches
The protocol for the report has been registered with PROSPERO, an international prospective registry of systematic reviews.11 We based our report methodology upon the Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) checklist and statement recommendations12 and the Cochrane Handbook for Systematic Reviews and Meta-Analysis13. Because this systematic review evaluated previously published studies, information technology was exempt from approval by our institutional review lath.
We searched the Pubmed, Cochrane CENTRAL, EMBASE, CINAHL, and SCOPUS databases. The initial search was conducted on August 9, 2014, and updated on August x, 2015. The search strategy, initially crafted for use in Pubmed and subsequently modified for the remaining databases, was created in conjunction with a medical librarian using controlled vocabulary and related synonyms/keywords for each database (Appendix 1). The search was conducted to identify studies that used SDM among patients making a decision about elective surgery.
Study selection
We reviewed articles that addressed apply of SDM when elective surgical care was an selection for treatment. Using 2 common definitions, we defined SDM as: 1. "a collaborative procedure that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, equally well every bit the patient's values and preferences;xiv " ii. "an approach where clinicians and patients share the all-time available evidence when faced with the task of making decisions, and where patients are supported to consider options, to attain informed preferences."15, 16
Articles were included if they: addressed an actual determination for an elective, or preference-sensitive, surgical procedure; used methods which incorporated, addressed, or measured SDM; included a minimum of seven patients; and were published in English. Articles were excluded if they were classified every bit commentary, stance, review, consensus argument, or committee written report; if conclusion about surgical care could non exist ascertained; if SDM was measured in a cohort of patients who all had undergone surgery; if surgical care practical to a life-threatening status, such as cancer, organ transplant, or aneurysm; or if the article addressed pregnancy, such every bit surgical mode of delivery or termination.
Two or more than investigators independently reviewed all identified titles, abstracts, and full-text articles to make up one's mind if they met inclusion criteria (Figure ane). The investigative team of reviewers included 4 faculty researchers who are content experts in shared decision-making and patient-provider communication, 3 post-doctoral and/or surgical fellows who are content experts in deport of systematic review and surgical care, and two enquiry coordinators who had led and co-authored numerous prior systematic reviews. In the effect of disagreement regarding study inclusion for total text then final review, reviewer teams reached a consensus via discussion.
Menstruum chart based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)12.
Information extraction and quality assessment
For each included commodity, we abstracted the following information: authors, year of publication, surgical subject, number of patients, study blueprint, clinical dilemma, surgical treatment option, alternating treatment options, background reason for analysis, study location and setting, baseline patient assessment, how SDM was used, clarification of decision aids when used, timing of outcome assessment, outcome measures used, percent of patients choosing surgery, additional cardinal findings, and notable written report limitations.
We determined the level of evidence for each study according to the guidelines outlined by the Eye for Prove-Based Medicine (CEBM, http://www.cebm.net/index). For randomized command trials, the Cochrane Handbook Version v.0.i assessment of risk of bias checklist was utilized13. The Newcastle-Ottawa Scale (NOS) for assessment of quality of observational studies was used to evaluate each accomplice or case-control study17. This scale assigns ratings based on three categories: (1) selection of cases and controls; (2) comparability of controls on basis of pattern/analysis; and (3) methods of ascertaining exposure.
Data synthesis
In view of the paucity of studies, diverse areas of focus and written report designs in identified articles, and data heterogeneity, nosotros did non perform a quantitative meta-assay. We analyzed articles using qualitative synthesis methods by outset grouping them into categories by study design, clinical content area, determination aid use, and consequence measures. We afterward identified common themes across manufactures and performed subgroup analyses.
RESULTS
Written report pick
The initial data search was conducted on August 9, 2014, and updated on August 10, 2015. Figure 1, the PRISMA period diagram, reflects the number of records identified, included, and excluded with reasons. Our initial search yielded xvi,063 papers. Assay identified 5,134 duplicates, which were excluded from review. 10,929 papers were identified for abstruse review. 142 papers underwent full-text review, and 41 were considered for data brainchild. Of those, 24 studies yielded assessments of surgical outcomes, and were included in the last analysis (Figure 1).
Description of included studies
Table ane shows full general demographics of the final included studies. Notably, 17/24 papers reported on patient cohorts comprised of both male and female participants, and all but 2 of the papers were based on adult patient cohorts, equally opposed to pediatric. 20 out of 24 studies were conducted in North America. The clinical dilemma well-nigh usually studied was spinal surgery (7/24), followed by orthopedic surgery, including articulation surgery for osteoarthritis (5/24), and gynecological surgery (iv/24). The bulk of studies (20/24) featured use or evaluation of a conclusion aid. But 7 papers directly evaluated communication between the medico and client in the context of SDM. Just 4 studies assessed perspectives of both medico and patient, every bit opposed to measuring but patient outcomes.
Tabular array 1
Characteristics of studies included in systematic review (N = 24)
| Domain | Study northward (%) |
|---|---|
| Written report Design | |
| Randomization | eleven (45%) |
| Sample Size | |
| N < 100 | 7 (29.ii%) |
| N 100 – 500 | 11 (45%) |
| Due north > 500 | half dozen (25%) |
| Population Gender | |
| Male person simply | 3 (12.5%) |
| Female person only | 4 (16.7%) |
| Both genders | 17 (70.8%) |
| Population Historic period | |
| Adult (no children evaluated) | 22 (91.half dozen%) |
| Continent of Origin | 20 (83%) |
| North America | 3 (12.5%) |
| Europe | 1 (4.2%) |
| Asia | |
| Surgical Specialty (clinical dilemma) | |
| Neurosurgery/Orthopedic Surgery (spine) | 7 (29.2%) |
| Orthopedic Surgery (osteoarthritis, Trigger Finger) | five (20.viii%) |
| Urology (benign prostatic hypertrophy) | 3 12.5%) |
| Gynecology (menorrhagia, incontinence) | 4 (sixteen.vii%) |
| General Surgery (obesity) | 1 (4.2%) |
| Plastic Surgery (wounds, reconstruction) | two (8.3%) |
| Otolaryngology (otitis media, tonsillitis, sinusitus; sleep apnea) | 1 (4.2%) |
| Mixed | ane (4.ii% |
| Format of Decision Aid Used in Analysis | |
| Multimedia Program (video & interactive) | 13 (54.ii%) |
| Written Cloth | 3 (12.five%) |
| Consult, Counselor or Coach | 4 (16.7 %) |
| None used | iv (16.vii %) |
The chief outcome assessed in this review was preference for surgery, along with secondary outcomes of decision conflict and quality. Conclusion quality, a primary focus in several studies, is an overarching measure out which incorporates adequate knowledge and data provision to the patient, overall satisfaction with the conclusion and conclusion-making process, and congruence with the patient's needs and values.18 As knowledge/grooming is an individually of import factor for decision-making that is often reported as an isolated effect measure, results regarding both improvements in decision quality overall (due north = 3) and preparation and noesis (n = 6) were noted, along with improvements in decision conflict (north = 6). Decision conflict describes a patient's level of uncertainty in choosing treatment options.19 Definitions for shared decision-making, conclusion conflict, and decision quality are presented in Table 2.
Tabular array 2
Definitions: Shared decision-making, determination conflict, and conclusion quality
| Shared decision-making | Collaborative procedure in which patients and providers piece of work together to find a mutually agreed upon treatment programme.1 Includes elements such equally information-sharing, determination back up, and collaborative communication, in gild to reach a joint decision in line with a patient's preferences49 |
| Decision conflict | A state of uncertainty regarding treatment options, or which action to take, when patients are faced with a particular decision (e.thou., surgical intervention)xix |
| Conclusion quality | The extent to which patients' decisions are based on bear witness-based knowledge, and are congruent with their values34 |
Preference for surgery
Pooled results of this analysis bespeak an ambiguity of the upshot of SDM on treatment preference. Some studies (n = ix) show a decrease in choice for surgery with the use of SDM (e.m. 26 – 38 % reduction of patients choosing articulation-replacement surgery; 22% reduction of patients choosing discectomy surgery)20, 21. Even so, a comparable number of studies (northward = 7) bespeak a lack of significant difference in treatment pick with use of SDM. It is likewise noted that 1 study found an increment in surgeries afterwards implementation of SDM.
There were few significant differentiations based on study design: all randomized studies (northward = eleven) assessed treatment preference equally a chief issue. 6 establish no difference in patients' treatment choice for or against surgery based on application of SDM, while 5 showed a decrease in choice for surgery. vii non-randomized studies direct assessed preference for surgery: 4 found that preference for surgery decreased with SDM, 2 found that preference for surgeries remained the same, and 1 institute that preference for surgeries increased, although the authors noted that external factors, such equally variations in personal values or overall decision certainty inside their particular dataset, might business relationship for these results.22
Decision Outcomes
Overall, conclusion conflict tended to decrease with SDM, while conclusion quality tended to increase. Of the 6 studies considered to straight assess decision conflict, 4 found that conclusion disharmonize decreased and two institute no difference. Results from all studies directly assessing decision quality overall (north = 3) institute that decision quality increased with use of SDM. iv studies assessing knowledge and training in isolation found an increase in decision grooming with SDM, and 2 studies showed no difference. There were no studies that establish that determination quality or knowledge decreased with use of SDM.
In that location were slight differentiations betwixt randomized and nonrandomized studies in assessments of determination conflict. Information technology is noted that ii randomized studies focused on decision conflict showed no difference,18, 23 and the balance indicated that disharmonize decreased with use of SDM. However, all non-randomized studies that focused on decision conflict equally a chief outcome found that conclusion conflict decreased with the introduction of SDM. In terms of decision quality, all randomized and nonrandomized studies that focused on decision quality overall equally a primary area of interest found that the use of SDM was related to an increment in decision quality. The bulk of studies specifically focused on knowledge and grooming were randomized. 2 out of 5 randomized studies assessing conclusion preparation found no difference in participant knowledge based on SDM intervention, while 3 randomized trials and 1 non-randomized trial establish a significant improvement in knowledge with use of SDM. Effigy 2 shows the cumulative affect of SDM on each outcome mensurate. Tables 3 and 4 summarize all studies included in this review.
Cumulative trends of key outcome measures across included studies
* Lower levels of determination conflict indicate a reduction in the disharmonize, which would exist regarded equally improved upshot, experienced by patients when facing treatment decisions
** Greater decision quality indicates a conclusion based on increased knowledge and information which is congruent with the patient's needs and values. The related gene of patient knowledge is also represented in this effigy, as it is often measured in isolation.
Table 3
Clarification of included studies with randomization in study design
| First Author, Yr | N | Surgical Treatment | SDMii clarification | Outcome(s) | % patients choosing surgery | Key findings |
|---|---|---|---|---|---|---|
| Arterburn et al, 201118 | 152 | Bariatric surgery | Video decision assistance or educational booklet with information on bariatric surgery, treatment options, and potential complications and costs. | Cognition Handling preference Determination conflict Determination self-efficacy Outcome expectations | Video: 42%; Booklet: 59% | No significant difference in choice for surgery All showed improved knowledge, decision disharmonize, and outcome expectations. |
| Barry et al, 199750 | 227 | Prostatectomy | thirty minute tailored video explaining importance of SDM and information about BPHthree treatment alternatives, followed by interactive module for learning nearly specific areas of interest for BPH and treatment options | Knowledge Satisfaction Distribution of treatments | Treatments selected at three months: DA4: iv.viii%; Command group: six.5% | Better noesis and satisfaction with SDM procedure, full general health perceptions and physical operation with SDM Distribution of treatment and decision satisfaction did not vary. |
| Brazell et al, 201523 | 104 | Surgery for pelvic organ prolapse | DA available in paper format or online, consisting of information regarding condition definitions, treatment options, chance of surgery, post-surgical expectations, and testimonials from former patients. | Conclusion disharmonize Treatment plan | 52% | No relation to determination conflict No departure in choice for surgery |
| Deyo et al, 200021 | 393 | Discectomy | Booklet with information on lumbar spine anatomy, treatment options, expected outcomes, self-test. SDM group as well viewed interactive videodisc, tailored to patients' characteristics: animated anatomical graphics, information on causes of back pain, and expected treatment outcomes and testimonials. | Determination for surgery | 26% of those who viewed interactive DA | Overall decision for surgery 22% lower videodisc group (26%) than command (33%). Videodisc group with herniated discs choice significantly less surgery (32%) than the non-intervention group (47%). Video group with spinal stenosis chose surgery more oft (39%) than the non-intervention group (29%). |
| Dobke et al, 200851 | 30 | Varied5 (wound) | Telemedicine consult held with wound nurse prior to a face-to-face engagement with surgeon. Included assessment of wound, discussion of rationale for management (emphasizing take chances projection), and benefits of surgery. | Duration of kickoff appointment Satisfaction with hereafter care decisions Conclusion conflict | Recommended surgery by doctor: 67% Accustomed recommendation after DA: 93% | Patients in intervention group had shorter face-to-face up appointments Greater decisional satisfaction, and lower decision disharmonize. |
| Kennedy et al, 200239 | 894 | Hysterectomy | Advisory book and videotape given to both groups. Women in intervention group also had an interview before their date, to discuss their options. | Health status treatments received for menorrhagia Price effectiveness | Interview group: 38% | No consistent relation to wellness status Hysterectomy rates lowest in women who received both DA and interview. Costs lowest for women who received both DA and interview |
| Phelan et al, 200147 | 100 | Lumbar spine surgery | One grouping received videodisc and booklet, i group received booklet. Booklet contained illustrations, information on treatment options, full general descriptions of expected outcomes for each treatment, and cocky-test. Interactive videodisc included estimator graphics, a presentation of potential causes of low dorsum and leg pain, risks and benefits of treatment options, and interviews from previous patients. | Knowledge Handling preference Evaluation of DA | Videodisc: 23% Booklet: 42% | Materials piece of cake to sympathize, adequate in assisting decision-making. Showed lower preference for surgical intervention Both groups showed improved knowledge Combination of the videodisc and booklet was more helpful for controlling than the booklet solitary. |
| Stacey et al, 201434 | 142 | Total knee arthoplasty | 50 minute video and accompanying booklet, providing data on different treatments, potential benefits and harms, and patient testimonials. | Feasibility, decision quality await for surgery | 79.7% SDM group; lxx.6% control grouping | No relation to await for surgery SDM group reported higher decision quality and cognition |
| Stacey et al, 201552 | 343 | Total joint anthroplasty (hip-knee osteoarthritis) | 50 minute video and booklet, providing data on handling options, benefits and risks of handling, and testimonials from former patients. | Look time for total articulation arthroplasty Effectiveness of DA | 73% SDM group; 80% control grouping | Patients in the intervention group had less await fourth dimension for surgery. Determination quality college in intervention group (56%) than the control (44%). DA group had fewer surgeries, higher conclusion quality (non significant) |
| Veroff et al, 201353 | 60185 | Variedsix | SDM-trained health coaches (nurses, therapists, pharmacists) provided SDM to participants, including readings, encouragements to actively participate in treatment decisions, and various conclusion aid materials (videos, leaflets, software). | Costs Infirmary admissions Rates of preference-sensitive surgeries Imaging rates | Overall: Enhanced support nine.nine% fewer surgeries Heart-specific: Enhanced support xx.nine% fewer surgeries | Enhanced support related to lower medical costs, fewer hospital admissions, and fewer preference-sensitive surgeries. Enhanced back up group had fewer imaging studies (nonsignificant) |
| Vuorma et al, 200354 | 569 | Hysterectomy | Informational booklet given to participants prior to gynecological appointment. Contained information about heavy flow, different treatment options, and benefits and risks of treatment. | Distribution of handling modalities Knowledge about treatment options Satisfaction with communication Anxiety | DA: 53% Control: 49% | New treatments less common in intervention group. Intervention group had increase in specific treatment decisions within outset 3 months. Additional information did non touch on surgery frequency |
Table 4
Description of included studies without randomization
| Kickoff Writer, Engagement | N | Surgical Treatment | SDM description | Result(s) | % patients choosing surgery | Cardinal findings |
|---|---|---|---|---|---|---|
| Arterburn et al, 201220 | 9515 | Joint Replacement | SDM through apply of a DA comprised of a booklet, DVD and/or online module. | Charge per unit of surgery Health care costs | DA: Hip: 26% fewer Knee: 38% fewer | 26% fewer hip replacements 38% fewer knee replacements 12–21% lower costs |
| Barrett et al, 200222 | 232 | Laminectomy | Interactive videodisc with information about back hurting and sciatica, benefits and risks of treatment options, and testimonials. Additional modules included information about transfusions, disabilities, alternative procedures. | Handling preference | 36% | Increase in number of patients who preferred surgery after being exposed to videodisc |
| Barry et al, 199555 | 373 | Prostatectomy | Interactive videodisc tailored to patient's characteristics (demographics, health, history of acute retention, and level of symptoms) with data on handling choices, benefits and risks, expected outcomes, examples (patient-physician), and an interactive elective section. | Treatment choice Symptoms Concerns well-nigh potential complications Program evaluation | 11.vii% | Participants felt that DA was useful, clear, informative, and balanced. Patients more likely to elect surgery because of negative symptoms they were experiencing, as opposed to the DA. |
| Bradbury et al, 199456 | 34 families | Microvascular toe transfer | Advisor met with families and assessed the emotional needs of the parents, provided them with information about treatment options, and gave families the opportunity to produce informed questions prior to coming together with a doctor. | Decision participation Factors influencing decisions made | 79.4% | Parents and children viewed themselves, surgeons, and counselors as all having of import roles in decision-making process. Parents almost probable to exist influenced by counseling and surgeon communication |
| Chorney et al, 20156 | 65 (parent and child) | Tonsillectomy, adenoidectomy, tympanostomy tube insertion | SDM assessed by the Shared Determination-Making Questionnaire–Patient Version (SDM-Q-9), and the Shared Decision Making Questionnaire–Physician Version (SDM-Q-Doc). | Decisional Disharmonize | 78% | SDM related to decisional conflict, such that parents who perceived greater levels of SDM reported lower levels of decisional conflict. |
| Doring et al, 201441 | 105 surgeons; 84 patients | Paw surgery | Cess of perceptions of patients and physicians regarding involvement in the decision-making process, manner in which a conclusion should exist reached, and utilise of DAs. | Command Preferences Preferred manner to make final determination Who involved in decision-making process7 | Likeliness to cull surgery: 1000 = 72% | Patients desired surgery less than physicians Physicians preferred SDM; patients preferred making their ain decisions separately from physicians (with their communication) Patient/doctor differences in opinions of benefits and disadvantages of treatment options. |
| Geller et al, 199757 | 52 | Hysterectomy | Extent to which patients perceived themselves every bit being involved in the health intendance/decision-making process. | Patient participation in handling decisions Satisfaction with care Treatment plan | 21% | Patients wanted to be involved in their handling decisions. When educated, many did not choose hysterectomy surgery |
| Gooberman-Hill et al, 201058 | 26 | Full joint replacement | Patients and physicians asked to evaluate their controlling procedure following appointments. | Factors associated with treatment decisions | 76% | Clinical and lifestyle factors essential for decision-making Roles assigned to clinicians may exist key component of manner in which SDM is employed; when patients viewed clinicians as "experts," they were more likely to heed their opinions Patients modeled their own communication and beliefs on their physicians. |
| Kim et al, 201546 | 555 | Discectomy | Consultation with data-sharing and participatory decision-making. Included booklet with data on health condition and handling options, beingness shown MRI scans, verbalization of advantages/disadvantages of treatment. | Decision for surgery | 31% | Employ of SDM with existence male, having leg pain, back-specific part, morphological stenotic grades, motor weakness, physical office and role, torso pain, social function, and emotional function were all associated with option for surgery. |
| Lurie et al, 2011thirty | 2505 | Lumbar spine surgery | Video including information almost status, testimonials of patients who had chosen each handling choice, benefits/risks of each treatment option. | Choice for surgery Decision certainty | 55% who were unsure shifted towards surgery | DA increased likelihood of change in preference and degree of certainty. Did non relate to a particular decision regarding surgery (solely the strength of that decision). |
| Shirley et al, 201459 | eleven | Surgical treatment for Neuromuscular Scoliosis (spinal surgery) | A written DA informed patients about treatment for neuromuscular scoliosis, including evidence-based data and treatment options for the condition. | Program evaluation: knowledge, SDM satisfaction determination conflict | 82% | Related to increased knowledge, satisfaction, and reduced decisional disharmonize. Clinicians reported satisfaction with the DA |
| Spunt et al, 199631 | 239 | Neurosurgery/ orthopaedic surgery (herniated disc; spinal stenosis) | Interactive videodisc, tailored to patient characteristics (e.k., age and diagnosis). Included narratives, animated graphics, data near risks and benefits. | DA evaluation Decision certainty | 70% intervention group, 79% control grouping | DA improved decision certainty Patients rated DA favorably in terms of understandability, involvement, information provided |
| Wagner et al, 1995lx | 406 | TURP8 | Interactive videodisc designed to assist in making informed decisions, regarding choice to take TURP, or choice to employ "watchful waiting." | Rate of preference for TURP | 21% | Reduction in rate of choosing to accept TURP with use of the DA. |
Assessment of chance of bias
Observational and RCT studies included in this review were assessed for bias. Results of these assessments tin can be seen in Tables 5 and half-dozen, and Appendix 2. Overall, reviewers found a low adventure of selection bias, attrition bias, and other biases, although performance and detection biases in SDM inquiry were potentially problematic. Specific results of bias elements are elaborated on in Appendix two.
Table five
Assessment of bias for RCT studies (due north = 11) by the Cochrane Handbook Checklist13
| Pick Bias | Blinding | Other Biases | Miscellaneous bias | ||||
|---|---|---|---|---|---|---|---|
| Study | Random sequence generation | Allotment Concealment | Functioning Bias: Blinding of participants and personnel | Detection Bias: Blinding of upshot cess | Attrition bias: Incomplete consequence data | Reporting bias: Selective reporting | Other biases |
| Arterburn 2011 | √ | ? | X | X | √ | ? | √ |
| Barry 1997 | √ | √ | √ | √ | √ | ? | √ |
| Brazell 2015 | √ | ? | X | X | ? | ? | √ |
| Deyo 2000 | √ | √ | X | ? | √ | ? | √ |
| Dobke 2008 | ? | √ | X | ? | √ | ? | √ |
| Kennedy 2002 | √ | ? | X | 10 | √ | ? | √ |
| Phelan 2000 | √ | √ | X | X | √ | ? | √ |
| Stacey 2014 | √ | √ | √ | 10 | √ | ? | √ |
| Stacey 2015 | √ | √ | √ | ? | √ | √ | √ |
| Veroff 2013 | √ | √ | X | X | √ | ? | ? |
| Vuorma 2013 | √ | √ | Ten | 10 | √ | ? | √ |
Table 6
Assessment of risk of bias for observational studies (due north=12) by the Newcastle-Ottawa Scale (NOS)17.
| Selection | Comparability | Outcome | ||||||
|---|---|---|---|---|---|---|---|---|
| Study | Representativeness of the exposed cohorts | Selection of the non-exposed cohorts | Ascertainment of exposure | Demonstration that outcome of involvement was not present at start of study | Comparability of cohorts on the basis of study pattern or assay | Assessment of outcome | Was follow-upwardly long plenty for the outcome to occur | Adequacy of follow-upward of cohorts |
| Spunt 1996 | * | * | * | * | ||||
| Bradbury 1994 | * | * | * | * | * | |||
| Lurie 2010 | * | * | * | * | * | * | ||
| Kim 2014 | * | * | * | * | * | * | ||
| Arterburn 2012 | * | * | * | ** | * | * | ||
| Barry 1995 | * | * | * | * | ||||
| Geller 1997 | * | * | * | * | * | |||
| Wagner 1995 | * | * | * | * | * | |||
| Barrett 2002 | * | * | * | * | * | |||
| Chorney 2015 | * | * | * | * | * | |||
| Doring 2014 | * | * | * | |||||
| Shirley 2014 | * | * | * | * | * | |||
DISCUSSION
In contempo years there has been increased attention devoted to patient and family unit-centered outcomes and reduction of waste material in healthcare.24 Although in certain clinical dilemmas scientific evidence has distinguished a clearly optimal handling pathway, the majority of health problems may exist managed in more than ane mode. As such, SDM has been heavily emphasized every bit a strategy to better treatment decisions and ensure the most ideal choice for each individual patient. Use of SDM has been broadly studied across health decisions including palliative care, cancer screening, trial inclusion, and medication use in the settings of chronic weather condition. SDM is touted every bit a potential solution for improving quality of care7 and guideline-based do.
The topic of this review was derived from an interest of the main team surrounding potential overuse of tonsillectomy in children. Given that rates of pediatric tonsillectomy are known to vary most five-fold across U.Due south. geographical regions,25 experts have suggested that SDM could potentially mitigate this unexplained variation in such a common surgical procedure,v however footling research exists to support this clause. Unfortunately, the current review included but 2 studies that evaluated selection for elective surgery in a pediatric patient population, and simply one written report evaluated use of SDM in otolaryngic practice. Indeed, as measuring patient centeredness becomes integral with delivery of quality healthcare, more pediatric disciplines including pediatric otolaryngology will need to evaluate furnishings of how we communicate, provide information, and share decisions with patients. Furthermore, larger prospective or population-based data on tonsillectomy surgical rates volition be needed to truly understand whether use of SDM will reduce variation in this procedure.
The primary upshot addressed in this systematic review was patient selection for an elective surgical procedure. Secondary outcomes of interest include determination conflict and conclusion quality. Overall, despite growing awareness of the potential benefits of SDM, at that place is a lack of research on its effectiveness, in this area that seems well suited for SDM. Furthermore, enquiry studies tend to focus more on patient experiences with determination-making than treatment preferences,26 such equally decision conflict or preparation, with a somewhat lower per centum of studies measuring decisions for elective surgery.two
The focus and findings of this review are particularly pertinent to the current climate in the United states of america, as many policy-makers and healthcare reform advocates are predicting a transformational impact of SDM on clinical practise, utilization, quality of intendance, and costs.27 As previously stated, PPACA section 3506 includes a provision for a "Plan to Facilitate SDM," including linguistic communication describing patient decision aids and preference-sensitive intendance, although this authorized initiative has been yet unfunded.28 1 objective stated within the Good for you People 2020 health communication initiatives is to increase the proportion of people involved in decisions as much every bit they wanted to exist.29 Private states including Maine, Oregon, Washington, Minnesota, and Vermont accept begun to contain SDM into legislation, public-private partnerships, and state standards and expectations.10
However despite the high energy and optimism surrounding use of SDM, this review shows that there may non be enough concrete data to back up its official incorporation into health policy. While the Institute of Medicine has prioritized application of SDM in comparative effectiveness research related to chronic conditions in children and adults, and organizations including the Agency for Healthcare Enquiry and Quality and the Patient-Centered Outcomes Enquiry Institute are following accommodate by increasing funding for projects which develop support tools and exam SDM implementation, more than enquiry and resource volition be required before definitive conclusions can be made almost the impact of SDM on choice for elective surgery.
Studies in this review showed that decision conflict over choosing elective surgery is alleviated with application of SDM. This finding is consequent with prior literature evaluating the consequence of determination aids.one, 2 Indeed, the use of SDM and decision aids (i.e., decision back up and data about treatment options) allows patients to go more confident in their choice to have, or not take, surgery30, 31 which then promotes health and well-existence both during and following the controlling process and performance.32, 33
Decision quality has focused on factors relating to the extent to which a decision is based on appropriate knowledge and is coinciding with the values and needs of the patient.34 Based on the reviewed studies, decision quality has been considered both inclusively, and in terms of the related gene of participants' data and cognition. The apply of SDM has been shown to increase the quality of decisions. In this review, while some papers measured "quality" as a key concept, others measured the individual component of patient knowledge, with a majority showing improved decision quality regardless of whether pick for surgery was fabricated. This suggests that the decision procedure, rather than the conclusion made, is key to improving outcomes and a potential focus for time to come interventions.
About studies in this review utilized decision aids for awarding of SDM. Determination aids, past definition, are "tools used to inform patients well-nigh available treatments, along with potential benefits, risks and costs, during clinical encounters."35 These tools, in varying degrees, present information on each treatment option and aim to appoint the patient and assistance them make an informed decision.36 A determination aid strives to make patients informed, and patients who are informed might exist more likely to interact with their doctors.37 However, despite how thorough the content is in a decision aid, its use does not guarantee straight involvement of the surgeon or explicit elicitation of patient values and preferences. SDM by definition involves a collaborative process that creates a partnership between the doc and patient.1, 38 Kennedy et al39 found that surgery rates were everyman when patients received both a decision assistance and an interview, equally opposed to a decision aid in isolation. Equally such, perchance a distinction betwixt information-based decision-making (i.e. informed controlling through utilize of decision aids) and shared decision-making should be more transparent. Of the 24 studies evaluated in this review, the majority (due north = 17) focused measured outcomes on the effectiveness of a determination aid without direct assessing medico-patient interactions or distinct collaboration. It is not clear if through evaluation of the effect of decision aids, we may fairly say nosotros have evaluated SDM.
There were some full general deficiencies in the torso of inquiry included in this systematic review. Amongst the papers reviewed, no noteworthy differences were found within subgroups. This may be due to a limited number of papers and populations available for analysis, and the relative distribution of those studies included in this review. Further, included studies largely measure employ of decision aids without addressing communication between the md and patient. As the very definition of SDM establishes it as a collaborative procedure betwixt the doctor and patient in order to reach a satisfactory decision,40 information technology is unclear whether researchers take illustrated the effect of SDM, or the result of data-giving. It is further noted that i written report reviewed in this paper did indicate that while doctors favor SDM in decision-making, patients actually prefer the provision of information and communication, without collaboration41. Although further research is needed in club to generalize these findings, results exercise indicate the importance of assessing the interplay betwixt doctors and patients with utilise of SDM. An additional concern is that several studies used invalidated tools to measure outcomes, or based findings on constructs with more cryptic definitions (e.g., decision quality), limiting our ability to generalize their findings.
Virtually studies included in this review assessed the effectiveness of SDM but did not explore potential misreckoning variables inherent to patient populations. Prior research has shown that gender, age, socioeconomic condition, literacy, race, and ethnicity may impact preference for SDM or related factors which contribute to the process, such as take chances-taking,42 assertiveness,43 and additional factors influencing controlling (due east.grand., uncertainty, data provision).44,45 However, with few exceptions,44, 46, 47 the reviewed papers did not typically appraise for differences based on demographic features, or include these factors in statistical analysis to command for misreckoning. In general, SDM research demonstrates a lack of focus on particular important demographic categories (e.g., pediatrics48).
In addition to limitations in the available SDM inquiry, it is of import to note potential limitations of this review. This review is the first to evaluate the effect of SDM on patient choice for surgery. The robust methodology and highly inclusive search strategy aspect merit to the findings. However there were some limitations in the conduct of this review that should be noted. In trying to ensure that no studies were missed, we employed a very broad search strategy, requiring each fellow member of the study team to review thousands of titles. As such, reviewer fatigue may have led to errors in categorizing articles for inclusion. We attempted to minimize this gamble by having each title reviewed past a minimum of 2 individuals. Unfortunately, the heterogeneity of clinical focus, study pattern and effect measures limits definitive pooled conclusions. Finally, there is always the possibility for bias in qualitative analysis, inclusive of systematic reviews. This includes bias that may bear on both choice of studies to review, every bit well every bit classification of studies inside particular categories (east.g., primary outcome categorizations). We have taken measures to accost study and reviewer bias, by systematically assessing the bias of observational studies, and also past double-coding each paper and performing meticulous consensus meetings.
Despite these limitations, this review provides an evaluation and synthesis of research assessing the impact of SDM on pick for elective surgery. As the outset study to do so, it establishes a framework for because potential effects of use of SDM on surgical handling preference besides as means to improving overall decision quality.
Conclusion
In today's healthcare environment, SDM and determination aids are being touted as a forthcoming and essential practise on the footing that they reduce surgical utilization and healthcare costs. This systematic review shows that the effect of SDM on preference-sensitive surgery choice is less clear cut. Our findings advise that the use of SDM may reduce or have no impact on patient choice for elective surgery. SDM may too promote a more than positive healthcare experience and controlling procedure for patients, regardless of their ultimate surgical conclusion. Nosotros have considered SDM and conclusion aids inclusively, withal there may be more of a differentiation between "informed" and "shared" decision-making worthy of report. Furthermore, future population-based research is needed to determine whether broader broadcasting of SDM tools for conditions where elective surgery is one treatment option may ultimately impact intendance utilization, including unnecessary geographical variation and overuse.
Acknowledgments
EFB is supported past the American-University of Otolaryngology Head and Neck Surgery Foundation Cochrane Scholars Honor. EFB is supported by grant number K08HS022932 from the Bureau for Healthcare Research and Quality. EFB is also supported by the American-Academy of Otolaryngology Head and Neck Surgery Foundation Cochrane Scholars Laurels; the Johns Hopkins Clinician Scientist Laurels; and the American Society of Pediatric Otolaryngology Career Development Award.
EAL is supported by grant number #K23HD073149 from the Eunice Kennedy Shriver National Institute of Child Wellness & Human Development.
NM is a Wellcome Trust Research Fellow.
The content in this manuscript is solely the responsibleness of the authors and does not necessarily represent the official views of the Bureau for Healthcare Research and Quality or the Eunice Kennedy Shriver National Found of Child Health & Human Evolution.
Appendix one: Original Pubmed Search Strategy
| "Shared controlling" [TW] OR "Shared conclusion-makings" [TW] OR "Shared conclusion making" [TW] OR "Shared decision makings" [TW] "Patient Participation"[Mesh] OR "Patient participation" [TW] OR "Rate of patient participation" [TW] OR "Rates of patient participation" [TW] OR "Patient participation charge per unit" [TW] OR "Patient participation rates" [TW] OR "Patient Preference"[Mesh] OR "Patient Preference"[TW] "Patient md advice" [TW] OR "Patient-physician communication" [TW] OR "Physician patient communication" [TW] OR "Medico-patient communication" [TW] |
| AND |
| "General Surgery"[Mesh] OR "Surgical Procedures, Operative"[Mesh] OR "surgery" [Subheading] OR "2d-Look Surgery"[Mesh] OR "Surgery, Computer-Assisted"[Mesh] OR "Corneal Surgery, Light amplification by stimulated emission of radiation"[Mesh] OR "Bariatric Surgery"[Mesh] OR "Natural Orifice Endoscopic Surgery"[Mesh] OR "Orthognathic Surgery"[Mesh] OR "Thoracic Surgery, Video-Assisted"[Mesh] OR "Video-Assisted Surgery"[Mesh] OR "Thoracic Surgery"[Mesh] OR "Surgery, Plastic"[Mesh] OR "Surgery, Oral"[Mesh] OR "Surgery Department, Infirmary"[Mesh] OR "Stapes Surgery"[Mesh] OR "Colorectal Surgery"[Mesh] OR "Ambulatory Surgical Procedures"[Mesh] OR "Dermatologic Surgical Procedures"[Mesh] OR "Urologic Surgical Procedures"[Mesh] OR "Fetoscopy"[Mesh] OR "Nasal Surgical Procedures"[Mesh] OR "Mastectomy, Segmental"[Mesh] OR "Obstetric Surgical Procedures"[Mesh] OR "Gynecologic Surgical Procedures"[Mesh] OR "Mandibular Reconstruction"[Mesh] OR "Endoscopy, Gastrointestinal"[Mesh] OR "Refractive Surgical Procedures"[Mesh] OR "Ultrasonic Surgical Procedures"[Mesh] OR "Cervicoplasty"[Mesh] OR "Surgical Procedures, Minimally Invasive"[Mesh] OR "Ureteroscopy"[Mesh] OR "Hysteroscopy"[Mesh] OR "Thoracoscopy"[Mesh] OR "Surgical Procedures, Pocket-size"[Mesh] OR "Sigmoidoscopy"[Mesh] OR "Reoperation"[Mesh] OR "Proctoscopy"[Mesh] OR "Laparoscopy"[Mesh] OR "Orthopedics"[Mesh] OR "Gastroscopy"[Mesh] OR "Laryngoscopy"[Mesh] OR "Mediastinoscopy"[Mesh] OR "Esophagoscopy"[Mesh] OR "Duodenoscopy"[Mesh] OR "Cystoscopy"[Mesh] OR "Culdoscopy"[Mesh] OR "Colposcopy"[Mesh] OR "Colonoscopy"[Mesh] OR "Bronchoscopy"[Mesh] OR "Arthroscopy"[Mesh] OR "Coronary Artery Bypass"[Mesh] OR "Hand-Assisted Laparoscopy"[Mesh] OR "otolaryngology"[MeSH] OR "ophthalmology"[MeSH] OR "surgical procedures, elective"[MeSH] OR "Urogenital Surgical Procedures"[Mesh] OR "Pulmonary Surgical Procedures"[Mesh] OR "Ophthalmologic Surgical Procedures"[Mesh] OR "Otologic Surgical Procedures"[Mesh] OR "Digestive System Surgical Procedures"[Mesh] OR "Cardiovascular Surgical Procedures"[Mesh] OR "Splenorenal Shunt, Surgical"[Mesh] OR "Specialties, Surgical"[Mesh] OR "Cardiac Surgical Procedures"[Mesh] OR "Biliary Tract Surgical Procedures"[Mesh] OR "Neurosurgical Procedures"[Mesh] OR "Reoperation"[Mesh] OR "Colorectal Surgery"[Mesh] OR "General Surgery"[Mesh] OR "Neurosurgery"[Mesh] OR "Gynecology"[Mesh] OR "Obstetrics"[Mesh] OR "Neurotology"[Mesh] OR "Traumatology"[Mesh] OR "Urology"[Mesh] |
| OR |
| "Pediatric surgery" [TW] OR "Peadiatric surgery" [TW] OR "General Surgery"[TW] OR "Operative Surgical Procedures"[TW] OR "surgery" [TW] OR "2nd-Look Surgery"[TW] OR "Computer-Assisted surgery"[TW] OR "Laser Corneal Surgery"[TW] OR "Bariatric Surgery"[TW] OR "Natural Orifice Endoscopic Surgery"[TW] OR "Orthognathic Surgery"[TW] OR " Video-Assisted Thoracic Surgery "[TW] OR "Video-Assisted Surgery"[TW] OR "Thoracic Surgery"[TW] OR "Plastic Surgery"[TW] OR "Oral Surgery"[TW] OR "Surgery Department"[TW] OR "Stapes Surgery"[TW] OR "Colorectal Surgery"[TW] OR "Convalescent Surgical Procedures"[TW] OR "Dermatologic Surgical Procedures"[TW] OR "Urologic Surgical Procedures"[TW] OR "Fetoscopy"[TW] OR "Nasal Surgical Procedures"[TW] OR "Mastectomy"[TW] OR "Obstetric Surgical Procedures"[TW] OR "Gynecologic Surgical Procedures"[TW] OR "Mandibular Reconstruction"[TW] OR "Endoscopy, Gastrointestinal"[TW] OR "Refractive Surgical Procedures"[TW] OR "Ultrasonic Surgical Procedures"[TW] OR "Cervicoplasty"[TW] OR "Minimally-invasive Surgical Procedures"[TW] OR "Ureteroscopy"[TW] OR "Hysteroscopy"[TW] OR "Thoracoscopy"[TW] OR "Minor Surgical Procedures"[TW] OR "Sigmoidoscopy"[TW] OR "Reoperation"[TW] OR "Proctoscopy"[TW] OR "Laparoscopy"[TW] OR "Orthopedics"[TW] OR "Gastroscopy"[TW] OR "Laryngoscopy"[TW] OR "Mediastinoscopy"[TW] OR "Esophagoscopy"[TW] OR "Duodenoscopy"[TW] OR "Cystoscopy"[TW] OR "Culdoscopy"[TW] OR "Colposcopy"[TW] OR "Colonoscopy"[TW] OR "Bronchoscopy"[TW] OR "Arthroscopy"[TW] OR "Coronary Artery Bypass"[TW] OR "Hand-Assisted Laparoscopy"[TW] OR "otolaryngology"[TW] OR "ophthalmology"[TW] OR "Constituent surgical procedures" [TW] OR "Urogenital Surgical Procedures"[TW] OR "Pulmonary Surgical Procedures"[TW] OR "Ophthalmologic Surgical Procedures"[TW] OR "Otologic Surgical Procedures"[TW] OR "Digestive System Surgical Procedures"[TW] OR "Cardiovascular Surgical Procedures"[TW] OR "Splenorenal Shunt, Surgical"[TW] OR "Specialties, Surgical"[TW] OR "Cardiac Surgical Procedures"[TW] OR "Biliary Tract Surgical Procedures"[TW] OR "Neurosurgical Procedures"[TW] OR "Reoperation"[TW] OR "Colorectal Surgery"[TW] OR "General Surgery"[TW] OR "Neurosurgery"[TW] OR "Gynecology"[TW] OR "Obstetrics"[TW] OR "Neurotology"[TW] OR "Traumatology"[TW] OR "Urology"[TW] |
Appendix 2: Cess of Bias in Reviewed Studies
Among the included studies, 12 were observational studies assessed past the NOS (Table 6). There was heterogeneity among the studies in their risk of bias with studies scoring betwixt 341 to viixx on the scale out of ix stars. For option bias, on a maximum of 4 stars, four studies had 2 stars,31, 41, 55, 59 and eight studies had 3 starssix, twenty, 22, 30, 46, 56, 57, 60. Just one written report scored two starsxx, and one scored one star30 for comparability, as most of the studies did not take a comparison group. For outcome assessment, out of a maximum of 3 stars, two studies scored 3 stars46, 59, eight studies scored ii stars6, xx, 22, 30, 31, 55–57, 60 and one study scored simply 1 star41. One paper58 was not assessed, as it was qualitative in design and did non fit in either observational or RCT categorizations.
The Cochrane Handbook Checklist13 was used to appraise the risk of bias for the 11 RCTs, which revealed low to moderate run a risk of bias in the studies (Table 5). Ten studies18, 20, 21, 23, 34, 39, 47, 50, 52, 54 were depression risk of bias for random sequence allocation with one51 having unknown risk of bias. For allocation concealment bias, 3 studies had unknown adventure of biaseighteen, 23, 39, with the remaining 8 having low risk of biastwenty, 21, 34, 47, 50–54. There was high risk of bias for blinding of participants and personnel in 8 studies which were not double-blindedeighteen, 20, 21, 23, 39, 47, 51, 53, 54, with only 3 studies being blinded for either2, 50, 52. Similarly for blinding of outcome assessment, 7 studies were not blindedtwo, 18, twenty, 23, 39, 47, 52–54, 3 studies did not provide information on blinding21, 51, 52 with only 1 written report having blinding for consequence cessfifty. Attrition bias was depression beyond 10 of the included studiesxviii, 20, 21, 34, 39, 47, 50–54 with only 1 study having unknown dropout from the RCT23. For selective reporting, equally virtually of the studies did not have a protocol, at that place was unknown chance of bias in ten studies18, 20, 21, 23, 34, 39, 47, 50, 51, 53, 54, with simply 1 report, which had a protocol and did not selectively report outcomes52. Ten of the studies did non take any other obvious sources of bias18, 21, 23, 34, 39, 47, 50–52, 54 with i report53 having unknown risk of bias as the report was conducted by a for-profit company and mainly focused on price and we are unable to ascertain if this introduces a source of bias.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4857133/
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