OBJECTIVE: To identify 1) conversation topics, 2) who initiated the topics, and 3) differences in topics with and without the use of a shared decision-making (SDM) tool in psychiatric outpatient consultations.
METHODS: We conducted qualitative content analysis of audio-recorded and transcribed data of psychiatric outpatient consultations. We included 52 participants - 25 in the SDM group and 27 in the treatment as usual (TAU) group - and 104 consultations were analyzed, two per participant. The word count per topic was calculated using the transcripts.
RESULTS: Five categories for 28 topics were generated. The categories and percentages of word count were: (1) symptoms: 26.1%, (2) life: 37.4%, (3) treatment/service use: 16.3%, (4) global state/goal: 7.3%, and (5) others: 12.9%. The SDM tool significantly increased the overall conversation word count and consultation time. No significant difference was observed for the topic distribution between the two groups.
CONCLUSIONS: Daily life issues - especially those related to work - were the main topics discussed in psychiatric consultations. The SDM tool seems to facilitate discussion of patients\' concerns, but the topic distribution is likely to be similar regardless of whether or not the SDM tool was used.
CONCLUSIONS: Outpatient psychiatrists are expected to effectively address life-related issues.

The objective of the study was to develop and test feasibility of a framework of patient-important practical issues.
Guidelines and shared decision-making tools help facilitate discussions about patient-important outcomes of care alternatives, but typically ignore practical issues patients consider when implementing care into their daily routines. Using grounded theory, practical issues in the HealthTalk.org registry and in Option Grids were identified and categorized into a framework. We integrated the framework into the MAGIC authoring and publication platform and digitally structured authoring and publication platform and appraised its use in The BMJ Rapid Recommendations.
The framework included the following 15 categories: medication routine, tests and visits, procedure and device, recovery and adaptation, coordination of care, adverse effects, interactions and antidote, physical well-being, emotional well-being, pregnancy and nursing, costs and access, food and drinks, exercise and activities, social life and relationships, work and education, travel and driving. Implementation in 15 BMJ Rapid Recommendations added 283 issues to 35 recommendations. The most frequently used category was procedure and device, and the least frequent was social life and relationship.
Adding practical issues systematically to evidence summaries is feasible and can inform guidelines and tools for shared decision-making. How this inclusion can improve patient-centered care remains to be determined.

Cancer is a leading cause of death in the United States. Primary care providers (PCPs) juggle patient cancer prevention and screening along with managing acute and chronic health problems. However, clinical decision support (CDS) may assist PCPs in addressing patients\' cancer prevention and screening needs during short clinic visits. In this paper, we describe pre-implementation study design and cancer screening and prevention CDS changes made to maximize utilization and better fit a healthcare system\'s goals and culture. We employed the Consolidated Framework for Implementation Research (CFIR), useful for evaluating the implementation of CDS interventions in primary care settings, in understanding barriers and facilitators that led to those changes.
In a three-arm, pragmatic, 36 clinic cluster-randomized control trial, we integrated cancer screening and prevention CDS and shared decision-making tools (SDMT) into an existing electronic medical record-linked cardiovascular risk management CDS system. The integrated CDS is currently being tested within a predominately rural upper Midwestern healthcare system. Prior to CDS implementation, we catalogued pre-implementation changes made from 2016 to 2018 based on: pre-implementation site engagement; key informant interviews with healthcare system rooming staff, providers, and leadership; and pilot testing. We identified influential barriers, facilitators, and changes made in response through qualitative content analysis of meeting minutes and supportive documents. We then coded pre-implementation changes made and associated barriers and facilitators using the CFIR.
Based on our findings from system-wide pre-implementation engagement, pilot testing, and key informant interviews, we made changes to accommodate the needs of the healthcare system based on barriers and facilitators that fell within the Intervention Characteristics, Inner Setting, and Outer Setting CFIR domains. Changes included replacing the expansion of medical assistant roles in one intervention arm with targeted SDMT, as well as altering cancer prevention CDS and study design elements.
Pre-implementation changes to CDS may help meet healthcare systems\' evolving needs and optimize the intervention by being responsive to real-world implementation barriers and facilitators. Frameworks like the CFIR are useful tools for identifying areas where pre-implementation barriers and facilitators may result in design changes, both to research studies and CDS systems.
NCT02986230.

OBJECTIVE: To determine if shared decision-making tools (SDMTs) improve clinical outcomes for these children. Shared decision making (SDM) is a collaborative process in which patients and clinicians jointly establish treatment plans that integrate clinical evidence and patient values/preferences. We previously reported less decisional conflict using a SDMT for families of children with obstructive sleep apnea (OSA) without tonsillar hypertrophyl; however, the clinical impact of this finding is unknown.
METHODS: Prospective single-blind randomized controlled trial for consecutive patients referred to a multidisciplinary upper airway center. The study group used a SDMT, whereas the control group did not; all were followed until their next appointment and polysomnogram.
RESULTS: We assessed 50 families (24 study, 26 controls); mean age of patients was 8.8 (95% confidence interval 6.9-10.6) years, and 44% were female. After their initial visit, there was agreement between families and providers on the best treatment option for 22 of 24 (91.7%) study patients and 12 of 26 (46.2%) controls (P < 0.001). Before the first follow-up, four control families (15.4%) modified their treatment plan, whereas none of the study families did so (P =  0.04). Continuous positive airway pressure (CPAP) compliance was 27% (3 of 11) for controls and 57% (5 of 8) for study patients (P =  0.11). The median obstructive apnea-hypopnea index significantly improved in study patients from 13.4 (range, 20.0-57.2) to 3.5 (range 0.4-45.5, P =  0.01] events per hour, but not in controls, with 9.4 (range, 0.9-76.2) to 4.9 (range, 0-116, P =  0.10) events per hour.
CONCLUSIONS: Families of children with OSA without tonsillar hypertrophy who were counseled regarding treatment options using SMDTs were more likely to undergo agreed upon treatment and had higher CPAP compliance.
METHODS: 1b. Laryngoscope, 129:2646-2651, 2019.