source: Endocrine Society

year: 2015

authors: Juan Pablo Brito, Ana Castaneda-Guarderas, Michael R Gionfriddo, Spyridoula Maraka, Naykky Maruquel Singh Ospina, Victor M Montori

There are three effective treatments for Graves Disease (GD): thyroidectomy, radioactive iodine, and antithyroid drugs. These options differ in their efficacy, safety, convenience, and costs; none is clearly superior to the others for all patients. Practice patterns, however, suggest that patients are more likely to receive a particular mode of therapy depending on where they receive care. This inconsistency of practice suggests that GD patients are not receiving evidence-based patient-centered care. The overall goal of this study was to develop a decision aid for the treatment of GD.

Methods:
To develop the decision aid, we used a framework consisting of appraisal of existing evidence, prototypes development, field-testing and training. To test its impact, we designed and conducted a quasi-randomized trial. We recruited patients referred to the Division of Endocrinology at Mayo Clinic in Rochester, MN for the management of GD during the period from April 2013 to December 2013 to and allocated them to usual care (UC); patients referred in the period January 2014 to September 2014 received care with GD choice. The primary outcomes were patient knowledge, patient involvement in decision-making and treatment choice.  

Results:
We engaged patients, clinicians, health service researchers, and designers to develop a decision aid for use during the clinical encounter, which we dubbed GD Choice. This is an interim report: of the 52 patients evaluable for analysis, 33 were in the UC arm and 19 in the decision aid arm.  Baseline characteristics were found to not differ between arms.  Compared to UC, patients receiving GD Choice had greater involvement in decision making, as measured by the OPTION scale (mean OPTION score, 38.5 vs. 30.8 out of 100 points, difference 7.6 (95% CI 1.9, 13.4). p=0.01). We also found a large but imprecise improvements in decisional uncertainty among patients using GD choice compared to patients in the UC arm (31/100 points vs. 19/100 points, p=0.19). There were no differences in participant-reported measures of shared decision making (SDMQ9). While imprecise, there was evidence of more knowledge about side effects in the GD Choice arm and evidence of difference in uptake of RAI across arms.

Conclusions:
We were able to develop GD Choice, a feasible, acceptable, efficient, and effective encounter decision aid to promote shared decision making about treatment options for Graves Disease. GD Choice improves patient involvement in decision making about treatment options without increasing the length of the consultation. However, knowledge transfer, decisional uncertainty, and effect on treatment choice yielded imprecise results suggesting no difference across both groups.

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