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      What is the effect of a decision aid in potentially vulnerable parents? Insights from the head CT choice randomized trial

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          Abstract

          Objective

          To test the hypotheses that use of the Head CT Choice decision aid would be similarly effective in all parent/patient dyads but parents with high (vs low) numeracy experience a greater increase in knowledge while those with low (vs high) health literacy experience a greater increase in trust.

          Methods

          This was a secondary analysis of a cluster randomized trial conducted at seven sites. One hundred seventy‐two clinicians caring for 971 children at intermediate risk for clinically important traumatic brain injuries were randomized to shared decision making facilitated by the DA (n = 493) or to usual care (n = 478). We assessed for subgroup effects based on patient and parent characteristics, including socioeconomic status (health literacy, numeracy and income). We tested for interactions using regression models with indicators for arm assignment and study site.

          Results

          The decision aid did not increase knowledge more in parents with high numeracy ( P for interaction [ P int] = 0.14) or physician trust more in parents with low health literacy ( P int = 0.34). The decision aid decreased decisional conflict more in non‐white parents (decisional conflict scale, −8.14, 95% CI: −12.33 to −3.95; P int = 0.05) and increased physician trust more in socioeconomically disadvantaged parents (trust in physician scale, OR: 8.59, 95% CI: 2.35‐14.83; P int = 0.04).

          Conclusions

          Use of the Head CT Choice decision aid resulted in less decisional conflict in non‐white parents and greater physician trust in socioeconomically disadvantaged parents. Decision aids may be particularly effective in potentially vulnerable parents.

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          Most cited references14

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          CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials.

          The CONSORT (Consolidated Standards of Reporting Trials) statement is used worldwide to improve the reporting of randomized, controlled trials. Schulz and colleagues describe the latest version, CONSORT 2010, which updates the reporting guideline based on new methodological evidence and accumulating experience.
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            Brief questions to identify patients with inadequate health literacy.

            No practical method for identifying patients with low heath literacy exists. We sought to develop screening questions for identifying patients with inadequate or marginal health literacy. Patients (n=332) at a VA preoperative clinic completed in-person interviews that included 16 health literacy screening questions on a 5-point Likert scale, followed by a validated health literacy measure, the Short Test of Functional Health Literacy in Adults (STOHFLA). Based on the STOFHLA, patients were classified as having either inadequate, marginal, or adequate health literacy. Each of the 16 screening questions was evaluated and compared to two comparison standards: (1) inadequate health literacy and (2) inadequate or marginal health literacy on the STOHFLA. Fifteen participants (4.5%) had inadequate health literacy and 25 (7.5%) had marginal health literacy on the STOHFLA. Three of the screening questions, "How often do you have someone help you read hospital materials?" "How confident are you filling out medical forms by yourself?" and "How often do you have problems learning about your medical condition because of difficulty understanding written information?" were effective in detecting inadequate health literacy (area under the receiver operating characteristic curve of 0.87, 0.80, and 0.76, respectively). These questions were weaker for identifying patients with marginal health literacy. Three questions were each effective screening tests for inadequate health literacy in this population.
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              Race, gender, and partnership in the patient-physician relationship.

              Many studies have documented race and gender differences in health care received by patients. However, few studies have related differences in the quality of interpersonal care to patient and physician race and gender. To describe how the race/ethnicity and gender of patients and physicians are associated with physicians' participatory decision-making (PDM) styles. Telephone survey conducted between November 1996 and June 1998 of 1816 adults aged 18 to 65 years (mean age, 41 years) who had recently attended 1 of 32 primary care practices associated with a large mixed-model managed care organization in an urban setting. Sixty-six percent of patients surveyed were female, 43% were white, and 45% were African American. The physician sample (n = 64) was 63% male, with 56% white, and 25% African American. Patients' ratings of their physicians' PDM style on a 100-point scale. African American patients rated their visits as significantly less participatory than whites in models adjusting for patient age, gender, education, marital status, health status, and length of the patient-physician relationship (mean [SE] PDM score, 58.0 [1.2] vs 60.6 [3.3]; P = .03). Ratings of minority and white physicians did not differ with respect to PDM style (adjusted mean [SE] PDM score for African Americans, 59.2 [1.7] vs whites, 61.7 [3.1]; P = .13). Patients in race-concordant relationships with their physicians rated their visits as significantly more participatory than patients in race-discordant relationships (difference [SE], 2.6 [1.1]; P = .02). Patients of female physicians had more participatory visits (adjusted mean [SE] PDM score for female, 62.4 [1.3] vs male, 59.5 [3.1]; P = .03), but gender concordance between physicians and patients was not significantly related to PDM score (unadjusted mean [SE] PDM score, 76.0 [1.0] for concordant vs 74.5 [0.9] for discordant; P = .12). Patient satisfaction was highly associated with PDM score within all race/ethnicity groups. Our data suggest that African American patients rate their visits with physicians as less participatory than whites. However, patients seeing physicians of their own race rate their physicians' decision-making styles as more participatory. Improving cross-cultural communication between primary care physicians and patients and providing patients with access to a diverse group of physicians may lead to more patient involvement in care, higher levels of patient satisfaction, and better health outcomes.
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                Author and article information

                Contributors
                Role: Research Fellow
                Role: Professor, Chair
                Role: Assistant Professor
                Role: Chief of Critical Care Services
                Role: Professor
                Role: Associate Professor
                Role: Associate Professor
                Role: Associate Professor
                Role: Data Quality Analyst
                Role: Professor
                Role: Senior Health Services Analyst
                Role: Senior Program Coordinator
                Role: Assistant Professor
                Role: Professor
                Role: Professor, Vice Chair for Researchehess@uabmc.edu
                Journal
                Health Expect
                Health Expect
                10.1111/(ISSN)1369-7625
                HEX
                Health Expectations : An International Journal of Public Participation in Health Care and Health Policy
                John Wiley and Sons Inc. (Hoboken )
                1369-6513
                1369-7625
                23 November 2019
                February 2020
                : 23
                : 1 ( doiID: 10.1111/hex.v23.1 )
                : 63-74
                Affiliations
                [ 1 ] Department of Emergency Medicine University of Alabama at Birmingham Birmingham AL USA
                [ 2 ] Departments of Emergency Medicine and Pediatrics University of California Davis School of Medicine University of California Davis Health Sacramento CA USA
                [ 3 ] Division of Pediatric Emergency Medicine Departments of Emergency Medicine and Pediatrics Mayo Clinic Rochester MN USA
                [ 4 ] Department of Pediatric Emergency Medicine Children’s Hospitals and Clinics of Minnesota Minneapolis MN USA
                [ 5 ] Department of Emergency Medicine University of California Davis School of Medicine University of California Davis Health Sacramento CA USA
                [ 6 ] Division of Pediatric Emergency Medicine Department of Pediatrics University of Minnesota Minneapolis MN USA
                [ 7 ] Division of Emergency Medicine Nationwide Children’s Hospital Columbus OH USA
                [ 8 ] Division of Emergency Medicine Boston Children’s Hospital Boston MA USA
                [ 9 ] Parent Representative Rochester MN USA
                [ 10 ] Division of Health Care Policy and Research Department of Health Sciences Research Mayo Clinic College of Medicine Rochester MN USA
                [ 11 ] Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery Rochester MN USA
                [ 12 ] Division of Trauma, Critical Care and General Surgery Departments of Emergency Medicine and Surgery Mayo Clinic College of Medicine Rochester MN USA
                [ 13 ] Yale University School of Medicine New Haven CT USA
                [ 14 ] Health Research & Educational Trust Chicago IL USA
                [ 15 ] Knowledge and Evaluation Research Unit Department of Internal Medicine Mayo Clinic Rochester MN USA
                [ 16 ] Department of Emergency Medicine Mayo Clinic Rochester MN USA
                Author notes
                [*] [* ] Correspondence

                Erik P. Hess, Department of Emergency Medicine, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL 35249, USA.

                Email: ehess@ 123456uabmc.edu

                Author information
                https://orcid.org/0000-0003-0595-2898
                https://orcid.org/0000-0002-6499-9592
                Article
                HEX12965
                10.1111/hex.12965
                6978876
                31758633
                3dcbafac-094a-484c-ac29-a4654fb535ea
                © 2019 The Authors Health Expectations published by John Wiley & Sons Ltd

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                : 11 April 2019
                : 24 July 2019
                : 28 August 2019
                Page count
                Figures: 4, Tables: 3, Pages: 12, Words: 7396
                Funding
                Funded by: Patient‐Centered Outcomes Research Institute (PCORI) , open-funder-registry 10.13039/100006093;
                Award ID: 12‐11‐4435
                Categories
                Original Research Paper
                Original Research Papers
                Custom metadata
                2.0
                February 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.7.5 mode:remove_FC converted:24.01.2020

                Health & Social care
                decision aid,head trauma,paediatrics,shared decision making
                Health & Social care
                decision aid, head trauma, paediatrics, shared decision making

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