Suchergebnisse

BACKGROUND: Decision quality measures the degree to which care decisions are knowledge-based and value-aligned. Because military service emphasizes hierarchy, command, and mandates some healthcare decisions, military service may attenuate patient autonomy in healthcare decisions and lower decision quality. VA is the nation's largest provider of orthopedic care. We compared decision quality in a sample of VA and non-VA patients seeking care for knee osteoarthritis. METHODS: Our study sample consisted of patients newly referred to our orthopedic clinic for the management of knee osteoarthritis. None of the study patients were exposed to a knee osteoarthritis decision aid. Consenting patients were administered the Hip/Knee Decision Quality Instrument (HK-DQI). In addition, they were surveyed about decision-making preferences and demographics. We compared results to a non-VA cohort from our academic institution's arthroplasty database. RESULTS: The HK-DQI Knowledge Score was lower in the VA cohort (45%, SD = 22, n = 25) compared with the non-VA cohort (53%, SD = 21, n = 177) (p = 0.04). The Concordance Score was lower in the VA cohort (36%, SD = 49%) compared with the control cohort (70%, SD 46%) (p = 0.003). Non-VA patients were more likely to make a high-quality decision (p = 0.05). Non-VA patients were more likely to favor a shared decision-making process (p = 0.002). CONCLUSIONS: Decision quality is lower in Veterans with knee osteoarthritis compared with civilians, placing them at risk for lower treatment satisfaction and possibly unwarranted surgical utilization. Our future work will examine if this difference is from conditioned military service behaviors or confounding demographic factors, and if conventional shared decision-making techniques will correct this deficiency.

PURPOSE: Due to the nature of military service, the patient–physician relationship in Veterans is unlike that seen in civilian life. The structure of the military is hypothesized to result in barriers to open patient–physician communication and patient participation in elective care decision-making. Decision quality is a measure of concordance between a chosen treatment and the aspects of medical care that matter most to an informed patient; high decision quality is synonymous with patient-centered care. While past research has examined how age and other demographic factors affect decision quality in Veterans, duration of military service, rank at discharge, and years since discharge have not been studied. PATIENTS AND METHODS: We enrolled 25 Veterans with knee osteoarthritis at a VA hospital. Enrollees completed a survey with demographic, military service, and decision-making preference questions and the Hip-Knee Decision Quality Instrument (HK-DQI), which measures patients' knowledge about their disease process, concordance of their treatment decision, and the considered elements in their decision-making process. RESULTS: The HK-DQI knowledge score had a significant, positive correlation with duration of military service (R(2)=0.36, p=0.004). Rank at discharge and years since discharge did not show a significant correlation with decision quality (p=0.500 and p=0.317, respectively). The concordance score did not show a statistically significant correlation with rank, duration of service, and years since discharge (p=0.640, p=0.486 and p=0.795, respectively). Additionally, decision process score was not significantly associated with rank, duration of military service, and years since discharge (p=0.380, p=0.885, and p=0.474, respectively). CONCLUSION: Decision quality in Veterans considering treatment for knee osteoarthritis appears to be correlated positively with duration of military service. These findings may present an opportunity for identification of Veterans at most risk of low decision quality and ...

Matthew J Sabatino,1,2 Clifford A Reilly,1 Samuel T Kunkel,1,2 Alexander J Titus,2,3 Dipak B Ramkumar,1,2 Philip P Goodney,2,4 Said A Ibrahim,5,6 Jonathan D Lurie,1,2 Eric R Henderson2,71Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA; 2The Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA; 3Program in Quantitative Biomedical Sciences, Geisel School of Medicine, Hanover, NH 03755, USA; 4Vascular Surgery Section, White River Junction VAMC, White River Junction, VT 05009, USA; 5Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA; 6Center of Innovation for Health Equity Research and Promotion (CHERP), VA Health Services and Research Development, Philadelphia, PA, 19104, USA; 7Orthopaedic Section, White River Junction VAMC, White River Junction, VT 05009, USAPurpose: Due to the nature of military service, the patient–physician relationship in Veterans is unlike that seen in civilian life. The structure of the military is hypothesized to result in barriers to open patient–physician communication and patient participation in elective care decision-making. Decision quality is a measure of concordance between a chosen treatment and the aspects of medical care that matter most to an informed patient; high decision quality is synonymous with patient-centered care. While past research has examined how age and other demographic factors affect decision quality in Veterans, duration of military service, rank at discharge, and years since discharge have not been studied.Patients and methods: We enrolled 25 Veterans with knee osteoarthritis at a VA hospital. Enrollees completed a survey with demographic, military service, and decision-making preference questions and the Hip-Knee Decision Quality Instrument (HK-DQI), which measures patients' knowledge about their disease process, concordance of their treatment decision, and the considered elements in their decision-making process.Results: The HK-DQI knowledge score had a significant, positive correlation with duration of military service (R2,=0.36, p=0.004). Rank at discharge and years since discharge did not show a significant correlation with decision quality (p=0.500 and p=0.317, respectively). The concordance score did not show a statistically significant correlation with rank, duration of service, and years since discharge (p=0.640, p=0.486 and p=0.795, respectively). Additionally, decision process score was not significantly associated with rank, duration of military service, and years since discharge (p=0.380, p=0.885, and p=0.474, respectively).Conclusion: Decision quality in Veterans considering treatment for knee osteoarthritis appears to be correlated positively with duration of military service. These findings may present an opportunity for identification of Veterans at most risk of low decision quality and customization of shared decision-making methods for Veterans by characteristics of military service.Keywords: Veterans, decision-quality, orthopaedics, knee osteoarthritis

Democracy should enable citizens to play an informed role in determining how power is exercised for their common wellbeing, but this only works if people have the understanding, skills and confidence to engage effectively in public affairs. Otherwise, any voting system can be subverted to serve the interests of propagandists and demagogues. This book brings together leading experts on learning for democracy to explore why and how the gap in civic competence should be bridged. Drawing on research findings and case examples from the UK, the US and elsewhere, it will set out why change is necessary, what could be taught differently to ensure effective political engagement, and how a lasting impact in improving citizens' learning for democratic participation can be made