Rationale & Objective Chronic kidney disease (CKD) can progress rapidly, and patients are often unprepared to make kidney failure treatment decisions. We aimed to better understand patients’ preferences for and experiences of shared and informed decision making (SDM) regarding kidney replacement therapy before kidney failure. Study Design Cross-sectional study. Setting & Participants Adults receiving nephrology care at CKD clinics in rural Pennsylvania. Predictors Estimated glomerular filtration rate, 2-year risk for kidney failure, duration and frequency of nephrology care, and preference for SDM. Outcomes Occurrence and extent of kidney replacement therapy discussions and participants’ satisfaction with those discussions. Analytic Approach Multivariable logistic regression to quantify associations between participants’ characteristics and whether they had discussions. Results The 447 study participants had a median age of 72 (IQR, 64-80) years and mean estimated glomerular filtration rate of 33 (SD, 12) mL/min/1.73 m 2 . Most (96%) were White, high school educated (67%), and retired (65%). Most (72%) participants preferred a shared approach to kidney treatment decision making, and only 35% discussed dialysis or transplantation with their kidney teams. Participants who had discussions (n = 158) were often completely satisfied (63%) but infrequently discussed potential treatment-related impacts on their lives. In multivariable analyses, those with a high risk for kidney failure within 2 years (OR, 3.24 [95% CI, 1.72-6.11]; P < 0.01), longer-term nephrology care (OR, 1.12 [95% CI, 1.05-1.20] per 1 additional year; P < 0.01), and more nephrology visits in the prior 2 years (OR, 1.34 [95% CI, 1.20-1.51] per 1 additional visit; P < 0.01) had higher odds of having discussed dialysis or transplantation. Limitations Single health system study. Conclusions Most patients preferred sharing CKD treatment decisions with their providers, but treatment discussions were infrequent and often did not address key treatment impacts. Longitudinal nephrology care and frequent visits may help ensure that patients have optimal SDM experiences.
Contemporary mental health policies call for increased involvement of consumers in leadership across mental health service design, delivery, and evaluation. However, consumer leadership is not currently well understood within academia or in mental health services themselves. This study investigates how consumer leadership is currently conceptualized by stakeholders at the service delivery level. To this end, semistructured interviews were conducted with 14 mental health organization members identifying as consumer leaders, colleagues supporting consumer leaders, or organization executives. Interview data were analysed using an inductive thematic analysis to develop a broad understanding of participants’ perceptions of consumer leadership. Findings indicate constructions of consumer leadership within mental health organizations can be understood in relation to four themes: consumer leadership roles, requirements, purpose, and process. Inconsistencies across participants’ perceptions of consumer leadership were identified as constituting barriers to its development, highlighting the need to better clarify the nature of consumer leadership.
The following abstracts are taken from journals of interest to our readers and are reviewed Diagn Cytopathol Nov 2005;33(5):338Y43 Many articles concerning conventional Pap smears, ThinPrep(R) liquid-based cytology (LBC) and Hybrid-Capture II HPV test (HC II) have been published. This study of 2585 women from the French Society of Clinical Cytology may be different for several reasons: 1) It was financially independent. 2) It compared the efficiency of the conventional Pap smear and LBC, of the conventional Pap smear and HC II \ , (Cytyc, Foxborough, MA). It included an economic study based on real costs. Colposcopy, was available and biopsies were performed whenever a lesion was detected for all subjects. The conventional Pap smear, the LBC (split-sample technique), the colposcopy, and the biopsies were done at the same time. Two groups were studied, a group A of a high-risk population, a group B of a screening population. The statistical analysis of the results showed that conventional Pap smears consistently had superior or equivalent sensitivity and specificity compared to LBC for the lesions at threshold CIN-1 (Cervical Intraepithelial Neoplasia) or CIN-2 or higher. It showed the low specificity of the HC II. Finally, the LBC mean cost was never covered by the Social Security tariff. Comment: This article is interesting in that it points out something we see in practice many HPV smears with no colposcopic findings. It points out the need to screen is probably as important as the way to screen. The conventional smear is still credible and perhaps a more reasonable alternative to the LBC in many settings. (TMJ) other settings, where the prevalence of cervical disease was higher. However, a combined use of VIA or VILI with the Pap test or HCII allowed specific detection of cervical abnormalities. Comment: We receive many submissions about alternatives to conventional Pap smears. Most are studying VIA in settings where Pap smears are too expensive to be used on a regular basis. I am sure that studies like the one above are valuable in determining a best test. The question however will always remain is a less sensitive test better than no test at all? (TMJ) Reproduced with permission from LO Sarian, SF Derchain, P Naud, et al. Evaluation of visual inspection with acetic acid (VIA), Lugol's iodine (VILI) cervical cytology and HPV testing as cervical screening tools in Latin America.
Policy mandates consumer involvement in decisions at all levels of the mental health system. One barrier to this involvement is the expectation that consumers involved in systemic work represent broader consumer experiences. To examine how the rhetoric of 'representation' was used in relation to consumer involvement in mental health, a qualitative exploratory design was employed using interviews for data collection. Participants were consumers (n = 6) working with public or private mental health organizations in Australia, and colleagues (n = 3) or managers (n = 5) of these consumers. Discursive psychological principles informed the analytic process, to explore contexts in which 'representativeness' was used to empower and disempower consumers. The findings suggest there is a lack of clarity about what is meant by representation in the mental health sector. Expecting individual consumer leaders to be representative of consumer views more broadly disempowered them in their roles. Some participants instead discussed ways that organizations should be responsible for seeking representation from more consumer leaders, thus empowering consumers working in the sector. Using the term 'representative' to refer to consumers working in mental health does not reflect the value of the consumer perspective and is not well understood within the sector. Comprehensive training should be provided so that mental health service providers are clear regarding the expectations of people in these roles.
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