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Biomedical subjects

Amiram Gafni

Publications and source records attributed to Amiram Gafni.

At least 19 recordsLinked to original sources
PubMed2006

Cultural influences on the physician-patient encounter: The case of shared treatment decision-making.

OBJECTIVE: In this paper we discuss the influence of culture on the process of treatment decision-making, and in particular, shared treatment decision-making in the physician-patient encounter. We explore two key issues: (1) the meaning of culture and the ways that it can affect treatment decision-making; (2) cultural issues and assumptions underlying the development and use of treatment decision aids. METHODS: This is a conceptual paper. Based on our knowledge and reading of the key literature in the treatment decision-making field, we looked for written examples where cultural influences were taken into account when discussing the physician-patient encounter and when designing instruments (decision aids) to help patients participate in making decisions. RESULTS: Our assessment of the situation is that to date, and with some recent exceptions, research in the above areas has not been culturally sensitive. CONCLUSION: We suggest that more research attention should be focused on exploring potential cultural variations in the meaning of and preferences for shared decision-making as well as on the applicability across cultural groups of decision aids developed to facilitate patient participation in treatment decision-making with physicians. PRACTICE IMPLICATIONS: Both patients and physicians need to be aware of the cultural assumptions underlying the development and use of decision aids and assess their cultural sensitivity to the needs and preferences of patients in diverse cultural groups.

Culture↗
PubMed2006

Capacity planning for cardiac catheterization: a case study.

BACKGROUND: Excessive waiting for procedures such as cardiac catheterization is an important issue for health care systems. Delays are generally attributed to a mismatch between demand and available capacity. Furthermore, due to the dynamic nature of short-term referral rates, procedure times, and patients' medical urgency, all of which are important contributors to the problem of excessive waiting time, it has been difficult to predict capacity needs accurately. The objective of our paper is to demonstrate how such calculations could be performed. METHODS: After constructing a patient flow model and populating it with appropriate data from 16 consecutive months of operations (n=6215 referrals) of a regional cardiac centre in Ontario, we used computer simulation to simulate the operations of catheterization laboratories in several "what-if" scenarios. We divided the patients into three urgency categories: U1--hospitalized patients, U2--urgent outpatients, U3--elective outpatients. We tested the accuracy of the model by comparing a 1-year sample of computer simulation with actual data which resulted in a highly significant correlation of 0.94. RESULTS: We observed from the referral cohort that waiting times were long, both overall and within each urgency category. We observed from the simulation models that: (1) a one-time infusion of capacity to clear the backlog failed to reduce the waiting times; (2) targeting extra capacity to highest urgency categories reduced waiting times overall and also benefited low urgency patients for whom specific increased capacity was not earmarked; (3) there were no significant effects on waiting times if in some cases patients or referring physicians were able to choose their cath physician; and (4) in situations where the arrival rates increased overall or within specific urgency categories, waiting times increased dramatically and failed to return to baseline for several months to years for the low urgency patients. Efficiency of the labs within the existing capacity could be improved by: (1) reducing changeover time between cases (2) externalizing and standardizing many of the pre- and post-procedural management of the patients, and (3) more carefully balancing the booking to reduce both slack and overtime. INTERPRETATION: Capacity determination is a complex and dynamic process. A combination of available clinical and administrative data, along with a computer simulation model, helps predict capacity needs and is the most appropriate strategy to minimize waiting of patients for procedures. This approach is generalizable and can lead to more effective management of waiting lists for a variety of procedures.

Cardiac Catheterization↗
PubMed2006

What is the number of older Canadians needed to screen by measurement of bone density to detect an undiagnosed case of osteoporosis? a population-based study from CaMos.

Routine bone mineral densitometry (BMD) screening has been recommended for women aged >or=65 yr (Osteoporosis Canada [OC], International Society for Clinical Densitometry [ISCD], Canadian and United States Task Forces on Preventative Healthcare, and National Osteoporosis Foundation) and for men >or=65 yr (OC) or >or=70 yr (ISCD). We estimated the number of older Canadians needed to screen (NNS) by BMD to detect an undiagnosed case of osteoporosis, using prospective, multicenter, population-based data from the Canadian Multicentre Osteoporosis Study (CaMos). We included participants aged >or=65 yr with baseline dual-energy X-ray absorptiometry (DXA) BMDs at the femoral neck and lumbar spine (L1-L4). Osteoporosis was defined by a T-score or=65 yr. The percentage prevalence and 95% confidence intervals were determined. In individuals aged >or=65 yr, the prevalence of osteoporosis was 25.6% in women (95% confidence interval, 24.0%, 27.3%) and 8.9% in men (7.3%, 10.8%). In 652 men aged >or=70 yr, the prevalence of osteoporosis was 11.3% (9.1%, 14.0%). Of the participants with BMD-defined osteoporosis, 76.6% of woman aged >or=65 yr (73.2%, 79.6%; 516 of 674 women), 93.4% of men aged >or=65 yr (86.4%, 96.9%; 85 of 91), and 93.2% of men >or=70 yr (84.9%, 97.0%; 68 of 73) were not aware of it. Thus, the minimum NNS by BMD testing to detect one previously undiagnosed case of osteoporosis in Canada is: 6 women aged >or=65 yr, 13 men aged >or=65 yr, and 10 men aged >or=70 yr.

Absorptiometry, Photon↗
PubMed2006

Recreation for children on social assistance, 4-17 years old, pays for itself the same year.

A randomized control trial completed in the Hamilton-Wentworth and Halton regions of Ontario, Canada, was created to assess the effects and expense of age-appropriate provider-initiated and subsidized versus self-directed and self-financed methods of recreation. Upon completion, this study proved that the annual per-person expenditure for the subsidized, quality recreation paid for itself by children's lower use of healthcare and social services. The children within the subsidized recreation group had lower use of physician, physiotherapy, probation, children's aid society, social work, psychologist and services in comparison with those in the non-subsidized group. The subsidized group also proved to be beneficial for the parents as well. The use of health and social services, by the parents in the subsidized group, was also decreased in comparison with those of the self-financed group. This group also proved to have improvement of the global socioeconomic status, with a 10% greater exit from the social assistance program within 1 year.

Adolescent↗
PubMed2006

The influence of child abuse on the pattern of expenditures in women's adult health service utilization in Ontario, Canada.

Childhood maltreatment is a common and serious problem for women, particularly in relation to impairment in adulthood. To our knowledge, no system-wide study has addressed the influence of childhood maltreatment on the cost of these women's adult health service utilization. This paper examines this relationship. The 1990 Ontario Health Survey (OHS) gathered information regarding determinants of physical health status and the use of health services. The 1991 Ontario Mental Health Supplement (OHSUP) examined a variety of childhood experiences as well as the prevalence of psychiatric disorders from a sample of OHS respondents. These were province-wide population health surveys of a probability-based sample of persons aged 15 years and older living in household dwellings in Ontario. The OHSUP randomly selected one member from each participating OHS household to be interviewed regarding personal experiences and mental health. This analysis used data from women aged 15-64 who participated in both the OHS and OHSUP. Self-reported health service utilization was collected in four groups of women--those who reported no history of child abuse, those with a history of physical abuse only, those who reported sexual abuse only, and those who reported both physical and sexual (combined) abuse. We hypothesized that a history of child abuse would result in greater adult health care costs. The results indicated that having a history of combined abuse nearly doubles mean annual ambulatory self-reported health care costs to 775 dollars (95% CI 504 dollars-1045 dollars) compared to a mean cost of 400 dollars with no abuse (95% CI 357 dollars-443 dollars). Median annual ambulatory self-reported health care costs were also increased in the combined abuse group, to 314 dollars (95% CI 220 dollars-429 dollars), compared to 138 dollars (95% CI 132 dollars-169 dollars) in those with no abuse. We conclude that child abuse in women is significantly associated with increased adult self-reported health care costs.

Adolescent↗
PubMed2006

The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial.

BACKGROUND: The Term Breech Trial compared the safety of planned cesarean and planned vaginal birth for breech presentations at term. The combined outcome of perinatal or neonatal death and serious neonatal morbidity was found to be significantly lower among babies delivered by planned cesarean section. In this study we conducted a cost analysis of the 2 approaches to breech presentations at delivery. METHODS: We used a third-party-payer (i.e., Ministry of Health) perspective. We included all costs for physician services and all hospital-related costs incurred by both the mother and the infant. We collected health care utilization and outcomes for all study participants during the trial. We used only the utilization data from countries with low national rates of perinatal death (< or = 20/1000). Seven hospitals across Canada (4 teaching and 3 community centres) were selected for unit cost calculations. RESULTS: The estimated mean cost of a planned cesarean was significantly lower than that of a planned vaginal birth (7165 dollars v. 8042 dollars per mother and infant; mean difference -877 dollars, 95% credible interval -1286 dollars to -473 dollars). The estimated mean cost of a planned cesarean was lower than that of a planned vaginal birth for both women having a first birth (7255 dollars v. 8440 dollars) and women having had at least one prior birth (7071 dollars v. 7559 dollars). Although the treatment effect was largest in the subgroup of women having their first child, there was no statistically significant interaction between treatment and parity since the 95% credible intervals for difference in treatment effects between parity equalling zero and parity of one or greater all include zero. INTERPRETATION: Planned cesarean section was found to be less costly than planned vaginal birth for the singleton fetus in a breech presentation at term in the Term Breech Trial.

Adult↗
PubMed2006

Seeking a second opinion: do patients need a second opinion when practice guidelines exist?

INTRODUCTION: Patients often search for a second opinion (i.e., a search for additional information on the diagnosis and/or treatment options and the potential prognosis, which will help the patient decide what to do or not to do, where, with whom and how). The scope of this phenomenon is not well documented. Also it is not clear if this is warranted or not. This paper aims to explore whether knowing that his clinician follows practice guidelines eliminates the need of a patient's to seek a second opinion. Given that practice guidelines should allow each patient to benefit from the best current clinical evidence, one might wonder if in such a context a second opinion is still necessary, and if so, for what reasons? METHODS: We review the literature to find the reasons that may prompt a patient to seek a second opinion before the implementation of practice guidelines. We then analyse, from a conceptual point of view, whether for 'informed patient' (i.e., one who knows about and understands practice guidelines) these reasons still hold after the implementation of practice guidelines and if new reasons for seeking a second opinion have emerged. We also discuss practical limitations to searching for a second opinion. RESULTS: We show that even if some reasons, like the search for a second opinion to check whether the treatment prescribed by the first physician is appropriate or not, can be questioned after the implementation of practice guidelines, an 'informed patient' may still wish to seek a second opinion stemming from new reasons which have emerged after the introduction of practice guidelines, e.g., to determine which practice guidelines his physician follows and whether they are appropriate to his case. SUMMARY AND CONCLUSION: We conclude that the implementation of practice guidelines will not eliminate the need for a second opinion consultation. On the contrary, the use of guidelines can even stimulate a broader request for second opinions. This conclusion however needs to be validated in an empirical study.

France↗
PubMed2006

What matters most in end-of-life care: perceptions of seriously ill patients and their family members.

BACKGROUND: Initiatives to improve end-of-life care are hampered by our nascent understanding of what quality care means to patients and their families. The primary purpose of this study was to describe what seriously ill patients in hospital and their family members consider to be the key elements of quality end-of-life care. METHODS: After deriving a list of 28 elements related to quality end-of-life care from existing literature, focus groups with experts and interviews with patients, we administered a face-to-face questionnaire to older patients with advanced cancer and chronic end-stage medical disease and their family members in 5 hospitals across Canada to assess their perspectives on the importance. We compared differences in ratings across various subgroups of patients and family members. RESULTS: Of 569 eligible patients and 176 family members, 440 patients (77%) and 160 relations (91%) agreed to participate. The elements rated as "extremely important" most frequently by the patients were "To have trust and confidence in the doctors looking after you" (55.8% of respondents), "Not to be kept alive on life support when there is little hope for a meaningful recovery" (55.7%), "That information about your disease be communicated to you by your doctor in an honest manner" (44.1%) and "To complete things and prepare for life's end - life review, resolving conflicts, saying goodbye" (43.9%). Significant differences in ratings of importance between patient groups and between patients and their family members were found for many elements of care. INTERPRETATION: Seriously ill patients and family members have defined the importance of various elements related to quality end-of-life care. The most important elements related to trust in the treating physician, avoidance of unwanted life support, effective communication, continuity of care and life completion. Variation in the perception of what matters the most indicates the need for customized or individualized approaches to providing end-of-life care.

Aged↗
PubMed2006

Incorporating patient preferences into orthopaedic practice: should the orthopaedic encounter change?

The issues concerning treatment decision-making are that often options for treatment lead to uncertain outcomes (benefits and risks) at the individual patient level and that both patients and physicians might value these outcomes differently. There are three main approaches commonly used to describe treatment decision-making including paternalistic, shared and informed decision-making. The challenge and responsibility of physicians is to effectively communicate to patients that they should feel welcome to participate in decision-making through whichever approach seems suitable to them. Changes in laws governing the ethics of medical practice mandate a more comprehensive decision-making tactic requiring a two-way flow of information between patient and physician. The key to information exchange lies in evoking patient preferences by informing the patient of the benefits and risks associated with each treatment option. Decision aids have been developed in a variety of forms to facilitate this transfer of information about available treatment alternatives in as unbiased fashion as possible. We believe that treatment options presented should include not only those available by the particular physicians at that institution but also those available at outside institutions and within other healthcare systems. We discuss barriers for physicians who wish to encourage patient participation such as the power differential that exists between patients and physicians, factors related to health policy, and those unique to surgery. We believe that investigation is necessary to understand how the differences between types of medical practices, or even within a medical field, will influence the importance that patients attach to having their values and preferences considered during treatment decision-making and to evaluate how this importance changes as the severity of adverse events associated with treatment outcomes changes. We feel that it is important for physicians and surgeons to begin to think about these issues and how they might investigate potential resolutions for incorporating patient values and sharing their own preferences for treatment options with their patients during the orthopaedic encounter.

Cost-Benefit Analysis↗
PubMed2006

Can contraindications compromise evidence-based, patient-centered clinical practice?

BACKGROUND: Despite their often weak evidence base, contraindications convey the unequivocally adverse risk-benefit profile of an intervention in a specific clinical context. However, some patients in that context may nonetheless prefer the contraindicated intervention (with its potential benefits and risks) to the available alternatives. The impact of contraindications on treatment decisions remains unexplored. OBJECTIVE: To provide an estimate of the impact of the "contraindication" label on treatment decisions. METHODS: We conducted an international 6-wave email/internet and fax survey of practicing clinicians who were members of the American Diabetes Association or the College of Physicians and Surgeons of Ontario and had available email addresses and fax numbers. Each participant considered one of two patient scenarios. In each scenario, the patient expressed a strong preference for use of a medication that carried a "contraindication" label despite weak evidence of harm. We designed these scenarios so that respondents who placed greater weight on patient preferences and research evidence than on the label "contraindication" would be ready to prescribe the contraindicated medication. We determined the frequency with which the label "contraindication" dominated participants' treatment decisions despite patient preferences and weak evidence of harm. RESULTS: 466 participants responded (22% response rate). Depending on the group and scenario, contraindications dominated the decisions of 47% to 89% of surveyed clinicians, superseding patient preferences and research evidence. CONCLUSIONS: The label "contraindication" may often dominate clinicians' decisions about treatment and may compromise evidence-based, patient-centered clinical practice. Further research should elucidate the process that leads to the formulation of contraindications and its impact on treatment decision-making.

Attitude of Health Personnel↗
PubMed2006

Hospital and home chemotherapy for children with leukemia: a randomized cross-over study.

BACKGROUND: The study objective was to compare a hospital-based and a home-based chemotherapy program for children with acute lymphoblastic leukemia (ALL) in relation to Quality of Life (QOL), safety, caregiver burden, and costs. PROCEDURE: A randomized cross-over trial (RCT) design with repeated measures was conducted with 23 children with ALL who attended the oncology outpatient clinic of a metropolitan university affiliated tertiary level pediatric hospital and who also received home visits from a community health services care provider in central Canada. RESULTS: During the home-treatment phase, children were more capable of maintaining their usual routines than when receiving hospital chemotherapy (Wilcoxon statistic = 80, P = 0.023), but they appeared to experience greater emotional distress (Wilcoxon sign rank statistic S = 66, P = 0.043) according to parental report. Treatment location had no effect on caregiver burden and adverse effects. No significant differences between groups existed with respect to societal costs of care. As the child's age increased, QOL improved relative to younger children (t(20) = -2.37, P = 0.02), the time burden related to child care tasks was reduced (t(21) = -3.56, P = 0.002), caregiver effort/difficulty in physical and behavioral support decreased (t(21) = -2.09, P = 0.049) and the odds of experiencing one or more adverse events decreased (OR = 0.79, CI = (0.63-1.00), chi(1) (2) = 4.01, P = 0.045). CONCLUSIONS: With few differences noted between groups, these results indicate preliminary support for administrating some or all of a child's chemotherapy at home. Home chemotherapy was associated with specific improvements and decrements in parent reported QOL. No effects were seen on burden of care, adverse events, or cost. Overall, young age adversely affected QOL, burden of care, and adverse events. These data provide important information to families and caregivers as they consider home or hospital-based therapy in childhood ALL.

Age Factors↗
PubMed2006

Sex differences in hospital admissions from emergency departments in asthmatic adults: a population-based study.

BACKGROUND: Women represent the majority of adult patients hospitalized for asthma. Analyzing the course of emergency department (ED) visits before hospital admission can help understanding of the mechanisms behind the excess of hospitalizations in women. OBJECTIVE: To investigate sex differences in hospital admission rates in adult patients with asthma visiting EDs in Ontario. METHODS: Asthmatic patients 18 to 55 years old who visited Ontario EDs between April 1, 2003, and March 31, 2004, were identified using the Canadian Institute for Health Information's National Ambulatory Care Reporting System. The generalized estimating equations for binary outcome were used to model rates of hospital admission with sex, age, and triage (severity) score as covariates. Analysis was further stratified by the ED volume. RESULTS: Women represented 62.2% of all ED visits. They were on average older than men, but both groups had similar distributions of triage scores. Female patients accounted for more hospital admissions than male patients (7.4% vs 4.5%). After adjusting for age and triage score, women were more likely to be admitted than men (odds ratio, 1.64; 95% confidence interval, 1.41-1.90). The interaction found between sex and triage level indicates that hospitalized women may have less severe asthma than hospitalized men. Analysis by ED volume did not significantly alter the results. CONCLUSION: The higher admission rates in women may be related to sex differences in the subjective perception of dyspnea, management of asthma by ED physician, or inadequate ambulatory care strategies in women and thus merit further investigation.

Adolescent↗
PubMed2006

Is fetal gender associated with emergency department visits for asthma during pregnancy?

BACKGROUND: To investigate if fetal gender (1) affects the risk of having an emergency department (ED) visit for asthma; and (2) is associated with adverse pregnancy outcomes among women who had at least one visit to the ED for asthma during pregnancy. METHODS: We linked two provincial administrative databases containing records on in-patient deliveries and ED visits. The study sample included women who delivered a live singleton baby between April 2003 and March 2004. Pregnant women who made at least one ED visit for asthma were counted as cases and the rest of the women as control subjects. We performed a multivariable analysis using logistic regression to model the risk of having an ED visit for asthma, with fetal gender being one of the predictors. In addition, a series of multivariable logistic regressions were also constructed separately for cases and controls for the following adverse delivery outcomes: low birth weight baby, preterm delivery, and delivery via Caesarian section. RESULTS: Among 109,173 live singleton deliveries, 530 women had visited ED due to asthma during pregnancy. While having an ED visit for asthma was positively associated with teenage pregnancy, low income, and presence of pregnancy-induced hypertension, it was not associated with fetal gender (OR 1.01, 95% CI 0.85-1.19). Fetal gender was not a significant predictor of adverse pregnancy outcomes among women who had an asthma ED visit during pregnancy. CONCLUSION: Fetal gender does not affect the risk of having an ED visit for asthma during pregnancy, and it is not associated with adverse pregnancy outcomes among women who had an asthma-related ED during pregnancy.

Adolescent↗
PubMed2006

Patient characteristics associated with nocturnal emergency department visits for asthma.

STUDY OBJECTIVES: To identify patient characteristics associated with nocturnal emergency department (ED) visits for asthma. METHODS: Asthmatic patients 18 to 55 years of age who visited Ontario EDs between April 1, 2003 and March 31, 2004, were identified through an administrative clinical database. Patients' time of ED presentation was analyzed for circadian pattern using histogram and polynomial regression. Risk of nocturnal visit (presentation at the ED between midnight and 8 AM) was modeled through generalized estimating equations with patient age, gender, and asthma severity level as covariates. The effect of nocturnal visit on return rate to the ED within 14 days after the initial visit was determined through Cox regression. RESULTS: During study period there were 31,490 ED visits for asthma made by 23,253 patients. Their time of ED visits displayed a distinct circadian pattern with peak between 7 and 8 PM, and trough at 5 AM. Approximately 22% of visits (6,868) occurred at night. Men had higher odds of presenting at night than women (OR 1.61; 1.49-1.73). Patients with mild asthma were significantly less likely to visit the ED at night than patients with moderate or severe asthma. Nocturnal presentation was not associated with higher odds of subsequent returns to the ED (HR 1.00; 0.89-1.14). CONCLUSION: Higher odds of nocturnal visits in men suggest the existence of gender-differences in health-seeking behavior in asthmatics. Although nocturnal visits are associated with more severe asthma, they do not lead to higher return rates.

Adolescent↗
PubMed2006

Changes in children's behavior and costs for service use associated with parents' response to treatment for dysthymia.

OBJECTIVE: This study examined differences in children's behavior and expenditures for health and social services used when their parents with dysthymia did or did not respond to antidepressant therapy. METHOD: Children ages 4 to 16 years of consenting parents enrolled in a treatment trial for dysthymia who did and did not respond to treatment were compared at baseline and 24 months. The responder was a parent with at least a 40% reduction in his or her baseline depressive symptoms using the Montgomery Asberg Depression Rating Scale. Children's behavior was measured using the Child Behavior Checklist, and expenditures for health and social services use was measured in Canadian dollars using the Health and Social Service Utilization Questionnaire. RESULTS: Children of parents with dysthymia who responded to treatment had significantly greater reductions in emotional symptoms at 2-year follow-up than children of nonresponders, along with an economically important (not statistically significant) reduction in expenditures for health and social services use. CONCLUSIONS: Reductions in parental symptoms of dysthymia may be associated with reductions in childhood behavioral problems and in expenditures for the child's use of services.

Adolescent↗
PubMed2006

Health promotion for frail older home care clients.

AIM: This paper reports a study evaluating the comparative effects and costs of a proactive nursing health promotion intervention in addition to usual home care for older people compared with usual home care services alone. BACKGROUND: An ageing population, budget constraints and technological advances in many countries have increased the pressure on home care resources. The result is a shift in nursing services from health promotion to meet the more pressing need for postacute care. For frail older people with long-term needs, these changes combine to create a fragmented system of health service delivery, characterized by providing nursing on demand rather than proactively. METHODS: A two-armed, single-blind, randomized controlled trial was carried out with older people > or =75 years and eligible for personal support services through a home care programme in Ontario, Canada. Participants were randomly allocated either to usual home care (control) or to a nursing (experimental) group. In addition to usual home care, the nursing group received a health assessment combined with regular home visits or telephone contacts, health education about management of illness, coordination of community services, and use of empowerment strategies to enhance independence. The data were collected in 2001-2002. RESULTS: Of the 288 older people who were randomly allocated at baseline, 242 (84%) completed the study (120 nursing group; 122 control group). Proactively providing older people with nursing health promotion, compared with providing nursing services on-demand, resulted in better mental health functioning (P = 0.009), a reduction in depression (P = 0.009), and enhanced perceptions of social support (P = 0.009) at no additional cost from a societal perspective. CONCLUSIONS: Home based nursing health promotion, proactively provided to frail older people with chronic health needs, enhances quality of life while not increasing the overall costs of health care. The results underscore the need to re-invest in nursing services for health promotion for older clients receiving home care.

Adaptation, Psychological↗
PubMed2006

A shared treatment decision-making approach between patients with chronic conditions and their clinicians: the case of diabetes.

In this paper, we discuss the Charles et al. approach to shared treatment decision-making (STDM) as applied to patients with chronic conditions and their clinicians. We perceive differences between the type of treatment decisions (e.g. end-of-life care, surgical treatment of cancer) that generated existing approaches of shared decision-making for acute care conditions (including the Charles et al. model) and the treatment decisions that patients with chronic conditions need to make and revisit on an ongoing basis. For instance, treatment decisions in the chronic care setting are more likely to require a more active patient role in carrying out the decision and to offer a longer window of opportunity to make decisions and to revisit and reverse them without important loss than acute care decisions. The latter may require minimal patient participation to realize, are often urgent, and may be irreversible. Given these differences, we explore the applicability of the Charles et al. model of STDM in the chronic care context, especially chronic care that relies heavily on patient self-management (e.g. diabetes). To apply the Charles et al. model in this clinical context, we suggest the need to emphasize the patient-clinician relationship as one of partners in making difficult treatment choices and to add a new component to the shared decision-making approach: the need for an ongoing partnership between the clinical team (not just the clinician) and the patient. In the last section of the paper, we explore potential healthcare system barriers to STDM in chronic care delivery. Throughout the discussion we identify areas for further research.

Aged↗