Best of the Best Gen Surg - Pilot Randomized Control Trial Evaluating the Use of a Shared Decision Making Aid for Older Ventral Hernia Patients - Dr. Kushner

So from the American Hernia Society we have the first paper presented by Doctor Bradley S. Kushner, and the paper is entitled Pilot Randomized Control Trial Evaluating the Use of a Shared Decision Making Aid for Older ventral hernia Patients. That would be me. Phase 2 of the longitudinal geriatric assessment and medical perspective screening, the GRMS program. That's what my grandchildren call me. Doctor Kushner, please present your paper. Hello, my name is Bradley Kushner. I'm a general surgery resident at the Washington University in St. Louis. I would like to thank Globalcast MD for the opportunity to share our pilot study evaluating the use of a shared decision making aid for older ventral hernia patients. The authors have no relevant disclosures to report. Shared decision making defined as care that is evidence informed, respectful, and responsive to an individual patient's preferences is ideally suited to the complex abdominal wall surgery. Shared decision making's collaborative communication processes encourages patients and their family to consider how, when, and if an abdominal wall defect should be repaired. Unfortunately, surgeons often struggle to perceive and to incorporate shared decision making into their practice. Surgical decision making is also complicated by the fact that the American population is rapidly aging. By the year 2050, the number of adults 60 years of age or older will at least double. Additionally, the decision to operate on an older patient is more complex. Older individuals often present with age-related risk factors and morbidities, many of which have been shown to predict the mortality and morbidity following eventual hernia repair. In phase 1 of our team's multi-phase project, the geriatric assessment and Medical Preoperative Screening Program, which we affectionately term cramps, we demonstrated that these age-related risk factors in our elective hernia population are both common and present a real challenge to the hernia surgeon. Now in phase 2 we sought to address whether using a novel shared decision making aid could improve the shared decision making process of older patients offered on elective ventral hernia repair. The novel shared decision making tool was designed based on the Agency for Healthcare Research and Quality suggested framework for incorporating shared decision making into practice and included 5 key parts as shown on the screen. The tool was designed to be completed in real time during the patient consultation and was designed to act as a living document that the patients could reference to and bring to their surgery date or subsequent appointments. In this pilot study, we evaluated the tools effectiveness and feasibility by enrolling patients 60 years of age or older with the ventral hernia repair. Patients were excluded if they were deemed to be a non-operative candidate despite potential future prehabilitation options or who had a documented history of cognitive impairment. Patients were randomized in a 1 to 1 fashion. In the experimental arm, the consultation was guided by the use of a novel shared decision making aid. During the 4 month trial enrollment period, 18 patients were consented and randomized, half to each of the experimental and control groups. The overall recruitment percentage was greater than 95%. The cohorts were well matched in terms of age, obesity, and gender. And we found that comorbidities and frailty were similar between both groups. The median time of consultation was 9 minutes longer in the experimental group. However, there was a higher retention of key hernia knowledge in the experimental group when patients were given a follow-up hernia quiz one week after the initial consultation. Also, 75% of patients in the experimental group perce perceived their visit as shared decision making as compared to only 50% in the control group when using the collaborate scale. Although while not statistically significant, we found a meaningful clinical decrease in the decisional conflict of patients in the experimental group. As previous groups have found that for every point decrease on the decisional conflict scale, there was an associated 19% less likelihood to blame doctors for poorer outcomes, therefore, our difference of 6 points was certainly clinically meaningful. Interestingly, the two most important treatment goals identified by patients in the experimental group were improving quality of life and preventing hernia recurrence. Only 1 patient previously had discussed their code status with their doctor, and only 33% had a documented power of attorney. Incorporating a formalized shared decision making tool into a busy hernia surgical practice is both feasible, and patients are overwhelmingly satisfied with having the tool serving as a living document for their reference. In fact, 100% of patients in the experimental group both enjoyed the shared decision making aid and found it to be a useful exercise when asked about it on exit interview. Our early results suggest that the incorporation of the shared decision making aid improves the retention of basic hernia knowledge and can clinically reduce the decisional conflict of patients. With this pilot study, we identified key action items for the tool's future incorporation, including condensing its aid to improve its usability. The Department of Minimally Invasive Surgery at the Washington University would like to thank everyone for their time and is happy to answer any additional questions in the future. So thank you very much. Uh, that's great. Uh, we really appreciate that paper very clearly presented. Um, I'm gonna ask Doctor Rosen if he has any comments on this. Yeah, sure. So first of all, Bradley and, and all, all the speakers, congratulations on being here. Uh, I think to me. You know, this is the excitement of research. Uh, great research often asks more questions than it answers, um, and it kind of propels us to go in different directions. So, kind of with that in mind, I, I really enjoyed this. I, I, I like the idea. I, I have two general questions for you. The first is, it actually the mechanics of running this. Um, when you consented the patients, and I, I, I, I'm just curious about the patient blinding. Because did the people who were not getting shared decision making know that something was being withheld from them after they signed the consent? So how did you manage that bias? Yeah. Well, uh, Doctor Ponskys and Doctor Rosen, thank you again for allowing me the opportunity to be here and thank you to Global Cat MD for the opportunity. Uh, yeah, Doctor Rosen, that's a great question. Um, so, uh, looking at the, uh, schedules of our three main hernia, uh, surgeons at our institution, identified patients who are eligible about a week or two before their first hernia clinic. Um, and after doing so, I ended up calling the patients, um, told them about our study in which we're looking about shared decision-making. Um, and I told them that they would be randomized to either a, a newer tool that they would be getting, um, or kind of the standard, um, shared decision-making visit that our surgeons typically do. Um, so, Um, actually, our IRB had us, uh, tell them after, um, the fact that ultimately those in the control group were, um, withheld the actual aid. However, um, the, uh, visit, um, kind of went as planned in terms of normal shared decision making that our hernia surgeons typically do. Right, I mean, I think, so, again, trying to design randomized trials, control bias and deal with blinding. I mean, it's one of the hardest things in the world to do while working in a busy clinic. So I, I think that's great. My other question, um, is just a general thought to challenge you, and I know that shared decision making is, uh, all the rave right now, um, but let me, I, I'm gonna, just for the sake of having an academic discussion, I'm gonna push back on shared decision making. Uh, perhaps take a bit of an old school approach and, and have you kind of, uh, debate me on, on, on, what if I took the approach that, you know, I, I'm in Charlotte today, so I took an airplane to get here. So what if I went up to my pilot and I said, hey, I'd like to have a shared decision-making, uh, discussion about the, the altitude, the speed. I'd like to be at the gate closest because I've gotta get to this talk, and I can't be late to that. And I've flown a lot, by the way, and I've looked online, and, and I've read a lot about it. So, so, and, and we do like to compare surgeons to pilots with timeouts and. And all those things. So, so what if I took the approach that, and, and, and, and I'm gonna add to that just one little bit cause kind of one of your conclusions concerns me. I, I worry that shared decision-making in today's world is being used so that if something goes wrong, we can kind of fall back and tell the patient, hey, we talked about this together, like we all agreed it was gonna be 25,000 ft, even though there's another plane there. So, so, are we not just, I mean, aren't we the surgeons? Don't we know, don't we have to make these decisions, be clear to patients about what we think is their best choice, and then let them decide if they want it or not. Yeah, I, you know, those are all really good points. Um, one thing that I think that hernia surgery is so interesting and, you know, specific to this shared decision-making is that there's so many different ways to repair a hernia. Um, so, for instance, you have a 60-year-old gentleman with a primary 4 centimeter ventral hernia or, um, a primary umbilical hernia. Um, how are you gonna repair that? You ask 10 hernia surgeons, you might get 10 different answers. So I think, uh, Also, with all of those repairs, there's a potential for a different quality of life for the patient, um, in terms of how big the operation would be, the percentage of hernia recurrence, um, kind of the potential options for the future. So there's so much to discuss with the patient and so many different options in hernia surgery that we can go so many different ways. So, you know, if the pilot, for example, um, you know, I, I'm no aviation aficionado, but I would assume that there's Maybe one or two right ways to fly a plane from Cleveland to Charlotte. I could be wrong, uh, but, uh, in terms of, uh, fuel, gas, um, Uh, kind of safety, you know, the, the pilot would probably have one or two different options, but, you know, is, is an iPod. Um, any different long term than, uh, you know, uh, a retromuscular repair. We, you know, we don't really know. Well, so that's actually, you, you answered the question there is we don't know what's better in hernia surgery. There's such poor data. So how do you really have a shared decision making? I just to answer my own question, I think the pilot would tell me to sit in the pilot would tell you to sit down. He would tell me to sit back and eat peanuts and get the flight attendant to hold you down. He'd be like, You get a drink and you get peanuts on my flight, and that's. It. If you don't think that, get off. Listen, I think first of all, just to summarize, first of all, Bradley, amazing paper, obviously sparks decision. Whenever Mike starts off nice, hold on because that means something's coming. Yeah. So, uh, one more question I want to ask you quickly. Doesn't this really just show that you spend more time with the patient and explain the options more carefully because you showed that the time with the patient was significantly higher, and we could use this approach again in everything we do. To get a better result and a better patient acceptance of what we do, don't you think? Yeah, you know, I, I think that's definitely part of it. Uh, one of our main conclusions from this pilot study was that, you know, obviously, there was a statistically greater amount of time that we did spend with the patient. And, you know, we can certainly look at that in one way being, that's great, we were able to spend more time with the patient. But in a kind of a society where we live in, where our institutions are trying to have us churn through patients, it's certainly Could be seen as a negative too. So, it's really about quality time we spend with the patients. So, the next step of our phase, which we're actually running right now and another randomized controlled trial is actually a condensed form of the shared decision-making aid. And what we've actually found is that the most important parts of the aid was, was not actually going through all the decision-making with them, but actually having it written down. Um, for the patient itself so that they could take home and they could discuss with their loved ones. Um, so we were able to kind of find the most important parts of the aid to keep including those, um, in our, um, kind of tool, uh, but also kind of, uh, neglecting or kind of getting rid of all the extraneous things that we didn't find were quite as helpful or influential. Alright, thank you, Bradley. We're gonna move on. Thank you for your, uh, great paper and we're gonna move on to the second paper very nice.