Adapting two American Decision Aids for Mild Traumatic Brain Injury to the Canadian Context Using the Nominal Group Technique.

BACKGROUND: Decision aids are patient-focused tools that have the potential to reduce the overuse of head computed tomography (CT) scans. OBJECTIVE: The objective of this study was to create a consensus among Canadian mild traumatic brain injury and emergency medicine experts on modifications required to adapt two American decision aids about head CT use for adult and paediatric mild traumatic brain injury to the Canadian context. METHODS: We invited 21 Canadian stakeholders and the two authors of the American decision aids to a Nominal Group Technique consensus meeting to generate suggestions for adapting the decision aids. This method encourages idea generation and sharing between team members. Each idea was discussed and then prioritised using a voting system. We collected data using videotaping, writing material and online collaborative writing tools. The modifications proposed were analysed using a qualitative thematic content analysis. RESULTS: Twenty-one participants took part in the meeting, including researchers and clinician researchers (n = 9; 43%), patient partners (n = 3; 14%) and decision makers (n = 2; 10%). A total of 84 ideas were generated. Participants highlighted the need to clarify the purpose of the decision aids, the nature of the problem being addressed and the target population. The tools require sociocultural adaptations, better identification of their target population, better description of head CT utility, advantages and related risks, modification of the visual and written representation of the risk of brain injury and head CT use, and locally adapted, patient follow-up plans. CONCLUSIONS: This study based on a Nominal Group Technique identified several adaptations for two American decision aids about head CT use for mild traumatic brain injury to support their use in Canada's different healthcare, social, cultural and legal context. These adaptations concerned the target users of the decision aids, the information presented, and how the benefits and risks were communicated in the decision aids. Future steps include prototyping the two adapted decision aids, conducting formative evaluations with actual emergency department patients and clinicians, and measuring the impact of the adapted tools on CT scan use.

A mild traumatic brain injury (also called concussion) can happen when the brain moves around in the skull after an impact to the head. A concussion is not a brain bleed and you cannot see a concussion. Concussions do not show up on a computed tomography (CT) scan. Brain bleeds do. Computed tomography scans are specialised X-ray machines that can detect serious brain injuries. Unfortunately, CT scan use also exposes patients to radiation and a future increased risk of cancer.Shared decision making involves health professionals and patients making decisions together based on the best available evidence, health professionals' experience, and patients' values and preferences. Shared decision making improves appropriate diagnostic test use.Two decision aids created in the USA are available to facilitate shared decision making regarding the use of head CT scans for patients with concussion. These decision aids are not fully adapted for use in Canada because the healthcare, social and legal context is different. Our study brought together patients and experts in the field of concussion and shared decision making to analyse these decision aids and propose adaptations that would increase their acceptance in Canadian emergency departments. We used a technique called the Nominal Group Technique to create a consensus about the most important changes to make to both original decision aids. The main adaptations needed for the Canadian context concerned avoiding information about cost and removing any information that does not change clinical management. This project will help us adapt two decision aids for clinical use in Canada and support appropriate CT scan use for patients with concussion.

Predictors of extracapsular extension and positive margins in African American and white men.

OBJECTIVE: Radical retropubic prostatectomy (RRP) pathology from African American (AA) and White men from 1988 to 1999 was examined to determine if the pre-treatment factors PSA, clinical stage, biopsy grade, age at surgery, and year of surgery (YOS) were predictive of extracapsular extension (ECE) and positive margins for each ethnic group. METHODS: Clinical and pathologic data was collected on 179 AA and 548 white men undergoing RRP from 1988 to 1999 at a tertiary military medical facility. Logistic regression with multivariate analysis was used to determine which pre-operative data-points were predictive of pathologic ECE and positive margins for each ethnic group. RESULTS: PSA, biopsy grade, age, and YOS (more recent years had better surgical pathology) were predictive of ECE for AA and white men. PSA, biopsy grade, and YOS were predictive of positive margins for AA men, while PSA and YOS were predictive of positive margins for white men. PSA continues to be a strong predictor of ECE and positive margins for both AA and white men. However, we describe for the first time, YOS being predictive of ECE and positive margins for both AA and White men, using multivariate regression analysis. CONCLUSION: This is thought to be reflective of the improving public awareness of prostate cancer that has occurred during the PSA-era, resulting in patients participating in screening programs and being diagnosed earlier. Close follow-up of these patients is warranted to determine if the improved pathologic stage of those patients treated more recently translates into improved disease-specific mortality.

Improved prostate cancer-specific survival and other disease parameters: impact of prostate-specific antigen testing.

OBJECTIVES: To determine how the implementation of prostate-specific antigen (PSA) testing has affected disease-specific survival and other characteristics of prostate cancer. METHODS: Data were collected on all patients with prostate cancer diagnosed between 1988 and 1998 and registered in the Center for Prostate Disease Research Database at Walter Reed Army Medical Center. Statistical analyses were used to summarize trends over time in survival, mortality, and clinical stage. RESULTS: Between 1988 and 1998, a total of 2042 patients with prostate cancer were registered at Walter Reed Army Medical Center. The 5-year disease-specific survival rate was 86.9% and 93.7% for patients diagnosed in the respective year groups of 1988 to 1991 and 1992 to 1994, with follow-up through December 1, 2000 (P < 0.001). Prostate cancer was the cause of death for 37.5% of the patients in 1988 to 1989 versus 15.4% in 1999 to 2000. Marked stage migration has occurred; from 1988 to 1998, the percentage of patients presenting with metastatic disease decreased from 14.1% to 3.3% (P < 0.001). CONCLUSIONS: A statistically significant improved 5-year disease-specific survival and a decreased chance of dying from prostate cancer has occurred after the widespread implementation of PSA. We suspect that PSA testing has resulted in fewer patients presenting with metastatic disease and more patients presenting with localized disease amenable to curative treatment. This portends well for the use of PSA screening to improve outcomes for prostate cancer. However, randomized trials are needed to confirm the improvements in survival and mortality.