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Korean J Anesthesiol > Volume 76(4); 2023 > Article
Kim: From evidence-based medicine to patient-centered care
In healthcare, interest in both evidence-based medicine (EBM) and patient-centered care (PCC) has grown over the past decade. While one could anticipate that a combination of EBM and PCC would enhance patient care, these two concepts also represent conflicting tendencies: standardization based on scientific knowledge and customization of medical practice based on patient and family preferences. To properly utilize EBM to deliver effective patient care, the Institute of Medicine has provided an updated definition of EBM that incorporates elements of PCC in clinical decision making; EBM provides specific tools for delivering high-quality care, and patients are involved in decision-making about the application of those tools [1,2]. Ideal healthcare decision making therefore requires that patients receive proper education using evidence-based data. To meet this end, patient decision aids have been utilized in various fields of medicine, including cardiology, urology, gynecology, endocrinology, oncology, and anesthesiology [3].
The current issue of the Korean Journal of Anesthesiology (KJA) includes a randomized controlled trial conducted by Wang et al. [4] that evaluates whether providing patient decision aids on two neuromuscular blocking agent reversal options (neostigmine and sugammadex) to patients undergoing surgery under general anesthesia increases patient satisfaction with the decision-making process. A total of 3,132 surgical patients were recruited for this study from two medical centers, 2,986 of which completed the survey and were allocated to either the classical group, which received a standard explanation, or the PtDA group, which received a set of patient decision aids developed and tested by anesthesiologists from the two hospitals. The patients’ degree of satisfaction with the decision-making process was evaluated using blinded outcome assessors, which included the four SURE (sure of myself, understand information, risk-benefit ratio, encouragement) screening test items. The patients’ baseline information and medical knowledge were also assessed. Compared to the classical group, the PtDA group felt more confident they had received sufficient medical information (P < 0.001), felt better informed about the advantages and disadvantages of the medications (P < 0.001), exhibited a superior understanding of the benefits and risks of their options (P < 0.001), and felt more confident about their choice (P < 0.001). These observations suggest that patient decision aids can be used to improve the quality of communication between physicians and patients and promote shared decision making.
As anesthesiologists generally perform the pre-anesthesia evaluation and consultation immediately before surgery, time is often limited and no established relationship with the patients and their families exists. Consequently, it may be difficult to provide anesthesia-related information adequately for patients to participate in the decision-making process without experiencing undue anxiety. Patient decision aids may thus be useful to better inform patients of their medical options and encourage them to participate in decision making based on their own preferences. In the field of anesthesiology, two regional anesthesia decision aids developed by the American Society of Anesthesiologists (ASA) Committee on Professional Liability [5] and the monitored anesthesia care (MAC) decision aid created by the ASA Committee on Patient Safety and Education [6] have recently been introduced. These decision aids have been shown to increase discussion, enhance participation, and improve patients’ knowledge of medical options in the decision-making processes, without increasing anxiety [5]. Wang et al. [4] presented another example of this tool, which could promote shared decision making, in the current issue of the KJA.
Patient decision aids could be useful for shared decision-making in the field of anesthesiology for various procedures, including sedation, regional anesthesia, general anesthesia, and pain management techniques. However, decision aids should only be used to facilitate patient participation in the decision-making process when multiple healthcare options with established risk-benefit trade-offs are available or for situations with clinical equipoise [3,7]; these tools should not be used when a superior choice is clearly known. Additionally, the key to ensuring effective PCC may not depend on the amount of biomedical information provided or the technical aspects of communication, especially for the anesthesia practices which have unique features unlike other clinical scenarios. The anesthesia consent is not a choice on whether the patients are going to undergo the procedure or not, since they have already agreed to the surgery necessitating anesthesia. When given the choice between regional and general anesthesia, one of the most common preference-sensitive decisions in the field of anesthesia, patients are usually more concerned about the anxiety they may feel if they are conscious during surgery than about weighing the risks and benefits of each anesthetic technique. In a study assessing the feasibility of an electronic MAC decision aid for breast conserving surgery, while 65.6% of participants reported that they would like to be provided with written information about anesthesia choices, 75% reported that they wanted their anesthesiologist or surgeon to make the decision regarding the type of anesthesia for them [6]. This shows that even though most patients want to be provided with options based on EBM, not all of them want to participate in decision-making. A greater problem is not that they are unwilling to participate in this process but that they cannot. Cultivating trust in the anesthesiologists’ effort to provide supportive care during the procedure for the patient, in addition to the decision aids, may be the key to effectively incorporating PCC in EBM.

NOTES

Funding

None.

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

References

1. Engle RL, Mohr DC, Holmes SK, Seibert MN, Afable M, Leyson J, et al. Evidence-based practice and patient-centered care: doing both well. Health Care Manage Rev 2021; 46: 174-84.
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2. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C., National Academy Press. 2001, p 337.

3. Urman RD, Southerland WA, Shapiro FE, Joshi GP. Concepts for the development of anesthesia-related patient decision aids. Anesth Analg 2019; 128: 1030-5.
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4. Wang LK, Lin YT, Chen JT, Lan W, Hung KC, Chen JY, et al. Effect of patient decision aids on choice between sugammadex and neostigmine in surgeries under general anesthesia: a multicenter randomized controlled trial. Korean J Anesthesiol 2023; 76: 280-93.
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5. Southerland WA, Tollinche LE, Shapiro FE. Decision aids: the role of the patient in perioperative safety. Int Anesthesiol Clin 2019; 57: 4-11.
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6. Beight L, Pardo J, McCarthy K, Dinkel A, de Lima A, Torous J, et al. An electronic monitored anesthesia care (MAC) decision aid for breast conserving surgery. J Clin Anesth 2022; 78: 110648.
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7. Southerland WA, Beight LJ, Shapiro FE, Urman RD. Decision aids in anesthesia: do they help? Curr Opin Anaesthesiol 2020; 33: 185-91.
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