2 Minute Medicine Rewind November 16, 2020

Advance care planning in patients with advanced cancer: A 6-country, cluster-randomised clinical trial

1. An advanced care planning (ACP) intervention was not found to increase quality of life compared to usual care, in patients with advanced lung or colorectal cancer.

2. ACP was found to increase the number of patients receiving specialized palliative care, and having advanced directives recorded in hospital files.

Evidence Rating Level: 1 (Excellent)

Discussions regarding end-of-life plans among patients, family, and healthcare professionals are associated with numerous positive outcomes, such as better emotional functioning, increased symptom resolution, and less demanding interventions. Advanced care planning (ACP) encompasses these discussions, and allows patients to outline their goals of care, keep a record of these goals, and identify decision makers on their behalf. Although ACP has been shown to increase patient conversations, there is limited and conflicting evidence on improvements in quality of life. Therefore, this 6-country, multi-centre randomized controlled trial examined the effects of ACP on quality of life outcomes, namely emotional function and advanced cancer symptoms. The study was conducted at 23 hospitals spread throughout Belgium, Denmark, Italy, the Netherlands, Slovenia, and Great Britain. The study population consisted of 1,130 patients with advanced lung or colorectal cancer, with 685 in the control group and 445 in the intervention: Hospitals were randomized into groups, instead of individual patients. The intervention group patients had conversations with physicians certified in ACP, and also received ACP leaflets. The control group had no changes made to their hospital’s usual care protocol. The results showed that overall quality of life was not different between the intervention and control groups, with both follow-up assessments having lower quality of life scores than at baseline (for the 11-12 week follow-up: T-score -5.7, 95% CI -14.4 to 2.9 for intervention; T-score -2.0, 95% CI -4.0 to 0.1 for control; p = 0.22). There were also no differences found for coping, health symptoms, patient satisfaction, and shared decision-making. However, the intervention group received specialist palliative care more frequently (37% versus 27%, p = 0.002) and had more advanced directives included in medical files (10% versus 3%, p < 0.001). In conclusion, this study found no evidence that ACP interventions improved quality of life in advanced lung or colorectal cancer patients, which may be a testament to the strengths of usual end-of-life care, but it also has implications for examining other end-of-life approaches that can improve quality of life.


Effect of a decision aid on the choice of pregnant women whether to have epidural anesthesia or not during labor

1. A decision aid tool significantly helped resolve decision conflict in patients contemplating the use of epidural anesthesia during labour.

Evidence Rating Level: 1 (Excellent)

In Japan, analgesic use in delivery of babies is low compared to other countries, with only 6.2% of women receiving epidural anesthesia in 2016. This could stem from a variety of reasons, such as few hospitals where epidurals can be provided (15.0%), cultural beliefs on labour pain, and lack of information provided to pregnant women. To address the latter cause, decision aids (DAs) have been proposed as a potential tool to educate patients on different treatment options available to them. The current study was a non-randomized controlled trial analyzing the effectiveness of DAs on influencing a pregnant woman’s choice to use epidural anesthesia or not. The control group of 150 women was recruited first, where patients were given a standard 10-page pamphlet at their 34-week gestation visit, outlining the benefits and potential consequences. The DA group was recruited next, comprising of 149 women: The 22-page DA pamphlet included more information on the options, presented a comparison in tables, and provided tools to aid in values clarification and the decision making process.  All participants had low-risk, singleton pregnancies. The primary outcome measured was a change in the mean Decision Conflict Scale score, a self-report questionnaire that measures a participant’s uncertainty surrounding a decision, with scores ranging from 0 to 100. This questionnaire was provided before and after the pamphlets were read through. The results showed that the DA group had significantly lower DCS scores than the control group (DCS -8.41, SD 8.79 in the DA group; DCS -1.69, SD 5.91 in the control; p < 0.001). Furthermore, the percentage of undecided women decreased significantly in the DA group, from 30.2% to 6.1% (p < 0.001), whereas the percentage was not different in the control group (40.7% to 38.9%). Study findings demonstrated that a DA for epidural anesthesia can help alleviate indecisiveness in patients, contributing to better informed and shared decision making.


Pregravid contraceptive use and fecundability: prospective cohort study

1. Injectable contraceptives were associated with the longest delays (2-8 menstrual cycles) in return of normal fertility, compared to other contraceptive methods.

2. No long-term and lasting effects on fecundability were associated with use of any of the studied contraceptive methods.

Evidence Rating Level: 2 (Good)

Fecundability is defined as the probability of pregnancy in a menstrual cycle without use of contraception. Current research on the association between contraceptive use and fecundability has been limited to the most common forms of contraception: Condoms and oral contraceptives. However, the use of long acting reversible contraception is growing, with 13% of American women aged 25-34 using these methods in 2015-17. Therefore, the current prospective cohort study aimed to examine the relationship between contraception type and fecundability. The study population included 17,954 women (and their male partners) from Denmark and North America, with 10,729 pregnancies and 66,759 menstrual cycles. Data was collected on the most recent contraceptive used before trying to conceive, and the number of menstrual cycles without contraception before conceiving. The results found that 38% of participants used oral contraceptives, 31% used barrier methods (condoms, diaphragm, sponge, foam), and 13% used long-term reversible contraceptives. Injectable contraceptives had the largest association with lowered fecundability in comparison to barrier methods (fecundability ratio 0.65, 95% CI 0.47-0.89). In participants using injectable contraceptives, a short-term delay of 5 to 8 menstrual cycles was found before normal fertility returned, along with a 4 cycle delay for patch contraceptives, 3 cycle delay for oral and ring contraceptives, and 2 cycle delay for implants and hormonal or copper intrauterine devices. On average, other forms of contraception were not associated with decreased fecundability compared with barrier methods. Overall, this study showed that although injectable contraceptives appeared to have longer delays in fertility return, there are little to no lasting effects associating fecundability with any of these contraceptive methods.


Modelling the household-level impact of a maternal respiratory syncytial virus (RSV) vaccine in a high-income setting

1. With 70% vaccination coverage, a 3rd trimester maternal vaccine for respiratory syncytial virus (RSV) was modelled to reduce RSV infection rates by 16.6% in infants younger than 3 months. 

2. Incidence rate of RSV infections in the first 6 months of life for infants born to unvaccinated mothers was 1.26 times that of those born to vaccinated mothers.

Evidence Rating Level: 2 (Good)

The respiratory syncytial virus (RSV) infects almost all children by their second birthday, and was responsible for 3.2 million hospitalisations in the year 2015 alone globally, for children younger than 5. Although there is currently no approved RSV vaccine, maternal immunisation in the third trimester of pregnancy ubiquitously used as a preventative strategy. However, RSV vaccines are expected to be short-lasting, making it important to study their public health implications through modelling frameworks. From past research, households have been identified as a significant contributor to RSV transmission, but modelling studies have not been conducted on high-income settings yet. The current study’s goal was to model the household-level impact of maternal RSV vaccines in a high-income country. This involved combining Australian census data with a model for RSV transmission, accounting for household and community population mixing, and defining the parameters for an infant’s immunity duration, which was found to depend on vaccination timing and the mother’s immunity duration. Overall, the results found that the largest benefit from maternal vaccination was for infants younger than 3 months, with a 16.6% reduction in infection incidence (interquartile range -14.2 to -19.8%), for a scenario of 70% vaccination coverage. For infants aged 3-6 months, the reduction was 5.3% (IQR -7.3 to 1%). All other age groups had similar incidence rates compared to no vaccination scenarios, with the exception of children aged 1-2, which had a predicted 2.8% increase in infection (IQR 0.3-5.8%). In conclusion, this study showed that maternal RSV vaccination can have a significant effect on lowering infection rates in infants younger than 3, but may have little impact in older age groups.


Life expectancy and health-adjusted life expectancy in people with inflammatory bowel disease

1. From 1996 to 2011, life expectancy for IBD patients increased by approximately 3 years, whereas from 1996 to 2008, healthy life expectancy decreased in males and stayed the same in females.

2. People with IBD continue to have lower life and healthy life expectancies than individuals without IBD, ranging from 3 to 14 year differences.

Evidence Rating Level: 2 (Good)

Inflammatory bowel disease (IBD) refers to a group of inflammatory conditions affecting the gastrointestinal system, such as Crohn disease and ulcerative colitis. The last few decades has seen new treatments targeted at stopping disease progression, as well as biologic therapies (therapies derived from organisms). However, previous studies on IBD mortality did not analyze life expectancy, and most took place prior to the advent of biologic therapies. The current study based in Ontario, Canada evaluated trends in life expectancy and health-adjusted life expectancy for individuals with IBD, also comparing their outcomes to individuals without IBD. This was a retrospective cohort study that matched each IBD patient to five non-IBD individuals, by age, sex, rural/urban status, and neighbourhood income quintile. Life and healthy life expectancies were calculated at four time points: July 1 of 1996, 2000, 2008, and 2011. The participants increased from 32,818 IBD patients to 83,672 IBD patients from 1996 to 2011 respectively. Overall, the results found that both life expectancy increased over time, whereas healthy life expectancy remained the same in females and decreased in males. From 1996 to 2011, life expectancy increased by 2.9 years in females (95% CI 1.3-4.5) and in males, this increased by 3.2 years (95% CI 2.1-4.4). For healthy life expectancy, from 1996 to 2008, there was no statistically significant difference in females, but in males, it decreased by 3.9 years (95% CI 1.2-6.6). As well, IBD patients had lower life and healthy life expectancies than individuals without IBD. For life expectancy, this ranged from 6.6-8.1 years for females and 5.0-6.1 years in males, and for healthy life expectancy, it ranged from 9.5-13.5 years for females and 2.6-6.7 years for males. In conclusion, this study demonstrates that although life expectancy is increasing for IBD patients, these individuals continue to have significantly lower life and healthy life expectancies than the general population.

Image: PD

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