Preferences in a group of patients with Cancer: A grounded theory

Purpose: This study was conducted to understand the preferences of patients with cancer in Medellin, Colombia. Methods: A qualitative approach based on the theoretical and methodological resources of the grounded theory was conducted. Between June 2020 and March 2021, patients over 18 years old with...

Full description

Autores:
Higuita Gutiérrez, Luis Felipe
Estrada Mesa, Diego Alejandro
Cardona Arias, Jaiberth Antonio
Tipo de recurso:
Article of investigation
Fecha de publicación:
2021
Institución:
Universidad Cooperativa de Colombia
Repositorio:
Repositorio UCC
Idioma:
OAI Identifier:
oai:repository.ucc.edu.co:20.500.12494/44464
Acceso en línea:
https://hdl.handle.net/20.500.12494/44464
Palabra clave:
Preferences
Cancer
Grounded theory
Rights
openAccess
License
Atribución
id COOPER2_ddeaba7a2e97bc2a258a2a63a27de3b8
oai_identifier_str oai:repository.ucc.edu.co:20.500.12494/44464
network_acronym_str COOPER2
network_name_str Repositorio UCC
repository_id_str
dc.title.spa.fl_str_mv Preferences in a group of patients with Cancer: A grounded theory
title Preferences in a group of patients with Cancer: A grounded theory
spellingShingle Preferences in a group of patients with Cancer: A grounded theory
Preferences
Cancer
Grounded theory
title_short Preferences in a group of patients with Cancer: A grounded theory
title_full Preferences in a group of patients with Cancer: A grounded theory
title_fullStr Preferences in a group of patients with Cancer: A grounded theory
title_full_unstemmed Preferences in a group of patients with Cancer: A grounded theory
title_sort Preferences in a group of patients with Cancer: A grounded theory
dc.creator.fl_str_mv Higuita Gutiérrez, Luis Felipe
Estrada Mesa, Diego Alejandro
Cardona Arias, Jaiberth Antonio
dc.contributor.author.none.fl_str_mv Higuita Gutiérrez, Luis Felipe
Estrada Mesa, Diego Alejandro
Cardona Arias, Jaiberth Antonio
dc.subject.spa.fl_str_mv Preferences
Cancer
Grounded theory
topic Preferences
Cancer
Grounded theory
description Purpose: This study was conducted to understand the preferences of patients with cancer in Medellin, Colombia. Methods: A qualitative approach based on the theoretical and methodological resources of the grounded theory was conducted. Between June 2020 and March 2021, patients over 18 years old with a confirmed diagnosis of cancer within the past 2 years treated in Medellin, Colombia, were selected. Theoretical saturation sampling was performed. Each participant was interviewed between 2 and 3 times in accordance with the open, axial, and selective coding of the grounded theory. Results: A common preference set emerged in all patients related to the attributes of healthcare professionals and is a category that unites their scientific and humanistic aspects. On the other hand, very heterogeneous preferences were presented that were associated with the doctor–patient relationship and the therapeutic objectives. In the doctor–patient relationship, there are those who adhere to a paternalistic model and those who opt for an informative model. In therapeutic objectives, two subcategories emerged: those who are inclined to preserve life and those who accord more value to the quality of life. Conclusion: The categories that emerged illustrate the complexity and challenges of the preferences of patients with cancer in theoretical and experiential terms for social studies of medicine, philosophy, and bioethics. From medical social studies, it’s emphasized that the experiences of dehumanization are constant, which generates shared preferences in the patients related to the ideal of the medical professional. From the philosophical perspective, the care received by patients coincides with what was called medicine for slaves in ancient Greece, insofar as patients are not assumed to be free subjects. With respect to bioethics, some ideas are raised contrary to the support of individual autonomy; relational autonomy and the respect for the person above the autonomy itself are advocated.
publishDate 2021
dc.date.issued.none.fl_str_mv 2021-10-21
dc.date.accessioned.none.fl_str_mv 2022-04-01T19:38:27Z
dc.date.available.none.fl_str_mv 2022-04-01T19:38:27Z
dc.type.none.fl_str_mv Artículos Científicos
dc.type.coar.none.fl_str_mv http://purl.org/coar/resource_type/c_2df8fbb1
dc.type.coarversion.none.fl_str_mv http://purl.org/coar/version/c_970fb48d4fbd8a85
dc.type.driver.none.fl_str_mv info:eu-repo/semantics/article
dc.type.version.none.fl_str_mv info:eu-repo/semantics/publishedVersion
format http://purl.org/coar/resource_type/c_2df8fbb1
status_str publishedVersion
dc.identifier.issn.spa.fl_str_mv 1177889X
dc.identifier.uri.spa.fl_str_mv doi: 10.2147/PPA.S328971
dc.identifier.uri.none.fl_str_mv https://hdl.handle.net/20.500.12494/44464
dc.identifier.bibliographicCitation.spa.fl_str_mv Higuita-Gutiérrez, L.F., Estrada Mesa, D.A. & Cardona Arias, J.A. (2021). Preferences in a Group of Patients with Cancer: A Grounded Theory. Patient Prefer Adherence. 2021; 15: 2313–2326.doi: 10.2147/PPA.S328971
identifier_str_mv 1177889X
doi: 10.2147/PPA.S328971
Higuita-Gutiérrez, L.F., Estrada Mesa, D.A. & Cardona Arias, J.A. (2021). Preferences in a Group of Patients with Cancer: A Grounded Theory. Patient Prefer Adherence. 2021; 15: 2313–2326.doi: 10.2147/PPA.S328971
url https://hdl.handle.net/20.500.12494/44464
dc.relation.isversionof.spa.fl_str_mv https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8526945/
dc.relation.ispartofjournal.spa.fl_str_mv Patient Prefer Adherence
dc.relation.references.spa.fl_str_mv Street RL Jr, Elwyn G, Epstein RM. Patient preferences and healthcare outcomes: an cological perspective. Expert Rev Pharmacoecon Outcomes Res. 2012;12(2):167–180. doi:10.1586/erp.12.3
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Vol. 6. New York: Oxford University Press; 2009
Guyatt GH, Haynes RB, Jaeschke RZ, et al. Users’ guides to the medical literature: XXV. Evidence-based medicine: principles for applying the users’ guides to patient care. Evidence-Based Medicine Working Group. JAMA. 2000;284(10):1290–1296. doi:10.1001/jama.284.10.1290
Mykhalovskiy E, Weir L. The problem of evidence-based medicine: directions for social science. Soc Sci Med. 2004;59(5):1059–1069
FDA. Patient Preference Information – Voluntary Submission, Review in Premarket Approval Applications, Humanitarian Device Exemption Applications, and De Novo Requests, and Inclusion in Decision Summaries and Device Labeling: Guidance for Industry, Food and Drug Administration Staff, and Other Stakeholders. U.S. Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health and Center for Biologics Evaluation and Research; 2016. Available from: https://www.fda.gov/media/92593/download.
Berwick D, Fox DM. Evaluating the quality of medical care”: Donabedian’s classic article 50 years later. Milbank Q. 2016;94(2):237–241. doi:10.1111/1468-0009.12189
Basch E, Barbera L, Kerrigan CL, Velikova G. Implementation of patient-reported outcomes in routine medical care. Am Soc Clin Oncol Educ Book. 2018;38:122–134. doi:10.1200/EDBK_200383
Pieterse AH, Stiggelbout AM. What are values, utilities, and preferences? A clarification in the context of decision making in health care, and an exploration of measurement issues. In: Diefenbach MA, Miller-Halegoua S, Bowen DJ, editors. Handbook of Health Decision Science. New York: Springer; 2016:377.
Brennan PF, Strombom I. Improving healthcare by understanding patient preferences: the role of computer technology. J Am Med Inform Assoc. 1998;5(3):257–262.
Florek AG, Wang CJ, Armstrong AW. Treatment preferences and treatment satisfaction among psoriasis patients: a systematic review. Arch Dermatol Res. 2018;310(4):271–319. doi:10.1007/s00403-018-1808-x
Mah HC, Muthupalaniappen L, Chong WW. Perceived involvement and preferences in shared decision-making among patients with hypertension. Fam Pract. 2016;33(3):296–301. doi:10.1093/fampra/cmw012
Gebhardt C, Gorba C, Oechsle K, Vehling S, Koch U, Mehnert A. Breaking bad news to cancer patients: content, communication preferences and psychological distress. Psychother Psychosom Med Psychol. 2017;67(7):312–321. doi:10.1055/s-0043-113628
Swift JK, Callahan JL. The impact of client treatment preferences on outcome: a meta-analysis. J Clin Psychol. 2009;65(4):368.
Street RL Jr, Voigt B. Patient participation in deciding breast cancer treatment and subsequent quality of life. Med Decis Making. 1997;17(3):298–306.
Moffett JK, Torgerson D, Bell-Syer S, et al. Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences. BMJ. 1999;319(7205):279–283
Epstein RM, Peters E. Beyond information: exploring patients’ preferences. JAMA. 2009;302(2):195–197.
Fraenkel L, McGraw S. Participation in medical decision-making: the patients’ perspective. Med Decis Making. 2007;27(5):533–538
Frankford D. Scientism and economics in the regulation of health care. J Health Polit Policy Law. 1994;19(4):773–799
Gandjour A. Patient preferences: a Trojan horse for evidence-based medicine? Eur J Health Econ. 2018;19(1):167–172. doi:10.1007/s10198-017-0916-4
Epstein RM, Street RL Jr. Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. Bethesda, MD: National Cancer Institute, NIH Publication No. 07-6225; 2007.
Pulgarín-Vergara D, Castro-Arroyave DM. Doctor-patient relationship in healthcare institutions of Medellin, Colombia. Rev salud pública. 2019;21(4):1–6.
Ministerio de Salud y Protección Social, Colombia. Encuesta Nacional de Evaluación de los Servicios de las EPS. Informe final. Bogotá: Proyectamos Colombia SAS; 2017 [National Survey of Evaluation of EPS Services. Final report. Bogotá: We project Colombia SAS; 2017]. Cited May 30, 2021. Available from: https://bit.ly/3gfd8N8. Accessed October 6, 2021. Spanish
Kelly MP, Heath I, Howick J, Greenhalgh T. The importance of values in evidence-based medicine. BMC Med Ethics. 2015;16(1):69. doi:10.1186/s12910-015-0063-3
Strauss A, Corbin J. Bases de investigación cualitativa. Técnicas y procedimientos para desarrollar la teoría fundamentada [Basics of qualitative research. Techniques and procedures for developing grounded theory]. 2nd ed. Medellín: Universidad de Antioquia; 2012. Spanish
Pope C, Mays N, eds. Qualitative Research in Health Care. 4th ed. Wiley Blackwell; 2020.
Castillo E, Vásquez ML. El rigor metodológico en la investigación cualitativa [Methodological rigor in qualitative research]. Colombia Médica. 2003;34(3):164–167. Spanish.
Warren C, McGraw AP, Van Boven L. Values and preferences: defining preference construction. Wiley Interdiscip Rev Cogn Sci. 2011;2(2):193–205. doi:10.1002/wcs.98
Hatamipour K, Rassouli M, Yaghmaie F, Zendedel K, Majd HA. Spiritual needs of cancer patients: a qualitative study. Indian J Palliat Care. 2015;21(1):61–67. doi:10.4103/0973-1075.150190
MacIntyre A. Tras la virtud [After virtue]. Barcelona: Crítica; 1984. Spanish.
dc.rights.license.none.fl_str_mv Atribución
dc.rights.accessrights.none.fl_str_mv info:eu-repo/semantics/openAccess
dc.rights.coar.none.fl_str_mv http://purl.org/coar/access_right/c_abf2
rights_invalid_str_mv Atribución
http://purl.org/coar/access_right/c_abf2
eu_rights_str_mv openAccess
dc.format.extent.spa.fl_str_mv 14
dc.coverage.temporal.spa.fl_str_mv 15
dc.publisher.spa.fl_str_mv Dove Press
Universidad Cooperativa de Colombia, Facultad de Ciencias de la Salud, Medicina, Medellín y Envigado
dc.publisher.program.spa.fl_str_mv Medicina
dc.publisher.place.spa.fl_str_mv Medellín
institution Universidad Cooperativa de Colombia
bitstream.url.fl_str_mv https://repository.ucc.edu.co/bitstreams/2f8bad52-9526-46bf-86c0-e3f7fa78151f/download
https://repository.ucc.edu.co/bitstreams/78279a4f-63a2-43d8-870c-ab1f48193f21/download
https://repository.ucc.edu.co/bitstreams/18355814-fff4-4b0a-b7e4-3cd376ea9e63/download
https://repository.ucc.edu.co/bitstreams/b58cdaee-fa2d-4a80-b2bb-6adde5d71e8d/download
bitstream.checksum.fl_str_mv bf7b81768abc6e65e63ace394ed8b6b0
3bce4f7ab09dfc588f126e1e36e98a45
265cfa9b27391e4f253fcc71a1bd0108
7e75c912cdd36dd66f2002dbde8ea944
bitstream.checksumAlgorithm.fl_str_mv MD5
MD5
MD5
MD5
repository.name.fl_str_mv Repositorio Institucional Universidad Cooperativa de Colombia
repository.mail.fl_str_mv bdigital@metabiblioteca.com
_version_ 1808789410523643904
spelling Higuita Gutiérrez, Luis FelipeEstrada Mesa, Diego AlejandroCardona Arias, Jaiberth Antonio152022-04-01T19:38:27Z2022-04-01T19:38:27Z2021-10-211177889Xdoi: 10.2147/PPA.S328971https://hdl.handle.net/20.500.12494/44464Higuita-Gutiérrez, L.F., Estrada Mesa, D.A. & Cardona Arias, J.A. (2021). Preferences in a Group of Patients with Cancer: A Grounded Theory. Patient Prefer Adherence. 2021; 15: 2313–2326.doi: 10.2147/PPA.S328971Purpose: This study was conducted to understand the preferences of patients with cancer in Medellin, Colombia. Methods: A qualitative approach based on the theoretical and methodological resources of the grounded theory was conducted. Between June 2020 and March 2021, patients over 18 years old with a confirmed diagnosis of cancer within the past 2 years treated in Medellin, Colombia, were selected. Theoretical saturation sampling was performed. Each participant was interviewed between 2 and 3 times in accordance with the open, axial, and selective coding of the grounded theory. Results: A common preference set emerged in all patients related to the attributes of healthcare professionals and is a category that unites their scientific and humanistic aspects. On the other hand, very heterogeneous preferences were presented that were associated with the doctor–patient relationship and the therapeutic objectives. In the doctor–patient relationship, there are those who adhere to a paternalistic model and those who opt for an informative model. In therapeutic objectives, two subcategories emerged: those who are inclined to preserve life and those who accord more value to the quality of life. Conclusion: The categories that emerged illustrate the complexity and challenges of the preferences of patients with cancer in theoretical and experiential terms for social studies of medicine, philosophy, and bioethics. From medical social studies, it’s emphasized that the experiences of dehumanization are constant, which generates shared preferences in the patients related to the ideal of the medical professional. From the philosophical perspective, the care received by patients coincides with what was called medicine for slaves in ancient Greece, insofar as patients are not assumed to be free subjects. With respect to bioethics, some ideas are raised contrary to the support of individual autonomy; relational autonomy and the respect for the person above the autonomy itself are advocated.https://scienti.minciencias.gov.co/cvlac/visualizador/generarCurriculoCv.do?cod_rh=00015017910000-0003-1361-3124https://scienti.minciencias.gov.co/gruplac/jsp/visualiza/visualizagr.jsp?nro=00000000011355luis.higuita@campusucc.edu.co14Dove PressUniversidad Cooperativa de Colombia, Facultad de Ciencias de la Salud, Medicina, Medellín y EnvigadoMedicinaMedellínhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8526945/Patient Prefer AdherenceStreet RL Jr, Elwyn G, Epstein RM. Patient preferences and healthcare outcomes: an cological perspective. Expert Rev Pharmacoecon Outcomes Res. 2012;12(2):167–180. doi:10.1586/erp.12.3Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Vol. 6. New York: Oxford University Press; 2009Guyatt GH, Haynes RB, Jaeschke RZ, et al. Users’ guides to the medical literature: XXV. Evidence-based medicine: principles for applying the users’ guides to patient care. Evidence-Based Medicine Working Group. JAMA. 2000;284(10):1290–1296. doi:10.1001/jama.284.10.1290Mykhalovskiy E, Weir L. The problem of evidence-based medicine: directions for social science. Soc Sci Med. 2004;59(5):1059–1069FDA. Patient Preference Information – Voluntary Submission, Review in Premarket Approval Applications, Humanitarian Device Exemption Applications, and De Novo Requests, and Inclusion in Decision Summaries and Device Labeling: Guidance for Industry, Food and Drug Administration Staff, and Other Stakeholders. U.S. Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health and Center for Biologics Evaluation and Research; 2016. Available from: https://www.fda.gov/media/92593/download.Berwick D, Fox DM. Evaluating the quality of medical care”: Donabedian’s classic article 50 years later. Milbank Q. 2016;94(2):237–241. doi:10.1111/1468-0009.12189Basch E, Barbera L, Kerrigan CL, Velikova G. Implementation of patient-reported outcomes in routine medical care. Am Soc Clin Oncol Educ Book. 2018;38:122–134. doi:10.1200/EDBK_200383Pieterse AH, Stiggelbout AM. What are values, utilities, and preferences? A clarification in the context of decision making in health care, and an exploration of measurement issues. In: Diefenbach MA, Miller-Halegoua S, Bowen DJ, editors. Handbook of Health Decision Science. New York: Springer; 2016:377.Brennan PF, Strombom I. Improving healthcare by understanding patient preferences: the role of computer technology. J Am Med Inform Assoc. 1998;5(3):257–262.Florek AG, Wang CJ, Armstrong AW. Treatment preferences and treatment satisfaction among psoriasis patients: a systematic review. Arch Dermatol Res. 2018;310(4):271–319. doi:10.1007/s00403-018-1808-xMah HC, Muthupalaniappen L, Chong WW. Perceived involvement and preferences in shared decision-making among patients with hypertension. Fam Pract. 2016;33(3):296–301. doi:10.1093/fampra/cmw012Gebhardt C, Gorba C, Oechsle K, Vehling S, Koch U, Mehnert A. Breaking bad news to cancer patients: content, communication preferences and psychological distress. Psychother Psychosom Med Psychol. 2017;67(7):312–321. doi:10.1055/s-0043-113628Swift JK, Callahan JL. The impact of client treatment preferences on outcome: a meta-analysis. J Clin Psychol. 2009;65(4):368.Street RL Jr, Voigt B. Patient participation in deciding breast cancer treatment and subsequent quality of life. Med Decis Making. 1997;17(3):298–306.Moffett JK, Torgerson D, Bell-Syer S, et al. Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences. BMJ. 1999;319(7205):279–283Epstein RM, Peters E. Beyond information: exploring patients’ preferences. JAMA. 2009;302(2):195–197.Fraenkel L, McGraw S. Participation in medical decision-making: the patients’ perspective. Med Decis Making. 2007;27(5):533–538Frankford D. Scientism and economics in the regulation of health care. J Health Polit Policy Law. 1994;19(4):773–799Gandjour A. Patient preferences: a Trojan horse for evidence-based medicine? Eur J Health Econ. 2018;19(1):167–172. doi:10.1007/s10198-017-0916-4Epstein RM, Street RL Jr. Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. Bethesda, MD: National Cancer Institute, NIH Publication No. 07-6225; 2007.Pulgarín-Vergara D, Castro-Arroyave DM. Doctor-patient relationship in healthcare institutions of Medellin, Colombia. Rev salud pública. 2019;21(4):1–6.Ministerio de Salud y Protección Social, Colombia. Encuesta Nacional de Evaluación de los Servicios de las EPS. Informe final. Bogotá: Proyectamos Colombia SAS; 2017 [National Survey of Evaluation of EPS Services. Final report. Bogotá: We project Colombia SAS; 2017]. Cited May 30, 2021. Available from: https://bit.ly/3gfd8N8. Accessed October 6, 2021. SpanishKelly MP, Heath I, Howick J, Greenhalgh T. The importance of values in evidence-based medicine. BMC Med Ethics. 2015;16(1):69. doi:10.1186/s12910-015-0063-3Strauss A, Corbin J. Bases de investigación cualitativa. Técnicas y procedimientos para desarrollar la teoría fundamentada [Basics of qualitative research. Techniques and procedures for developing grounded theory]. 2nd ed. Medellín: Universidad de Antioquia; 2012. SpanishPope C, Mays N, eds. Qualitative Research in Health Care. 4th ed. Wiley Blackwell; 2020.Castillo E, Vásquez ML. El rigor metodológico en la investigación cualitativa [Methodological rigor in qualitative research]. Colombia Médica. 2003;34(3):164–167. Spanish.Warren C, McGraw AP, Van Boven L. Values and preferences: defining preference construction. Wiley Interdiscip Rev Cogn Sci. 2011;2(2):193–205. doi:10.1002/wcs.98Hatamipour K, Rassouli M, Yaghmaie F, Zendedel K, Majd HA. Spiritual needs of cancer patients: a qualitative study. Indian J Palliat Care. 2015;21(1):61–67. doi:10.4103/0973-1075.150190MacIntyre A. Tras la virtud [After virtue]. Barcelona: Crítica; 1984. Spanish.PreferencesCancerGrounded theoryPreferences in a group of patients with Cancer: A grounded theoryArtículos Científicoshttp://purl.org/coar/resource_type/c_2df8fbb1http://purl.org/coar/version/c_970fb48d4fbd8a85info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionAtribucióninfo:eu-repo/semantics/openAccesshttp://purl.org/coar/access_right/c_abf2PublicationORIGINALHiguita Gutierrez LF. Preferences in a Group of Patients with Cancer a grounded theory.pdfHiguita Gutierrez LF. Preferences in a Group of Patients with Cancer a grounded theory.pdfArtículoapplication/pdf568719https://repository.ucc.edu.co/bitstreams/2f8bad52-9526-46bf-86c0-e3f7fa78151f/downloadbf7b81768abc6e65e63ace394ed8b6b0MD51LICENSElicense.txtlicense.txttext/plain; charset=utf-84334https://repository.ucc.edu.co/bitstreams/78279a4f-63a2-43d8-870c-ab1f48193f21/download3bce4f7ab09dfc588f126e1e36e98a45MD52THUMBNAILHiguita Gutierrez LF. Preferences in a Group of Patients with Cancer a grounded theory.pdf.jpgHiguita Gutierrez LF. Preferences in a Group of Patients with Cancer a grounded theory.pdf.jpgGenerated Thumbnailimage/jpeg5415https://repository.ucc.edu.co/bitstreams/18355814-fff4-4b0a-b7e4-3cd376ea9e63/download265cfa9b27391e4f253fcc71a1bd0108MD53TEXTHiguita Gutierrez LF. Preferences in a Group of Patients with Cancer a grounded theory.pdf.txtHiguita Gutierrez LF. Preferences in a Group of Patients with Cancer a grounded theory.pdf.txtExtracted texttext/plain83143https://repository.ucc.edu.co/bitstreams/b58cdaee-fa2d-4a80-b2bb-6adde5d71e8d/download7e75c912cdd36dd66f2002dbde8ea944MD5420.500.12494/44464oai:repository.ucc.edu.co:20.500.12494/444642024-08-10 22:47:34.535restrictedhttps://repository.ucc.edu.coRepositorio Institucional Universidad Cooperativa de Colombiabdigital@metabiblioteca.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