- 1. What evidence are you proposing to translate into practice?
The use of a decision aid in patients with early stage breast cancer deciding between mastectomy and breast-conserving therapy. Decision aids are a tool used to promote shared decision making and patient centered care, which is especially useful for healthcare decisions where more than one option is supported by medical evidence (1). Decision aids have been shown to be effective in many different clinical scenarios (2). Surgical treatment for early stage breast cancer is an important target for implementation research because although decision aids for this decision have been shown to be effective (3) and surgeons have expressed interest in using them (4), very few patients receive them. In addition, variation in surgical practices suggests that patients may not be participating in decision making (5).
a. Justify that this evidence is “ready for translation.”
A systematic review in 2006 found 11 studies focusing on decision aids for breast cancer patients deciding between mastectomy and breast conserving therapy. These studies showed that decision aids had positive impacts on patient knowledge, quality of life, desire to participate in decision making, decisional conflict, and patient and physician satisfaction (3). A more recent Cochrane review of decision aids for treatment or screening decisions (which included 5 randomized controlled trials using decision aids to help patients choose between mastectomy and breast conserving therapy for breast cancer) found decision aids resulted in increased knowledge, participation in decision making, and clarity regarding personal values while reducing decisional conflict (2). A meta-analysis of decision aids used in surgical patients, which included six studies of decision aids in patients undergoing mastectomy or breast conserving therapy had similar results (6). One challenge to synthesizing this data is the sheer heterogeneity of the decision aid tools themselves and the populations they are used in. Overall, these studies show that decision aids are a beneficial adjunct to the patient-physician encounter for many types of decisions, specifically the decision about surgery for patients with early stage breast cancer.
One difficult decision is which decision aid to use. I am choosing to focus on a decision aid designed specifically for low health-literacy women (7). This aid is administered online and is free to the public. It is interactive, easy to use, available in Spanish, and developed in line with recommended guidelines.
b. Identify a single, key behavior change target for your translational activity.
Patient participation in decision making regarding surgical treatment for early stage breast cancer.
c. Conduct a “gap analysis” of your target behavior. Look to diverse sources for “best guess” estimates if specific measures are not available.
Although 64% of women with early stage breast cancer desire participation in shared decision making, only 33% feel that they had an active role (8). Decision aids are a tool that can be used to promote participation in shared decision making and close this gap.
2. What is the quality (performance) gap?
Implementation of decision aids is not widespread and there are no national studies that have looked at the use of decision aids in routine clinical practice. A study evaluating the implementation of decision aids for breast cancer across 10 outpatient community and 2 academic centers, only 39% of eligible patients received the decision aids (9). Barriers to decision aid implementation include lack of clinical support, competing priorities, and difficulty scheduling (10), as well as by lack of support from both physicians and nurses, failure to integrate the decision aid into routine clinical practice (9), and perceived lack of time (11) or space (3).
3. What is the outcome gap?
Patient knowledge: a meta-analysis of studies measuring patient knowledge after using decision aids for breast cancer surgery showed that patient knowledge increased by 24% following use of the decision aid (3). This was particularly marked in patients with low levels of knowledge prior to using the decision aid. A randomized controlled trial of the decision aid we propose to implement increased knowledge significantly among those assigned to the decision aid compared to controls using a validated knowledge tool (7).
Patient satisfaction: A systematic review of decision aids used in this patient population showed that patients who were assigned to the decision aid were more likely to report satisfaction with their decision (3).
4. Is there evidence that changing performance will improve health (clinical outcomes)?
Patient knowledge: Patients with poor health literacy are more likely to rate their health as poor and use more emergency care than patients with good health literacy (12, 13). This may indicate that patients who are more knowledgeable about their health use less healthcare resources.
Patient satisfaction: Patient satisfaction is being used as a quality indicator and as a basis for physician reimbursement. Although the impact of decision aids on HCAHPS for patients undergoing surgery for early stage breast cancer is not known, decision aids have been linked to increased patient satisfaction (3).
5. References
1. Holmes-Rovner M, Nelson WL, Pignone M, Elwyn G, Rovner DR, O'Connor AM, et al. Are Patient Decision Aids the Best Way to Improve Clinical Decision Making? Report of the IPDAS Symposium. Medical Decision Making. 2007;27(5):599-608.
2. Stacey D, Legare F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. The Cochrane database of systematic reviews. 2014;1:Cd001431.
3. Waljee JF, Rogers MA, Alderman AK. Decision aids and breast cancer: do they influence choice for surgery and knowledge of treatment options? Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2007;25(9):1067-73.
4. Schubart JR, Dominici LS, Farnan M, Kelly TA, Manahan ER, Rahman ER, et al. Shared decision making in breast cancer: national practice patterns of surgeons. Ann Surg Oncol. 2013;20(10):3323-9.
5. Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin JS. Geographic variation in the use of breast-conserving treatment for breast cancer. The New England journal of medicine. 1992;326(17):1102-7.
6. Knops AM, Legemate DA, Goossens A, Bossuyt PM, Ubbink DT. Decision aids for patients facing a surgical treatment decision: a systematic review and meta-analysis. Ann Surg. 2013;257(5):860-6.
7. Jibaja-Weiss ML, Volk RJ, Granchi TS, Neff NE, Robinson EK, Spann SJ, et al. Entertainment education for breast cancer surgery decisions: a randomized trial among patients with low health literacy. Patient education and counseling. 2011;84(1):41-8.
8. Keating NL, Guadagnoli E, Landrum MB, Borbas C, Weeks JC. Treatment decision making in early-stage breast cancer: should surgeons match patients' desired level of involvement? Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2002;20(6):1473-9.
9. Silvia KA, Ozanne EM, Sepucha KR. Implementing breast cancer decision aids in community sites: barriers and resources. Health expectations : an international journal of public participation in health care and health policy. 2008;11(1):46-53.
10. Silvia KA, Sepucha KR. Decision aids in routine practice: lessons from the breast cancer initiative. Health expectations : an international journal of public participation in health care and health policy. 2006;9(3):255-64.
11. Holmes-Rovner M, Valade D, Orlowski C, Draus C, Nabozny-Valerio B, Keiser S. Implementing shared decision-making in routine practice: barriers and opportunities. Health expectations : an international journal of public participation in health care and health policy. 2000;3(3):182-91.
12. Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. American journal of public health. 1997;87(6):1027-30.
13. Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. American journal of public health. 2002;92(8):1278-83.