Expanding the reach of decision and communication aids in a breast care center: a quality improvement study.
ABSTRACT One academically based breast cancer clinic implements decision and communication aids as part of routine clinical care. This quality improvement study aimed to expand reach of these supportive materials and services with budget-neutral program changes.
We used program theory and continuous quality improvement to design changes to our program. We calculated reach as the number of new patient visits for which we administered decision and communication aids. We compared reach before and after the program changes.
Program changes included: reassigning program outreach tasks from over-committed to under-utilized personnel; deploying personnel in floating rather than fixed schedules; and creating a waitlist so service delivery was dynamically reallocated from overbooked to underbooked personnel. Before these changes, we reached 208 visitors with decision aids, and 142 visitors with communication aids. Changes were associated with expanded reach, culminating in program year 2008 with the delivery of 936 decision aids and 285 communication aids.
We observed over a fourfold increase in decision aid reach and a twofold increase in communication aid reach. We attribute increases to recent program changes.
This study illustrates how program theory and quality improvement methods can contribute to expanded reach of decision and communication aids.
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ABSTRACT: Decision aids educate patients about treatment options and outcomes. Communication aids include question lists, consultation summaries, and audio-recordings. In efficacy studies, decision aids increased patient knowledge, while communication aids increased patient question-asking and information recall. Starting in 2004, we trained successive cohorts of post-baccalaureate, pre-medical interns to coach patients in the use of decision and communication aids at our university-based breast cancer clinic. From July 2005 through June 2012, we used the RE-AIM framework to measure Reach, Effectiveness, Adoption, Implementation and Maintenance of our interventions. 1. Reach: Over the study period, our program sent a total of 5,153 decision aids and directly administered 2,004 communication aids. In the most recent program year (2012), out of 1,524 eligible patient appointments, we successfully contacted 1,212 (80 %); coached 1,110 (73 %) in the self-administered use of decision and communication aids; sent 958 (63 %) decision aids; and directly administered communication aids for 419 (27 %) patients. In a 2010 survey, coached patients reported self-administering one or more communication aids in 81 % of visits 2. Effectiveness: In our pre-post comparisons, decision aids were associated with increased patient knowledge and decreased decisional conflict. Communication aids were associated with increased self-efficacy and number of questions; and with high ratings of patient preparedness and satisfaction 3. Adoption: Among visitors sent decision aids, 82 % of survey respondents reviewed some or all; among those administered communication aids, 86 % reviewed one or more after the visit 4. Through continuous quality adaptations, we increased the proportion of available staff time used for patient support (i.e. exploitation of workforce capacity) from 29 % in 2005 to 84 % in 2012 5. Maintenance: The main barrier to sustainability was the cost of paid intern labor. We addressed this by testing a service learning model in which student interns work as program coaches in exchange for academic credit rather than salary. The feasibility test succeeded, and we are now expanding the use of unpaid interns. We have sustained a clinic-wide implementation of decision and communication aids through a novel staffing model that uses paid and unpaid student interns as coaches.BMC Health Services Research 05/2015; 15(1). DOI:10.1186/s12913-015-0872-6 · 1.66 Impact Factor
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ABSTRACT: The majority of patients diagnosed with early-stage breast cancer are in a position to choose between having a mastectomy or lumpectomy with radiation therapy (breast-conserving therapy). Since the long-term survival rates for mastectomy and for lumpectomy with radiation therapy are comparable, patients' informed preferences are important for decision-making. Although most clinicians believe that they do include patients in the decision-making process, the information that women with breast cancer receive regarding the surgical options is often rather subjective, and does not invite patients to express their preferences. Shared decision-making (SDM) is meant to help patients clarify their preferences, resulting in greater satisfaction with their final choice. Patient decision aids can be very supportive in SDM. We present the protocol of a study to β test a patient decision aid and optimise strategies for the implementation of SDM regarding the treatment of early-stage breast cancer in the actual clinical setting. This paper concerns a pre-implementation and post-implementation study, lasting from October 2014 to June 2015. The intervention consists of implementing SDM using a patient decision aid. The intervention will be evaluated using qualitative and quantitative measures, acquired prior to, during and after the implementation of SDM. Outcome measures are knowledge about treatment, perceived SDM and decisional conflict. We will also conduct face-to-face interviews with a sample of these patients and their care providers, to assess their experiences with the implementation of SDM and the patient decision aid. This protocol was approved by the Maastricht University Medical Centre (MUMC) ethics committee. The findings will be disseminated through peer-reviewed journal articles and presentations at national conferences. Findings will be used to finalise a multi-faceted implementation strategy to test the implementation of SDM and a patient decision aid in terms of cost-effectiveness, in a multicentre cluster randomised controlled trial (RCT). NTR4879. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.BMJ Open 03/2015; 5(3):e007698. DOI:10.1136/bmjopen-2015-007698 · 2.06 Impact Factor
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