S. Patricia Pinfold

Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada

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Publications (5)27.18 Total impact

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    ABSTRACT: To quantify the clinical consistency of expert panelists' ratings of appropriateness of pre-operative and post-operative chemotherapy plus radiation for rectal cancer. A panel of nine physicians (two surgeons, four medical oncologists, three radiation oncologists) rated the appropriateness of providing pre-operative and post-operative treatments for rectal cancer, utilizing a modified-Delphi (RAND/UCLA) approach. Clinical scenarios were paired so that each component of a pair differed by only one clinical feature (e.g. tumor stage). A pair of appropriateness ratings was defined as inconsistent when the clinical scenario that should have had the higher (or at least equal) appropriateness rating was given a lower rating. The rate of inconsistency was analyzed for panelists' ratings of pre- and post-operative chemotherapy plus radiation. The final panel rating was inconsistent for 1.19% of pre-operative scenario pairs, and 0.77% of post-operative scenario pairs. Using the conventional RAND/UCLA definition of appropriateness, the magnitude of the inconsistency would produce inconsistent appropriateness ratings in 0.43% of pre-operative and 0.11% of post-operative scenario pairs. There was significant variation in the rate of inconsistency among individual panelists' final ratings of both pre-operative (range: 0.43-5.17%, P < 0.001) and post-operative (range: 0.51-2.34%, P < 0.001) scenarios. Panelists' overall average rate of inconsistency improved significantly after the panel meeting and discussion (from 5.62 to 2.25% for pre-operative scenarios, and from 1.47 to 1.24% for post-operative scenarios, both P < 0.05). There was no clear difference between specialty groups. Inconsistency was related to the structure of the rating manual: in the second round there were no inconsistent ratings when scenario pairs occurred on the same page of the manual. The RAND/UCLA appropriateness method can produce ratings for cancer treatment that are highly clinically consistent. Modifications to the structure of rating manuals to facilitate direct assessment of consistency at the time of rating may reduce inconsistency further.
    Health Policy 01/2005; 71(1):57-65. DOI:10.1016/j.healthpol.2004.05.004 · 1.91 Impact Factor
  • David W. Petrik · David R. McCready · Vivek Goel · S. Patricia Pinfold · Carol A. Sawka ·
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    ABSTRACT: Increased emphasis on breast conservation and the primacy of the patient's preferences has led to the promotion and increased use of a two-step surgical strategy (definitive operation only after a final tissue diagnosis from a biopsy done on a previous visit) in the treatment of early breast cancer, with the assumption being that this is more conducive to the performance of breast-conserving surgery (BCS). We sought to test this by examining the effect of the surgical strategy (one-step versus two-step) on the operation performed (BCS versus mastectomy). A random sample of women with node-negative breast cancer diagnosed in 1991 in Ontario was drawn from the Ontario Cancer Registry database and matched to the Canadian Institute of Health Information and Ontario Health Insurance Plan databases (n = 643). This provided information on the timing and nature of all surgical procedures performed as well as patient, tumor, hospital, and surgeon characteristics. The surgical strategy was defined as either a one-step procedure (biopsy and definitive surgery performed at the same time) or a two-step procedure (surgical biopsy and pathologic diagnosis, followed by definitive surgery at a later date). The axillary lymph node dissection was used to define the definitive procedure. BCS was employed in 68% of patients, and this did not differ significantly between the one-step and two-step groups (66% versus 70%). Patients with palpable lesions had a significantly lower rate of breast conservation than those with nonpalpable lesions. Other variables associated with a lower rate of BCS were larger tumor size, presence of extensive ductal carcinoma in situ (DCIS), and central or multifocal tumors. The use of a one-step procedure was associated with a patient age of more than 50 years, a palpable mass, tumor size larger than 1 cm, previous fine needle aspiration (FNA) biopsy, absence of extensive DCIS, and surgery in an academic setting. Breast conservation was not affected by the surgical strategy used or the timing of the decision, but was associated with several accepted tumor factors. This study shows that, contrary to the opinion of some, there is a group of breast cancer patients in whom treatment in a one-step manner is appropriate.
    The Breast Journal 05/2001; 7(3):158-65. DOI:10.1046/j.1524-4741.2001.007003158.x · 1.41 Impact Factor
  • S. Patricia Pinfold · Vivek Goel · Carol Sawka ·
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    ABSTRACT: The quality of coding for breast surgical procedures was examined by comparing hospital discharge abstracts and physician claims with data abstracted from records of women diagnosed with node-negative breast cancer from April 1, 1991, to December 31, 1991. The node-negative breast cancer cohort was linked with a population registry file. Hospital discharge abstracts and physician billing claims were retrieved for matched subjects. Overall agreement between two data sets was defined as the number of cases for which there was a match by specific type of procedure out of all eligible cases that were matched with the health care utilization file. Specific agreement was assessed by the kappa statistic, using only those records in the administrative data set that were coded for mastectomy or breast-conserving surgery. Of 735 eligible cases in the node-negative breast cancer cohort, 655 (89.1%) were linked to a health care utilization file. Overall agreement between surgeon billing claims and charts was 95.4% (CI = 93.5, 96.9) for most definitive procedure. Agreement for breast surgery type was 98.1% (kappa = 0.96; CI = 0.87,1.0) for cases coded as breast-conserving surgery or mastectomy. When hospital discharge and chart data were compared, overall agreement was 86.2% (CI = 83.4, 88.8), whereas agreement for breast surgery type was 93.2% (kappa = 0.86; CI = 0.77, 0.94). Overall, definitive surgical procedure in the two administrative databases accurately reflected information recorded in patients' charts. Physician claims appeared to provide more accurate information than did hospital discharge data.
    Medical Care 02/2000; 38(1):99-107. DOI:10.1097/00005650-200001000-00011 · 3.23 Impact Factor
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    ABSTRACT: To examine variations in physicians' opinions about the appropriateness and content of decision aids for women with breast cancer and criteria for their evaluation. Cross-sectional survey of all 144 Ontario oncologists by Dillman's mailed survey design. The response rate was 87%. The predominant current practice pattern was to spontaneously inform patients about the treatment recommendations, degree of certainty regarding the recommendations, treatment regime, benefits and side effects. Most respondents (94%) endorsed patient decision aids, particularly when there was high uncertainty about providing adjuvant treatment. Over three-quarters endorsed measuring the following outcomes of decision aids: patients' clarity of trade-offs involved (e.g. survival vs. side effects); comprehension of treatment alternatives, risks and benefits; accuracy of expectations; decision satisfaction; anxiety; commitment to the decision; length of time to complete the decision aid; and decision uncertainty. The least support was for the use of the decision itself as an outcome measure. There is considerable consensus regarding the indications for, content and criteria for evaluating decision aids which should be considered when developing aids relevant to the needs of clinicians and patients.
    Patient Education and Counseling 03/1997; 30(2):143-53. DOI:10.1016/S0738-3991(96)00948-2 · 2.20 Impact Factor
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    ABSTRACT: To examine variations in physicians' recommendations for systemic adjuvant therapy in the treatment of women with node-negative breast cancer (NNBC) and to determine factors used in making specific recommendations. A questionnaire was sent by mail to all 149 Ontario physicians who actively treated breast cancer in 1993. The questionnaire described 48 clinical scenarios of women with NNBC, which included all possible combinations of the following factors: menopausal status, tumor size, hormone receptor status, histologic and nuclear grade, and lymphatic and/or vascular invasion. Respondents rated the appropriateness of administering tamoxifen, combination chemotherapy, or both tamoxifen and combination chemotherapy on a nine-point scale from extremely inappropriate to extremely appropriate. Respondent agreement and disagreement were tabulated for each scenario, and factors associated with specific treatment ratings were analyzed by logistic regression. The response rate was 87%. Agreement for the appropriateness of specific therapies was most evident where clinical trials have demonstrated efficacy, whereas disagreement was observed in scenarios in which support for a specific treatment is not available in the current literature. Relevant tumor- and patient-specific factors were used in decision-making; personal characteristics of the respondents had no statistically significant impact on appropriateness ratings. The physicians surveyed had good knowledge of NNBC prognostic factors, but had a range of opinion on optimal therapy for many clinical scenarios, which reflects current knowledge of the benefits of adjuvant therapy for NNBC.
    Journal of Clinical Oncology 07/1995; 13(6):1459-69. · 18.43 Impact Factor