Jeffrey Belkora

University of California, San Francisco, San Francisco, California, United States

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Publications (56)171.97 Total impact

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    ABSTRACT: Qualitative studies have identified barriers to communication and informed decision making among breast cancer survivors making treatment decisions. The prevalence of these barriers is unknown. To quantify the need for decision support among breast cancer survivors. We surveyed 2,521 breast cancer survivors participating in an online registry hosted by the Cancer Support Community to find out what proportion of breast cancer patients: made decisions during their first visit with a specialist; received satisfactory information before that visit; asked questions and received responses; and endorsed expanded use of decision support. We received 1,017 (41%) responses and analyzed 917 surveys from women who lived in the United States. Most of the respondents recalled making treatment decisions during their first visit (52%). A minority (14%) received information before the first specialist visit. At least 25% of respondents rated their satisfaction below 7 on a scale of 10 for decision-making, information, and questions asked and answered. Respondents endorsed the need for assistance with obtaining information, listing questions, taking notes, and making audio-recordings of visits. The respondent sample skewed younger and had higher-stage cancer compared with all breast cancer survivors. Responses were subject to recall bias. Cancer survivors expressed gaps in their care with respect to reviewing information, asking questions, obtaining answers, and making decisions. Implementing decision and communication aids immediately upon diagnosis, when treatment decisions are being made, would address these gaps. ©2015 Frontline Medical Communications.
    03/2015; 13(3):104-12. DOI:10.12788/jcso.0116
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    ABSTRACT: It is unclear how socioeconomic (SES) status influences the effectiveness of shared decision making (SDM) tools. The purpose of this study was to assess the impact SES on the utility of SDM tools among patients with hip and knee osteoarthritis (OA). We performed a secondary analysis of data from a randomized controlled trial of 123 patients with hip or knee OA. Higher education and higher income were independently associated with higher knowledge survey scores. Patients with private insurance were 2.7 times more likely than patients with Medicare to arrive at a decision during the initial office visit. Higher education was associated with lower odds of choosing surgery, even after adjusting for knowledge. Patient knowledge of their medical condition and treatment options varies with SES. Level of Evidence: Level II, Prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
    The Journal of Arthroplasty 09/2014; 30(2). DOI:10.1016/j.arth.2014.09.006 · 2.37 Impact Factor
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    ABSTRACT: Despite evidence that decision and communication aids are effective for enhancing the quality of preference-sensitive decisions, their adoption in the field of orthopaedic surgery has been limited. The purpose of this mixed-methods study was to evaluate the perceived value of decision and communication aids among different healthcare stakeholders.
    BMC Health Services Research 08/2014; 14(1):366. DOI:10.1186/1472-6963-14-366 · 1.66 Impact Factor
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    ABSTRACT: Background Men with prostate cancer face preference-sensitive decisions when choosing among treatments with similar survival outcomes but different procedures, risks and potential complications. A decision-support intervention, ‘Decision Navigation’ assists men with prostate cancer to prepare a question list (consultation plan) for their doctors and provides them with a consultation summary and audio recording. A randomised controlled trial of Decision Navigation showed advantages over usual care on quantitative measures including confidence in decision-making and regret. Objective The aim of this study was to gain a qualitative understanding of patient's and doctor's perspectives on Decision Navigation. Methods Six patients who received Decision Navigation were purposively selected for interview out of 62 randomised controlled trial participants. All four doctors who consulted Navigated patients were interviewed. Interview data was analysed using framework analysis. Results Patients reported that planning for the consultation helped them to frame their questions, enabling them to participate in consultations and take responsibility for making decisions. They reported feeling more confident in the decisions made, having a written report of the key information and an audio recording. Patients considered routine information relating to side effects was inadequate. Doctors reported that consultation plans made them aware of patients' concerns and ensured comprehensive responses to questions posed. Doctors also endorsed implementing Decision Navigation as part of routine care. Conclusion Results suggest that Decision Navigation facilitated patients' involvement in treatment decision-making. Prostate patients engaging in preference-sensitive decision-making welcomed this approach to personalised tailored support. Copyright © 2014 John Wiley & Sons, Ltd.
    Psycho-Oncology 06/2014; DOI:10.1002/pon.3466 · 4.04 Impact Factor
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    Steven J Katz, Jeffrey Belkora, Glyn Elwyn
    Journal of Oncology Practice 05/2014; 10(3):206-8. DOI:10.1200/JOP.2014.001434
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    ABSTRACT: Understanding of cancer outcomes is limited by data fragmentation. In the current study, the authors analyzed the information yielded by integrating breast cancer data from 3 sources: electronic medical records (EMRs) from 2 health care systems and the state registry. Diagnostic test and treatment data were extracted from the EMRs of all patients with breast cancer treated between 2000 and 2010 in 2 independent California institutions: a community-based practice (Palo Alto Medical Foundation; "Community") and an academic medical center (Stanford University; "University"). The authors incorporated records from the population-based California Cancer Registry and then linked EMR-California Cancer Registry data sets of Community and University patients. The authors initially identified 8210 University patients and 5770 Community patients; linked data sets revealed a 16% patient overlap, yielding 12,109 unique patients. The percentage of all Community patients, but not University patients, treated at both institutions increased with worsening cancer prognostic factors. Before linking the data sets, Community patients appeared to receive less intervention than University patients (mastectomy: 37.6% vs 43.2%; chemotherapy: 35% vs 41.7%; magnetic resonance imaging: 10% vs 29.3%; and genetic testing: 2.5% vs 9.2%). Linked Community and University data sets revealed that patients treated at both institutions received substantially more interventions (mastectomy: 55.8%; chemotherapy: 47.2%; magnetic resonance imaging: 38.9%; and genetic testing: 10.9% [P < .001 for each 3-way institutional comparison]). Data linkage identified 16% of patients who were treated in 2 health care systems and who, despite comparable prognostic factors, received far more intensive treatment than others. By integrating complementary data from EMRs and population-based registries, a more comprehensive understanding of breast cancer care and factors that drive treatment use was obtained. Cancer 2013. © 2013 American Cancer Society.
    Cancer 01/2014; 120(1). DOI:10.1002/cncr.28395 · 4.90 Impact Factor
  • UK Society of Behavioural Medicine (UKSBM); 12/2013
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    ABSTRACT: We operate a decision support program in a medical center in San Francisco. In this program, postbaccalaureate, premedical interns deliver decision and communication, aids to patients. We asked whether working in this program helped these premedical interns develop key physician competencies. To measure physician competencies, we adopted the standards of the Accreditation Committee on Graduate Medical Education (ACGME), which accredits residency programs in the USA. The ACGME competencies are patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice. We developed a survey for our program alumni to rate themselves on a scale from 0 (none) to 100 (perfect) on each competency, before and after their time in our program. The survey also solicited free-text comments regarding each competency. In June 2012, we e-mailed all 47 alumni a link to our online survey and then analyzed responses received by July 15, 2012. We visually explored the distributions of ratings and compared medians. We selected the most specific and concrete comments from the qualitative responses. Respondents (21/47 or 45 %) reported that their participation in Decision Services increased their competencies across the board. Qualitative comments suggest that this is because students accompanied patients on their clinic journeys (seeing multiple facets of the systems of care) while also actively facilitating patient physician communication. Providing decision support can improve self-ratings of crucial physician competencies. Educators should consider deploying premedical and medical students as decision support coaches to increase competencies through experiential learning.
    Journal of Cancer Education 10/2013; 29(1). DOI:10.1007/s13187-013-0565-y · 1.05 Impact Factor
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    ABSTRACT: Purpose: National Quality Forum has identified shared decision making (SDM) as a key measure gap. One challenge in performance measurement of SDM is that for many decisions, reliable patient identification is only feasible after treatment has occurred. However, there are concerns, e.g. recall bias, when patients’ knowledge, involvement and goals are collected after treatment. The objective of this study was to examine how performance measurement would be impacted if patients are surveyed shortly after (one month) or long after (one year) treatment. Method: Longitudinal, multi-site survey of breast cancer (BC) patients, with measurements at 1 month and 1 year after surgery. Patients completed the BC Surgery Decision Quality Instrument to assess knowledge, goals and involvement in decision-making. Total knowledge and involvement scores were scaled from 0-100% with higher scores indicating higher knowledge and involvement. We tested several hypotheses: (1) knowledge scores would decline (2) the decline would be greater for quantitative items than qualitative items, (3) involvement scores would decline and (4) goals (e.g. desire to keep breast, remove breast for peace of mind and avoid radiation) would become more aligned with choices over time. Changes in scores were examined using paired t-tests. Result: 267/444 (60%) completed 1 month and 229/267 (86%) completed 1-year assessment. The mean total knowledge score did not change (69.2% (SD16.6%) 1-month versus 69.4% (SD17.7%) 1-year, p=0.86). Patients scored the same on quantitative items (61.3% 1-month versus 59.8% 1-year, p=0.65). The reports of involvement did not change (66.8% (SD24.7%) versus 65.2% (SD26.1%), p=0.31). Only one of the goals, avoid radiation, changed significantly and became less important for all patients over time (for lumpectomy patients, mean difference=-0.44, p=0.03 and for mastectomy patients, mean difference=-0.93, p=0.05). Despite the minimal change in mean scores, many respondents had knowledge scores (116/229, 50%) or involvement scores (163/229, 70%) change by >10% with increases balancing out decreases. Conclusion: Contrary to our hypotheses, we did not find differences in the mean scores for knowledge, involvement or goals. For population-level assessments, it may be reasonable to survey BC patients up to a year after the decision, greatly increasing feasibility of measurement. However, scores changed markedly for many at the individual-level and additional studies are needed to examine factors associated with these changes and to confirm these results for other decisions.
    The 35th Annual Meeting of the Society for Medical Decision Making; 10/2013
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    M Danesh, J Belkora, S Volz, H S Rugo
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    ABSTRACT: In the setting of breast oncology consultations, we sought to understand communication patterns between patients with advanced breast cancer and their oncologists during visits with Decision Support Services. This is a descriptive study analyzing themes and their frequencies of premeditated question lists of patients with metastatic breast cancer. We identified topics physicians most commonly discussed among themes previously found, documenting questions patients with metastatic breast cancer prepare for physician consultations and oncologists' response. Inclusion criteria were as follows: diagnosis of metastatic breast cancer, completion of a question list before meeting with an oncologist, and receipt of a summary of the consultation. We identified 59 women with metastatic breast cancer who received both documents. We reviewed the question lists and consultation summaries of these patients. Of the 59 patients whose documents we reviewed, patients most often asked about prognosis (38), symptom management (31), clinical trials (43), and quality of life (38). Physicians answered questions about prognosis infrequently (37 % of the time); other questions that were answered more than commonly are the following: symptom management (81 %), clinical trials (79 %), and quality of life (66 %). Breast cancer patients have many questions regarding their disease, its treatment, and symptoms, which were facilitated in this setting by Decision Support Services. Question lists may be insufficient to bridge the divide between physicians and patient information needs in the setting of metastatic breast cancer, particularly regarding prognosis. Patients may need additional assistance defining question lists, and physicians may benefit from training in communication, particularly regarding discussions of prognosis and end of life.
    Journal of Cancer Education 10/2013; 29(1). DOI:10.1007/s13187-013-0566-x · 1.05 Impact Factor
  • International Journal of Radiation OncologyBiologyPhysics 10/2013; 87(2):S39-S40. DOI:10.1016/j.ijrobp.2013.06.105 · 4.18 Impact Factor
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    ABSTRACT: Despite evidence that shared decision-making tools for treatment decisions improve decision quality and patient engagement, they are not commonly employed in orthopaedic practice. The purpose of this study was to evaluate the impact of decision and communication aids on patient knowledge, efficiency of decision making, treatment choice, and patient and surgeon experience in patients with osteoarthritis of the hip or knee. One hundred and twenty-three patients who were considered medically appropriate for hip or knee replacement were randomized to either a shared decision-making intervention or usual care. Patients in the intervention group received a digital video disc and booklet describing the natural history and treatment alternatives for hip and knee osteoarthritis and developed a structured list of questions for their surgeon in consultation with a health coach. Patients in the control group received information about the surgeon's practice. Both groups reported their knowledge and stage in decision making and their treatment choice, satisfaction, and communication with their surgeon. Surgeons reported the appropriateness of patient questions and their satisfaction with the visit. The primary outcome measure tracked whether patients reached an informed decision during their first visit. Statistical analyses were performed to evaluate differences between groups. Significantly more patients in the intervention group (58%) reached an informed decision during the first visit compared with the control group (33%) (p = 0.005). The intervention group reported higher confidence in knowing what questions to ask their doctor (p = 0.0034). After the appointment, there was no significant difference between groups in the percentage of patients choosing surgery (p = 0.48). Surgeons rated the number and appropriateness of patient questions higher in the intervention group (p < 0.0001), reported higher satisfaction with the efficiency of the intervention group visits (p < 0.0001), and were more satisfied overall with the intervention group visits (p < 0.0001). Decision and communication aids used in orthopaedic practice had benefits for both patients and surgeons. These findings could be important in facilitating adoption of shared decision-making tools into routine orthopaedic practice. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
    The Journal of Bone and Joint Surgery 09/2013; 95(18):1633-9. DOI:10.2106/JBJS.M.00004 · 4.31 Impact Factor
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    ABSTRACT: OBJECTIVE: Does decision navigation (DN) increase prostate cancer patients' confidence and certainty in treatment decisions, while reducing regret associated with the decisions made? METHODS: Two hundred eighty-nine newly diagnosed prostate cancer patients were eligible. 123 consented and were randomised to usual care (n = 60) or navigation (n = 63). The intervention involved a 'navigator' guiding the patient in creating a personal question list for a consultation and providing a CD and typed summary of the consultation to patients, the general practitioner and physician. The primary outcome was decisional self efficacy. Secondary outcomes included decisional conflict (DCS) and decisional regret (RS). Measures of mood (Hospital Anxiety and Depression Scale) and adjustment (Mental Adjustment to Cancer Scale) were included to detect potential adverse effects of the intervention. RESULTS: ANOVA showed a main effect for the group (F = 7.161, df 1, p = 0.009). Post hoc comparisons showed significantly higher decisional self efficacy in the navigated patients post-consultation and 6 months later. Decisional conflict was lower for navigated patients initially (t = 2.005, df = 105, p = 0.047), not at follow-up (t = 1.969, df = 109, p = 0.052). Regret scores were significantly lower in the navigation group compared to the controls 6 months later (t = -2.130, df = 100, p = 0.036). There was no impact of the intervention on mood or adjustment. CONCLUSION: Compared to control patients, navigated patients were more confident in making decisions about cancer treatment, were more certain they had made the right decision after the consultation and had less regret about their decision 6 months later. Decision navigation was feasible, acceptable and effective for newly diagnosed prostate cancer patients in Scotland. Copyright © 2012 John Wiley & Sons, Ltd.
    Psycho-Oncology 05/2013; 22(5). DOI:10.1002/pon.3093 · 4.04 Impact Factor
  • Shelley Volz, Dan H Moore, Jeffrey K Belkora
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    ABSTRACT: Background Our breast cancer clinic promotes patient use of decision and communication aids (DAs/CAs) through two mechanisms: coaching and prompting. From January through September 2010, we provided services to 462 of 1106 new visitors (42%). Of those 462 visitors, 267 (58%) received coaching. For the remainder (195 or 42%), the best we could do was prompt them to self-administer the DA and CAs.Objective We wanted to learn whether patients prompted to use DAs/CAs did so.Methods We surveyed prompted patients after their visits. We asked how much of each DA they reviewed, whether they listed questions, made notes and audio-recorded their consultations. We tallied frequencies and explored associations using logistic regression.ResultsOf the 195 prompted patients, 82 responded to surveys (42%). Nearly all (66/73 or 90%) reported reviewing some or all of the booklets and 52/73 (71%) reported viewing some or all of the DVDs. While 63/78 (81%) responded that they wrote a question list, only 14/61 (23%) said they showed it to their doctor. Two-thirds (51/77 or 66%) said someone took notes, but only 16/79 (20%) reported making audio recordings.DiscussionMore patients reported following prompts to use DAs than CAs. Few reported showing question lists to physicians or recording their visits. Our exploratory analyses surfaced associations between using CAs and race/ethnicity or education that merit further investigation.Conclusion Prompting patients assures better use of decision than communication aids. Clinicians may need to take a more active role to ensure patients receive adequate notes and recordings.
    Health expectations: an international journal of public participation in health care and health policy 01/2013; 18(3). DOI:10.1111/hex.12042 · 2.85 Impact Factor
  • International Conference On Communication In Healthcare; 09/2012
  • International Conference On Communication In Healthcare; 09/2012
  • M Pass, S Volz, A Teng, L Esserman, J Belkora
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    ABSTRACT: The aim of this paper is to examine how physician behavior facilitated or impeded our implementation of decision and communication aids in a breast cancer clinic. Staff interns provided decision and communication aids to patients and wrote up case notes for each patient they served. We used grounded theory to code our staff interns' case notes. We then identified barriers and facilitators to our program's implementation from each category we generated in the coding. Facilitators included physicians reading patient questions and then bringing the staff interns to the consultation. Barriers included physicians forgetting to bring the staff interns to the appointments and discouraging interns from speaking during the consultation. Physicians vary in their cooperation with our program. Our next steps will be to inquire directly with physicians about how to adapt our program design. We will also seek to position the staff interns as mentees to increase physician commitment to our program.
    Journal of Cancer Education 08/2012; DOI:10.1007/s13187-012-0402-8 · 1.05 Impact Factor
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    ABSTRACT: Our community-based participatory research partnership previously evaluated Consultation Planning (CP), a question-listing intervention delivered in-person. We now report on effectiveness, cost, and value of delivering CP by telephone (Tele-CP). Between 2007 and 2010, we randomly assigned rural women with a diagnosis of breast cancer to receive Tele-CP or In-Person CP. We compared ratings of decision self-efficacy (0 minimum to 4 maximum) with a pre-specified non-inferiority margin of 15%. We also explored psychosocial and economic outcomes. Tele-CP (n=35) recipients reported mean decision self-efficacy ratings of 3.53 versus 3.44 for in-person (n=32). Under intent-to-treat analysis, we rejected the null hypothesis of greater than 0.52 inferiority for Tele-CP (95% CI for difference: -0.44 to 0.13, p=0.006). The intervention costs averaged $48 for Tele-CP versus $78 in-person (95% CI for difference: -$63 to $2). Mean willingness-to-pay was $154 for Tele-CP and $144 for in-person (95% CI for difference: -$88 to $108). Tele-CP was non-inferior to In-Person CP, cost no more, and was equally valued by patients. Telephone delivery of Consultation Planning can achieve comparable quality, cost, and value as in-person. Organizations offering Consultation Planning or similar question-listing interventions should consider adopting telephone delivery.
    Patient Education and Counseling 07/2012; 89(1):134-42. DOI:10.1016/j.pec.2012.06.009 · 2.60 Impact Factor
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    ABSTRACT: The purpose of this paper is to examine the acceptability, feasibility, reliability and validity of a new decision quality instrument that assesses the extent to which patients are informed and receive treatments that match their goals. Cross-sectional mail survey of recent breast cancer survivors, providers and healthy controls and a retest survey of survivors. The decision quality instrument includes knowledge questions and a set of goals, and results in two scores: a breast cancer surgery knowledge score and a concordance score, which reflects the percentage of patients who received treatments that match their goals. Hypotheses related to acceptability, feasibility, discriminant validity, content validity, predictive validity and retest reliability of the survey instrument were examined. We had responses from 440 eligible patients, 88 providers and 35 healthy controls. The decision quality instrument was feasible to implement in this study, with low missing data. The knowledge score had good retest reliability (intraclass correlation coefficient=0.70) and discriminated between providers and patients (mean difference 35%, p<0.001). The majority of providers felt that the knowledge items covered content that was essential for the decision. Five of the 6 treatment goals met targets for content validity. The five goals had moderate to strong retest reliability (0.64 to 0.87). The concordance score was 89%, indicating that a majority had treatments concordant with that predicted by their goals. Patients who had concordant treatment had similar levels of confidence and regret as those who did not. The decision quality instrument met the criteria of feasibility, reliability, discriminant and content validity in this sample. Additional research to examine performance of the instrument in prospective studies and more diverse populations is needed.
    BMC Medical Informatics and Decision Making 06/2012; 12:51. DOI:10.1186/1472-6947-12-51 · 1.50 Impact Factor
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    ABSTRACT: Explore the validity of using patient reports to measure shared decision making (SDM). 178 patients diagnosed with breast cancer obtained SDM assistance in a university-based clinic. Trained observers rated physician SDM behaviors and surveyed patients. We calculated the frequency with which patients and observers reported maximum SDM behaviors for each survey item. We also calculated agreement frequency between patients and observers. Over 90% of patients rated doctors as reflecting SDM competencies. Patients reported doctors making recommendations more than soliciting their preferred choice (90% vs. 69%, p<0.001). Patients heard benefits discussed "a lot" more often than they heard risks and side effects discussed "a lot" (81% vs. 58%, p<0.001). Agreement between patients and observers was 75%. In cases of disagreement, patients more frequently perceived SDM behaviors than did observers (15% vs. 9%, p=0.002), suggesting a possible agreement bias. High agreement supports further investigation into using patients as efficient and effective raters of SDM. Patient ratings may be inflated by agreement bias. Doctors presentations may be biased toward discussing benefits more than risks. Policy makers can solicit patient ratings of SDM as long as they are aware of possibly inflated ratings due to agreement bias.
    Patient Education and Counseling 02/2012; 88(1):93-9. DOI:10.1016/j.pec.2012.01.008 · 2.60 Impact Factor

Publication Stats

368 Citations
171.97 Total Impact Points


  • 2007–2015
    • University of California, San Francisco
      • • Institute for Health Policy Studies
      • • Department of Surgery
      San Francisco, California, United States
  • 2014
    • Palo Alto Medical Foundation
      Palo Alto, California, United States
  • 2002–2009
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2003
    • Harvard Medical School
      Boston, Massachusetts, United States