[Show abstract][Hide abstract] 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; · 0.88 Impact Factor
[Show abstract][Hide abstract] 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; · 0.88 Impact Factor
[Show abstract][Hide abstract] 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. · 3.23 Impact Factor
[Show abstract][Hide abstract] 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. RESULTS: Of 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. DISCUSSION: More 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; · 1.80 Impact Factor
[Show abstract][Hide abstract] 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; · 0.88 Impact Factor
[Show abstract][Hide abstract] 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. · 2.60 Impact Factor
[Show abstract][Hide abstract] 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. · 1.60 Impact Factor
[Show abstract][Hide abstract] 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. · 2.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Adjuvant! is a model that provides recurrence and mortality risk predictions for patients with breast cancer considering adjuvant therapies. Although low-risk patients who saw Adjuvant! chose adjuvant therapy less frequently, whether this was because of educational or other aspects of the decision aid is unknown. The authors explored whether Adjuvant! affects choice of therapy through increased patient knowledge. A subset of data were analyzed from a cluster randomized trial in which oncology practices in 2 major United States cities were randomly assigned to use either Adjuvant! or an informational pamphlet to educate patients. Of 405 patients, 48 were low-risk, with 28 assigned to the decision aid and 20 to the pamphlet. Among the low-risk patients, using frequency tables and Fisher exact tests, the authors explored whether Adjuvant! was associated with more accurate patient estimates of survival; whether accuracy was associated with treatment choice; and whether, after controlling for accuracy, any remaining association was seen between Adjuvant! and treatment choice. Adjuvant! was associated with more accurate estimates of baseline prognosis compared with the pamphlet (57% vs. 25%; P = .04). Patients who had more accurate estimates of baseline prognosis were less likely to choose adjuvant therapy (62% vs. 89%; P = .04). After controlling for accuracy, no statistically significant association was found between the use of Adjuvant! and adjuvant therapy (P = .59 and P = .11 for inaccurate and accurate patients, respectively). Adjuvant! seems to influence patient choice through educational rather than other means of persuasion. However, many patients held inaccurate risk perceptions after viewing Adjuvant!.
Journal of the National Comprehensive Cancer Network: JNCCN 07/2011; 9(7):707-12. · 5.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We examined the reach and impact of five decision aids (DAs) routinely distributed to breast cancer patients as part of a shared decision making demonstration project.
From 2005 to 2008, we surveyed patients' change in knowledge and decisional conflict (DC) before and after their review of DAs. Using bivariate tests, we identified significant predictors of change in knowledge or decisional conflict and entered significant predictors into a multivariate regression model.
We distributed 1553 DAs to 1098 patients and received 549 completed surveys. The DAs were associated with increased knowledge and decreased DC. For knowledge, significant predictors of above-average change included: lower baseline knowledge and viewing the surgery decision aid. For decisional conflict, significant predictors of above-average change included: higher decisional conflict; viewing any of the early-stage cancer DAs; and Hispanic ethnicity.
DAs used in routine care were associated with significant knowledge gains and reductions in decisional conflict. Some subsets of patients (those reporting low baseline knowledge, high DC, or Hispanic ethnicity) may benefit more than others.
Breast cancer patients benefit overall from routine distribution of DAs. Our exploratory findings may be useful in generating hypotheses to identify target populations who would most benefit from reviewing DAs.
Patient Education and Counseling 06/2011; 86(2):195-204. · 2.60 Impact Factor
[Show abstract][Hide abstract] 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.
Patient Education and Counseling 05/2011; 83(2):234-9. · 2.60 Impact Factor