Implementing Patient-Oriented Decision Support Into Breast Cancer Care

Abstract

A multidisciplinary approach to breast cancer treatment provides optimal care. However, the decision making process can be overwhelming for the individual patient. Decision aids (DAs) educate patients about treatment options and outcomes. Communication aids (CAs) help patients identify questions for their physicians and provide written summaries and audio-recordings of consultations. We examined the effect of DAs and CAs on communication and treatment decision making in our breast cancer clinic. DAs/CAs were integrated into our breast cancer clinic in 2005. Trained counselors provided patients with educational written materials and videos from Informed Medical Decisions Foundation and assisted them in creating and prioritizing a list of questions before their physician visits (surgeons, radiation oncologists, medical oncologists, and plastic surgeons). The counselors accompanied patients on each visit. They were given written summaries and audio recordings of visits. Software, internet, and telephone communications were used to track and deliver the services. Patients were surveyed before and after receiving DAs/CAs using O'Connor's Decisional Conflict Scale (DCS) which measures patient uncertainty regarding the best course of action (scale 1-5; lower scores more certainty) and knowledge items from Sepucha's Decision Quality Instrument (DQI) which reflects an informed choice. Custom instruments measured question self-efficacy (confidence patient knows what questions to ask) and satisfaction with DAs/CAs on a scale of 0 to 10 (maximum). Between 2005 and 2010, DAs grew annually from 208 to 1,027 (total 3,208) while CAs grew annually from 142 to 348 (total 1,228). Post-DA surveys found an increase in patient knowledge (correct responses) from 45% to 74%; decrease in decision conflict scores (2.61 to 2.09) (p < 0.001). Post-CA survey found increase in the number of patient questions (9 to 24) and question self-efficacy (6.7 to 8.1) (p < 0.001). Follow-up survey of DAs and CAs found satisfaction 8.9/10. In 2009-2010, 83% of 1,355 new patients were offered CAs: 67% accepted the offer. Follow-up surveys found that 76% viewed DA videos and 93% read DA booklets. Eighty-three percent reviewed their consultation summaries and 56% reviewed the audio-recordings. We have effectively integrated DAs and CAs into routine breast cancer care. We have demonstrated a positive effect on patient-physician communication, a greater satisfaction with the physician consultation and an improved understanding of treatment options; all of which facilitate the decision-making process.