Monitoring the implementation of Consultation Planning, Recording, and Summarizing in a breast care center
Introduction
Breast cancer patients consult specialists to arrive at treatment strategies, choosing among surgery, radiation, chemotherapy, hormone therapy, and biologic therapy. These treatments offer reduction in mortality and recurrence risk, at the cost of increased risk of complications, side effects, and long-term harm. As a means to effective information gathering and participation in decisions, experts advise breast cancer patients to make a list of questions before they attend their meetings with specialists; bring a friend to take notes; and make an audio-recording of the consultation [1].
Researchers have systematically reviewed the evidence base surrounding such visit preparation, audio-recording, and summarizing practices. Scott et al. found that providing audio recordings and/or consultation summaries can increase patient knowledge and patient satisfaction [2]. Kinnersley et al. found that “interventions before consultations for helping patients address their information needs… seem to help patients ask more questions in consultations” [3]. These and other reviews are not definitive, due to the relatively small number of studies and the mixed results. However, as Kinnersley and colleagues point out, “In terms of practice there are strong justifications unrelated to evidence-based medicine for adopting a collaborative approach to the medical encounter, such as, for example, patient preferences and moral imperatives” [3].
Indeed, based on our studies of visit preparation and recording [4], [5], [6], as well as evidence about the benefits of very similar interventions [7], [8], we began to pilot Consultation Planning, Recording, and Summarizing (CPRS) in 1998 at the UCSF BCC. Since then, we have found no research describing the routine implementation of visit preparation, recording, and summarizing interventions as integrated components of a clinical service. While the components have been shown in clinical studies to be satisfying to patients, and effective to varying degrees in improving various patient outcomes, researchers do not know whether integration into a clinic workflow is possible, how it affects patient measures such as self-efficacy and decisional conflict, and whether integration into routine practice is acceptable to physicians, schedulers, and staff affected by the interventions and can be sustained over the long term.
We therefore monitored our implementation of Consultation Planning, Recording, and Summarizing at the point in its evolution when we were integrating it more fully into programs in our clinic. Our hypotheses were that CPRS could be integrated into clinical care at our academic medical enter, that it would be associated with improvements in patient self-efficacy and decisional conflict, that it would be acceptable to physicians, schedulers, and staff, and that we could engage in continuous quality improvement to sustain and enhance the implementation. Specifically, this study asked the following questions:
- 1.
How many patients did we serve with CPRS?
- 2.
What changes in decisional self-efficacy and decisional conflict did we observe in a convenience sample of patients using CPRS?
- 3.
What aspects of CPRS should be continued, discontinued, or improved in order to assure the ongoing success of the implementation?
Section snippets
Setting and population
The UCSF Breast Care Center (BCC) is a multidisciplinary clinic in a university medical center. In 2005, the BCC saw 599 breast cancer patients new to the clinic who consulted specialists about treatment decisions over the course of 843 visits, with 44% of those visits being to 5 surgeons and 56% to 9 oncologists. The average age in 2005 was 57 years. The distribution of diagnosis by stage was 94 new patients with ductal or lobular carcinoma in situ (16%); 414 patients with stage 1–3 breast
Results
Study Question 1: 278 patients received CPRS over 22 months. We estimated that our maximum theoretical capacity during this period was approximately 880 CPRS service units, meaning that the exploitation rate was approximately 32%.
Study Question 2: We approached 38 patients (out of 278, 13%), all female, to answer DSE and DCS surveys. These patients met the physician criteria of not being engaged in other clinic activities such as filling out patient history forms or being roomed by nurses. One
Discussion
We asked questions about the number of patients provided with the service, levels of decisional self-efficacy and decisional conflict among survey respondents, and aspects of program design that should be continued, discontinued, or modified.
Study Question 1: We found that 278 patients were provided with CPRS over the study period, compared to our CPRS capacity in that period of 880, a service exploitation rate of 32%. On one hand, we were pleased that this novel and complex program reached 278
Role of funding sources
The Foundation for Informed Medical Decision Making (grant 0015) and United States Department of Defense (DAMD17-03-0481) provided funding for this study. During the analysis and reporting phase of the study, Dr. Belkora was also supported by a career development award from the National Institute of Child Health and Human Development (NICHD) and the Office of Research on Women's Health (ORWH), grant number 5 K12 HD052163. The funding sources had no involvement in any aspect of the study.
Conflicts of interest
The authors report no conflicts of interest.
Acknowledgements
The authors wish to thank the patients, physicians, administrators, premedical interns, and employees of the UCSF Breast Care Center. We also thank Karen Sepucha for ongoing collaboration related to decision support at our Breast Care Center; Martha Daschbach for assistance with regulatory compliance; the staff of the Fishbon Library for research assistance; Pam Derish for scientific writing instruction; and Dan Moore for statistical advice.
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