Monitoring the implementation of Consultation Planning, Recording, and Summarizing in a breast care center

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Abstract

Objective

We implemented and monitored a clinical service, Consultation Planning, Recording and Summarizing (CPRS), in which trained facilitators elicit patient questions for doctors, and then audio-record, and summarize the doctor–patient consultations.

Methods

We trained 8 schedulers to offer CPRS to breast cancer patients making treatment decisions, and trained 14 premedical interns to provide the service. We surveyed a convenience sample of patients regarding their self-efficacy and decisional conflict. We solicited feedback from physicians, schedulers, and CPRS staff on our implementation of CPRS.

Results

278 patients used CPRS over the 22-month study period, an exploitation rate of 32% compared to our capacity. 37 patients responded to surveys, providing pilot data showing improvements in self-efficacy and decisional conflict. Physicians, schedulers, and premedical interns recommended changes in the program's locations; delivery; products; and screening, recruitment and scheduling processes.

Conclusion

Our monitoring of this implementation found elements of success while surfacing recommendations for improvement.

Practice implications

We made changes based on study findings. We moved Consultation Planning to conference rooms or telephone sessions; shortened the documents produced by CPRS staff; diverted slack resources to increase recruitment efforts; and obtained a waiver of consent in order to streamline and improve ongoing evaluation.

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.

References (22)

  • P.N. Butow et al.

    Patient participation in the cancer consultation: Evaluation of a question prompt sheet

    Ann Oncol

    (1994)
  • S. Ford et al.

    The influence of audiotapes on patient participation in the cancer consultation

    Eur J Cancer

    (1995)
  • A. Cranney et al.

    Development and pilot testing of a decision aid for postmenopausal women with osteoporosis

    Patient Educ Couns

    (2002)
  • M. Weiss

    Seven minutes! How to get the most from your doctor visit

    (2007)
  • J.T. Scott et al.

    Recordings or summaries of consultations for people with cancer

    Cochrane Database Syst Rev

    (2003)
  • P. Kinnersley et al.

    Interventions before consultations for helping patients address their information needs

    Cochrane Database Syst Rev

    (2007)
  • Belkora JK, Mindful collaboration: Prospect mapping as an action research approach to planning for medical...
  • K. Sepucha et al.

    Building bridges between physicians and patients: Results of a pilot study examining new tools for collaborative decision making

    J Clin Oncol

    (2000)
  • K. Sepucha et al.

    Consultation planning to help patients prepare for medical consultations: Effect on communication and satisfaction for patients and physicians

    J Clin Oncol

    (2002)
  • K.R. Sepucha et al.

    Building bridges between physicians and patients: Results of a pilot study examining new tools for collaborative decision making in breast cancer

    J Clin Oncol

    (2000)
  • K.R. Sepucha et al.

    Consultation planning to help breast cancer patients prepare for medical consultations: Effect on communication and satisfaction for patients and physicians

    J Clin Oncol

    (2002)
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