Qualitative analysis of shared decision-making for chemoprevention in the primary care setting: provider-related barriers

User Comprehension and EHR Integration of the RealRisks Decision Aid for Breast Cancer Risk Assessment: A Qualitative Study

RealRisks is a decision aid that integrates patient-generated and electronic health record (EHR) data using Fast Healthcare Interoperability Resources (FHIR). It offers modules to enhance understanding of breast cancer risk and a way for individuals to review and modify their EHR data before it is used in their personal risk assessment. RealRisks intends to encourage high-risk patients to take risk-reducing measures. To better understand how patients understand risk and barriers to action, we conducted in-depth interviews as part of a usability study to assess the clarity and interpretability of RealRisks. Overall, participants demonstrated an improved understanding of breast cancer risk after using RealRisks. However, challenges were noted for certain concepts, in particular, lifetime risk, how benign breast disease affects your risk, and the differences between hereditary, sporadic, and familial cancer. The EHR download feature was well-received, but some raised concerns about insurance and privacy/security.

Shared Decision Making Among Racially and/or Ethnically Diverse Populations in Primary Care: A Scoping Review of Barriers and Facilitators

PURPOSE

Disparities in the use of shared decision making (SDM) affect minoritized patients. We sought to identify the barriers and facilitators to SDM among diverse patients.

METHODS

We conducted a scoping review in adherence to the Joanna Briggs Institute's methodologic framework. Our search of 4 databases-PubMed, Scopus, CINAHL Plus with Full Text, and PsycINFO-used controlled vocabulary and key word terms related to SDM in the care of racially and/or ethnically diverse adults in the primary care setting. We included peer-reviewed studies conducted in the United States or Canada that evaluated the process of decision making and that had populations in which more than 50% of patients were from racial and/or ethnic minorities. Unique records were uploaded to a screening platform for independent review by 2 team members. We used grounded theory to guide our inductive approach and completed a thematic analysis.

RESULTS

A total of 39 studies met all inclusion criteria. We identified 5 overarching themes: (1) factors regarding the decision-making process during the clinical encounter, (2) clinician practice characteristics, (3) trust in the clinician/health care system, (4) cultural congruence between clinician and patient, and (5) extrinsic factors affecting the decision-making process. Barriers of SDM included cultural and language discordance; prejudice, bias, and stereotypes; mistrust; and clinician time constraints. Facilitators of SDM included cultural concordance between clinician and patient; clinician language competence; and clear, honest, and humanistic communication with patients having the ability to ask questions.

CONCLUSIONS

We identified a set of potentially modifiable factors that facilitate or impede SDM. Our findings can help inform strategies and interventions to improve SDM among racially and/or ethnically diverse patient populations.

Use of web-based decision support to improve informed choice for chemoprevention: a qualitative analysis of pre-implementation interviews (SWOG S1904)

BACKGROUND

Women with high-risk breast lesions, such as atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS), have a 4- to tenfold increased risk of breast cancer compared to women with non-proliferative breast disease. Despite high-quality data supporting chemoprevention, uptake remains low. Interventions are needed to break down barriers.

METHODS

The parent trial, MiCHOICE, is a cluster randomized controlled trial evaluating the effectiveness and implementation of patient and provider decision support tools to improve informed choice about chemoprevention among women with AH or LCIS. For this pre-implementation analysis, 25 providers participated in semi-structured interviews prior to accessing decision support tools. Interviews sought to understand attitudes/beliefs and barriers/facilitators to chemoprevention.

RESULTS

Interviews with 25 providers (18 physicians and 7 advanced practice providers) were included. Providers were predominantly female (84%), white (72%), and non-Hispanic (88%). Nearly all providers (96%) had prescribed chemoprevention for eligible patients. Three themes emerged in qualitative analysis. The first theme describes providers' confidence in chemoprevention and the utility of decision support tools. The second theme elucidates barriers to chemoprevention, including time constraints, risk communication and perceptions of patients' fear of side effects and anxiety. The third theme is the need for early implementation of decision support tools.

CONCLUSIONS

This qualitative study suggests that providers were interested in the early inclusion of decision aids (DA) in their chemoprevention discussion workflow. The DAs may help overcome certain barriers which were elucidated in these interviews, including patient level concerns about side effects, clinic time constraints and difficulty communicating risk. A multi-faceted intervention with a DA as one active component may be needed.

TRIAL REGISTRATION

This trial was registered with the NIH clinical trial registry, clinicaltrials.gov, NCT04496739.

Developing decision support tools for high-risk women and healthcare providers to increase chemoprevention informed choice and uptake: A retrospective translational science case study

Retrospective case studies are one approach to help identify processes underlying the translation of successful health interventions. This case study investigates the development of RealRisks and Breast Cancer Risk Navigation (BNAV), decision support tools for breast cancer risk assessment, and risk-stratified prevention. Following a recently developed protocol for retrospective translational science case studies, we examined the career trajectory of Dr Katherine Crew as she expanded from basic science to interdisciplinary, patient-oriented research in oncology and began collaboration with Dr Rita Kukafka, a public health informatician focused on communicating risk. Data collection methods included key informant interviews and examination of peer-reviewed publications, funded grants, and news articles associated with the research. Data were analyzed to identify key milestones in the development of RealRisks and BNAV and to elucidate facilitators and barriers to the translational process. Facilitators to translation included funding and infrastructure provided by a Clinical and Translational Science Award (CTSA), the creation of an interdisciplinary team, and broad support from stakeholders including patient advocacy groups. Barriers to translation included limited mid-career support, ongoing costs for technology, and the time required to establish interdisciplinary, team science efforts. The findings reported here can be used to inform ongoing efforts to develop a more robust science of translation.

Making Informed Choices On Incorporating Chemoprevention into carE (MiCHOICE, SWOG 1904): Design and methods of a cluster randomized controlled trial

INTRODUCTION

Women with atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS) have a significantly increased risk of breast cancer, which can be substantially reduced with antiestrogen therapy for chemoprevention. However, antiestrogen therapy for breast cancer risk reduction remains underutilized. Improving knowledge about breast cancer risk and chemoprevention among high-risk patients and their healthcare providers may enhance informed decision-making about this critical breast cancer risk reduction strategy.

METHODS/DESIGN

We are conducting a cluster randomized controlled trial to evaluate the effectiveness and implementation of patient and provider decision support tools to improve informed choice about chemoprevention among women with AH or LCIS. We have cluster randomized 26 sites across the U.S. through the SWOG Cancer Research Network. A total of 415 patients and 200 healthcare providers are being recruited. They are assigned to standard educational materials alone or combined with the web-based decision support tools. Patient-reported and clinical outcomes are assessed at baseline, after a follow-up visit at 6 months, and yearly for 5 years. The primary outcome is chemoprevention informed choice after the follow-up visit. Secondary endpoints include other patient-reported outcomes, such as chemoprevention knowledge, decision conflict and regret, and self-reported chemoprevention usage. Barriers and facilitators to implementing decision support into clinic workflow are assessed through patient and provider interviews at baseline and mid-implementation.

RESULTS/DISCUSSION

With this hybrid effectiveness/implementation study, we seek to evaluate if a multi-level intervention effectively promotes informed decision-making about chemoprevention and provide valuable insights on how the intervention is implemented in U.S.

CLINICAL SETTINGS

TRIAL REGISTRATION

NCT04496739.

A Scoping Review of Personalized, Interactive, Web-Based Clinical Decision Tools Available for Breast Cancer Prevention and Screening in the United States

Introduction. Personalized web-based clinical decision tools for breast cancer prevention and screening could address knowledge gaps, enhance patient autonomy in shared decision-making, and promote equitable care. The purpose of this review was to present evidence on the availability, usability, feasibility, acceptability, quality, and uptake of breast cancer prevention and screening tools to support their integration into clinical care. Methods. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist to conduct this review. We searched 6 databases to identify literature on the development, validation, usability, feasibility, acceptability testing, and uptake of the tools into practice settings. Quality assessment for each tool was conducted using the International Patient Decision Aid Standard instrument, with quality scores ranging from 0 to 63 (lowest-highest). Results. We identified 10 tools for breast cancer prevention and 9 tools for screening. The tools included individual (e.g., age), clinical (e.g., genomic risk factors), and health behavior (e.g., alcohol use) characteristics. Fourteen tools included race/ethnicity, but no tool incorporated contextual factors (e.g., insurance, access) associated with breast cancer. All tools were internally or externally validated. Six tools had undergone usability testing in samples including White (median, 71%; range, 9%-96%), insured (99%; 97%-100%) women, with college education or higher (60%; 27%-100%). All of the tools were developed and tested in academic settings. Seven (37%) tools showed potential evidence of uptake in clinical practice. The tools had an average quality assessment score of 21 (range, 9-39). Conclusions. There is limited evidence on testing and uptake of breast cancer prevention and screening tools in diverse clinical settings. The development, testing, and integration of tools in academic and nonacademic settings could potentially improve uptake and equitable access to these tools.

Highlights

There were 19 personalized, interactive, Web-based decision tools for breast cancer prevention and screening.Breast cancer outcomes were personalized based on individual clinical characteristics (e.g., age, medical history), genomic risk factors (e.g., BRCA1/2), race and ethnicity, and health behaviors (e.g., smoking). The tools did not include contextual factors (e.g., insurance status, access to screening facilities) that could potentially contribute to breast cancer outcomes.Validation, usability, acceptability, and feasibility testing were conducted mostly among White and/or insured patients with some college education (or higher) in academic settings. There was limited evidence on testing and uptake of the tools in nonacademic clinical settings.

Barriers to Mammography Screening among Black Women at a Community Health Center in South Florida, USA

Background

In the United States (US), Black/African American women suffer disproportionately from breast cancer health disparities with a 40% higher death rate compared to White women. Mammography screening is considered a critical tool in mitigating disparities, yet Black women experience barriers to screening and are more likely to be diagnosed with advanced-stage breast cancer. The purpose of this study was to assess the relative frequency of mammography screening and to examine perceived and actual barriers to screening among women who receive care in our nurse-led community health center.

Methods

We conducted a survey examining frequency of mammography screening and beliefs about breast cancer including perceived susceptibility, perceived benefits, and perceived barriers to mammography screening, guided by the Champion Health Belief Model.

Results

A total of 30 Black/African American women completed the survey. The mean age of the participants was 54.3 years ± 9.17 (SD); 43.3% had a high school education or less; 50% had incomes below $60,000 per year; 26.7% were uninsured; 10% were on Medicaid; and only 50% were working full-time. We found that only half of the participants reported having annual mammograms 16 (53.3%), 1 (3.3%) every 6 months, 8 (26.6%) every 2-3 years, and 5 (16.7%) never had a mammogram in their lifetime. Frequently cited barriers included: 'getting a mammogram would be inconvenient for me'; 'getting a mammogram could cause breast cancer'; 'the treatment I would get for breast cancer would be worse than the cancer itself'; 'being treated for breast cancer would cause me a lot of problems'; 'other health problems would keep me from having a mammogram'; concern about pain with having a mammogram would keep me from having one; and not being able to afford a mammogram would keep me from having one'. Having no health insurance was also a barrier.

Conclusion

This study found suboptimal utilization of annual screening mammograms among low-income Black women at a community health center in Florida and women reported several barriers. Given the high mortality rate of breast cancer among Black/African American women, we have integrated a Patient Navigator in our health system to reduce barriers to breast cancer screening, follow-up care, and to facilitate timely access to treatment, thus ultimately reducing breast cancer health disparities and promoting health equity.