Measuring the quality of surgical decisions for Latina breast cancer patients

Measure of Caregiver Attention-Deficit/Hyperactivity Disorder Knowledge Is Responsive to Decision Aid on Treatment for Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Adapt and test a measure of knowledge for caregivers of children with attention-deficit/hyperactivity disorder (ADHD) and evaluate the impact of the information component of a decision aid (DA) on participant knowledge.

METHODS

A set of seven knowledge items were created based on prior knowledge measures and clinical guidelines. As part of a larger cross-sectional survey study of caregivers of children diagnosed with ADHD, caregivers were randomized to one of two arms: 1) a DA arm, where participants reviewed the information component of the Cincinnati Children's Hospital's DA, and 2) a control arm, where participants were not shown a DA. All participants completed the seven knowledge items. Knowledge items were assessed for difficulty, quality of distractors, acceptability, and redundancy. Total knowledge scores (0-100) for the DA and control arm were compared.

RESULTS

Caregivers were assigned to the DA arm (n = 243) or the control arm (n = 260). All 7 knowledge items were retained as no items were too difficult or too easy, all response options were used, there were little missing data, and no items were redundant. The overall knowledge score was normally distributed, and almost covered the full range of scores (5-100). Those who received the DA component had higher knowledge scores (M=68, SD=23) than those who did not receive the DA component (M=60, SD=19, P < .01, d=0.4).

CONCLUSIONS

The Caregiver ADHD Knowledge (CAKe) measure was acceptable and demonstrated construct validity as those who were assigned to review the DA component demonstrated greater knowledge than those who were not assigned to review the DA component.

Performance of the shared decision-making process scale for use in evaluation of hereditary cancer genetic testing decisions

This study aimed to evaluate feasibility, acceptability, reliability, and validity of the existing four-item Shared Decision Making (SDM) Process Scale for use in evaluating genetic testing decisions. Patients from a large hereditary cancer genetics practice were invited to participate in a two-part survey after completing pre-test genetic counseling. The online survey included the SDM Process Scale and the SURE scale, a measure of decisional conflict. SDM Process scores were compared to SURE scores to test convergent validity, and respondents were sent a second survey 1 week later to assess retest reliability. The response rate was 65% (n = 259/398) and missing data was low (<1%). SDM scores ranged from zero to four with a mean of 2.3 (SD = 1.1). Retest reliability was good, with intraclass correlation of 0.84, 95% confidence interval (0.79, 0.88). No relationship was found between SDM Process scores and decisional conflict (p = 0.46), likely because 85% of participants reported no decisional conflict. The four-item SDM Process Scale demonstrated feasibility, acceptability, and retest reliability, but not convergent validity with decisional conflict. These findings provide initial evidence for use of this scale to measure patient perceptions of SDM in pre-test counseling for hereditary cancer genetic testing.

Evaluation of the shared decision-making process scale in cancer screening and medication decisions

OBJECTIVES

Examine reliability and validity of the Shared Decision-Making (SDM) Process scale for cancer screening and medication decisions.

METHODS

Secondary data analysis from 6174 participants who made decisions about cancer screening (breast, colon or prostate) or medication (menopause, depression, hypertension or high cholesterol). Key measures included the SDM Process scale, decisional conflict, decision regret, and decision quality. Construct validity was examined by testing whether higher SDM Process scores were associated with lower regret, lower decisional conflict and higher decision quality. Meta-analyses summarized data across studies. Some studies assessed the scale's reliability.

RESULTS

Average SDM Process scores ranged from 1.2 to 2.5. There was a moderate-to-large, positive association between scores and lack of decisional conflict (cancer screening: d=0.61, CI(0.38, 0.84), p < .001; medications: d=0.36, CI(0.29, 0.44), p < .001). High scores were associated with lower decision regret (cancer screening: d=-0.24, CI(-0.37, -0.11), p < .001; medications: d=-0.30, CI(-0.40,-0.20), p < .001). There was no relationship with decision quality. Retest reliability was acceptable (ICC>0.7) for seven of eight clinical samples.

CONCLUSIONS

The SDM Process scale demonstrated construct validity and retest reliability in cancer screening and medication decisions.

PRACTICE IMPLICATIONS

The validated SDM Process scale is a short, patient reported metric to evaluate the current state of SDM.

Decision quality and regret with treatment decisions in women with breast cancer: Pre-operative breast MRI and breast density

PURPOSE

We evaluated self-report of decision quality and regret with breast cancer surgical treatment by pre-operative breast MRI use in women recently diagnosed with breast cancer.

METHODS

We conducted a survey with 957 women aged 18 + with stage 0-III breast cancer identified in the Breast Cancer Surveillance Consortium. Participants self-reported receipt of pre-operative breast MRI. Primary outcomes were process measures in the Breast Cancer Surgery Decision Quality Instrument (BCS-DQI) (continuous outcome) and Decision Regret Scale (dichotomized outcome as any/none). Generalized estimating equations with linear and logit link were used to estimate adjusted associations between breast MRI and primary outcomes. All analyses were also stratified by breast density.

RESULTS

Survey participation rate was 27.9% (957/3430). Study population was primarily > 60 years, White, college educated, and diagnosed with early-stage breast cancer. Pre-operative breast MRI was reported in 46% of women. A higher proportion of women who were younger age (< 50 years), commercially insured, and self-detected their breast cancer reported pre-operative breast MRI use. In adjusted analysis, pre-operative breast MRI use compared with no use was associated with a small but statistically significantly higher decision quality scores (69.5 vs 64.7, p-value = 0.043). Decision regret did not significantly differ in women who reported pre-operative breast MRI use compared with no use (54.2% v. 48.7%, respectively, p-value = 0.11). Study results did not vary when stratified by breast density for either primary outcome.

CONCLUSIONS AND RELEVANCE

Breast MRI use in the diagnostic work-up of breast cancer does not negatively alter women's perceptions of surgical treatment decisions in early survivorship.

CLINICAL TRIALS REGISTRATION NUMBER

NCT03029286.

Validation of the SDM Process Scale to Evaluate Shared Decision-Making at Clinical Sites

The Shared Decision-Making (SDM) Process scale (scored 0-4) uses 4 questions about decision-making behaviors: discussion of options, pros, cons, and preferences. We use data from mail surveys of patients who made surgical decisions at 9 clinical sites and a national web survey to assess the reliability and validity of the measure to assess shared decision-making at clinical sites. Patients at sites using decision aids to promote shared decision-making for hip, knee, back, or breast cancer surgery had significantly higher scores than national cross-section samples of surgical patients for 3 of 4 comparisons and significantly higher scores for both comparisons with “usual care sites.” Reliability was supported by an intra-class correlation at the clinical site level of 0.93 and an average correlation of SDM scores for knee and hip surgery patients treated at the same sites of 0.56. The results document the reliability and validity of the measure to assess the degree of shared decision-making for surgical decisions at clinical sites.

Relationships among Antecedents, Processes, and Outcomes for Shared Decision Making: A Cross-Sectional Survey of Patients with Lumbar Degenerative Disease

BACKGROUND

Among musculoskeletal disorders, lumbar degenerative disease (LDD) is the leading cause of total disability-adjusted life years globally. Clinical guidelines for LDD describe multiple treatment options in which shared decision making becomes appropriate.

OBJECTIVES

To explore the relationships among measures of decision antecedents, process, and outcomes in patients with LDD.

METHODS

Patients with LDD were recruited from outpatient clinics in a teaching hospital in Taiwan and administered surveys to collect measures of decision antecedents, processes, and outcomes. Multiple linear regression was conducted to assess the association between decision antecedents and the decision making process. Hierarchical linear regression was conducted to assess the relationships among decision antecedents, the decision making process, and decision outcomes.

RESULTS

A total of 132 patients (mean age, 61 years) completed the survey. After adjustment for personal factors, 2 decision antecedents (namely, decision making self-efficacy and readiness) significantly predicted patients' experiences of engaging in shared decision making (SDM). Decision making readiness and process were associated with fewer decisional conflicts and greater decision satisfaction.

LIMITATIONS

Models derived from cross-sectional surveys cannot establish causal relationships among decision antecedents, decision making processes, and decision outcomes.

CONCLUSIONS

Our results support the SDM framework, which proposes relationships among decision antecedents, the decision making process, and decision outcomes.

A concept analysis of decision regret in women with breast cancer

The aim of this article is to understand the components of decision regret for women making breast cancer treatment decisions. Patient-centered care models encourage women to become more active in the decision-making process, inadvertently exposing them to the risk of experiencing decision regret. Enhancing the understanding of the concept of decision regret can offer insight into ways to mitigate this phenomenon. The Walker and Avant method was used to analyze this concept. Using PubMed, CINAHL, ERIC, Academic Search Complete, PsychINFO, SocINDEX, Joanna Briggs Institute of EBP Database, and an online dictionary, articles from 2011 to 2021 were analyzed to identify concept uses, attributes, antecedents, and consequences. Decision regret in women making breast cancer healthcare decisions is a negative cognitive-emotional response to a treatment decision that involves counterfactual thinking with three targets of regret: outcome regret, chosen option regret, and process regret. Experiencing decision regret can reduce a woman's quality of life, inflict psychological distress, and impact future decision-making. Unfavorable outcomes, decision uncertainty, and breakdowns in the decision-making process can lead to decision regret. Findings provide information on identifying women experiencing decision regret and illustrate opportunities to address causative factors through patient education and support to promote optimal patient outcomes.

Unmet Information Needs Among Hispanic Women with Thyroid Cancer

CONTEXT

Thyroid cancer is the second most common cancer in Hispanic women.

OBJECTIVE

To determine the relationship between acculturation level and unmet information needs among Hispanic women with thyroid cancer.

DESIGN

Population-based survey study.

PARTICIPANTS

Hispanic women from Los Angeles Surveillance Epidemiology and End Results registry with thyroid cancer diagnosed in 2014-2015 who had previously completed our thyroid cancer survey in 2017-2018 (N = 273; 80% response rate).

MAIN OUTCOME MEASURES

Patients were asked about 3 outcome measures of unmet information needs: (1) internet access, (2) thyroid cancer information resources used, and (3) ability to access information. Acculturation was assessed with the Short Acculturation Scale for Hispanics (SASH). Health literacy was measured with a validated single-item question.

RESULTS

Participants' median age at diagnosis was 47 years (range 20-79) and 48.7% were low-acculturated. Hispanic women were more likely to report the ability to access information "all of the time" if they preferred thyroid cancer information in mostly English compared to mostly Spanish (88.5% vs 37.0%, P < 0.001). Low-acculturated (vs high-acculturated) Hispanic women were more likely to have low health literacy (47.2% vs 5.0%, P < 0.001) and report use of in-person support groups (42.0% vs 23.1%, P = 0.006). Depending on their level of acculturation, Hispanic women accessed the internet differently (P < 0.001) such that low-acculturated women were more likely to report use of only a smartphone (34.0% vs 14.3%) or no internet access (26.2% vs 1.4%).

CONCLUSIONS

Low-acculturated (vs high-acculturated) Hispanic women with thyroid cancer have greater unmet information needs, emphasizing the importance of patient-focused approaches to providing medical information.

Financial Hardship Among Hispanic Women with Thyroid Cancer

Background: Little is known about financial hardship among Hispanic women with thyroid cancer. The goal of this study was to determine the prevalence of financial hardship and to identify correlates of financial hardship in this understudied patient group. Methods: We surveyed Hispanic women who had diagnoses of thyroid cancer reported to the Los Angeles Surveillance Epidemiology and End Results (SEER) registry in 2014-2015, and who had previously completed our thyroid cancer survey in 2017-2018 (N = 273; 80% response rate). Acculturation was assessed with the Short Acculturation Scale for Hispanics (SASH). Patients were asked about three outcome measures since their thyroid cancer diagnosis: (i) financial status, (ii) insurance status, and (iii) material measures of financial hardship, collapsed into a single composite measure of financial hardship. We used multivariable logistic regression to identify correlates of financial hardship. Results: Patients' median age at diagnosis was 47 years (range 20-79 years); 49% were low-acculturated and 47% reported financial hardship. Since their thyroid cancer diagnosis, 31% and 12% of the cohort reported being worse off regarding financial and insurance status, respectively. In multivariable analysis, high-acculturated older women were less likely to experience financial hardship compared with high-acculturated 20-year-old women. While financial hardship decreased with age for high-acculturated women (p = 0.002), financial hardship remained elevated across all age groups for low-acculturated women (p = 0.54). Conclusions: Our findings suggest that across all age groups, low-acculturated Hispanic women with thyroid cancer are vulnerable to financial hardship, emphasizing the need for tailored patient-focused interventions.

Surgery decision conflict and its related factors among newly diagnosed early breast cancer patients in China: A cross-sectional study

Aim

The aim of this study was to explore surgery decision conflict and its related factors among newly diagnosed early breast cancer patients in China.

Design

A cross‐sectional survey study was conducted.

Methods

A total of 262 patients confronted with surgery decision‐making were enrolled. The related factors were assessed with a demographic questionnaire, the Chinese version of the Decision Conflict Scale (DCS‐C‐16) and the Patient Participation Competence Scale (PPCS).

Results

Patients had a high level of decision conflict that was negatively correlated with the PPCS score. Age, marital status, living environment, education level, family income, cancer stage and the PPCS score were independent factors influencing decision conflict. Marital status, education level, cancer stage and participation competence were significant predictors of decision conflict. Patients who had higher participation competence were married, were well educated and had a lower cancer stage were likely to experience lower decision conflict.

Development and Evaluation of the Shared Decision Making Process Scale: A Short Patient-Reported Measure

Background

The Shared Decision Making (SDM) Process scale is a short patient-reported measure of the amount of SDM that occurs around a medical decision. SDM Process items have been used previously in studies of surgical decision making and exhibited discriminant and construct validity.

Method

Secondary data analysis was conducted across 8 studies of 11 surgical conditions with 3965 responses. Each study contained SDM Process items that assessed the discussion of options, pros and cons, and preferences. Item wording, content, and number of items varied, as did inclusion of measures assessing decision quality, decisional conflict (SURE scale), and regret. Several approaches for scoring, weighting, and the number of items were compared to identify an optimal approach. Optimal SDM Process scores were compared with measures of decision quality, conflict, and regret to examine construct validity; meta-analysis generated summary results.

Results

Although all versions of the scale were highly correlated, a short, partial credit, equally weighted version of the scale showed favorable properties. Overall, higher SDM Process scores were related to higher decision quality ( d = 0.18, P = 0.029), higher SURE scale scores ( d = 0.57, P < 0.001), and lower decision regret ( d = −0.34, P < 0.001). Significant heterogeneity was present in all validity analyses.

Limitations

Included studies all focused on surgical decisions, several had small sample sizes, and many were retrospective.

Conclusion

SDM Process scores showed resilience to coding changes, and a scheme using the short, partial credit, with equal weights was adopted. The SDM Process scores demonstrated a small, positive relationship with decision quality and were consistently related to lower decision conflict and less regret, providing evidence of validity across several surgical decisions.

Impact of Timing on Measurement of Decision Quality and Shared Decision Making: Longitudinal Cohort Study of Breast Cancer Patients

Purpose.The objective of this study was to examine whether scores of shared decision-making measures differ when collected shortly after (1 month) or long after (1 year) breast cancer surgical treatment decisions. Methods. Longitudinal, multisite survey of breast cancer (BC) patients, with measurements at 1 month and 1 year after surgery at 4 cancer centers. Patients completed the BC Surgery Decision Quality Instrument (used to generate a knowledge score, ratings of goals, and concordance with treatment preferences) and Shared Decision Making (SDM) Process survey at both time points. We tested several hypotheses related to the scores over time, including whether the scores discriminated between sites that did and did not offer formal decision support services. Exploratory analyses examined factors associated with large increases and decreases in scores over time. Results. Across the 4 sites, 229 patients completed both assessments. The mean total knowledge scores (69.2% [SD 16.6%] at 1 month and 69.4% [SD 17.7%] at 1 year, P = 0.86), SDM Process scores (2.7 [SD 1.1] 1 month v. 2.7 [SD 1.2] 1 year, P = 0.68), and the percentage of patients receiving their preferred treatment (92% at 1 month and 92% at 1 year, P = 1.0) were not significantly different over time. The site using formal decision support had significantly higher knowledge and SDM Process scores at 1 month, and only the SDM Process scores remained significantly higher at 1 year. A significant percentage of patients had large changes in their individual knowledge and SDM Process scores, with increases balancing out decreases. Conclusion. For population-level assessments, it is reasonable to survey BC patients up to a year after the decision, greatly increasing feasibility of measurement. For those evaluating decision support interventions, shorter follow-up is more likely to detect an impact on knowledge scores.

Local Therapy Decisional Regret in Older Women With Breast Cancer: A Population-Based Study

PURPOSE

Older women with nonmetastatic breast cancer can often choose from several surgery and radiation treatment options. Little is known regarding how these choices contribute to decisional regret, which is a negative emotion reflecting the idea that another surgery or radiation decision might have been preferable. We sought to characterize the burden of and examine potential risk factors for local therapy decisional regret among a population-based cohort of older breast cancer survivors.

METHODS AND MATERIALS

National Medicare claims for age ≥67 female breast cancer incident in 2009 identified patients treated with lumpectomy plus whole-breast irradiation, brachytherapy, or endocrine therapy or mastectomy with or without radiation. We sampled 330 patients per treatment group (N = 1650), of whom 1253 agreed to receive a paper survey including the Decisional Regret Scale and EQ-5D-3L Health-Utility Scale. Local therapy regret was defined as neutral or worse response to questions regarding surgery- or radiation-related decisional regret. Local therapy regret risk factors were evaluated using a multivariable generalized linear model. Association of local therapy regret with health utility was modeled using multivariable linear regression.

RESULTS

The response rate was 30.2% (n = 498 of 1650); 421 surveys were included in this analysis. Median diagnosis age was 72 years, and surveys were completed 6 years after diagnosis. Overall, 23.8% of respondents (n = 100) reported experiencing local therapy decisional regret. Type of local therapy was not associated with local therapy regret. Predictors of increased regret included black race (risk ratio [RR], 2.09; 95% confidence interval [CI], 1.33-3.29), high school education or less (RR, 1.87; 95% CI, 1.27-2.75), and axillary nodal dissection (RR, 2.13; 95% CI, 1.33-3.41). Local therapy regret was not associated with health utility (P = .37).

CONCLUSIONS

Local therapy regret afflicts nearly one quarter of our cohort of older breast cancer survivors, and it is associated with black race, less education, and more extensive nodal dissection, but not breast surgery. Regret is distinct from health utility, suggesting that it is a unique psychosocial construct that merits further study and mitigation strategies.

Adapting the Breast Cancer Surgery Decision Quality Instrument for Lower Socioeconomic Status: Improving Readability, Acceptability, and Relevance

Introduction. Breast cancer is the second most common malignancy in women. The Decision Quality Instrument (DQI) measures the extent to which patients are informed and involved in breast surgery decisions and receive treatment that aligns with their preferences. There are limited data on the performance of the DQI in women of lower socioeconomic status (SES). Our aims were to 1) examine (and if necessary adapt) the readability, usability, and acceptability of the DQI and 2) explore whether it captures factors important to breast cancer surgery decisions among women of lower SES (relevance). Methods. We conducted semistructured cognitive interviews with women of lower SES (based on insurance status, income, and education) who had completed early-stage breast cancer treatments at three cancer centers. We used a two-step thematic analysis with dual independent coding. The study team (including Patient Partners and a Community Advisory Board) reviewed and refined suggested changes. The revised DQI was presented in two focus groups of breast cancer survivors. Results. We conducted 39 interviews. Participants found most parts of the DQI to be helpful and easy to understand. We made the following suggested changes: 1) added a glossary of key terms, 2) added two answer choices and an open text question in the goals and concerns subscale, 3) reworded the treatment intention question, and 4) revised the knowledge subscale instructions since several women disliked the wording and were unsure of what was expected. Discussion. The readability, usability, acceptability, and relevance of a measure that was primarily developed and validated in women of higher SES required adaptation for optimal use by women of lower SES. Further research will test these adaptations in lower SES populations.

Treatment experiences of Latinas after diagnosis of breast cancer

BACKGROUND

The authors examined racial/ethnic differences in patient perspectives regarding their breast cancer treatment experiences.

METHODS

A weighted random sample of women newly diagnosed with breast cancer between 2013 and 2015 in Los Angeles County and Georgia were sent surveys 2 months after undergoing surgery (5080 women; 70% response rate). The analytic sample was limited to patients residing in Los Angeles County (2397 women).

RESULTS

The pattern of visits with different specialists before surgery was found to be similar across racial/ethnic groups. Low acculturated Latinas (Latinas-LA) were less likely to report high clinician communication quality for both surgeons and medical oncologists (<69% vs >72% for all other groups; P<.05). The percentage of patients who reported high satisfaction regarding how physicians worked together was similar across racial/ethnic groups. Latinas-LA were more likely to have a low autonomy decision style (48% vs 24%-50% for all other groups; P<.001) and were more likely to report receiving too much information versus other ethnic groups (20% vs <16% for other groups; P<.001). Patients who reported a low autonomy decision style were more likely to rate the amount of information they received for the surgery decision as "too much" (16% vs 9%; P<.001).

CONCLUSIONS

There appears to be moderate disparity in breast cancer treatment communication and decision-making experiences reported by Latinas-LA versus other groups. The approach to treatment decision making by Latinas-LA represents an important challenge to health care providers. Initiatives are needed to improve patient engagement in decision making and increase clinician awareness of these challenges in this patient population. Cancer 2017;123:3022-30. © 2017 American Cancer Society.