1
|
Leonard ME, Horns JJ, Allen-Brady K, Ozanne EM, Wallace AS, Brooke BS, Supiano MA, Cohan JN. Recurrence of severe diverticulitis is associated with age and birth decade. J Gastrointest Surg 2024; 28:507-512. [PMID: 38583903 DOI: 10.1016/j.gassur.2023.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 04/09/2024]
Abstract
BACKGROUND The risk of recurrence is an important consideration when deciding to treat patients medically or with elective colectomy after recovery from diverticulitis. It is unclear whether age is associated with recurrence. This study aimed to examine the relationship between age and the risk of recurrent diverticulitis while considering important epidemiologic factors, such as birth decade. METHODS The Utah Population Database was used to identify individuals with incident severe diverticulitis, defined as requiring an emergency department visit or hospitalization, between 1998 and 2018. This study measured the relationship between age and recurrent severe diverticulitis after adjusting for birth decade and other important variables, such as sex, urban/rural status, complicated diverticulitis, and body mass index using a Cox proportional hazards model. RESULTS The cohort included 8606 individuals with a median age of 61 years at index diverticulitis diagnosis. After adjustment, among individuals born in the same birth decade, increasing age at diverticulitis onset was associated with an increased risk of recurrent diverticulitis (hazard ratio [HR] for 10 years, 1.8; 95% CI, 1.5-2.1). Among individuals with the same age of onset, those born in a more recent birth decade were also at greater risk of recurrent diverticulitis (HR, 1.9; 95% CI, 1.6-2.3). CONCLUSION Among individuals with an index episode of severe diverticulitis, recurrence was associated with increasing age and more recent birth decade. Clinicians may wish to employ age-specific strategies when counseling patients regarding treatment options after a diverticulitis diagnosis.
Collapse
Affiliation(s)
- Molly E Leonard
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, United States
| | - Joshua J Horns
- Department of Surgery, University of Utah, Salt Lake City, Utah, United States
| | - Kristina Allen-Brady
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, United States
| | - Andrea S Wallace
- College of Nursing, University of Utah, Salt Lake City, Utah, United States
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, United States
| | - Mark A Supiano
- Division of Geriatrics, Department of Internal Medicine, Spencer Fox Eccles School of Medicine and University of Utah Center on Aging, Salt Lake City, Utah, United States
| | - Jessica N Cohan
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, United States.
| |
Collapse
|
2
|
Thorpe A, Delaney RK, Pinto NM, Ozanne EM, Pershing ML, Hansen LM, Lambert LM, Fagerlin A. Parents' Psychological and Decision-Making Outcomes following Prenatal Diagnosis with Complex Congenital Heart Defect: An Exploratory Study. MDM Policy Pract 2023; 8:23814683231204551. [PMID: 37920604 PMCID: PMC10619352 DOI: 10.1177/23814683231204551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 08/24/2023] [Indexed: 11/04/2023] Open
Abstract
Background. Parents with a fetus diagnosed with a complex congenital heart defect (CHD) are at high risk of negative psychological outcomes. Purpose. To explore whether parents' psychological and decision-making outcomes differed based on their treatment decision and fetus/neonate survival status. Methods. We prospectively enrolled parents with a fetus diagnosed with a complex, life-threatening CHD from September 2018 to December 2020. We tested whether parents' psychological and decision-making outcomes 3 months posttreatment differed by treatment choice and survival status. Results. Our sample included 23 parents (average Age[years]: 27 ± 4, range = 21-37). Most were women (n = 18), non-Hispanic White (n = 20), and married (n = 21). Most parents chose surgery (n = 16), with 11 children surviving to the time of the survey; remaining parents (n = 7) chose comfort-directed care. Parents who chose comfort-directed care reported higher distress (x ¯ = 1.51, s = 0.75 v. x ¯ = 0.74, s = 0.55; Mdifference = 0.77, 95% confidence interval [CI], 0.05-1.48) and perinatal grief (x ¯ = 91.86, s = 22.96 v. x ¯ = 63.38, s = 20.15; Mdifference = 27.18, 95% CI, 6.20-48.16) than parents who chose surgery, regardless of survival status. Parents who chose comfort-directed care reported higher depression (x ¯ = 1.64, s = 0.95 v. x ¯ = 0.65, s = 0.49; Mdifference = 0.99, 95% CI, 0.10-1.88) than parents whose child survived following surgery. Parents choosing comfort-directed care reported higher regret (x ¯ = 26.43, s = 8.02 v. x ¯ = 5.00, s = 7.07; Mdifference = 21.43, 95% CI, 11.59-31.27) and decisional conflict (x ¯ = 20.98, s = 10.00 v. x ¯ = 3.44, s = 4.74; Mdifference = 17.54, 95% CI; 7.75-27.34) than parents whose child had not survived following surgery. Parents whose child survived following surgery reported lower grief (Mdifference = -19.71; 95% CI, -39.41 to -0.01) than parents whose child had not. Conclusions. The results highlight the potential for interventions and care tailored to parents' treatment decisions and outcomes to support parental coping and well-being. Highlights Question: Do the psychological and decision-making outcomes of parents differ based on their treatment decision and survival outcome following prenatal diagnosis with complex CHD?Findings: In this exploratory study, parents who decided to pursue comfort-directed care after a prenatal diagnosis reported higher levels of psychological distress and grief as well as higher decisional conflict and regret than parents who decided to pursue surgery.Meaning: The findings from this exploratory study highlight potential differences in parents' psychological and decision-making outcomes following a diagnosis of complex CHD for their fetus, which appear to relate to the treatment approach and the treatment outcome and may require tailoring of psychological and decision support.
Collapse
Affiliation(s)
- Alistair Thorpe
- University of Utah Intermountain Healthcare Department of Population Health Sciences, Salt Lake City, UT, USA
- Department of Applied Health Research, University College London, London, UK
| | - Rebecca K. Delaney
- University of Utah Intermountain Healthcare Department of Population Health Sciences, Salt Lake City, UT, USA
| | - Nelangi M. Pinto
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Division of Pediatric Cardiology at Seattle Children’s Hospital, Seattle, WA, USA
| | - Elissa M. Ozanne
- University of Utah Intermountain Healthcare Department of Population Health Sciences, Salt Lake City, UT, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mandy L. Pershing
- University of Utah Intermountain Healthcare Department of Population Health Sciences, Salt Lake City, UT, USA
| | - Lisa M. Hansen
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Linda M. Lambert
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Angela Fagerlin
- University of Utah Intermountain Healthcare Department of Population Health Sciences, Salt Lake City, UT, USA
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation
| |
Collapse
|
3
|
Delaney RK, Thorpe A, Pinto NM, Ozanne EM, Pershing ML, Hansen LM, Lambert LM, Tanner K, Fagerlin A. Parents' quality of life and health after treatment decision for a fetus with severe congenital heart defect. J Pediatr Nurs 2023; 70:20-25. [PMID: 36791586 PMCID: PMC10182246 DOI: 10.1016/j.pedn.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/10/2023] [Accepted: 02/03/2023] [Indexed: 02/16/2023]
Abstract
PURPOSE This exploratory study examines differences in parents' quality of life by treatment decision and the child's survival outcome in the context of life-threatening congenital heart disease (CHD). DESIGN AND METHODS Parents of a fetus or neonate diagnosed with severe CHD enrolled in the observational control group of a clinical trial (NCT04437069) and completed quality of life (i.e., contact with clinicians, social support, partner relationship, state of mind), mental and physical health survey measures. Comparisons were made between parents who chose comfort-directed care or surgery and between those whose child did and did not survive. RESULTS Parents who chose surgery and their child did not survive reported the most contact with their clinicians. Parents who chose comfort-directed care reported lower social support than parents who chose surgery and their child did not survive as well as poorer state of mind compared to parents who chose surgery. CONCLUSIONS Some aspects of parents' quality of life differed based on their treatment decision. Parents who choose comfort-directed care are vulnerable to some negative outcomes. PRACTICE IMPLICATIONS Decision support tools and bereavement resources to assist parents with making and coping with a complex treatment decision is important for clinical care.
Collapse
Affiliation(s)
- Rebecca K Delaney
- University of Utah Intermountain Healthcare Department of Population Health Sciences, University of Utah Health, Salt Lake City, USA.
| | - Alistair Thorpe
- University of Utah Intermountain Healthcare Department of Population Health Sciences, University of Utah Health, Salt Lake City, USA
| | - Nelangi M Pinto
- Department of Pediatrics, University of Utah, Salt Lake City, USA
| | - Elissa M Ozanne
- University of Utah Intermountain Healthcare Department of Population Health Sciences, University of Utah Health, Salt Lake City, USA
| | - Mandy L Pershing
- University of Utah Intermountain Healthcare Department of Population Health Sciences, University of Utah Health, Salt Lake City, USA
| | - Lisa M Hansen
- Department of Pediatrics, University of Utah, Salt Lake City, USA
| | - Linda M Lambert
- Department of Pediatrics, University of Utah, Salt Lake City, USA
| | - Kirstin Tanner
- University of Utah Intermountain Healthcare Department of Population Health Sciences, University of Utah Health, Salt Lake City, USA
| | - Angela Fagerlin
- University of Utah Intermountain Healthcare Department of Population Health Sciences, University of Utah Health, Salt Lake City, USA; Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, USA.
| |
Collapse
|
4
|
Jones AE, McCarty MM, Cameron KA, Cavanaugh KL, Steinberg BA, Passman R, Kansal P, Guzman A, Chen E, Zhong L, Fagerlin A, Hargraves I, Montori VM, Brito JP, Noseworthy PA, Ozanne EM. Development of Complementary Encounter and Patient Decision Aids for Shared Decision Making about Stroke Prevention in Atrial Fibrillation. MDM Policy Pract 2023; 8:23814683231178033. [PMID: 38178866 PMCID: PMC10765759 DOI: 10.1177/23814683231178033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/06/2023] [Indexed: 01/06/2024] Open
Abstract
Introduction Decision aids (DAs) are helpful instruments used to support shared decision making (SDM). Patients with atrial fibrillation (AF) face complex decisions regarding stroke prevention strategies. While a few DAs have been made for AF stroke prevention, an encounter DA (EDA) and patient DA (PDA) have not been created to be used in conjunction with each other before. Design Using iterative user-centered design, we developed 2 DAs for anticoagulation choice and stroke prevention in AF. Prototypes were created, and we elicited feedback from patients and experts via observations of encounters, usability testing, and semistructured interviews. Results User testing was done with 33 experts (in AF and SDM) and 51 patients from 6 institutions. The EDA and PDA underwent 1 and 4 major iterations, respectively. Major differences between the DAs included AF pathophysiology and a preparation to meet with the clinician in the PDA as well as different language throughout. Content areas included personalized stroke risk, differences between anticoagulants, and risks of bleeding. Based on user feedback, developers 1) addressed feelings of isolation with AF, 2) improved navigation options, 3) modified content and flow for users new to AF and those experienced with AF, 4) updated stroke risk pictographs, and 5) added structure to the preparation for decision making in the PDA. Limitations These DAs focus only on anticoagulation for stroke prevention and are online, which may limit participation for those less comfortable with technology. Conclusions Designing complementary DAs for use in tandem or separately is a new method to support SDM between patients and clinicians. Extensive user testing is essential to creating high-quality tools that best meet the needs of those using them. Highlights First-time complementary encounter and patient decision aids have been designed to work together or separately.User feedback led to greater structure and different experiences for patients naïve or experienced with anticoagulants in patient decision aids.Online tools allow for easier dissemination, use in telehealth visits, and updating as new evidence comes out.
Collapse
Affiliation(s)
- Aubrey E. Jones
- College of Pharmacy, Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Madeleine M. McCarty
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Kenzie A. Cameron
- Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL, USA
| | - Kerri L. Cavanaugh
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin A. Steinberg
- School of Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Rod Passman
- Feinberg School of Medicine, Department of Medicine, Division of Cardiology, Northwestern University, Chicago, IL, USA
| | - Preeti Kansal
- Feinberg School of Medicine, Department of Medicine, Division of Cardiology, Northwestern University, Chicago, IL, USA
| | - Adriana Guzman
- Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL, USA
| | - Emily Chen
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lingzi Zhong
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Angela Fagerlin
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, USA
| | - Ian Hargraves
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Victor M. Montori
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Juan P. Brito
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Elissa M. Ozanne
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
5
|
Delaney RK, Pinto NM, Ozanne EM, Stark LA, Pershing ML, Thorpe A, Witteman HO, Thokala P, Lambert LM, Hansen LM, Greene TH, Fagerlin A. Study protocol for a randomised clinical trial of a decision aid and values clarification method for parents of a fetus or neonate diagnosed with a life-threatening congenital heart defect. BMJ Open 2021; 11:e055455. [PMID: 34893487 PMCID: PMC8666895 DOI: 10.1136/bmjopen-2021-055455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Parents who receive the diagnosis of a life-threatening, complex heart defect in their fetus or neonate face a difficult choice between pursuing termination (for fetal diagnoses), palliative care or complex surgical interventions. Shared decision making (SDM) is recommended in clinical contexts where there is clinical equipoise. SDM can be facilitated by decision aids. The International Patient Decision Aids Standards collaboration recommends the inclusion of values clarification methods (VCMs), yet little evidence exists concerning the incremental impact of VCMs on patient or surrogate decision making. This protocol describes a randomised clinical trial to evaluate the effect of a decision aid (with and without a VCM) on parental mental health and decision making within a clinical encounter. METHODS AND ANALYSIS Parents who have a fetus or neonate diagnosed with one of six complex congenital heart defects at a single tertiary centre will be recruited. Data collection for the prospective observational control group was conducted September 2018 to December 2020 (N=35) and data collection for two intervention groups is ongoing (began October 2020). At least 100 participants will be randomised 1:1 to two intervention groups (decision aid only vs decision aid with VCM). For the intervention groups, data will be collected at four time points: (1) at diagnosis, (2) postreceipt of decision aid, (3) postdecision and (4) 3 months postdecision. Data collection for the control group was the same, except they did not receive a survey at time 2. Linear mixed effects models will assess differences between study arms in distress (primary outcome), grief and decision quality (secondary outcomes) at 3-month post-treatment decision. ETHICS AND DISSEMINATION This study was approved by the University of Utah Institutional Review Board. Study findings have and will continue to be presented at national conferences and within scientific research journals. TRIAL REGISTRATION NUMBER NCT04437069 (Pre-results).
Collapse
Affiliation(s)
- Rebecca K Delaney
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nelangi M Pinto
- Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Elissa M Ozanne
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Louisa A Stark
- Human Genetics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Mandy L Pershing
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Alistair Thorpe
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Holly O Witteman
- Family and Emergency Medicine, Laval University, Quebec City, Quebec, Canada
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Linda M Lambert
- Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Lisa M Hansen
- Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Tom H Greene
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Angela Fagerlin
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
- VA HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, UT, USA
| |
Collapse
|
6
|
Pinto NM, Patel A, Delaney RK, Donofrio MT, Marino BS, Miller S, Ozanne EM, Zickmund SL, Karasawa MH, Pershing ML, Fagerlin A. Provider insights on shared decision-making with families affected by CHD. Cardiol Young 2021; 32:1-8. [PMID: 34728001 PMCID: PMC10029115 DOI: 10.1017/s1047951121004406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Little data exist on provider perspectives about counselling and shared decision-making for complex CHD, ways to support and improve the process, and barriers to effective communication. The goal of this qualitative study was to determine providers' perspectives regarding factors that are integral to shared decision-making with parents faced with complex CHD in their fetus or newborn; and barriers and facilitators to engaging in effective shared decision-making. METHODS We conducted semi-structured interviews with providers from different areas of practice who care for fetuses and/or children with CHD. Providers were recruited from four geographically diverse centres. Interviews were recorded, transcribed, and analysed for key themes using an open coding process with a grounded theory approach. RESULTS Interviews were conducted with 31 providers; paediatric cardiologists (n = 7) were the largest group represented, followed by nurses (n = 6) and palliative care providers (n = 5). Key barriers to communication with parents that providers identified included variability among providers themselves, factors that influenced parental comprehension or understanding, discrepant expectations, circumstantial barriers, and trust/relationship with providers. When discussing informational needs of parents, providers focused on comprehensive short- and long-term outcomes, quality of life, and breadth and depth that aligned with parental goals and needs. In discussing resources to support shared decision-making, providers emphasised the need for comprehensive, up-to-date information that was accessible to parents of varying situations and backgrounds. CONCLUSIONS Provider perspectives on decision-making with families with CHD highlighted key communication issues, informational priorities, and components of decision support that can enhance shared decision-making.
Collapse
Affiliation(s)
- Nelangi M Pinto
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Angira Patel
- Divisions of Cardiology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rebecca K Delaney
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Mary T Donofrio
- Division of Pediatric Cardiology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Bradley S Marino
- Divisions of Cardiology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stephen Miller
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Susan L Zickmund
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, USA
| | - Michelle H Karasawa
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Mandy L Pershing
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, USA
| |
Collapse
|
7
|
Rogers AM, Lauren BN, Woo Baidal JA, Ozanne EM, Hur C. Corrigendum to "Persistent effects of the COVID-19 pandemic on diet, exercise, risk for food insecurity, and quality of life: A longitudinal study among U.S. adults" [Appetite 167 (2021) 105639]. Appetite 2021; 168:105701. [PMID: 34607699 PMCID: PMC9025975 DOI: 10.1016/j.appet.2021.105701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Alexandra M Rogers
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, United States; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, United States
| | - Brianna N Lauren
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, United States; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, United States
| | - Jennifer A Woo Baidal
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Irving Medical Center, New York, NY, United States
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Chin Hur
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, United States; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, United States.
| |
Collapse
|
8
|
Cohan JN, Ozanne EM, Hofer RK, Kelly YM, Kata A, Larsen C, Finlayson E. Ileostomy or ileal pouch-anal anastomosis for ulcerative colitis: patient participation and decisional needs. BMC Gastroenterol 2021; 21:347. [PMID: 34538236 PMCID: PMC8451075 DOI: 10.1186/s12876-021-01916-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Up to 30% of patients with ulcerative colitis will undergo surgery resulting in an ileal pouch-anal anastomosis (IPAA) or permanent end ileostomy (EI). We aimed to understand how patients decide between these two options. METHODS We performed semi-structured interviews with ulcerative colitis patients who underwent surgery. Areas of questioning included the degree to which patients participated in decision-making, challenges experienced, and suggestions for improving the decision-making process. We analyzed the data using a directed content and thematic approach. RESULTS We interviewed 16 patients ranging in age from 28 to 68 years. Nine were male, 10 underwent IPAA, and 6 underwent EI. When it came to participation in decision-making, 11 patients felt independently responsible for decision-making, 3 shared decision-making with the surgeon, and 2 experienced surgeon-led decision-making. Themes regarding challenges during decision-making included lack of support from family, lack of time to discuss options with the surgeon, and the overwhelming complexity of the decision. Themes for ways to improve decision-making included the need for additional information, the desire for peer education, and earlier consultation with a surgeon. Only 3 patients were content with the information used to decide about surgery. CONCLUSIONS Patients with ulcerative colitis who need surgery largely experience independence when deciding between IPAA and EI, but struggle with inadequate educational information and social support. Patients may benefit from early access to surgeons and peer guidance to enhance independence in decision-making. Preoperative educational materials describing surgical complications and postoperative lifestyle could improve decision-making and facilitate discussions with loved ones.
Collapse
Affiliation(s)
- Jessica N Cohan
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Rebecca K Hofer
- Department of Family and Community Medicine, University of California, San Francisco, CA, USA
| | - Yvonne M Kelly
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Anna Kata
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Craig Larsen
- Department of Surgery, New York Presbyterian-Queens, Flushing, NY, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, CA, USA
| |
Collapse
|
9
|
Rogers AM, Lauren BN, Woo Baidal JA, Ozanne EM, Hur C. Persistent effects of the COVID-19 pandemic on diet, exercise, risk for food insecurity, and quality of life: A longitudinal study among U.S. adults. Appetite 2021; 167:105639. [PMID: 34384807 PMCID: PMC8990782 DOI: 10.1016/j.appet.2021.105639] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/22/2021] [Accepted: 08/06/2021] [Indexed: 01/20/2023]
Abstract
COVID-19 has affected the health and well-being of almost every American. The aim of this study was to examine the sustained impacts of COVID-19 prevention measures on the diet and exercise habits, risk for food insecurity, and quality of life among adults in the U.S. We conducted a longitudinal study using a convenience sample of participants recruited via Amazon's Mechanical Turk (MTurk) platform between March 30 and April 7, 2020, and 8 months into the outbreak, from November 2 to November 21, 2020. We compared self-reported diet and exercise habits and risk for food insecurity shortly after the pandemic began, in April, to those reported in November. We also measured changes in quality-of-life using the PROMIS-29 + 2 (PROPr) scale. A total of 636 respondents completed both surveys. Compared to reports in April, respondents ate lunch and dinner out more frequently in November and consumed more take-out and fast food. Weekly frequencies of consuming frozen food and the number of daily meals were slightly lower in November than they were in April. 54% of respondents screened positively for being at risk for food insecurity in April, reducing to 41% by November. In April, survey respondents were found to have lower quality-of-life relative to U.S. population norms, but by November levels of depression and cognitive function had improved. Our findings underscore how the initial effects of the pandemic on diet, exercise, risk for food insecurity, and quality of life have evolved. As U.S. states re-open, continued efforts to encourage healthy eating and support mental health, especially to reduce feelings of anxiety and social isolation, remain important to mitigate the potential long-term effects of the pandemic.
Collapse
Affiliation(s)
- Alexandra M Rogers
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, USA; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, USA
| | - Brianna N Lauren
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, USA; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, USA
| | - Jennifer A Woo Baidal
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Irving Medical Center, New York, NY, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Chin Hur
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, USA; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, USA.
| |
Collapse
|
10
|
Lauren BN, Silver ER, Faye AS, Rogers AM, Woo-Baidal JA, Ozanne EM, Hur C. Predictors of households at risk for food insecurity in the United States during the COVID-19 pandemic. Public Health Nutr 2021; 24:3929-3936. [PMID: 33500018 PMCID: PMC8207551 DOI: 10.1017/s1368980021000355] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 01/04/2021] [Accepted: 01/20/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To examine associations between sociodemographic and mental health characteristics with household risk for food insecurity during the COVID-19 outbreak. DESIGN Cross-sectional online survey analysed using univariable tests and a multivariable logistic regression model. SETTING The United States during the week of 30 March 2020. PARTICIPANTS A convenience sample of 1965 American adults using Amazon's Mechanical Turk platform. Participants reporting household food insecurity prior to the pandemic were excluded from analyses. RESULTS One thousand two hundred and fifty participants reported household food security before the COVID-19 outbreak. Among this subset, 41 % were identified as at risk for food insecurity after COVID-19, 55 % were women and 73 % were white. On a multivariable analysis, race, income, relationship status, living situation, anxiety and depression were significantly associated with an incident risk for food insecurity. Black, Asian and Hispanic/Latino respondents, respondents with an annual income <$100 000 and those living with children or others were significantly more likely to be newly at risk for food insecurity. Individuals at risk for food insecurity were 2·60 (95 % CI 1·91, 3·55) times more likely to screen positively for anxiety and 1·71 (95 % CI 1·21, 2·42) times more likely to screen positively for depression. CONCLUSIONS An increased risk for food insecurity during the COVID-19 pandemic is common, and certain populations are particularly vulnerable. There are strong associations between being at risk for food insecurity and anxiety/depression. Interventions to increase access to healthful foods, especially among minority and low-income individuals, and ease the socioemotional effects of the outbreak are crucial to relieving the economic stress of this pandemic.
Collapse
Affiliation(s)
- Brianna N Lauren
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, 622 W 168th St, PH9E-105, New York, NY10032, USA
| | - Elisabeth R Silver
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, 622 W 168th St, PH9E-105, New York, NY10032, USA
| | - Adam S Faye
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Alexandra M Rogers
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, 622 W 168th St, PH9E-105, New York, NY10032, USA
| | - Jennifer A Woo-Baidal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake, UT, USA
| | - Chin Hur
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, 622 W 168th St, PH9E-105, New York, NY10032, USA
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
11
|
Baucom KJW, Pershing ML, Dwenger KM, Karasawa M, Cohan JN, Ozanne EM. Barriers and Facilitators to Enrollment and Retention in the National Diabetes Prevention Program: Perspectives of Women and Clinicians Within a Health System. Womens Health Rep (New Rochelle) 2021; 2:133-141. [PMID: 34036296 PMCID: PMC8139255 DOI: 10.1089/whr.2020.0102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 12/26/2022]
Abstract
Background: More than 10% of US adults are living with type 2 diabetes. The Centers for Disease Control and Prevention established the National Diabetes Prevention Program (National DPP) in 2010 in an effort to delay or prevent this disease among individuals at high risk. Unfortunately, enrollment and retention rates are low. This qualitative study aims to understand barriers and facilitators to enrolling and completing the National DPP among women, and to provide recommendations for improvement. Methods: Semistructured interviews were conducted with the following: (1) women who were eligible for the National DPP, but declined to enroll (n=11); (2) women who enrolled in the National DPP, but did not complete the program (n=12); and (3) clinicians who treat women eligible for the National DPP (n=12). Transcripts of the interviews were coded using content analysis. Results: The 35 interviews (23 patients and 12 clinicians) provided further insight into known barriers, such as the cost of the program, the time that it takes, and inconvenient locations. The study also identified previously undiscovered barriers, including the program not meeting participants' expectations and facilitating referrals. Furthermore, improved communication between clinicians, patients, and National DPP staff could ensure that both clinicians and National DPP staff are aware of patients' goals and their individual barriers to success. Conclusions: Enrollment and retention in the National DPP may be improved with additional communication, more training for National DPP staff to work more closely with participants, adding better incentives to participation, and making the program more accessible through flexibility in time and/or locations.
Collapse
Affiliation(s)
- Katherine Jane Williams Baucom
- Department of Psychology, College of Social and Social Behavioral Science, University of Utah, Salt Lake City, Utah, USA
| | - Mandy L Pershing
- Division of Health System Innovation and Research, Department of Population Health Sciences, School of Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Kaitlyn M Dwenger
- Division of Health System Innovation and Research, Department of Population Health Sciences, School of Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Michelle Karasawa
- Division of Health System Innovation and Research, Department of Population Health Sciences, School of Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Jessica N Cohan
- Division of Health System Innovation and Research, Department of Population Health Sciences, School of Medicine, University of Utah Health, Salt Lake City, Utah, USA.,Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Elissa M Ozanne
- Division of Health System Innovation and Research, Department of Population Health Sciences, School of Medicine, University of Utah Health, Salt Lake City, Utah, USA
| |
Collapse
|
12
|
Torres Roldan VD, Brand-McCarthy SR, Ponce OJ, Belluzzo T, Urtecho M, Espinoza Suarez NR, Toloza FJK, Thota AD, Organick PW, Barrera F, Liu-Sanchez C, Jaladi S, Prokop L, Ozanne EM, Fagerlin A, Hargraves IG, Noseworthy PA, Montori VM, Brito JP. Shared Decision Making Tools for People Facing Stroke Prevention Strategies in Atrial Fibrillation: A Systematic Review and Environmental Scan. Med Decis Making 2021; 41:540-549. [PMID: 33896270 PMCID: PMC8191170 DOI: 10.1177/0272989x211005655] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Shared decision making (SDM) tools can help implement guideline recommendations for patients with atrial fibrillation (AF) considering stroke prevention strategies. We sought to characterize all available SDM tools for this purpose and examine their quality and clinical impact. METHODS We searched through multiple bibliographic databases, social media, and an SDM tool repository from inception to May 2020 and contacted authors of identified SDM tools. Eligible tools had to offer information about warfarin and ≥1 direct oral anticoagulant. We extracted tool characteristics, assessed their adherence to the International Patient Decision Aids Standards, and obtained information about their efficacy in promoting SDM. RESULTS We found 14 SDM tools. Most tools provided up-to-date information about the options, but very few included practical considerations (e.g., out-of-pocket cost). Five of these SDM tools, all used by patients prior to the encounter, were tested in trials at high risk of bias and were found to produce small improvements in patient knowledge and reductions in decisional conflict. CONCLUSION Several SDM tools for stroke prevention in AF are available, but whether they promote high-quality SDM is yet to be known. The implementation of guidelines for SDM in this context requires user-centered development and evaluation of SDM tools that can effectively promote high-quality SDM and improve stroke prevention in patients with AF.
Collapse
Affiliation(s)
- Victor D Torres Roldan
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah R Brand-McCarthy
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Oscar J Ponce
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tereza Belluzzo
- General Medicine, Charles University in Prague, Medical Faculty of Hradec Králové, Hradec Kralove, Czech Republic
| | - Meritxell Urtecho
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Freddy J K Toloza
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anjali D Thota
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paige W Organick
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francisco Barrera
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), School of Medicine, Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | | | - Soumya Jaladi
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Larry Prokop
- Department of Library-Public Services, Mayo Clinic, Rochester MN, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA.,Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation
| | - Ian G Hargraves
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Peter A Noseworthy
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
13
|
Cohan JN, Orleans B, Brecha FS, Huang LC, Presson A, Fagerlin A, Ozanne EM. Factors Associated With Decision Regret Among Patients With Diverticulitis in the Elective Setting. J Surg Res 2021; 261:159-166. [PMID: 33429225 DOI: 10.1016/j.jss.2020.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/18/2020] [Accepted: 12/07/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND We aimed to identify decision process measures associated with patient decisional regret regarding the decision to pursue elective colectomy or observation for diverticulitis. MATERIALS AND METHODS This was a single-center cross-sectional survey study. We included adult patients treated for diverticulitis between 2014 and 2019 and excluded patients who required urgent or emergent colectomy. The primary outcome was regret regarding the decision to pursue elective surgery or observation for diverticulitis, measured using the Decision Regret Scale. We used multivariable linear regression to examine hypothesized predictors of decision regret, including decisional conflict (Decision Conflict Scale and its subscales), shared decision-making, and decision role concordance. RESULTS Of 923 eligible patients, 133 were included in the analysis. Patients had a median of five episodes of diverticulitis (interquartile range 3-8), occurring a median of 2 y (interquartile range 1-3) before survey administration. Thirty-eight patients (29%) underwent elective surgery for diverticulitis. Decision regret (Decision Regret Scale score ≥25) was present in 42 patients (32%). After controlling for surgery, gender, health status, and years since treatment, decision regret was associated with decisional conflict and inversely associated with values clarity, decision role concordance, shared decision-making, and feeling informed, supported, and effective in decision-making (all P < 0.001). CONCLUSIONS Nearly one-third of survey respondents experienced regret regarding the decision between elective surgery and observation for diverticulitis. Decision regret may be reduced through efforts to improve patient knowledge, values clarity, role concordance, and shared decision-making.
Collapse
Affiliation(s)
- Jessica N Cohan
- Department of Surgery, University of Utah, Salt Lake City, Utah; Department of Population Health Sciences, University of Utah, Salt Lake City, Utah.
| | - Brian Orleans
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | | | - Lyen C Huang
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Angela Presson
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| |
Collapse
|
14
|
Ozanne EM, Noseworthy PA, Cameron KA, Schmidt M, Cavanaugh K, Pershing ML, Guzman A, Sivly A, Fagerlin A. Shared Decision Making in the Era of Telehealth: Implications for Practice and Research. MDM Policy Pract 2020; 5:2381468320976364. [PMID: 33344769 PMCID: PMC7727056 DOI: 10.1177/2381468320976364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/04/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Kenzie A Cameron
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Monika Schmidt
- Department of Medicine, US Department of Veterans Affairs, Nashville, Tennessee
| | - Kerri Cavanaugh
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mandy L Pershing
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Adriana Guzman
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Angela Sivly
- Department of Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| |
Collapse
|
15
|
Delaney RK, Sisco-Taylor B, Fagerlin A, Weir P, Ozanne EM. A systematic review of intensive outpatient care programs for high-need, high-cost patients. Transl Behav Med 2020; 10:1187-1199. [PMID: 33044534 DOI: 10.1093/tbm/ibaa017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Five percent of the patient population accounts for 50% of U.S. healthcare expenditures. High-need, high-cost patients are medically complex for numerous reasons, often including behavioral health needs. Intensive outpatient care programs (IOCPs) are emerging, innovative clinics which provide patient-centered care leveraging multidisciplinary teams. The overarching goals of IOCPs are to reduce emergency department visits and hospitalizations (and related costs), and improve care continuity and patient outcomes. The purpose of this review was to examine the effectiveness of IOCPs on multiple outcomes to inform clinical care. A systematic search of the literature was conducted to identify articles. Six studies were included that varied in rigor of research design, analysis, and measurement of outcomes. Most studies reported results on healthcare utilization (n = 4) and costs (n = 3), with fewer reporting results on patient-reported and health-related outcomes (n = 2). Overall, there were decreasing trends in emergency department visits and hospitalizations. However, results on healthcare utilization varied based on time of follow-up, with shorter follow-up times yielding more significant results. Two of the three studies that evaluated costs found significant reductions associated with IOCPs, and the third was cost-neutral. Two studies reported improvements in patient-reported outcomes (e.g., satisfaction, depression, and anxiety). Overall, these programs reported positive impacts on healthcare utilization and costs; however, few studies evaluated patient characteristics and behaviors (e.g., engagement in care) which may serve as key mechanisms of program effectiveness. Future research should examine patient characteristics, behaviors, and clinic engagement metrics to inform clinical practice.
Collapse
Affiliation(s)
- Rebecca K Delaney
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Brittany Sisco-Taylor
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA.,Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, USA
| | - Peter Weir
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| |
Collapse
|
16
|
Sharib J, Esserman L, Koay EJ, Maitra A, Shen Y, Kirkwood KS, Ozanne EM. Cost-effectiveness of consensus guideline based management of pancreatic cysts: The sensitivity and specificity required for guidelines to be cost-effective. Surgery 2020; 168:601-609. [PMID: 32739138 PMCID: PMC8754171 DOI: 10.1016/j.surg.2020.04.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/25/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Detection of cystic lesions of the pancreas has outpaced our ability to stratify low-grade cystic lesions from those at greater risk for pancreatic cancer, raising a concern for overtreatment. METHODS We developed a Markov decision model to determine the cost-effectiveness of guideline-based management for asymptomatic pancreatic cysts. Incremental costs per quality-adjusted life year gained and survival were calculated for current management guidelines. A sensitivity analysis estimated the effect on cost-effectiveness and mortality if overtreatment of low-grade cysts is avoided, and the sensitivity and specificity thresholds required of methods of cyst stratification to improve costs expended. RESULTS "Surveillance" using current management guidelines had an incremental cost-effectiveness ratio of $171,143/quality adjusted life year compared with no surveillance or operative treatment ("do nothing"). An incremental cost-effectiveness ratio for surveillance decreases to $80,707/quality adjusted life year if the operative overtreatment of low-grade cysts was avoided. Assuming a societal willingness-to-pay of $100,000/quality adjusted life year, the diagnostic specificity for high-risk cysts must be >67% for surveillance to be preferred over surgery and "do nothing." Changes in sensitivity alone cannot make surveillance cost-effective. Most importantly, survival in surveillance is worse than "do nothing" for 3 years after cyst diagnosis, although long-term survival is improved. The disadvantage is eliminated when overtreatment of low-grade cysts is avoided. CONCLUSION Current management of pancreatic cystic lesions is not cost-effective and may increase mortality owing to overtreatment of low-grade cysts. The specificity for risk stratification for high-risk cysts must be greater than 67% to make surveillance cost-effective.
Collapse
Affiliation(s)
- Jeremy Sharib
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Laura Esserman
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anirban Maitra
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yu Shen
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kimberly S Kirkwood
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA.
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
| |
Collapse
|
17
|
Brecha FS, Ozanne EM, Esplin J, Stoddard GJ, Nirula R, Huang LC, Cohan JN. Patient Willingness to Accept Antibiotic Side Effects to Reduce Surgical Site Infection After Colorectal Surgery. J Surg Res 2020; 261:417-422. [PMID: 32917390 DOI: 10.1016/j.jss.2020.07.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/25/2020] [Accepted: 07/11/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Mechanical bowel preparation with antibiotics is associated with decreased surgical site infections (SSI) after colorectal surgery. However, antibiotics have side effects, such as vomiting. It is unknown how patient willingness to take antibiotics is affected by side effect severity. MATERIALS AND METHODS This was a single-center study of 86 patients (37 undergoing colorectal surgery) using a modified standard gamble technique. We presented patients with four hypothetical scenarios, holding SSI reduction constant and varying antibiotic side effect severity. Patients reported willingness to take antibiotics using a scale from 0 to 100. Patients also reported the maximum level of side effects they would accept. We examined the association between side effect severity and willingness to take antibiotics with a multivariable mixed-effects regression model and investigated differences in surgical and nonsurgical patients. RESULTS After adjusting for age, sex, and patient type, willingness scores decreased with increasing side effect severity. No side effects: 92 (CI 86,99), mild: 83 (CI 76,90), moderate: 76 (CI 69,83), and severe: 46 (CI 38,52), P < 0.001. Surgical patients were more willing to take antibiotics at all severity levels compared with nonsurgical patients, P < 0.001. Surgical (57%) and nonsurgical (58%) patients reported that they would accept moderate side effects. Patients with prior SSI (n = 5) would take antibiotics regardless of side effect severity. CONCLUSIONS Increasing antibiotic side effect severity is associated with decreased willingness to take antibiotics during bowel preparation, despite a reduction in SSI. Adherence may be improved with strategies that increase patient education and decrease side effects during bowel preparation.
Collapse
Affiliation(s)
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Jordan Esplin
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Gregory J Stoddard
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Lyen C Huang
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Jessica N Cohan
- Department of Surgery, University of Utah, Salt Lake City, Utah; Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| |
Collapse
|
18
|
Ozanne EM, Soeteman DI, Frank ES, Clarke J, Hassett MJ, Stout NK, Punglia RS. Commentary: Creating a patient-centered decision aid for ductal carcinoma in situ. Breast J 2020; 26:1498-1499. [PMID: 32034829 DOI: 10.1111/tbj.13779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/22/2020] [Accepted: 01/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Djøra I Soeteman
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts
| | - Elizabeth S Frank
- Dana-Farber/Harvard Center Breast Cancer Advocacy Group, DFCI, Boston, Massachusetts
| | - John Clarke
- Cornerstone Systems Northwest Inc, Boston, Massachusetts
| | | | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | |
Collapse
|
19
|
Bannon BL, Lucier M, Fagerlin A, Kim J, Kiraly B, Weir P, Ozanne EM. Evaluation of the intensive outpatient clinic: study protocol for a prospective study of high-cost, high-need patients in the University of Utah Health system. BMJ Open 2019; 9:e024724. [PMID: 30782742 PMCID: PMC6361483 DOI: 10.1136/bmjopen-2018-024724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The University of Utah (UofU) Health intensive outpatient clinic (IOC) is a primary care clinic for medically complex (high-cost, high-need) patients with Medicaid. The clinic consists of a multidisciplinary care team aimed at providing coordinated, comprehensive and patient-centred care. The protocol outlines the quantitative design of an evaluation study to determine the IOC's effects on reducing healthcare utilisation and costs, as well as improving patient-reported health outcomes and quality of care. METHODS AND ANALYSIS High-risk patients, with high utilisation and multiple chronic illnesses, were identified in the Medicaid ACO population managed by the UofU Health plans for IOC eligibility. A prospective, case-control study design is being used to match 100 IOC patients to 200 control patients (receiving usual care within the UofU) based on demographics, health utilisation and medical complexity for evaluating the primary outcome of change in healthcare utilisation and costs. For the secondary outcomes of patient health and care quality, a prepost design will be used to examine within-person change across the 18 months of follow-up (ie, before and after IOC intervention). Logistic regression and hierarchical, longitudinal growth modelling are the two primary modelling approaches. ETHICS AND DISSEMINATION This work has received ethics approval by the UofU Institutional Review Board. Results from the evaluation of primary and secondary outcomes will be disseminated in scientific research journals and presented at national conferences.
Collapse
Affiliation(s)
- Brittany L Bannon
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michelle Lucier
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
- VA Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, Utah, USA
| | - Jaewhan Kim
- Department of Health and Kinesiology, University of Utah, Salt Lake City, Utah, USA
| | - Bernadette Kiraly
- Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Peter Weir
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| |
Collapse
|
20
|
Ozanne EM, Howe R, Mallinson D, Esserman L, Van't Veer LJ, Kaplan CP. Evaluation of National Comprehensive Cancer Network guideline-based Tool for Risk Assessment for breast and ovarian Cancer (N-TRAC): A patient-reported survey for genetic high-risk assessment for breast and ovarian cancers in women. J Genet Couns 2019; 28:507-515. [PMID: 30663827 DOI: 10.1002/jgc4.1051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 09/07/2018] [Accepted: 09/15/2018] [Indexed: 11/09/2022]
Abstract
Identification of mutations that increase lifetime risk of breast and ovarian cancer is critical to improving women's health. Because these mutations are relatively rare in the general population, there is a need for efficient methods to identify appropriate women to undergo genetic testing. The objective of this study was to assess the feasibility, accuracy, and performance of the NCCN guideline-based Tool for Risk Assessment for breast and ovarian Cancer (N-TRAC)-a patient-facing assessment for those affected and unaffected by cancer. This study enrolled a prospective cohort of 100 affected and 100 unaffected women that used N-TRAC in a clinical setting. Recommendations for referral to genetic counseling based on N-TRAC and other standard risk assessment methods were compared.Seventy-seven of the 100 affected women and 35 of the 100 unaffected women were identified as high risk by N-TRAC. The average completion time was approximately 2 min for both groups. N-TRAC accuracy for family history was exceptional in both groups (kappa > 0.96). N-TRAC and other risk assessment methods do not always identify the same high risk population. N-TRAC is an accurate and feasible tool that can assist in identifying women at increased risk for hereditary breast and ovarian cancer and may lead to more informed decision-making.
Collapse
Affiliation(s)
- Elissa M Ozanne
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Rebecca Howe
- Frank H. Netter School of Medicine, Quinnipiac University, North Haven, Connecticut
| | - David Mallinson
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Laura Esserman
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California.,Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California.,Departments of Surgery and Radiology, University of California, San Francisco, San Francisco, California.,Carol Franc Buck Breast Cancer Center, University of California, San Francisco, San Francisco, California
| | - Laura J Van't Veer
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | - Celia P Kaplan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California.,Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California.,Center for Aging in Diverse Communities, Department of Medicine, University of California San Francisco, San Francisco, California
| |
Collapse
|
21
|
He X, Schifferdecker KE, Ozanne EM, Tosteson ANA, Woloshin S, Schwartz LM. How Do Women View Risk-Based Mammography Screening? A Qualitative Study. J Gen Intern Med 2018; 33:1905-1912. [PMID: 30066118 PMCID: PMC6206346 DOI: 10.1007/s11606-018-4601-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/25/2018] [Accepted: 07/12/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Decades of persuasive messages have reinforced the importance of traditional screening mammography at regular intervals. A potential new paradigm, risk-based screening, adjusts mammography frequency based on a woman's estimated breast cancer risk in order to maximize mortality reduction while minimizing false positives and overdiagnosis. Women's views of risk-based screening are unknown. OBJECTIVE To explore women's views and personal acceptability of a potential risk-based mammography screening paradigm. DESIGN Four semi-structured focus group discussions about screening mammography and surveys before provision of information about risk-based screening. We analyzed coded focus group transcripts using a mixed deductive (content analysis) and inductive (grounded theory) approach. PARTICIPANTS Convenience sample of 29 women (40-74 years old) with no personal history of breast cancer recruited by print and online media in New Hampshire and Vermont. RESULTS Twenty-seven out of 29 women reported having undergone mammography screening. All participants were white and most were highly educated. Some women accepted the idea that early cancer detection with traditional screening was beneficial-although many also reported hearing inconsistent recommendations from clinicians and mixed messages from media reports about mammography. Some women were familiar with a risk-based screening paradigm (primarily related to cervical cancer, n = 8) and thought matching screening mammography frequency to personal risk made sense (n = 8). Personal acceptability of risk-based screening was mixed. Some believed risk-based screening could reduce the harms of false positives and overdiagnosis (n = 7). Others thought screening less often might result in missing a dangerous diagnosis (n = 14). Many (n = 18) expressed concerns about the feasibility of risk-based screening and questioned whether breast cancer risk estimates could be accurate. Some suspected that risk-based mammography was motivated by a desire to save money (n = 6). CONCLUSION Some women thought risk-based screening made sense. Willingness to abandon traditional screening for the new paradigm was mixed. Broad acceptability of risk-based screening will require clearer communication about its rationale and feasibility and consistent messages from the health care team.
Collapse
Affiliation(s)
- Xiaofei He
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
| | - Karen E Schifferdecker
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.,Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Anna N A Tosteson
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.,Dartmouth-Hitchcock Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Steven Woloshin
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.,Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Dartmouth-Hitchcock Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Lisa M Schwartz
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.,Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Dartmouth-Hitchcock Norris Cotton Cancer Center, Lebanon, NH, USA
| |
Collapse
|
22
|
Henderson LM, Hubbard RA, Zhu W, Weiss J, Wernli KJ, Goodrich ME, Kerlikowske K, DeMartini W, Ozanne EM, Onega T. Preoperative Breast Magnetic Resonance Imaging Use by Breast Density and Family History of Breast Cancer. J Womens Health (Larchmt) 2018; 27:987-993. [PMID: 29334616 DOI: 10.1089/jwh.2017.6428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Use of preoperative breast magnetic resonance imaging (MRI) among women with a new breast cancer has increased over the past decade. MRI use is more frequent in younger women and those with lobular carcinoma, but associations with breast density and family history of breast cancer are unknown. MATERIALS AND METHODS Data for 3075 women ages >65 years with stage 0-III breast cancer who underwent breast conserving surgery or mastectomy from 2005 to 2010 in the Breast Cancer Surveillance Consortium were linked to administrative claims data to assess associations of preoperative MRI use with mammographic breast density and first-degree family history of breast cancer. Multivariable logistic regression estimated adjusted odds ratios (OR) and 95% confidence intervals (95% CI) for the association of MRI use with breast density and family history, adjusting for woman and tumor characteristics. RESULTS Overall, preoperative MRI use was 16.4%. The proportion of women receiving breast MRI was similar by breast density (17.6% dense, 16.9% nondense) and family history (17.1% with family history, 16.5% without family history). After adjusting for potential confounders, we found no difference in preoperative MRI use by breast density (OR = 0.95 for dense vs. nondense, 95% CI: 0.73-1.22) or family history (OR = 0.99 for family history vs. none, 95% CI: 0.73-1.32). CONCLUSIONS Among women aged >65 years with breast cancer, having dense breasts or a first-degree relative with breast cancer was not associated with greater preoperative MRI use. This utilization is in keeping with lack of evidence that MRI has higher yield of malignancy in these subgroups.
Collapse
Affiliation(s)
- Louise M Henderson
- 1 Department of Radiology, The University of North Carolina , Chapel Hill, North Carolina
| | - Rebecca A Hubbard
- 2 Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Weiwei Zhu
- 3 Kaiser Permanente Washington Health Research Institute , Seattle, Washington
| | - Julie Weiss
- 4 Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth , Lebanon , New Hampshire
| | - Karen J Wernli
- 3 Kaiser Permanente Washington Health Research Institute , Seattle, Washington
| | - Martha E Goodrich
- 4 Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth , Lebanon , New Hampshire
| | - Karla Kerlikowske
- 5 Departments of Medicine and Epidemiology and Biostatistics, University of California , San Francisco, San Francisco, California
| | - Wendy DeMartini
- 6 Department of Radiology, Stanford University , Stanford, California
| | - Elissa M Ozanne
- 7 Department of Population Health Sciences, University of Utah School of Medicine , Salt Lake City, Utah
| | - Tracy Onega
- 8 The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center , Geisel School of Medicine at Dartmouth, Lebanon , New Hampshire
| |
Collapse
|
23
|
Forcino RC, Barr PJ, O'Malley AJ, Arend R, Castaldo MG, Ozanne EM, Percac-Lima S, Stults CD, Tai-Seale M, Thompson R, Elwyn G. Using CollaboRATE, a brief patient-reported measure of shared decision making: Results from three clinical settings in the United States. Health Expect 2017; 21:82-89. [PMID: 28678426 PMCID: PMC5750739 DOI: 10.1111/hex.12588] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2017] [Indexed: 12/30/2022] Open
Abstract
Introduction CollaboRATE is a brief patient survey focused on shared decision making. This paper aims to (i) provide insight on facilitators and challenges to implementing a real‐time patient survey and (ii) evaluate CollaboRATE scores and response rates across multiple clinical settings with varied patient populations. Method All adult patients at three United States primary care practices were eligible to complete CollaboRATE post‐visit. To inform key learnings, we aggregated all mentions of unanticipated decisions, problems and administration errors from field notes and email communications. Mixed‐effects logistic regression evaluated the impact of site, clinician, patient age and patient gender on the CollaboRATE score. Results While CollaboRATE score increased only slightly with increasing patient age (OR 1.018, 95% CI 1.014‐1.021), female patient gender was associated with significantly higher CollaboRATE scores (OR 1.224, 95% CI 1.073‐1.397). Clinician also predicts CollaboRATE score (random effect variance 0.146). Site‐specific factors such as clinical workflow and checkout procedures play a key role in successful in‐clinic implementation and are significantly related to CollaboRATE scores, with Site 3 scoring significantly higher than Site 1 (OR 1.759, 95% CI 1.216 to 2.545) or Site 2 (z=−2.71, 95% CI −1.114 to −0.178). Discussion This study demonstrates that CollaboRATE can be used in diverse primary care settings. A clinic's workflow plays a crucial role in implementation. Patient experience measurement risks becoming a burden to both patients and administrators. Episodic use of short measurement tools could reduce this burden.
Collapse
Affiliation(s)
- Rachel C Forcino
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
| | - Paul J Barr
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
| | - Roger Arend
- Dartmouth-Hitchcock Patient and Family Advisory Council, Lebanon, NH, USA
| | - Molly G Castaldo
- Dartmouth Master of Health Care Delivery Science Program, Hanover, NH, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Sanja Percac-Lima
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Chelsea HealthCare Center, Chelsea, MA, USA
| | - Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Ming Tai-Seale
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Rachel Thompson
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
| |
Collapse
|
24
|
Barr PJ, Forcino RC, Thompson R, Ozanne EM, Arend R, Castaldo MG, O'Malley AJ, Elwyn G. Evaluating CollaboRATE in a clinical setting: analysis of mode effects on scores, response rates and costs of data collection. BMJ Open 2017; 7:e014681. [PMID: 28341691 PMCID: PMC5372080 DOI: 10.1136/bmjopen-2016-014681] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/06/2017] [Accepted: 02/13/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Shared decision-making (SDM) has become a policy priority, yet its implementation is not routinely assessed. To address this gap we tested the delivery of CollaboRATE, a 3-item patient reported experience measure of SDM, via multiple survey modes. OBJECTIVE To assess CollaboRATE response rates and respondent characteristics across different modes of administration, impact of mode and patient characteristics on SDM performance and cost of administration per response in a real-world primary care practice. DESIGN Observational study design, with repeated assessment of SDM performance using CollaboRATE in a primary care clinic over 15 months of data collection. Different modes of administration were introduced sequentially including paper, patient portal, interactive voice response (IVR) call, text message and tablet computer. PARTICIPANTS Consecutive patients ≥18 years, or parents/guardians of patients <18 years, visiting participating primary care clinicians. MAIN MEASURES CollaboRATE assesses three core SDM tasks: (1) explanation about health issues, (2) elicitation of patient preferences and (3) integration of patient preferences into decisions. Responses to each item range from 0 (no effort was made) to 9 (every effort was made). CollaboRATE scores are calculated as the proportion of participants who report a score of nine on each of the three CollaboRATE questions. KEY RESULTS Scores were sensitive to mode effects: the paper mode had the highest average score (81%) and IVR had the lowest (61%). However, relative clinician performance rankings were stable across the different data collection modes used. Tablet computers administered by research staff had the highest response rate (41%), although this approach was costly. Clinic staff giving paper surveys to patients as they left the clinic had the lowest response rate (12%). CONCLUSIONS CollaboRATE can be introduced using multiple modes of survey delivery while producing consistent clinician rankings. This may allow routine assessment and benchmarking of clinician and clinic SDM performance.
Collapse
Affiliation(s)
- Paul J Barr
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - Rachel C Forcino
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - Rachel Thompson
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - Elissa M Ozanne
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - Roger Arend
- Dartmouth-Hitchcock Patient and Family Advisory Council, Lebanon, New Hampshire, USA
| | - Molly Ganger Castaldo
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
- Dartmouth Master of Health Care Delivery Science Program, Hanover, New Hampshire, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| |
Collapse
|
25
|
Punglia RS, Cronin AM, Uno H, Stout NK, Ozanne EM, Greenberg CC, Frank ES, Schrag D. Association of Regional Intensity of Ductal Carcinoma In Situ Treatment With Likelihood of Breast Preservation. JAMA Oncol 2017; 3:101-104. [PMID: 27442038 DOI: 10.1001/jamaoncol.2016.2164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Large regional variation exists in the use of radiotherapy after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS). Although patients who do not receive initial radiotherapy for DCIS are candidates for subsequent BCS if they experience a second breast event, many undergo mastectomy instead. Objective To examine whether regional practice patterns of radiotherapy for DCIS affect the use of mastectomy in these patients. Design, Setting, and Participants A retrospective analysis of population-based databases (Surveillance, Epidemiology, and End Results [SEER] and SEER-Medicare). Data were obtained for 2679 women in SEER with a diagnosis of DCIS between 1990 and 2011 and for 757 women in SEER-Medicare with a DCIS diagnosis between 1991 and 2009 who had not undergone radiotherapy for DCIS and experienced a subsequent breast cancer or DCIS diagnosis. Exposures Treatment intensity for primary DCIS (high, medium, low), as defined by separating health service areas (HSAs) into 3 clusters based on radiotherapy use. Main Outcomes and Measures Mastectomy vs BCS at a second breast event defined as DCIS recurrence or new invasive cancer. Results The median (SD) ages of the participants was 64 (13) years for the 2679 SEER population and 79 (6) years for the SEER-Medicare cohort. Residence in an HSA characterized by greater radiotherapy use for DCIS increased the likelihood of receiving mastectomy vs BCS at a subsequent breast event, even among women who had not previously received radiotherapy for DCIS. Adjusted odds ratios for receiving mastectomy were 1.43 (95% CI, 1.10-1.85) and 1.90 (95% CI, 1.27-2.84) in SEER and SEER-Medicare databases, respectively, among women residing in an HSA with the greatest radiotherapy use vs the least, corresponding to an adjusted increase from 40.8% to 49.6%, and from 38.6% to 54.5%. Conclusions and Relevance Areas with more radiotherapy use for DCIS had increased use of mastectomy at the time of a second breast event even among patients eligible for breast conservation. This association suggests that physician-related factors are affecting the likelihood of breast preservation.
Collapse
Affiliation(s)
- Rinaa S Punglia
- Department of Radiation Therapy, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Angel M Cronin
- Division of Population Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Elissa M Ozanne
- The Dartmouth Institute, Geisel School of Medicine, Hanover, New Hampshire
| | - Caprice C Greenberg
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine, Madison
| | - Elizabeth S Frank
- Dana-Farber/Harvard Center Breast Cancer Advocacy Group, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Deborah Schrag
- Division of Population Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
26
|
Ozanne EM, Weiss JE, Onega T, DeMartini W, Kerlikowske K, Buist DSM, Henderson L, Hubbard RA, Goodrich M, Tosteson ANA, Virnig BA, O'Donoghue C. Locoregional treatment of breast cancer in women with and without preoperative magnetic resonance imaging. Am J Surg 2016; 213:132-139.e2. [PMID: 27421187 DOI: 10.1016/j.amjsurg.2016.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 03/16/2016] [Accepted: 03/31/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Preoperative magnetic resonance imaging (MRI) use has increased among older women diagnosed with breast cancer. MRI detects additional malignancy, but its impact on locoregional surgery and radiation treatment remains unclear. METHODS We examined the associations of preoperative MRI with initial locoregional treatment type (mastectomy, breast conserving surgery [BCS] with radiation therapy [RT], and BCS without RT) and BCS reoperation rates for Surveillance, Epidemiology, and End Results Medicare women diagnosed with stages 0 to III breast cancer from 2005 to 2009 (n = 55,997). RESULTS We found no association of initial locoregional treatment of mastectomy (odds ratios [OR], 1.04; 95% confidence intervals, .98 to 1.11) or reoperation after initial BCS (OR, .96; 95% confidence intervals, .89 to 1.03) between women with preoperative MRI (16.2%) compared to women without MRI. However, women with MRI who had initial BCS were more likely to undergo RT (OR, 1.09 [1.02 to 1.16]). CONCLUSIONS Preoperative breast MRI in Medicare-enrolled women with stages 0 to III breast cancer was not associated with increased mastectomy. However, in older women with MRI undergoing BCS, there was a greater use of RT.
Collapse
Affiliation(s)
- Elissa M Ozanne
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Julie E Weiss
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, 46 Centerra Parkway, Suite 105, Lebanon, NH 03766, USA.
| | - Tracy Onega
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, 46 Centerra Parkway, Suite 105, Lebanon, NH 03766, USA
| | - Wendy DeMartini
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Karla Kerlikowske
- Department of Medicine, University of California, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Diana S M Buist
- Department of Epidemiology, Group Health Research Institute, Seattle, WA, USA
| | - Louise Henderson
- Department of Radiology, The University of North Carolina, Chapel Hill, NC, USA
| | - Rebecca A Hubbard
- Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Martha Goodrich
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, 46 Centerra Parkway, Suite 105, Lebanon, NH 03766, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Beth A Virnig
- Department of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Cristina O'Donoghue
- Department of Surgical Oncology, Surgical Oncology, Moffitt Cancer Center, Tampa, FL, USA
| |
Collapse
|
27
|
Barnes AJ, Hanoch Y, Miron-Shatz T, Ozanne EM. Tailoring risk communication to improve comprehension: Do patient preferences help or hurt? Health Psychol 2016; 35:1007-16. [PMID: 27183307 DOI: 10.1037/hea0000367] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Risk communication tools can facilitate patients' understanding of risk information. In this novel study, we examine the hypothesis that risk communication methods tailored to individuals' preferences can increase risk comprehension. METHOD Preferences for breast cancer risk formats, and risk comprehension data were collected using an online survey from 361 women at high risk for breast cancer. Women's initial preferences were assessed by asking them which of the following risk formats would be the clearest: (a) percentage, (b) frequency, (c) bar graph, (d) pictogram, and (e) comparison to other women. Next, women were presented with 5 different formats for displaying cancer risks and asked to interpret the risk information presented. Finally, they were asked again which risk format they preferred. RESULTS Initial preferences for risk formats were not associated with risk comprehension scores. However, women with lower risk comprehension scores were more likely to update their risk format preferences after they evaluated risks in different formats. Less numerate women were more likely to prefer graphical rather than numeric risk formats. Importantly, we found that women preferring graphical risk formats had lower risk comprehension in these formats compared to numeric formats. In contrast, women preferring numeric formats performed equally well across formats. CONCLUSIONS Our findings suggest that tailoring risk communication to patient preferences may not improve understanding of medical risks, particularly for less numerate women, and point to the potential perils of tailoring risk communication formats to patient preferences. (PsycINFO Database Record
Collapse
Affiliation(s)
- Andrew J Barnes
- Department of Healthcare Policy and Research, School of Medicine, Virginia Commonwealth University
| | | | | | - Elissa M Ozanne
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth
| |
Collapse
|
28
|
Ozanne EM, Stout NK, Schneider K, Soeteman D, Schrag D, Fordis M, Punglia RS. Abstract P2-10-01: onlineDeCISion.org: An interactive web-based clinical decision aid for DCIS treatment. Cancer Res 2015. [DOI: 10.1158/1538-7445.sabcs14-p2-10-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose: Treatment decisions regarding Ductal Carcinoma in Situ (DCIS) are complex, and patients often have inaccurate and incomplete understanding of the risks and benefits they face. Our objective was to create a web-based decision aid (onlineDeCISion.org) that can be used in clinical practice to guide both clinicians and their patients with these decisions.
Methods: We developed a web-based clinical decision aid to provide tailored information about DCIS treatment choices including an individual patient’s risk of recurrence, likelihood of long-term breast preservation and survival outcomes following up to 6 different treatment strategies for DCIS (lumpectomy, lumpectomy with radiation, lumpectomy with tamoxifen, lumpectomy with radiation and tamoxifen, and mastectomy with or without breast reconstruction). The decision aid is populated by our previously developed simulation model of DCIS outcomes. A theoretical framework and best-practices for web-based decision tools guided the development of the decision aid including semi-structured interviews and usability testing with a diverse group of multidisciplinary clinicians and patient advocates.
Results: The decision aid was designed to include these key features: 1) descriptions of treatment options; 2) ability to input patient health-adjusted age; 3) tailored likelihood of time-specific (10-year and lifetime) recurrence and survival outcomes; and 4) projections of downstream effects of each treatment. The decision aid provides default recurrence risks based on clinical trial data but allows clinicians to customize 10-year DCIS and invasive recurrence risks to retain flexibility to display expected outcomes for individual patients. These estimates can be based on the patient’s actual age, or age adjusted for health status, allowing for a more realistic expectation of the benefits each treatment holds.
Conclusion: Our web-based decision aid displays tailored outcomes following different treatment strategies for DCIS, allowing patients to be better informed about the tradeoffs of treatments available to them and select treatments consonant with their personal preferences, improving the quality of decision making for DCIS. The interactive design features allow users of the decision aid the ability to address uncertainty around risks of recurrence and comorbidity risks and facilitate the use of the decision aid across diverse populations. While the decision aid warrants further evaluation, the results of our study promise to improve decision making in patients with DCIS.
Citation Format: Elissa M Ozanne, Natasha K Stout, Katharine Schneider, Djøra Soeteman, Deborah Schrag, Michael Fordis, Rinaa S Punglia. onlineDeCISion.org: An interactive web-based clinical decision aid for DCIS treatment [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-10-01.
Collapse
|
29
|
Barr PJ, Thompson R, Walsh T, Grande SW, Ozanne EM, Elwyn G. Correction: the psychometric properties of CollaboRATE: a fast and frugal patient-reported measure of the shared decision-making process. J Med Internet Res 2015; 17:e32. [PMID: 25667387 PMCID: PMC4353887 DOI: 10.2196/jmir.4272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 01/23/2015] [Indexed: 11/23/2022] Open
Affiliation(s)
- Paul James Barr
- The Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, NH, United States.
| | | | | | | | | | | |
Collapse
|
30
|
Esserman LJ, Alvarado MD, Howe RJ, Mohan AJ, Harrison B, Park C, O'Donoghue C, Ozanne EM. Application of a decision analytic framework for adoption of clinical trial results: are the data regarding TARGIT-A IORT ready for prime time? Breast Cancer Res Treat 2014; 144:371-8. [PMID: 24584875 PMCID: PMC3949013 DOI: 10.1007/s10549-014-2881-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 01/10/2014] [Indexed: 11/26/2022]
Abstract
The results from randomized clinical trials are often adopted slowly. This practice potentially prevents many people from benefiting from more effective care. Provide a framework for analyzing clinical trial results to determine whether and when early adoption of novel interventions is appropriate. The framework includes the evaluation of three components: confidence in trial results, impact of early, and late adoption if trial results are reversed or sustained. The adverse impact of early adoption, and the opportunity cost of late adoption are determined using Markov modeling to simulate the impact of early and late adoption in terms of quality of life years and resources gained or lost. We applied the framework to the TARGIT-A randomized clinical trial comparing intraoperative radiation (IORT) to standard external beam radiation (EBRT) and considered these results in the context of trials comparing endocrine therapy with and without radiation therapy in postmenopausal women. Confidence in the TARGIT-A trial 4 year results is high because the peak hazard for local recurrence in the trial is between 2 and 3 years. This is consistent with most trials, and no second peak has been observed in similar patient populations, suggesting that the TARGIT-A trial results are stable. The interventions offer approximately equivalent life expectancy. If IORT local recurrences rate were as high as 10 % at 10 years (which is higher than expected), we would project only 0.002 fewer expected life years (less than 1 day) compared to EBRT if IORT is adopted early. However, there is a $1.7 billion opportunity cost of waiting an additional 5 years to adopt IORT in low risk, hormone-receptor-positive, postmenopausal women. EBRT costs an additional $1467 in indirect costs per patient. Applying an evaluative framework for the adoption of clinical trial results to the TARGIT-A IORT therapy trial results in the assessment that the trial results are stable, early adoption would lead to minimal adverse impact, and substantially less resource use. Both IORT and no radiation are reasonable strategies to adopt.
Collapse
Affiliation(s)
- L J Esserman
- University of California, 1600 Divisadero, 2nd Floor, Box1710, San Francisco, CA, 94115, USA,
| | | | | | | | | | | | | | | |
Collapse
|
31
|
O'Donoghue C, Eklund M, Ozanne EM, Esserman LJ. Aggregate cost of mammography screening in the United States: comparison of current practice and advocated guidelines. Ann Intern Med 2014; 160:145. [PMID: 24658691 PMCID: PMC4142190 DOI: 10.7326/m13-1217] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Controversy exists over how often and at what age mammography screening should be implemented. Given that evidence supports less frequent screening, the cost differences among advocated screening policies should be better understood. OBJECTIVE To estimate the aggregate cost of mammography screening in the United States in 2010 and compare the costs of policy recommendations by professional organizations. DESIGN A model was developed to estimate the cost of mammography screening in 2010 and 3 screening strategies: annual (ages 40 to 84 years), biennial (ages 50 to 69 years), and U.S. Preventive Services Task Force (USPSTF) guidelines (biennial for those aged 50 to 74 years and personalized based on risk for those younger than 50 years and based on comorbid conditions for those 75 years and older). SETTING United States. PATIENTS Women aged 40 to 85 years. INTERVENTION Mammography annually, biennially, or following USPSTF guidelines. MEASUREMENTS Cost of screening per year, using Medicare reimbursements. RESULTS The estimated cost of mammography screening in the United States in 2010 was $7.8 billion, with approximately 70% of women screened. The simulated cost of screening 85% of women was $10.1 billion, $2.6 billion, and $3.5 billion for annual, biennial, and USPSTF guidelines, respectively. The largest drivers of cost (in order) were screening frequency, percentage of women screened, cost of mammography, percentage of women screened with digital mammography, and percentage of mammography recalls. LIMITATION Cost estimates and assumptions used in the model were conservative. CONCLUSION The cost of mammography varies by at least $8 billion per year on the basis of screening strategy. The USPSTF guidelines are based on the scientific evidence to date to maximize patient benefit and minimize harm but also result in far more effective use of resources. PRIMARY FUNDING SOURCE University of California and the Safeway Foundation.
Collapse
|
32
|
Ozanne EM, Howe R, Omer Z, Esserman LJ. Development of a personalized decision aid for breast cancer risk reduction and management. BMC Med Inform Decis Mak 2014; 14:4. [PMID: 24422989 PMCID: PMC3899602 DOI: 10.1186/1472-6947-14-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 01/02/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Breast cancer risk reduction has the potential to decrease the incidence of the disease, yet remains underused. We report on the development a web-based tool that provides automated risk assessment and personalized decision support designed for collaborative use between patients and clinicians. METHODS Under Institutional Review Board approval, we evaluated the decision tool through a patient focus group, usability testing, and provider interviews (including breast specialists, primary care physicians, genetic counselors). This included demonstrations and data collection at two scientific conferences (2009 International Shared Decision Making Conference, 2009 San Antonio Breast Cancer Symposium). RESULTS Overall, the evaluations were favorable. The patient focus group evaluations and usability testing (N = 34) provided qualitative feedback about format and design; 88% of these participants found the tool useful and 94% found it easy to use. 91% of the providers (N = 23) indicated that they would use the tool in their clinical setting. CONCLUSION BreastHealthDecisions.org represents a new approach to breast cancer prevention care and a framework for high quality preventive healthcare. The ability to integrate risk assessment and decision support in real time will allow for informed, value-driven, and patient-centered breast cancer prevention decisions. The tool is being further evaluated in the clinical setting.
Collapse
Affiliation(s)
- Elissa M Ozanne
- Department of Surgery, Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, 35 Centerra Parkway, Lebanon, NH 03766, USA
| | - Rebecca Howe
- Department of Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Zehra Omer
- University of Massachusetts, Worcester, USA
| | - Laura J Esserman
- Department of Surgery, University of California at San Francisco, San Francisco, CA, USA
| |
Collapse
|
33
|
Barr PJ, Thompson R, Walsh T, Grande SW, Ozanne EM, Elwyn G. The psychometric properties of CollaboRATE: a fast and frugal patient-reported measure of the shared decision-making process. J Med Internet Res 2014; 16:e2. [PMID: 24389354 PMCID: PMC3906697 DOI: 10.2196/jmir.3085] [Citation(s) in RCA: 210] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 12/14/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patient-centered health care is a central component of current health policy agendas. Shared decision making (SDM) is considered to be the pinnacle of patient engagement and methods to promote this are becoming commonplace. However, the measurement of SDM continues to prove challenging. Reviews have highlighted the need for a patient-reported measure of SDM that is practical, valid, and reliable to assist implementation efforts. In consultation with patients, we developed CollaboRATE, a 3-item measure of the SDM process. OBJECTIVE There is a need for scalable patient-reported measure of the SDM process. In the current project, we assessed the psychometric properties of CollaboRATE. METHODS A representative sample of the US population were recruited online and were randomly allocated to view 1 of 6 simulated doctor-patient encounters in January 2013. Three dimensions of SDM were manipulated in the encounters: (1) explanation of the health issue, (2) elicitation of patient preferences, and (3) integration of patient preferences. Participants then completed CollaboRATE (possible scores 0-100) in addition to 2 other patient-reported measures of SDM: the 9-item Shared Decision Decision Making Questionnaire (SDM-Q-9) and the Doctor Facilitation subscale of the Patient's Perceived Involvement in Care Scale (PICS). A subsample of participants was resurveyed between 7 and 14 days after the initial survey. We assessed CollaboRATE's discriminative, concurrent, and divergent validity, intrarater reliability, and sensitivity to change. RESULTS The final sample consisted of 1341 participants. CollaboRATE demonstrated discriminative validity, with a significant increase in CollaboRATE score as the number of core dimensions of SDM increased from zero (mean score: 46.0, 95% CI 42.4-49.6) to 3 (mean score 85.8, 95% CI 83.2-88.4). CollaboRATE also demonstrated concurrent validity with other measures of SDM, excellent intrarater reliability, and sensitivity to change; however, divergent validity was not demonstrated. CONCLUSIONS The fast and frugal nature of CollaboRATE lends itself to routine clinical use. Further assessment of CollaboRATE in real-world settings is required.
Collapse
Affiliation(s)
- Paul James Barr
- The Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, NH, United States
| | | | | | | | | | | |
Collapse
|
34
|
Ozanne EM. Overdiagnosis and Overtreatment of Breast Cancer: How Can We Promote Informed Patient Choice? Curr Breast Cancer Rep 2013. [DOI: 10.1007/s12609-013-0128-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
35
|
Alvarado MD, Conolly J, Park C, Sakata T, Mohan AJ, Harrison BL, Hayes M, Esserman LJ, Ozanne EM. Patient preferences regarding intraoperative versus external beam radiotherapy following breast-conserving surgery. Breast Cancer Res Treat 2013; 143:135-40. [PMID: 24292868 DOI: 10.1007/s10549-013-2782-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 11/18/2013] [Indexed: 01/09/2023]
Abstract
The TARGIT-A Trial is an international randomized, prospective trial comparing intraoperative radiotherapy (IORT) for equivalence to external beam radiotherapy (EBRT) following lumpectomy for invasive breast cancer in selected low-risk patients; early results suggest that outcomes are similar. In addition to effectiveness data and cost considerations, the preferences of patients should help inform practice. This study was undertaken to explore and quantify preference in choosing between IORT and the current standard, EBRT. Eligible subjects were current or past candidates for breast-conserving surgery and radiation being seen at the University of California, San Francisco Breast Care Center. A trade-off technique varying the risk of local recurrence for IORT was used to quantify any additional accepted risk that these patients would accept to receive either treatment. Patients were first presented with a slideshow comparing EBRT with the experimental IORT option before being asked their preferences given hypothetical 10-year local recurrence risks. Patients were then given a questionnaire on demographic, social and clinical factors. Data from 81 patients were analyzed. The median additional accepted risk to have IORT was 2.3 % (-9 to 39 %), mean 3.2 %. Only 7 patients chose to accept additional risk for EBRT; 22 accepted IORT at no additional risk; and the remaining 52 chose IORT with some additional risk. Patients weigh trade-offs of risks and benefits when presented with medical treatment choices. Our results show that the majority of breast cancer patients will accept a small increment of local risk for a simpler delivery of radiation. Further studies that incorporate outcome and side effect data from the TARGIT-A trial clarify the expected consequences of a local recurrence, and include an expanded range of radiation options that could help guide clinical decision making in this area.
Collapse
Affiliation(s)
- Michael D Alvarado
- Department of Surgery, UCSF Comprehensive Cancer Center, University of California, Box 1710, 1600 Divisadero, San Francisco, CA, 94143-1710, USA,
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Affiliation(s)
- Zehra B Omer
- Massachusetts General Hospital-Institute for Technology Assessment, Boston
| | | | | | | | | |
Collapse
|
37
|
Elwyn G, Barr PJ, Grande SW, Thompson R, Walsh T, Ozanne EM. Developing CollaboRATE: a fast and frugal patient-reported measure of shared decision making in clinical encounters. Patient Educ Couns 2013; 93:102-107. [PMID: 23768763 DOI: 10.1016/j.pec.2013.05.009] [Citation(s) in RCA: 231] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 05/08/2013] [Accepted: 05/13/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Measuring the process of shared decision making is a challenge, which constitutes a barrier to research and implementation. The aim of the study was to report the development of CollaboRATE, brief patient-reported measure of shared decision making. METHODS We used the following stages: (1) item formulation; (2) cognitive interviews; (3) item refinement; and (4) pilot testing of final items. Participants were over 18 years old, recruited from the public areas of the Dartmouth-Hitchcock Medical Center. RESULTS The key finding of this study is that developing a brief patient-reported measure of shared decision making requires a move away from terms such as 'decisions', 'options' and 'preferences'. Although technically correct, these terms act as barriers. They are often unfamiliar, and they also implicitly assume that patients are willing to take active roles in decision making; whereas patients are often unaware that decisions are required, or have taken place, never mind feel that they could or should have participated in them. CONCLUSION These methods have allowed us to develop a brief, patient-reported measure of shared decision making that is highly accessible to intended users. PRACTICE IMPLICATIONS The potential strength of the CollaboRATE will be the ability for completion in less than 30s, and across a range of routine settings.
Collapse
Affiliation(s)
- Glyn Elwyn
- The Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, NH 03755, USA.
| | | | | | | | | | | |
Collapse
|
38
|
Alvarado MD, Mohan AJ, Esserman LJ, Park CC, Harrison BL, Howe RJ, Thorsen C, Ozanne EM. Cost-effectiveness analysis of intraoperative radiation therapy for early-stage breast cancer. Ann Surg Oncol 2013; 20:2873-80. [PMID: 23812769 DOI: 10.1245/s10434-013-2997-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Shortened courses of radiation therapy have been shown to be similarly effective to whole-breast external-beam radiation therapy (WB-EBRT) in terms of local control. We sought to analyze, from a societal perspective, the cost-effectiveness of two radiation strategies for early-stage invasive breast cancer: single-dose intraoperative radiation therapy (IORT) and the standard 6-week course of WB-EBRT. METHODS We developed a Markov decision-analytic model to evaluate these treatment strategies in terms of life expectancy, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio over 10 years. RESULTS IORT single-dose intraoperative radiation therapy was the dominant, more cost-effective strategy, providing greater quality-adjusted life years at a decreased cost compared with 6-week WB-EBRT. The model was sensitive to health state utilities and recurrence rates, but not costs. IORT was either the preferred or dominant strategy across all sensitivity analyses. The two-way sensitivity analyses demonstrate the need to accurately determine utility values for the two forms of radiation treatment and to avoid indiscriminate use of IORT. CONCLUSIONS With less cost and greater QALYs than WB-EBRT, IORT is the more valuable strategy. IORT offers a unique example of new technology that is less costly than the current standard of care option but offers similar efficacy. Even when considering the capital investment for the equipment ($425 K, low when compared with the investments required for robotic surgery or high-dose-rate brachytherapy), which could be recouped after 3-4 years conservatively, these results support IORT as a change in practice for treating early-stage invasive breast cancer.
Collapse
Affiliation(s)
- Michael D Alvarado
- Department of Surgery, UCSF Comprehensive Cancer Center, San Francisco, CA, USA.
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Soeteman DI, Stout NK, Ozanne EM, Greenberg C, Hassett MJ, Schrag D, Punglia RS. Modeling the effectiveness of initial management strategies for ductal carcinoma in situ. J Natl Cancer Inst 2013; 105:774-81. [PMID: 23644480 DOI: 10.1093/jnci/djt096] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The prevalence of ductal carcinoma in situ (DCIS) and the marked variability in patterns of care highlight the need for comparative effectiveness research. We sought to quantify the tradeoffs among alternative management strategies for DCIS with respect to disease outcomes and breast preservation. METHODS We developed a disease simulation model integrating data from the published literature to simulate the clinical events after six treatments (lumpectomy alone, lumpectomy with radiation, lumpectomy with radiation and tamoxifen, lumpectomy with tamoxifen, and mastectomy with and without breast reconstruction) for women with newly diagnosed DCIS. Outcomes included disease-free, invasive disease-free, and overall survival and breast preservation. RESULTS For a cohort of 1 million simulated women aged 45 years at diagnosis, both mastectomy and lumpectomy with radiation and tamoxifen were associated with a 12-month improvement in overall survival relative to lumpectomy alone. Adding radiation therapy to lumpectomy resulted in a 6-month improvement in overall survival but decreased long-term breast-preservation outcomes (likelihood of lifetime breast preservation = 0.781 vs 0.843 for lumpectomy alone). This decrement with radiation therapy was mitigated by the addition of tamoxifen (likelihood of lifetime breast preservation = 0.846). CONCLUSIONS Overall survival benefits of the six management strategies for DCIS are within 1 year, suggesting that treatment decisions can be informed by the patient's preference for breast preservation and disutility for recurrence. Our delineation of personalized outcomes for each strategy can help patients understand the implications of their treatment choice, so their decisions may reflect their own personal values and help improve the quality of care for patients with DCIS.
Collapse
Affiliation(s)
- Djøra I Soeteman
- Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA.
| | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
Abstract
Background: Multiple mammography screening strategies exist; however, the resources associated with screening strategies are not well known and are rarely discussed. Many organizations recommend annual mammography for women over the age of 40, while the United States Preventative Services Task Force (USPSTF) and most countries outside the US recommend biennial screening, focusing screening efforts on women over 50 years. Additionally, some suggest risk-based approaches to improve screening. This analysis seeks to estimate the aggregate cost of mammography screening in the US in 2010 and to then further compare the costs of these proposed strategies, specifically comparing annual versus biennial screening.
Methods: We simulated the annual cost of mammography in the US under the following screening strategies: 1) estimate of screening that occurred in 2010 under current policy, 2) annual screening of women older than 40 years, 3) biennial screening of women 50 to 75 years, and 4) biennial screening of women 50 to 75 years and high risk women 40–50 years following USPSTF guidelines. The simulated 2010 screening policy was based on current screening rates ranging from 51% of forty-year-old women to 66% of sixty-five-year-old women. Screening strategies 2–4 simulated screening 85% of women overall, and for the USPSTF policy 20% of women 40–50 years were estimated to be high risk. The simulation was carried out using R statistical software.
Results: Aggregate costs of the four screening strategies were estimated. The total cost of mammography screening in the US in 2010 was estimated to be $7.95 billion. The projected cost under an annual screening policy beginning at 40 years was $10.71 billion. The projected cost of biennial screening from 50–75 years was $5.25 billion compared to $5.33 billion following the USPSTF guidelines. The biennial USPSTF policy cost $5.38 billion less than annual screening. The largest drivers of cost were the percent of women screened, the cost of a mammogram, and the percent of women recalled after mammography.
Conclusions: The costs of mammography vary greatly by strategy and are relevant to screening policy. The basic biennial strategy was the least expensive; however for a slight increase in cost, the USPSTF 2009 guideline strategy screened more age appropriate women for $2.62 billion less than current policy. For less cost, the modeled USPSTF guidelines screened 85% of women compared to current policies that screen less than 65% of women. Biennial screening provides screening to more women, lowers overall false-positive rates, and improves capacity for access to high-quality equipment and well-trained mammographers. As data to support evidenced based strategies increase, resources can be better allocated toward screening a broader, larger population of women that are most likely to benefit from screening. With no evidence for adverse outcomes, a biennial screening policy enables the population of US women to benefit from mammography for less cost.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-02-12.
Collapse
Affiliation(s)
- CM Thorsen
- University of California, San Francisco, CA; Karolinska Institute, Stockholm, Sweden
| | - M Eklund
- University of California, San Francisco, CA; Karolinska Institute, Stockholm, Sweden
| | - EM Ozanne
- University of California, San Francisco, CA; Karolinska Institute, Stockholm, Sweden
| | - LJ Esserman
- University of California, San Francisco, CA; Karolinska Institute, Stockholm, Sweden
| |
Collapse
|
41
|
Alvarado MD, Harrison BL, Solin LJ, Ozanne EM. Abstract P5-15-01: Cost-effectiveness of gene expression profiling for ductal carcinoma in-situ (Oncotype DCIS Score). Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p5-15-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
BACKGROUND: Ductal carcinoma in-situ (DCIS) affects nearly 50,000 women each year. More than 75% of women who receive lumpectomy (BCS) for DCIS undergo whole breast radiation (XRT), which is known to prevent local recurrences. A molecular assay for DCIS has recently been validated, that identifies low-risk biology and may give insight into the need for adjuvant XRT. We sought to determine the cost-effectiveness of the Oncotype DCIS Score™ for risk stratification in newly diagnosed DCIS.
METHODS: We conducted a cost-effectiveness analysis of using this molecular assay (validated in the E5194 study) compared to standard clinical assessment to determine treatment recommendation for XRT. A Markov model was developed in TreeAge Pro 2011 and simulated relevant outcomes over a lifetime horizon for 55-year-old women. For those in the intervention arm who are stratified by the assay, it was assumed that 75% of women (low DCIS score) did not receive XRT and had local risk of recurrence (LRR) of 12%; 25% were intermediate or high risk by the DCIS score (LRR of 26%) and received 6 weeks of XRT with an assumed LRR of 13%. For those in the standard care arm who are stratified by clinical assessment, an assumed 25% did not receive XRT and had LRR of 15.4%; 75% received 6 weeks of XRT with an estimated LRR of 7.7%. Recurrence rates were based on ECOG 5194 and assumed 50% reduction with XRT. Utilities were derived from literature. Direct medical costs were obtained from Medicare fee schedule; indirect costs (time and transportation for XRT) were ascertained.
RESULTS: On average, the intervention (assay) strategy was less costly than the clinical assessment strategy by approximately $1000/patient, with similar life expectancies (17.15 vs 17.11, respectively) and quality-adjusted life-years (QALYs) (16.777 vs 16.789). The incremental cost-effectiveness ratio (ICER) for changing strategy from the assay to clinical assessment was approximately $95,000/QALY, at the upper limit of the societal accepted willingness-to-pay threshold.
CONCLUSIONS: Based on the conservative assumptions that the benefit of XRT is independent of biology and that at least 75% of patients in E5194 would typically be offered XRT, the assay strategy is more cost-effective than standard clinical assessment. Additional research is needed to better understand health state utilities associated with less treatment as it pertains to risk of recurrence. Further validation studies of the assay are needed to accurately assess radiation benefit across all risk groups.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-15-01.
Collapse
Affiliation(s)
- MD Alvarado
- University of California, San Francisco, CA; Albert Einstein Medical Center, Philadelphia, PA
| | - BL Harrison
- University of California, San Francisco, CA; Albert Einstein Medical Center, Philadelphia, PA
| | - LJ Solin
- University of California, San Francisco, CA; Albert Einstein Medical Center, Philadelphia, PA
| | - EM Ozanne
- University of California, San Francisco, CA; Albert Einstein Medical Center, Philadelphia, PA
| |
Collapse
|
42
|
Thorsen CM, Weiss JE, Kerlikowske K, Ozanne EM, Buist DS, Hubbard RA, Tosteson AN, Henderson LM, Virnig BA, Goodrich ME, Onega TL. Abstract P4-01-15: Impact of Preoperative MRI on the Surgical Treatment of Breast Cancer: A SEER-Medicare Analysis. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p4-01-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Preoperative magnetic resonance imaging (MRI) use has increased for women with invasive breast cancer and ductal carcinoma in situ (DCIS). Prior studies have disputed whether preoperative MRI is associated with increased rates of mastectomy. We evaluated the rates of mastectomy versus breast conserving surgery (BCS) and their association with preoperative MRI in older women.
Methods: We identified women in SEER-Medicare 66 years or older diagnosed with DCIS or invasive breast cancer between 2002 and 2007 treated within 6 months of diagnosis with mastectomy or breast conserving surgery (BCS) with or without radiotherapy (RT). Preoperative MRI was defined as MRI occurring before a woman's first surgery after her initial diagnosis. We looked for surgical treatment (BCS or mastectomy) and radiotherapy, age at diagnosis, year of diagnosis and cancer type, overall and separately by receipt of MRI. We examined the association of surgical treatment with MRI using multivariable logistic regression adjusting for age at diagnosis, year of diagnosis, cancer type and radiotherapy.
Results: Among the 70,758 women identified, 5,126 (7.2%) had a preoperative MRI. The overall use of MRI increased from 1.2% in 2002 to 18.0% in 2007 (p < 0.0001). Women with MRI were more likely to undergo mastectomy than those without MRI (331 per 1000 vs. 314 per 1000; respectively, p < 0.0001) and more likely to undergo BCS RT (432 per 1000 vs. 354 per 1000; respectively, p < 0.0001).
Conclusion: The use of preoperative MRI has increased in recent years and is significantly associated with increased rates of BCS RT and mastectomy. Limitations of this study include that it is an observational analysis and that selection bias may exist for MRI and aggressive treatment that is not related to what is observed on MRI. Further studies are needed to understand how patient characteristics and information obtained from MRI influence treatment choices.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-01-15.
Collapse
Affiliation(s)
- CM Thorsen
- University of California, San Francisco, CA; Dartmouth Medical School, Lebanon, NH; University of Washington, Seattle, WA; University of North Carolina, Chapel Hill, NC; University of Minnesota, Minneapolis, MN
| | - JE Weiss
- University of California, San Francisco, CA; Dartmouth Medical School, Lebanon, NH; University of Washington, Seattle, WA; University of North Carolina, Chapel Hill, NC; University of Minnesota, Minneapolis, MN
| | - K Kerlikowske
- University of California, San Francisco, CA; Dartmouth Medical School, Lebanon, NH; University of Washington, Seattle, WA; University of North Carolina, Chapel Hill, NC; University of Minnesota, Minneapolis, MN
| | - EM Ozanne
- University of California, San Francisco, CA; Dartmouth Medical School, Lebanon, NH; University of Washington, Seattle, WA; University of North Carolina, Chapel Hill, NC; University of Minnesota, Minneapolis, MN
| | - DS Buist
- University of California, San Francisco, CA; Dartmouth Medical School, Lebanon, NH; University of Washington, Seattle, WA; University of North Carolina, Chapel Hill, NC; University of Minnesota, Minneapolis, MN
| | - RA Hubbard
- University of California, San Francisco, CA; Dartmouth Medical School, Lebanon, NH; University of Washington, Seattle, WA; University of North Carolina, Chapel Hill, NC; University of Minnesota, Minneapolis, MN
| | - AN Tosteson
- University of California, San Francisco, CA; Dartmouth Medical School, Lebanon, NH; University of Washington, Seattle, WA; University of North Carolina, Chapel Hill, NC; University of Minnesota, Minneapolis, MN
| | - LM Henderson
- University of California, San Francisco, CA; Dartmouth Medical School, Lebanon, NH; University of Washington, Seattle, WA; University of North Carolina, Chapel Hill, NC; University of Minnesota, Minneapolis, MN
| | - BA Virnig
- University of California, San Francisco, CA; Dartmouth Medical School, Lebanon, NH; University of Washington, Seattle, WA; University of North Carolina, Chapel Hill, NC; University of Minnesota, Minneapolis, MN
| | - ME Goodrich
- University of California, San Francisco, CA; Dartmouth Medical School, Lebanon, NH; University of Washington, Seattle, WA; University of North Carolina, Chapel Hill, NC; University of Minnesota, Minneapolis, MN
| | - TL Onega
- University of California, San Francisco, CA; Dartmouth Medical School, Lebanon, NH; University of Washington, Seattle, WA; University of North Carolina, Chapel Hill, NC; University of Minnesota, Minneapolis, MN
| |
Collapse
|
43
|
Howe R, Omer Z, Hanoch Y, Miron-Shatz T, Thorsen C, Ozanne EM. Abstract P4-11-03: Single nucleotide polymorphism testing for breast cancer risk assessment: patient trust and willingness to pay. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p4-11-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The field of breast cancer risk assessment is advancing rapidly with recent discoveries about risk conferring single nucleotide polymorphisms (SNPs). While these discoveries can promote personalized medicine, they are often brought to the market with direct to consumer (DTC) testing before data can support their widespread use and before reliable options for dealing with testing outcomes can be offered. In this context, and knowing that patients often misunderstand risk information, it is unclear how patients will respond to these options.
Methods: We surveyed high risk women's interest in SNP testing. Participants were recruited from the Cancer Genetics Network (CGN), a national network of cancer centers that maintains a database of individuals with a family history of cancer. Participants were asked to answer questions regarding their interest in SNP testing including: whether they trust it, how much they would be willing to pay for testing, how they prefer to be tested, and how they would proceed with information identifying them as below or above average risk.
Results: 189 women without a history of breast cancer or SNP testing completed the questionnaire. The average age of the participants was 49, ranging from 30 to 65. All participants had at least one relative with breast or ovarian cancer. 13% had previously tested positive for a BRCA mutation, and 33% had received BRCA testing. Most women (90%) did not know what SNP testing was prior to the survey. Once SNP testing was described, 68% of women were interested in DTC SNP testing; at the same time, only 38% of the participants reported that they trusted DTC SNP testing.
Conclusion: While our results show that women are interested in DTC SNP testing, their willingness to pay is lower than the DTC cost (∼$300). Involvement of genetic counselors and providers in SNP testing discussions may be needed to overcome the current lack of trust of DTC testing among patients. Many women showed interest in lifestyle interventions, suggesting that these interventions should be incorporated as part of standard follow-up recommendations. When identified by SNP testing as “below average” risk, women do not seem to trust the results enough to forego regular mammograms. As DTC testing becomes more common, and as more SNP tests become available, it will be necessary for the medical community to address patients' interest in these tests and to assist in interpreting results.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-11-03.
Collapse
Affiliation(s)
- R Howe
- Universiy of California San Francisco, CA; Massachusetts General Hospital, Boston, MA; Plymouth University, United Kingdom; Ono Academic College, Israel
| | - Z Omer
- Universiy of California San Francisco, CA; Massachusetts General Hospital, Boston, MA; Plymouth University, United Kingdom; Ono Academic College, Israel
| | - Y Hanoch
- Universiy of California San Francisco, CA; Massachusetts General Hospital, Boston, MA; Plymouth University, United Kingdom; Ono Academic College, Israel
| | - T Miron-Shatz
- Universiy of California San Francisco, CA; Massachusetts General Hospital, Boston, MA; Plymouth University, United Kingdom; Ono Academic College, Israel
| | - C Thorsen
- Universiy of California San Francisco, CA; Massachusetts General Hospital, Boston, MA; Plymouth University, United Kingdom; Ono Academic College, Israel
| | - EM Ozanne
- Universiy of California San Francisco, CA; Massachusetts General Hospital, Boston, MA; Plymouth University, United Kingdom; Ono Academic College, Israel
| |
Collapse
|
44
|
Ozanne EM, Crawford B, Petruse A, Madlensky L, Weiss L, Hogarth M, Wenger N, Goodman D, Park H, Anton-Culver H, Yasmeen S, Howell L, Ojeda H, Parker BA, Kaplan C, van't VL, Esserman L, Naeim A. Abstract P4-13-13: Risk Assessment and Personalized Decision Support: The University of California Athena Breast Health Network. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p4-13-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The Athena Breast Health Network is a University of California (UC) initiative to drive rapid innovation in patient-centered prevention, screening, and treatment of breast cancer. Athena is a collaborative of the five UC medical centers and UC Berkeley that integrates clinical care and research, rapidly mobilizing data and research to enable continuous improvement in patient care and outcomes. The first initiative of Athena was to implement risk assessment for women being screened for breast cancer and to offer tailored referrals for women found to be at increased risk of developing breast cancer.
Methods: Patients who enroll in Athena complete an electronic questionnaire to collect personal and family history data prior to their mammography screening visit. These data are used to generate multiple risk assessments using the NCCN and USPSTF guidelines, and BCRAT (Gail model). Data on established breast cancer risk factors such as chest wall radiation and history of hormone replacement therapy are also collected and used to identify women at potentially increased risk. Upon enrollment, women are given the opportunity to provide a blood or saliva sample for research purposes.
Women who meet Athena-defined criteria that identify them to be at increased risk receive a referral to a Breast Health Specialist (BHS). The BHS identifies individual patient needs for prevention and screening services, including genetic counseling and testing, provides referrals to a High Risk Breast Clinic or nurse practitioner, and conducts lifestyle modification counseling. BHS have special training in breast cancer risk assessment, and some are licensed genetic counselors. Primary care and/or referring providers are directly informed of risk assessment results through mailings or the electronic medical record.
Results: The recruitment goal enrollment for Athena is 150,000 and to date more than 17,000 women have been enrolled across the five centers. Of those enrolled, 32% indicated that they have a family history of cancer. 56% of the cohort consented to participate in research, and 40% provided a biospecimen for research purposes. Across the five centers, 32 educational outreach sessions about Athena were held, reaching approximately 375 providers.
Conclusion: Successful implementation of the Athena risk assessment and decision support process will enable the identification of high risk women who are most likely to benefit from tailored screening or risk reducing interventions and who otherwise may not have been referred for risk reducing measures. By identifying women at the highest risk and connecting them to screening and prevention resources, the Athena Breast Health Network aims to ultimately reduce the incidence of breast cancer in its participant cohort.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-13-13.
Collapse
Affiliation(s)
- EM Ozanne
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - B Crawford
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - A Petruse
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - L Madlensky
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - L Weiss
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - M Hogarth
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - N Wenger
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - D Goodman
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - H Park
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - H Anton-Culver
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - S Yasmeen
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - L Howell
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - H Ojeda
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - BA Parker
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - C Kaplan
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - Veer L van't
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - L Esserman
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| | - A Naeim
- University of California, San Francisco, CA; University of California, Los Angeles, CA; University of California, San Diego, CA; Athena Program Management Office, San Francisco, CA; University of California, Davis, CA; University of California, Irvine, CA
| |
Collapse
|
45
|
Ozanne EM, Drohan B, Bosinoff P, Semine A, Jellinek M, Cronin C, Millham F, Dowd D, Rourke T, Block C, Hughes KS. Which Risk Model to Use? Clinical Implications of the ACS MRI Screening Guidelines. Cancer Epidemiol Biomarkers Prev 2012; 22:146-9. [DOI: 10.1158/1055-9965.epi-12-0570] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
46
|
Thorsen CM, Kaplan CP, Brasic N, Esserman LJ, Luce JA, Howe R, Veer LJV', Bravo C, Wheelock A, Ozanne EM. Abstract B81: Can “mHealth” improve risk assessment? A usability study of older, low-income women answering the Athena Breast Health Questionnaire app. Cancer Epidemiol Biomarkers Prev 2012. [DOI: 10.1158/1055-9965.disp12-b81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Introduction: Mobile health (mHealth) tools may offer an opportunity for breast cancer screening and prevention especially among minority populations who are known to access the internet at higher rates with mobile devices. However, the use of mHealth applications (apps) has not been well studied in older, low-income, minority populations. This study sought to determine the usability of an mHealth Breast Health Risk Assessment Questionnaire app for older, low-income women.
Methods: We performed fifteen semi-structured interviews of women with diverse backgrounds who used the Athena Breast Health Questionnaire iPad app, which was available in Spanish and English. The app was developed by the Athena Breast Health Network, a breast cancer screening collaboration of the five University of California medical centers. Women were recruited during their screening mammography visit at the San Francisco General Hospital Avon Mammography Center.
Results: Fifteen women were interviewed; five Hispanic, five non-Hispanic white, three African American and two Filipina women. Four women were Spanish speaking only. The median age of women was 61 (range, 45-79). The women's level of education ranged from third grade to graduate school. Fourteen women owned a mobile phone, three owned a smart phone, and three had previously used an iPad. The average time to complete the questionnaire for all women was 16.4 minutes (range, 6.6-35 minutes). The subgroup of Spanish speaking women took longer, averaging 24.5 minutes. The majority of women needed initial instruction regarding scrolling and free text entry.
All fifteen women interviewed thought the Athena Breast Health Questionnaire app was easy or very easy to use. Eleven women preferred answering the iPad questionnaire compared to the pen-and-paper form previously completed for their mammogram. Two women preferred pen-and-paper, both Spanish speaking; and two women had no preference, including one who started using a mobile phone within the past month and another woman who did not own one. Three of the four women who did not prefer the app had lower than a tenth grade education. All four that did not prefer the app were concerned that a clinic would not be able to offer the initial instruction needed or to provide assistance for questions though they thought the app was easy to use.
Conclusion: Older, low-income, minority women easily used a mHealth app to answer a breast health risk assessment questionnaire. Particular formats of questions, such as the use of scrolling, were initially difficult but participants easily overcame such difficulties and learned the skills of using a touchscreen. Spanish speaking women had a lower preference for the app, but this finding may be confounded with education level. Further evaluation of the validity of women's responses using the app in a clinical setting is needed.
Citation Format: Cristina M. Thorsen, Celia P. Kaplan, Natasha Brasic, Laura J. Esserman, Judith A. Luce, Rebecca Howe, Laura J. van 't Veer, Carolina Bravo, Alyse Wheelock, Elissa M. Ozanne, . Athena Breast Health Network Investigators. Can “mHealth” improve risk assessment? A usability study of older, low-income women answering the Athena Breast Health Questionnaire app. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr B81.
Collapse
|
47
|
Lowry KP, Lee JM, Kong CY, McMahon PM, Gilmore ME, Cott Chubiz JE, Pisano ED, Gatsonis C, Ryan PD, Ozanne EM, Gazelle GS. Annual screening strategies in BRCA1 and BRCA2 gene mutation carriers: a comparative effectiveness analysis. Cancer 2012; 118:2021-30. [PMID: 21935911 PMCID: PMC3245774 DOI: 10.1002/cncr.26424] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 06/10/2011] [Accepted: 06/20/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although breast cancer screening with mammography and magnetic resonance imaging (MRI) is recommended for breast cancer-susceptibility gene (BRCA) mutation carriers, there is no current consensus on the optimal screening regimen. METHODS The authors used a computer simulation model to compare 6 annual screening strategies (film mammography [FM], digital mammography [DM], FM and magnetic resonance imaging [MRI] or DM and MRI contemporaneously, and alternating FM/MRI or DM/MRI at 6-month intervals) beginning at ages 25 years, 30 years, 35 years, and 40 years, and 2 strategies of annual MRI with delayed alternating DM/FM versus clinical surveillance alone. Strategies were evaluated without and with mammography-induced breast cancer risk using 2 models of excess relative risk. Input parameters were obtained from the medical literature, publicly available databases, and calibration. RESULTS Without radiation risk effects, alternating DM/MRI starting at age 25 years provided the highest life expectancy (BRCA1, 72.52 years, BRCA2, 77.63 years). When radiation risk was included, a small proportion of diagnosed cancers was attributable to radiation exposure (BRCA1, <2%; BRCA2, <4%). With radiation risk, alternating DM/MRI at age 25 years or annual MRI at age 25 years/delayed alternating DM at age 30 years was the most effective, depending on the radiation risk model used. Alternating DM/MRI starting at age 25 years also produced the highest number of false-positive screens per woman (BRCA1, 4.5 BRCA2, 8.1). CONCLUSIONS Annual MRI at age 25 years/delayed alternating DM at age 30 years is probably the most effective screening strategy in BRCA mutation carriers. Screening benefits, associated risks, and personal acceptance of false-positive results should be considered in choosing the optimal screening strategy for individual women.
Collapse
Affiliation(s)
- Kathryn P. Lowry
- Massachusetts General Hospital, Institute for Technology Assessment, Boston, MA
- Harvard Medical School, Boston, MA
| | - Janie M. Lee
- Massachusetts General Hospital, Institute for Technology Assessment, Boston, MA
- Harvard Medical School, Boston, MA
| | - Chung Y. Kong
- Massachusetts General Hospital, Institute for Technology Assessment, Boston, MA
- Harvard Medical School, Boston, MA
| | - Pamela M. McMahon
- Massachusetts General Hospital, Institute for Technology Assessment, Boston, MA
- Harvard Medical School, Boston, MA
| | - Michael E. Gilmore
- Massachusetts General Hospital, Institute for Technology Assessment, Boston, MA
| | | | - Etta D. Pisano
- Medical University of South Carolina College of Medicine, Charleston, SC
| | | | | | - Elissa M. Ozanne
- Massachusetts General Hospital, Institute for Technology Assessment, Boston, MA
- Harvard Medical School, Boston, MA
| | - G. Scott Gazelle
- Massachusetts General Hospital, Institute for Technology Assessment, Boston, MA
- Harvard Medical School, Boston, MA
- Harvard School of Public Health, Boston, MA
| |
Collapse
|
48
|
Ozanne EM, O'Connell A, Bouzan C, Bosinoff P, Rourke T, Dowd D, Drohan B, Millham F, Griffin P, Halpern EF, Semine A, Hughes KS. Bias in the reporting of family history: implications for clinical care. J Genet Couns 2012; 21:547-56. [PMID: 22237666 DOI: 10.1007/s10897-011-9470-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 12/08/2011] [Indexed: 12/22/2022]
Abstract
Family history of cancer is critical for identifying and managing patients at risk for cancer. However, the quality of family history data is dependent on the accuracy of patient self reporting. Therefore, the validity of family history reporting is crucial to the quality of clinical care. A retrospective review of family history data collected at a community hospital between 2005 and 2009 was performed in 43,257 women presenting for screening mammography. Reported numbers of breast, colon, prostate, lung, and ovarian cancer were compared in maternal relatives vs. paternal relatives and in first vs. second degree relatives. Significant reporting differences were found between maternal and paternal family history of cancer, in addition to degree of relative. The number of paternal family histories of cancer was significantly lower than that of maternal family histories of cancer. Similarly, the percentage of grandparents' family histories of cancer was significantly lower than the percentage of parents' family histories of cancer. This trend was found in all cancers except prostate cancer. Self-reported family history in the community setting is often influenced by both bloodline of the cancer history and the degree of relative affected. This is evident by the underreporting of paternal family histories of cancer, and also, though to a lesser extent, by degree. These discrepancies in reporting family history of cancer imply we need to take more care in collecting accurate family histories and also in the clinical management of individuals in relation to hereditary risk.
Collapse
Affiliation(s)
- Elissa M Ozanne
- Institute for Health Policy Studies, Department of Surgery, University of California, San Francisco, CA, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Campbell S, Stowe K, Ozanne EM. Interprofessional practice and decision support: An organizational framework applied to a mental health setting. J Interprof Care 2011; 25:423-7. [DOI: 10.3109/13561820.2011.621768] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
50
|
Ozanne EM, Shieh Y, Barnes J, Bouzan C, Hwang ES, Esserman LJ. Characterizing the impact of 25 years of DCIS treatment. Breast Cancer Res Treat 2011; 129:165-73. [PMID: 21390494 DOI: 10.1007/s10549-011-1430-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 02/26/2011] [Indexed: 11/29/2022]
Abstract
The significant increase in the detection and treatment of ductal carcinoma in situ (DCIS) since the introduction of screening mammography has not been accompanied by the anticipated reduction in invasive breast cancer (IBC) incidence. The prevalence of DCIS requires a reexamination of the population level effects of detecting and treating DCIS. To further our understanding of the possible impact of DCIS diagnosis and treatment on IBC incidence in the U.S., we simulated breast cancer incidence over 25 years under various assumptions regarding the baseline incidence of IBC and the progression of DCIS to IBC. The simulations demonstrate a tradeoff between the expected increased incidence of IBC absent any DCIS detection and treatment and the rate of progression of DCIS to IBC. Our analyses indicate that a high progression of DCIS to IBC implies a significant increase in incidence of IBC over what is observed had we not detected and treated DCIS. Conversely, if we assume that there would not have been a significant increase over and above the observed incidence evident in SEER, then our model indicates that the rate of DCIS progression to clinically significant IBC is low. Given the tradeoff illustrated by our model, we must reevaluate the assumption that DCIS is a short-term obligate precursor of invasive cancer and instead focus on further exploration of the true natural history of DCIS.
Collapse
Affiliation(s)
- Elissa M Ozanne
- Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | | | | | | | | | | |
Collapse
|