Implementation and sustainability factors of two early-stage breast cancer conversation aids in diverse practices

Abstract

Background Conversation aids can facilitate shared decision-making and improve patient-centered outcomes. However, few examples exist of sustained use of conversation aids in routine care due to numerous barriers at clinical and organizational levels. We explored factors that will promote the sustained use of two early-stage breast cancer conversation aids. We examined differences in opinions between the two conversation aids and across socioeconomic strata. Methods We nested this study within a randomized controlled trial that demonstrated the effectiveness of two early-stage breast cancer surgery conversation aids, one text-based and one picture-based. These conversation aids facilitated more shared decision-making and improved the decision process, among other outcomes, across four health systems with socioeconomically diverse patient populations. We conducted semi-structured interviews with a purposive sample of patient participants across conversation aid assignment and socioeconomic status (SES) and collected observations and field notes. We interviewed trial surgeons and other stakeholders. Two independent coders conducted framework analysis using the NOrmalization MeAsure Development through Normalization Process Theory. We also conducted an inductive analysis. We conducted additional sub-analyses based on conversation aid assignment and patient SES. Results We conducted 73 semi-structured interviews with 43 patients, 16 surgeons, and 14 stakeholders like nurses, cancer center directors, and electronic health record (EHR) experts. Patients and surgeons felt the conversation aids should be used in breast cancer care in the future and were open to various methods of giving and receiving the conversation aid (EHR, email, patient portal, before consultation). Patients of higher SES were more likely to note the conversation aids influenced their treatment discussion, while patients of lower SES noted more influence on their decision-making. Intervention surgeons reported using the conversation aids did not lengthen their typical consultation time. Most intervention surgeons felt using the conversation aids enhanced their usual care after using it a few times, and most patients felt it appeared part of their normal routine. Conclusions Key factors that will guide the future sustained implementation of the conversation aids include adapting to existing clinical workflows, flexibility of use, patient characteristics, and communication preferences. Trial registration ClinicalTrials.gov Identifier: NCT03136367, registered on May 2, 2017

Supporting translation of research evidence into practice—the use of Normalisation Process Theory to assess and inform implementation within randomised controlled trials: a systematic review

“…Schnabel et al [ 104 ] UK Qualitative Stroke services Augmented arm rehabilitation, supported self-management after stroke Prospective 33. Schubbe et al [ 105 ] USA Qualitative Surgery Conversation aids for shared decision-making for breast cancer Prospective 34. Sharpe et al [ 106 ] Canada Qualitative Primary care Paediatric asthma Retrospective 35.…”

“…The operationalisation of NPT within the included studies is best categorised as either prospective, in which the initial utilisation of NPT occurs prior to or during the RCT, or retrospective, in which NPT is applied to data that had been previously collected during the RCT after its completion (Table 2 ). The majority of studies, 81% ( n = 34) [ 36 , 68 – 77 , 80 – 91 , 94 , 95 , 97 – 102 , 104 , 105 , 107 , 109 – 114 ], applied NPT prospectively. In exploring the relationship between retrospective or prospective use of NPT and the methodology used in the included studies, out of the 11 studies which used mixed-methods, six [ 69 , 88 – 91 , 98 , 101 , 113 ] applied NPT only to the qualitative aspects of the study and five [ 73 , 81 – 84 , 93 , 102 , 107 ] applied NPT both qualitatively and quantitatively, of which three studies [ 73 , 93 , 107 ] utilised the NoMAD tool.…”

Clinician-Spoken Plain Language in Health Care Encounters: A Qualitative Analysis to Assess Measurable Elements

“…Other people in the transcript were not included in the analysis, such as family members, friends, patient advocates, or resident clinicians, as we were focused on the 2 people who had agreed to be included in the analysis. We have reported collection and calculation methods for patient and surgeon demographic data elsewhere 31,34 …”

“…We have reported collection and calculation methods for patient and surgeon demographic data elsewhere. 31,34 Data analysis Analysis framework. We conducted a dual independent, hybrid (deductive with inductive elements), 35 framework qualitative analysis using ATLAS.ti Mac software, version 8.4.13 to version 9.0.15 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany).…”

Improving shared decision making in virtual breast cancer surgery consultations

“…When discussing surgical options , surgeons often use drawings and graphical aids, which have been shown to improve patient knowledge and decision satisfaction. 23 , 24 , 25 , 26 , 27 , 28 , 29 These documents faciliate presentation of options and enumerate the risks and benefits of the choices, specific to an individual patient. We have observed that some surgeons offer their graphical aids for patients to take home for further review and reference.…”