Implementation and Sustainability Factors of Two Early-Stage Breast Cancer Conversation Aids in Diverse Practices

Abstract

BackgroundConversation aids can facilitate shared decision making and improve patient-centered outcomes. However, there are few examples of sustained use of conversation aids in routine care due to numerous barriers at clinical and organizational levels. We explored strategies that will promote the sustained use of two early-stage breast cancer conversation aids. We examined any differences in experiences and opinions between the two conversation aids and across socioeconomic strata. MethodsWe nested this study within a randomized controlled trial evaluating two early-stage breast cancer surgery treatment conversation aids, one text-based and one picture-based, across four health systems with socioeconomically diverse patient populations. We conducted semi-structured interviews with a sample of patient participants, purposively sampled across conversation aid assignment and socioeconomic status (SES), and collected observations and field-notes. We also interviewed trial surgeons and other stakeholders. We conducted a framework analysis of all interviews, notes, and observations with two independent coders using the NOrmalization MeAsure Development through Normalization Process Theory. We also conducted an inductive analysis. We conducted additional sub-analyses based on which conversation aid was used/received and patient SES. ResultsWe 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 was similar to their usual care after using it a few times, and most patients felt it appeared part of their normal routine. ConclusionsKey factors that will help guide the future sustained implementation of the conversation aids include adapting to existing clinical workflows, flexibility of use, patient characteristics and communication preferences.Trial registrationNCT03136367 at ClinicalTrials.gov