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Riganti P, Ruiz Yanzi MV, Escobar Liquitay CM, Sgarbossa NJ, Alarcon-Ruiz CA, Kopitowski KS, Franco JV. Shared decision-making for supporting women's decisions about breast cancer screening. Cochrane Database Syst Rev 2024; 5:CD013822. [PMID: 38726892 PMCID: PMC11082933 DOI: 10.1002/14651858.cd013822.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
BACKGROUND In breast cancer screening programmes, women may have discussions with a healthcare provider to help them decide whether or not they wish to join the breast cancer screening programme. This process is called shared decision-making (SDM) and involves discussions and decisions based on the evidence and the person's values and preferences. SDM is becoming a recommended approach in clinical guidelines, extending beyond decision aids. However, the overall effect of SDM in women deciding to participate in breast cancer screening remains uncertain. OBJECTIVES To assess the effect of SDM on women's satisfaction, confidence, and knowledge when deciding whether to participate in breast cancer screening. SEARCH METHODS We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 August 2023. We also screened abstracts from two relevant conferences from 2020 to 2023. SELECTION CRITERIA We included parallel randomised controlled trials (RCTs) and cluster-RCTs assessing interventions targeting various components of SDM. The focus was on supporting women aged 40 to 75 at average or above-average risk of breast cancer in their decision to participate in breast cancer screening. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and conducted data extraction, risk of bias assessment, and GRADE assessment of the certainty of the evidence. Review outcomes included satisfaction with the decision-making process, confidence in the decision made, knowledge of all options, adherence to the chosen option, women's involvement in SDM, woman-clinician communication, and mental health. MAIN RESULTS We identified 19 studies with 64,215 randomised women, mostly with an average to moderate risk of breast cancer. Two studies covered all aspects of SDM; six examined shortened forms of SDM involving communication on risks and personal values; and 11 focused on enhanced communication of risk without other SDM aspects. SDM involving all components compared to control The two eligible studies did not assess satisfaction with the SDM process or confidence in the decision. Based on a single study, SDM showed uncertain effects on participant knowledge regarding the age to start screening (risk ratio (RR) 1.18, 95% confidence interval (CI) 0.61 to 2.28; 133 women; very low certainty evidence) and frequency of testing (RR 0.84, 95% CI 0.68 to 1.04; 133 women; very low certainty evidence). Other review outcomes were not measured. Abbreviated forms of SDM with clarification of values and preferences compared to control Of the six included studies, none evaluated satisfaction with the SDM process. These interventions may reduce conflict in the decision made, based on two measures, Decisional Conflict Scale scores (mean difference (MD) -1.60, 95% CI -4.21 to 0.87; conflict scale from 0 to 100; 4 studies; 1714 women; very low certainty evidence) and the proportion of women with residual conflict compared to control at one to three months' follow-up (rate of women with a conflicted decision, RR 0.75, 95% CI 0.56 to 0.99; 1 study; 1001 women, very low certainty evidence). Knowledge of all options was assessed through knowledge scores and informed choice. The effect of SDM may enhance knowledge (MDs ranged from 0.47 to 1.44 higher scores on a scale from 0 to 10; 5 studies; 2114 women; low certainty evidence) and may lead to higher rates of informed choice (RR 1.24, 95% CI 0.95 to 1.63; 4 studies; 2449 women; low certainty evidence) compared to control at one to three months' follow-up. These interventions may result in little to no difference in anxiety (MD 0.54, 95% -0.96 to 2.14; scale from 20 to 80; 2 studies; 749 women; low certainty evidence) and the number of women with worries about cancer compared to control at four to six weeks' follow-up (RR 0.88, 95% CI 0.73 to 1.06; 1 study, 639 women; low certainty evidence). Other review outcomes were not measured. Enhanced communication about risks without other SDM aspects compared to control Of 11 studies, three did not report relevant outcomes for this review, and none assessed satisfaction with the SDM process. Confidence in the decision made was measured by decisional conflict and anticipated regret of participating in screening or not. These interventions, without addressing values and preferences, may result in lower confidence in the decision compared to regular communication strategies at two weeks' follow-up (MD 2.89, 95% CI -2.35 to 8.14; Decisional Conflict Scale from 0 to 100; 2 studies; 1191 women; low certainty evidence). They may result in higher anticipated regret if participating in screening (MD 0.28, 95% CI 0.15 to 0.41) and lower anticipated regret if not participating in screening (MD -0.28, 95% CI -0.42 to -0.14). These interventions increase knowledge (MD 1.14, 95% CI 0.61 to 1.62; scale from 0 to 10; 4 studies; 2510 women; high certainty evidence), while it is unclear if there is a higher rate of informed choice compared to regular communication strategies at two to four weeks' follow-up (RR 1.27, 95% CI 0.83 to 1.92; 2 studies; 1805 women; low certainty evidence). These interventions result in little to no difference in anxiety (MD 0.33, 95% CI -1.55 to 0.99; scale from 20 to 80) and depression (MD 0.02, 95% CI -0.41 to 0.45; scale from 0 to 21; 2 studies; 1193 women; high certainty evidence) and lower cancer worry compared to control (MD -0.17, 95% CI -0.26 to -0.08; scale from 1 to 4; 1 study; 838 women; high certainty evidence). Other review outcomes were not measured. AUTHORS' CONCLUSIONS Studies using abbreviated forms of SDM and other forms of enhanced communications indicated improvements in knowledge and reduced decisional conflict. However, uncertainty remains about the effect of SDM on supporting women's decisions. Most studies did not evaluate outcomes considered important for this review topic, and those that did measured different concepts. High-quality randomised trials are needed to evaluate SDM in diverse cultural settings with a focus on outcomes such as women's satisfaction with choices aligned to their values.
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Affiliation(s)
- Paula Riganti
- Family and Community Medicine Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M Victoria Ruiz Yanzi
- Family and Community Medicine Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Nadia J Sgarbossa
- Health Department, Universidad Nacional de La Matanza, Buenos Aires, Argentina
| | - Christoper A Alarcon-Ruiz
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Karin S Kopitowski
- Family and Community Medicine Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Va Franco
- Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Conley CC, Wernli KJ, Knerr S, Li T, Leppig K, Ehrlich K, Farrell D, Gao H, Bowles EJA, Graham AL, Luta G, Jayasekera J, Mandelblatt JS, Schwartz MD, O'Neill SC. Using Protection Motivation Theory to Predict Intentions for Breast Cancer Risk Management: Intervention Mechanisms from a Randomized Controlled Trial. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2023; 38:292-300. [PMID: 34813048 PMCID: PMC9124715 DOI: 10.1007/s13187-021-02114-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 06/13/2023]
Abstract
The purpose of this study is to evaluate the direct and indirect effects of a web-based, Protection Motivation Theory (PMT)-informed breast cancer education and decision support tool on intentions for risk-reducing medication and breast MRI among high-risk women. Women with ≥ 1.67% 5-year breast cancer risk (N = 995) were randomized to (1) control or (2) the PMT-informed intervention. Six weeks post-intervention, 924 (93% retention) self-reported PMT constructs and behavioral intentions. Bootstrapped mediations evaluated the direct effect of the intervention on behavioral intentions and the mediating role of PMT constructs. There was no direct intervention effect on intentions for risk-reducing medication or MRI (p's ≥ 0.12). There were significant indirect effects on risk-reducing medication intentions via perceived risk, self-efficacy, and response efficacy, and on MRI intentions via perceived risk and response efficacy (p's ≤ 0.04). The PMT-informed intervention effected behavioral intentions via perceived breast cancer risk, self-efficacy, and response efficacy. Future research should extend these findings from intentions to behavior. ClinicalTrials.gov Identifier: NCT03029286 (date of registration: January 24, 2017).
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Affiliation(s)
- Claire C Conley
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 2115 Wisconsin Avenue NW, Suite 300, Washington, DC, 20007, USA
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Sarah Knerr
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Tengfei Li
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, USA
| | | | - Kelly Ehrlich
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Erin J A Bowles
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Amanda L Graham
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 2115 Wisconsin Avenue NW, Suite 300, Washington, DC, 20007, USA
- Truth Initiative, Washington, DC, USA
| | - George Luta
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, USA
| | - Jinani Jayasekera
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 2115 Wisconsin Avenue NW, Suite 300, Washington, DC, 20007, USA
| | - Jeanne S Mandelblatt
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 2115 Wisconsin Avenue NW, Suite 300, Washington, DC, 20007, USA
| | - Marc D Schwartz
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 2115 Wisconsin Avenue NW, Suite 300, Washington, DC, 20007, USA
| | - Suzanne C O'Neill
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 2115 Wisconsin Avenue NW, Suite 300, Washington, DC, 20007, USA.
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Jull J, Köpke S, Smith M, Carley M, Finderup J, Rahn AC, Boland L, Dunn S, Dwyer AA, Kasper J, Kienlin SM, Légaré F, Lewis KB, Lyddiatt A, Rutherford C, Zhao J, Rader T, Graham ID, Stacey D. Decision coaching for people making healthcare decisions. Cochrane Database Syst Rev 2021; 11:CD013385. [PMID: 34749427 PMCID: PMC8575556 DOI: 10.1002/14651858.cd013385.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching. OBJECTIVES To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects. SEARCH METHODS We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions. DATA COLLECTION AND ANALYSIS Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence. MAIN RESULTS Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms. For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low. AUTHORS' CONCLUSIONS Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.
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Affiliation(s)
- Janet Jull
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Sascha Köpke
- Institute of Nursing Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Meg Carley
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Research Centre for Patient Involvement, Aarhus University & the Central Denmark Region, Aarhus, Denmark
| | - Anne C Rahn
- Institute of Social Medicine and Epidemiology, Nursing Research Unit, University of Lubeck, Lubeck, Germany
| | - Laura Boland
- Integrated Knowledge Translation Research Network, The Ottawa Hospital Research Institute, Ottawa, Canada
- Western University, London, Canada
| | - Sandra Dunn
- BORN Ontario, CHEO Research Institute, School of Nursing, University of Ottawa, Ottawa, Canada
| | - Andrew A Dwyer
- William F. Connell School of Nursing, Boston University, Chestnut Hill, Massachusetts, USA
- Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jürgen Kasper
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Simone Maria Kienlin
- Faculty of Health Sciences, Department of Health and Caring Sciences, University of Tromsø, Tromsø, Norway
- The South-Eastern Norway Regional Health Authority, Department of Medicine and Healthcare, Hamar, Norway
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Canada
| | - Krystina B Lewis
- School of Nursing, University of Ottawa, Ottawa, Canada
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Canada
| | | | - Claudia Rutherford
- School of Psychology, Quality of Life Office, University of Sydney, Camperdown, Australia
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Junqiang Zhao
- School of Nursing, University of Ottawa, Ottawa, Canada
| | - Tamara Rader
- Canadian Agency for Drugs and Technologies in Health (CADTH), Ottawa, Canada
| | - Ian D Graham
- Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
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Bowles EJA, O'Neill SC, Li T, Knerr S, Mandelblatt JS, Schwartz MD, Jayasekera J, Leppig K, Ehrlich K, Farrell D, Gao H, Graham AL, Luta G, Wernli KJ. Effect of a Randomized Trial of a Web-Based Intervention on Patient-Provider Communication About Breast Density. J Womens Health (Larchmt) 2021; 30:1529-1537. [PMID: 34582721 PMCID: PMC8823670 DOI: 10.1089/jwh.2021.0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Breast density increases breast cancer risk and decreases mammographic detection. We evaluated a personalized web-based intervention designed to improve breast cancer risk communication between women and their providers. Materials and Methods: This was a secondary outcome analysis of an online randomized trial. Women aged 40-69 years were randomized, February 2017-May 2018, to a control (n = 503) versus intervention website (n = 492). The intervention website included information about breast density, personalized breast cancer risk, chemoprevention, and magnetic resonance imaging. Participants self-reported communication about density with providers (yes/no) at 6 weeks and 12 months. We used logistic regression with generalized estimating equations to evaluate the association of study arm with density communication. In secondary analyses, we tested if the intervention was associated with indicators of patient activation (breast cancer worry, perceived risk, or health care use). Results: Women (mean age 62 years) in the intervention versus control arm were 2.39 times (95% confidence interval [CI] = 1.37-4.18) more likely to report density communication at 6 weeks; this effect persisted at 12 months (odds ratio [OR] = 1.71, 95% CI = 1.25-2.35). At 6 weeks, this effect was only significant among women who reported (OR = 3.23, 95% CI = 1.24-8.40) versus did not report any previous density discussions (OR = 1.64, 95% CI = 0.83-3.26). A quarter of women in each arm never had a density conversation at any time during the study. Conclusions: Despite providing personalized density and risk information, the intervention did not promote density discussions between women and their providers who had not had them previously. This intervention is unlikely to be used clinically to motivate density conversations in women who have not had them before. Clinical trial registration number NCT03029286.
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Affiliation(s)
- Erin J. Aiello Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA.,Address correspondence to: Erin J. Aiello Bowles, MPH, Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101, USA
| | - Suzanne C. O'Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Tengfei Li
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, District of Columbia, USA
| | - Sarah Knerr
- Department of Health Services, University of Washington, Seattle, Washington, USA
| | - Jeanne S. Mandelblatt
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Marc D. Schwartz
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Jinani Jayasekera
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Kathleen Leppig
- Clinical Genetics, Washington Permanente Medical Group, Seattle, Washington, USA
| | - Kelly Ehrlich
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | | | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Amanda L. Graham
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA.,Truth Initiative, Washington, District of Columbia, USA
| | - George Luta
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, District of Columbia, USA
| | - Karen J. Wernli
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
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Hamel LM, Dougherty DW, Hastert TA, Seymour EK, Kim S, Assad H, Phalore J, Soulliere R, Eggly S. The DISCO App: A pilot test of a multi-level intervention to reduce the financial burden of cancer through improved cost communication ☆. PEC INNOVATION 2021; 1:100002. [PMCID: PMC10194252 DOI: 10.1016/j.pecinn.2021.100002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 05/30/2023]
Abstract
Objective Financial toxicity affects 30–50% of people with cancer in the US. Although experts recommend patients and physicians discuss treatment cost, cost discussions occur infrequently. We pilot-tested the feasibility, acceptability and influence on outcomes of the DIScussions of COst (DISCO) App, a multi-level communication intervention designed to improve cost discussions and related outcomes. Methods While waiting to see their physician, patients (n = 32) used the DISCO App on a tablet. Physicians were given a cost discussion tip sheet. Clinic visits were video recorded and patients completed pre- and post-intervention measures of self-efficacy for managing costs, self-efficacy for interacting with physicians, cost-related distress, and perceptions of the DISCO App. Coders observed the recordings to determine the presence of cost discussions, initiators, and topics. Results Most patients reported needing ≤15 min to use the DISCO App, and that it made it easier to ask cost-related questions. Findings showed increased self-efficacy for managing treatment costs (p = .02) and for interacting with physicians (p = .001). All visits included a cost discussion. Conclusions Prompting patients to discuss costs may improve cost treatment discussions and related outcomes. Innovation An app-based and tailorable treatment-cost communication intervention is feasible, acceptable, and demonstrates promise in prompting cost discussions and improving outcomes. Trial registration: Clinical Trials.gov registration number: NCT03676920 (September 19, 2018).
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Affiliation(s)
- Lauren M. Hamel
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R St, Detroit, MI, 48201, USA
| | - David W. Dougherty
- Dana-Farber Cancer Institute, 450 Brookline Ave DA 941, Boston, MA 02215, USA
| | - Theresa A. Hastert
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R St, Detroit, MI, 48201, USA
| | | | - Seongho Kim
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R St, Detroit, MI, 48201, USA
| | - Hadeel Assad
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R St, Detroit, MI, 48201, USA
| | - Jasminder Phalore
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R St, Detroit, MI, 48201, USA
| | | | - Susan Eggly
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, 4100 John R St, Detroit, MI, 48201, USA
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Oktay LA, Abuelgasim E, Abdelwahed A, Houbby N, Lampridou S, Normahani P, Peters N, Jaffer U. Factors Affecting Engagement in Web-Based Health Care Patient Information: Narrative Review of the Literature. J Med Internet Res 2021; 23:e19896. [PMID: 34554104 PMCID: PMC8498891 DOI: 10.2196/19896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/06/2020] [Accepted: 11/02/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Web-based content is rapidly becoming the primary source of health care information. There is a pressing need for web-based health care content to not only be accurate but also be engaging. Improved engagement of people with web-based health care content has the potential to inform as well as influence behavioral change to enable people to make better health care choices. The factors associated with better engagement with web-based health care content have previously not been considered. OBJECTIVE The aims of this study are to identify the factors that affect engagement with web-based health care content and develop a framework to be considered when creating such content. METHODS A comprehensive search of the PubMed and MEDLINE database was performed from January 1, 1946, to January 5, 2020. The reference lists of all included studies were also searched. The Medical Subject Headings database was used to derive the following keywords: "patient information," "online," "internet," "web," and "content." All studies in English pertaining to the factors affecting engagement in web-based health care patient information were included. No restrictions were set on the study type. Analysis of the themes arising from the results was performed using inductive content analysis. RESULTS The search yielded 814 articles, of which 56 (6.9%) met our inclusion criteria. The studies ranged from observational and noncontrolled studies to quasi-experimental studies. Overall, there was significant heterogeneity in the types of interventions and outcome assessments, which made quantitative assessment difficult. Consensus among all authors of this study resulted in six categories that formed the basis of a framework to assess the factors affecting engagement in web-based health care content: easy to understand, support, adaptability, accessibility, visuals and content, and credibility and completeness. CONCLUSIONS There is a paucity of high-quality data relating to the factors that improve the quality of engagement with web-based health care content. Our framework summarizes the reported studies, which may be useful to health care content creators. An evaluation of the utility of web-based content to engage users is of significant importance and may be accessible through tools such as the Net Promoter score. Web 3.0 technology and development of the field of psychographics for health care offer further potential for development. Future work may also involve improvement of the framework through a co-design process.
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Affiliation(s)
| | | | | | - Nour Houbby
- Imperial College London, London, United Kingdom
| | | | | | | | - Usman Jaffer
- Imperial College NHS Trust, London, United Kingdom
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Wernli KJ, Knerr S, Li T, Leppig K, Ehrlich K, Farrell D, Gao H, Bowles EJA, Graham AL, Luta G, Jayasekera J, Mandelblatt JS, Schwartz MD, O’Neill SC. Effect of Personalized Breast Cancer Risk Tool on Chemoprevention and Breast Imaging: ENGAGED-2 Trial. JNCI Cancer Spectr 2021; 5:pkaa114. [PMID: 33554037 PMCID: PMC7853161 DOI: 10.1093/jncics/pkaa114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/14/2020] [Accepted: 11/09/2020] [Indexed: 12/12/2022] Open
Abstract
Background Limited evidence exists about how to communicate breast density-informed breast cancer risk to women at elevated risk to motivate cancer prevention. Methods We conducted a randomized controlled trial evaluating a web-based intervention incorporating personalized breast cancer risk, information on chemoprevention, and values clarification on chemoprevention uptake vs active control. Eligible women aged 40-69 years with normal mammograms and elevated 5-year breast cancer risk were recruited from Kaiser Permanente Washington from February 2017 to May 2018. Chemoprevention uptake was measured as any prescription for raloxifene or tamoxifen within 12 months from baseline in electronic health record pharmacy data. Secondary outcomes included breast magnetic resonance imaging (MRI), mammography use, self-reported distress, and communication with providers. We calculated unadjusted odds ratios (ORs) using logistic regression models and mean differences using analysis of covariance models with 95% confidence intervals (CIs) with generalized estimating equations. Results We randomly assigned 995 women to the intervention arm (n = 492) or control arm (n = 503). The intervention (vs control) had no effect on chemoprevention uptake (OR = 1.04, 95% CI = 0.07 to 16.62). The intervention increased breast MRI use (OR = 5.65, 95% CI = 1.61 to 19.74) while maintaining annual mammography (OR = 0.98, 95% CI = 0.75 to 1.28). Women in the intervention (vs control) arm had 5.67-times higher odds of having discussed chemoprevention or breast MRI with provider by 6 weeks (OR = 5.67, 95% CI = 2.47 to 13.03) and 2.36-times higher odds by 12 months (OR = 2.36, 95% CI = 1.65 to 3.37). No measurable differences in distress were detected. Conclusions A web-based, patient-level intervention activated women at elevated 5-year breast cancer risk to engage in clinical discussions about chemoprevention, but uptake remained low.
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Affiliation(s)
- Karen J Wernli
- Correspondence to: Karen J. Wernli, PhD, Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA (e-mail: )
| | - Sarah Knerr
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Tengfei Li
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, USA
| | | | - Kelly Ehrlich
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Erin J A Bowles
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Amanda L Graham
- Truth Initiative, Washington, DC, USA,Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - George Luta
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, USA
| | - Jinani Jayasekera
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Jeanne S Mandelblatt
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Marc D Schwartz
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Suzanne C O’Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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8
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Wernli KJ, Bowles EA, Knerr S, Leppig KA, Ehrlich K, Gao H, Schwartz MD, O’Neill SC. Characteristics Associated with Participation in ENGAGED 2 - A Web-based Breast Cancer Risk Communication and Decision Support Trial. Perm J 2020; 24:1-4. [PMID: 33482952 PMCID: PMC7849258 DOI: 10.7812/tpp/19.205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 10/14/2020] [Accepted: 03/01/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE We evaluated demographic and clinical characteristics associated with participation in a clinical trial testing the efficacy of an online tool to support breast cancer risk communication and decision support for risk mitigation to determine the generalizability of trial results. METHODS Eligible women were members of Kaiser Permanente Washington aged 40-69 years with a recent normal screening mammogram, heterogeneously or extremely dense breasts and a calculated risk of > 1.67% based on the Breast Cancer Surveillance Consortium 5-year breast cancer risk model. Trial outcomes were chemoprevention and breast magnetic resonance imaging by 12-months post-baseline. Women were recruited via mail with phone follow-up using plain language materials notifying them of their density status and higher than average breast cancer risk. Multivariable logistic regression calculated independent odds ratios (ORs) for associations between demographic and clinical characteristics with trial participation. RESULTS Of 2,569 eligible women contacted, 995 (38.7%) participated. Women with some college (OR = 1.99, 95% confidence interval [CI] 1.34-2.96) or college degree (OR = 3.35, 95% CI 2.29-4.90) were more likely to participate than high school-educated women. Race/ethnicity also was associated with participation (African-American OR = 0.50, 95% CI 0.29-0.87; Asian OR = 0.22, 95% CI 0.12-0.41). Multivariate adjusted ORs for family history of breast/ovarian cancer were not associated with trial participation. DISCUSSION Use of plain language and potential access to a website providing personal breast cancer risk information and education were insufficient in achieving representative participation in a breast cancer prevention trial. Additional methods of targeting and tailoring, potentially facilitated by clinical and community outreach, are needed to facilitate equitable engagement for all women.
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Affiliation(s)
- Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Erin A Bowles
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | | | | | - Kelly Ehrlich
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Marc D Schwartz
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Suzanne C O’Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
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Mahorter SS, Knerr S, Bowles EJA, Wernli KJ, Gao H, Schwartz MD, O'Neill SC. Prior breast density awareness, knowledge, and communication in a health system-embedded behavioral intervention trial. Cancer 2020; 126:1614-1621. [PMID: 31977078 DOI: 10.1002/cncr.32711] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/22/2019] [Accepted: 12/16/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Breast density is an important breast cancer risk factor and a focus of recent national and state health policy efforts. This article describes breast density awareness, knowledge, and communication among participants in a health system-embedded trial with clinically elevated breast cancer risk 1 year before state-mandated density disclosure. METHODS Trial participants' demographics and prior health history were ascertained from electronic health records. The proportions of women reporting prior breast density awareness, knowledge of density's masking effect, and communication with a provider about their own breast density were calculated using baseline interview data collected from 2017 to 2018. Multiple logistic regression was used to estimate associations between women's characteristics and density awareness, knowledge, and communication. RESULTS Although the overwhelming majority of participants had heard of breast density (91%) and were aware of breast density's masking effect (87%), only 60% had ever discussed their breast density with a provider. Annual mammography screening was associated with prior breast density awareness (odds ratio [OR], 2.97; 95% confidence interval [CI], 1.29-6.81), knowledge (OR, 2.83; 95% CI, 1.20-6.66), and communication (OR, 2.87; 95% CI, 1.34-6.16) compared with an infrequent or unknown screening interval. Receipt of breast biopsy was also associated with prior knowledge (OR, 1.60; 95% CI, 1.04-2.45) and communication (OR, 1.36; 95% CI, 1.00-1.85). CONCLUSIONS Breast density awareness and knowledge are high among insured women participating in clinical research, even in the absence of mandated density disclosure. Patient-provider communication about personal density status is less common, particularly among women with fewer interactions with breast health specialists.
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Affiliation(s)
- Siobhan S Mahorter
- Department of Health Services, University of Washington, Seattle, Washington
| | - Sarah Knerr
- Department of Health Services, University of Washington, Seattle, Washington
| | | | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Marc D Schwartz
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Suzanne C O'Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
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10
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Haas JS, Giess CS, Harris KA, Ansolabehere J, Kaplan CP. Randomized Trial of Personalized Breast Density and Breast Cancer Risk Notification. J Gen Intern Med 2019; 34:591-597. [PMID: 30091121 PMCID: PMC6445917 DOI: 10.1007/s11606-018-4622-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/15/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Despite widespread implementation of mammographic breast density (MBD) notification laws, the impact of these laws on knowledge of MBD and knowledge of breast cancer risk is limited by the lack of tools to promote informed decision-making in practice. OBJECTIVE To develop and evaluate whether brief, personalized informational videos following a normal mammogram in addition to a legislatively required letter about MBD result can improve knowledge of MBD and breast cancer risk compared to standard care (i.e., legislatively required letter about MBD included with the mammogram result). DESIGN/PARTICIPANTS Prospective randomized controlled trial of English-speaking women, age 40-74 years, without prior history of breast cancer, receiving a screening mammogram with a normal or benign finding (intervention group n = 235, control group n = 224). INTERVENTION brief (3-5 min) video, personalized to a woman's MBD result and breast cancer risk. MAIN MEASURES Primary outcomes were a woman's knowledge of her MBD and risk of breast cancer. Secondary outcomes included whether a woman reported that she discussed the results of her mammogram with her primary care provider (PCP). KEY RESULTS Relative to women in the control arm, women in the intervention arm had greater improvement in their knowledge of both their personal MBD (intervention pre/post 39.2%/ 77.5%; control pre/post 36.2%/ 37.5%; odds ratio (OR) 5.34 for change for intervention vs. control, 95% confidence interval (CI) 3.87-7.36; p < 0.001) and risk of breast cancer (intervention pre/post: 66.8%/74.0%; control pre/post 67.9%/ 65.2%; OR 1.42, 95% confidence interval (CI) 1.09-1.84; p = 0.01). Women in the intervention group were more likely than those in the control group to report discussing the results of their mammogram with their PCP (p = 0.05). CONCLUSIONS Brief, personalized videos following mammography can improve knowledge of MBD and personal risk of breast cancer compared to a legislatively mandated informational letter. Trial Registration Clinicaltrials.gov (NCT02986360).
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Affiliation(s)
- Jennifer S Haas
- Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Catherine S Giess
- Department of Radiology, Division of Breast Imaging, Brigham and Women's Hospital, Boston, MA, USA
| | - Kimberly A Harris
- Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Julia Ansolabehere
- Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Celia P Kaplan
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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