Plastic Surgeon Expertise in Predicting Breast Reconstruction Outcomes for Patient Decision Analysis

Patient-Reported Outcomes of Breast Reconstruction: Does the Quality of Decisions Matter?

BACKGROUND

Little is known about how the quality of decisions influences patient-reported outcomes (PROs). We hypothesized that higher decision quality for breast reconstruction would be independently associated with better PROs.

METHODS

We conducted a prospective cohort study of patients undergoing mastectomy with or without reconstruction. Patients were enrolled before surgery and followed for 18 months. We used BREAST-Q scales to measure PROs and linear regression models to explore the relationship between decision quality (based on knowledge and preference concordance) and PROs. Final models were adjusted for baseline BREAST-Q score, radiation, chemotherapy, and major complications.

RESULTS

The cohort included 101 patients who completed baseline and 18-month surveys. Breast reconstruction was independently associated with higher satisfaction with breasts (β = 20.2, p = 0.0002), psychosocial well-being (β = 14.4, p = 0.006), and sexual well-being (β = 15.7, p = 0.007), but not physical well-being. Patients who made a high-quality decision had similar PROs as patients who did not. Among patients undergoing mastectomy with reconstruction, higher decision quality was associated with lower psychosocial well-being (β = -14.2, p = 0.01).

CONCLUSIONS

Breast reconstruction was associated with better PROs in some but not all domains. Overall, making a high-quality decision was not associated with better PROs. However, patients who did not have reconstruction had a trend toward better well-being after making a high-quality decision, whereas patients who did have reconstruction had poorer well-being after making a high-quality decision. Additional research on the relationship between decision quality and PROs is needed.

Visual Preoperative Risk Depiction Tools for Shared Decision-making: A Pilot Study from the Surgeon's Perspective

Shared decision-making (SDM) and effective risk communication improve patient satisfaction, adherence to treatment, and understanding of perioperative care pathways. Available risk calculators are less relevant for low-risk operations. The aim of this pilot study was to develop graphical risk visualization tools to enhance surgical SDM discussions preoperatively.

Methods

Complications for reduction mammoplasty and skin grafting in a burns setting were sourced from the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator, the American Society of Plastic Surgeons website, peer-reviewed literature, and available clinical data. Pre- and postoperative patient satisfaction data were collected from the published literature on Breast-Q patient-reported outcomes for reduction mammoplasty. Everyday risk comparisons were collected from a general online database search. Three distinct risk depiction tools (spiral, tile, and scatter plot) were developed in the Microsoft Office Suite. Anonymous REDCap surveys were sent to healthcare practitioners for feedback.

Results

Twenty-six survey results were collected. Twenty-four respondents (92%) agreed these graphics would be useful for SDM discussions. Nineteen respondents (73%) either agreed or strongly agreed that these graphics depicted risk in a meaningful way. Fifteen respondents (58%) indicated they would use these graphics in daily practice. The majority of respondents preferred the spiral design (58%). Areas for improvement included design simplification and written explanations to accompany graphics. Feedback from the survey was incorporated into the spiral design.

Conclusions

Risk visualization tools meaningfully depict surgical risks to improve communication in SDM. This study proposes a tool that can be adapted for many surgical procedures.

A Randomized Controlled Trial Evaluating the BREASTChoice Tool for Personalized Decision Support About Breast Reconstruction After Mastectomy

OBJECTIVE

To evaluate a web-based breast reconstruction decision aid, BREASTChoice.

SUMMARY AND BACKGROUND DATA

Although postmastectomy breast reconstruction can restore quality of life and body image, its morbidity remains substantial. Many patients lack adequate knowledge to make informed choices. Decisions are often discordant with patients' preferences.

METHODS

Adult women with stages 0-III breast cancer considering postmastectomy breast reconstruction with no previous reconstruction were randomized to BREASTChoice or enhanced usual care (EUC).

RESULTS

Three hundred seventy-six patients were screened; 120 of 172 (69.8%) eligible patients enrolled. Mean age = 50.7 years (range 25-77). Most were Non-Hispanic White (86.3%) and had a college degree (64.3%). Controlling for health literacy and provider seen, BREASTChoice users had higher knowledge than those in EUC (84.6% vs. 58.2% questions correct; P < 0.001). Those using BREASTChoice were more likely to know that reconstruction typically requires more than 1 surgery, delayed reconstruction lowers one's risk, and implants may need replacement over time (all ps < 0.002). BREASTChoice compared to EUC participants also felt more confident understanding reconstruction information (P = 0.009). There were no differences between groups in decisional conflict, decision process quality, shared decision-making, quality of life, or preferences (all ps > 0.05). There were no differences in consultation length between BREASTChoice and EUC groups (mean = 29.7 vs. 30.0 minutes; P > 0.05). BREASTChoice had high usability (mean score = 6.3/7). Participants completed BREASTChoice in about 27 minutes.

CONCLUSIONS

BREASTChoice can improve breast reconstruction decision quality by improving patients' knowledge and providing them with personalized risk estimates. More research is needed to facilitate point-of-care decision support and examine BREASTChoice's impact on patients' decisions over time.

Can physician gestalt predict survival in patients with resectable pancreatic adenocarcinoma?

PURPOSE

Clinician gestalt may hold unexplored information that can be capitalized upon to improve existing nomograms. The study objective was to evaluate physician ability to predict 2-year overall survival (OS) in resected pancreatic ductal adenocarcinoma (PDAC) patients based on pre-operative clinical characteristics and routine CT imaging.

METHODS

Ten surgeons and two radiologists were provided with a clinical vignette (including age, gender, presenting symptoms, and pre-operative CA19-9 when available) and pre-operative CT scan for 20 resected PDAC patients and asked to predict the probability of each patient reaching 2-year OS. Receiver operating characteristic curves were used to assess agreement and to compare performance with an established institutional nomogram.

RESULTS

Ten surgeons and 2 radiologists participated in this study. The area under the curve (AUC) for all physicians was 0.707 (95% CI 0.642-0.772). Attending physicians with > 5 years experience performed better than physicians with < 5 years of clinical experience since completion of post-graduate training (AUC = 0.710, 95% CI [0.536-0.884] compared to AUC = 0.662, 95% CI [0.398-0.927]). Radiologists performed better than surgeons (AUC = 0.875, 95% CI [0.765-0.985] compared to AUC = 0.656, 95% CI [0.580-0.732]). All but one physician outperformed the clinical nomogram (AUC = 0.604).

CONCLUSIONS

This pilot study demonstrated significant promise in the quantification of physician gestalt. While PDAC remains a difficult disease to prognosticate, physicians, particularly those with more clinical experience and radiologic expertise, are able to perform with higher accuracy than existing nomograms in predicting 2-year survival.

Helping patients make choices about breast reconstruction: a decision analysis approach

Decision analysis can help breast reconstruction patients and their surgeons to methodically evaluate clinical alternatives and make hard decisions. The purpose of this article is to help plastic surgeons guide patients in making decisions though a case study in breast reconstruction. By making good decisions, patient outcomes may be improved. This article aims to illustrate decision analysis techniques from the patient perspective, with an emphasis on her values and preferences. The authors introduce normative decision-making through a fictional breast reconstruction patient and systematically build the decision basis to help her make a good decision. The authors broadly identify alternatives of breast reconstruction, propose types of outcomes that the patient should consider, discuss sources of probabilistic information and outcome values, and demonstrate how to make a good decision. The concepts presented here may be extended to other shared decision-making problems in plastic and reconstructive surgery. In addition, the authors discuss how sensitivity analysis may test the robustness of the decision and how to evaluate the quality of decisions. The authors also present tools to help implement these concepts in practice. Finally, the authors examine limitations that hamper adoption of patient decision analysis in reconstructive surgery and health care in general. In particular, the authors emphasize the need for routine collection of quality-of-life information, out-of-pocket expense, and recovery time.