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Kling SMR, Kalwani NM, Winget M, Gupta K, Saliba-Gustafsson EA, Baratta J, Garvert DW, Veruttipong D, Brown-Johnson CG, Vilendrer S, Gaspar C, Levin E, Tsai S. An initiative to promote value-based stress test selection in primary care and cardiology clinics: A mixed methods evaluation. J Eval Clin Pract 2024; 30:107-118. [PMID: 37459156 DOI: 10.1111/jep.13896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 03/01/2024]
Abstract
OBJECTIVES Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower-cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value-based, guideline-concordant ordering practices in primary care (PC) and cardiology clinics. METHODS Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019-February 2020); Period 1 with reduced stress ECG report turnaround time + PC-targeted education (began June 2020); and Period 2 with the addition of electronic health record-based alternative alert (AA) providing point-of-care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2. RESULTS Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value-based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p < 0.0001) from baseline to Period 1. Most PCPs identified the AA as the most impactful initiative, yet stress ECG ordering did not change (6% ± 6%; p = 0.34) between Periods 1 and 2. In contrast, cardiologists reportedly relied on their expertise rather than AAs, yet their stress ECGs orders increased from Period 1 to 2 to a larger degree in the cardiology clinic with the AA (12% ± 5%; p = 0.01) than clinics without the AA (6% ± 2%; p = 0.01). The percent of stress ECGs ordered was higher in Period 2 than baseline for both specialties (both p < 0.0001). CONCLUSIONS This initiative influenced ordering behaviour in PC and cardiology clinics. However, clinicians' perceptions of the initiative varied between specialties and did not always align with the observed behaviour change.
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Affiliation(s)
- Samantha M R Kling
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Neil M Kalwani
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Marcy Winget
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kush Gupta
- Stanford University School of Medicine, Stanford, California, USA
| | - Erika A Saliba-Gustafsson
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Juliana Baratta
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Donn W Garvert
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Darlene Veruttipong
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Cati G Brown-Johnson
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Stacie Vilendrer
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
| | | | - Eleanor Levin
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
| | - Sandra Tsai
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
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Siegel SD, Rowland JP, Leonard DJ, Katurakes N, Bittner-Fagan H, Hoffman M, Hall-McBride R, Hicks LS, Petrelli NJ. A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together. Popul Health Manag 2024; 27:84-86. [PMID: 37909492 DOI: 10.1089/pop.2023.0178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Affiliation(s)
- Scott D Siegel
- Helen F. Graham Cancer Center and Research Institute, ChristianaCare, Newark, Delaware, USA
| | - Jennifer P Rowland
- Helen F. Graham Cancer Center and Research Institute, ChristianaCare, Newark, Delaware, USA
| | - Dawn J Leonard
- Helen F. Graham Cancer Center and Research Institute, ChristianaCare, Newark, Delaware, USA
| | - Nora Katurakes
- Helen F. Graham Cancer Center and Research Institute, ChristianaCare, Newark, Delaware, USA
| | | | - Matthew Hoffman
- Obstetrics and Gynecology, ChristianaCare, Newark, Delaware, USA
| | - Robert Hall-McBride
- Helen F. Graham Cancer Center and Research Institute, ChristianaCare, Newark, Delaware, USA
| | - LeRoi S Hicks
- Internal Medicine, ChristianaCare, Newark, Delaware, USA
- Institute for Research in Equity and Community Health, ChristianaCare, Newark, Delaware, USA
| | - Nicholas J Petrelli
- Helen F. Graham Cancer Center and Research Institute, ChristianaCare, Newark, Delaware, USA
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Ropers FG, Rietveld S, Rings EHHM, Bossuyt PMM, van Bodegom-Vos L, Hillen MA. Diagnostic testing in children: A qualitative study of pediatricians' considerations. J Eval Clin Pract 2023; 29:1326-1337. [PMID: 37221991 DOI: 10.1111/jep.13867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
AIMS AND OBJECTIVES Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation. METHOD We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes. RESULTS Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes. CONCLUSION We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.
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Affiliation(s)
- Fabienne G Ropers
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Rietveld
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick M M Bossuyt
- Amsterdam University Medical Centers, University of Amsterdam, Epidemiology & Data Science, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Leti van Bodegom-Vos
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Marij A Hillen
- Amsterdam University Medical Centers, location AMC, Amsterdam Public Health, Medical Psychology, Amsterdam, The Netherlands
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Schrager S, Evaristo C, Little T, DuBenske L, Burnside ES. Patient and Clinician Characteristics That Predict Breast Cancer Screening Behavior in 40-49-Year-Old Women. J Patient Cent Res Rev 2021; 8:331-335. [PMID: 34722801 DOI: 10.17294/2330-0698.1814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Guidelines recommend that clinicians practice shared decision-making (SDM) with women in their 40s to discuss breast cancer screening. Traditionally, SDM includes discussion of values and preferences to help determine a decision that is congruent with what the patient desires. We analyzed 54 women's breast cancer screening decisions after a SDM conversation with their clinician. We looked at both patient and clinician characteristics that predicted whether or not a woman would get a screening mammogram. Women with a family history of breast cancer or who had a previous abnormal mammogram had higher rates of screening. Screening rates also varied widely between clinicians, raising the question of whether clinician attitudes impacted the SDM conversation.
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Affiliation(s)
- Sarina Schrager
- University of Wisconsin Department of Family Medicine and Community Health, Madison, WI
| | - Claudia Evaristo
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Terry Little
- University of Wisconsin Department of Radiology, Madison, WI
| | - Lori DuBenske
- University of Wisconsin Carbone Cancer Center, Madison, WI
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Sullivan CL, Butler R, Evans J. Impact of a Breast Cancer Screening Algorithm on Early Detection. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Gunn CM, Maschke A, Paasche-Orlow MK, Kressin NR, Schonberg MA, Battaglia TA. Engaging Women with Limited Health Literacy in Mammography Decision-Making: Perspectives of Patients and Primary Care Providers. J Gen Intern Med 2021; 36:938-945. [PMID: 32935318 PMCID: PMC8042081 DOI: 10.1007/s11606-020-06213-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Limited health literacy is a driver of cancer disparities and associated with less participation in medical decisions. Mammography screening decisions are an exemplar of where health literacy may impact decision-making and outcomes. OBJECTIVE To describe informational needs and shared decision-making (SDM) experiences among women ages 40-54 who have limited health literacy and primary care providers (PCPs). DESIGN Qualitative, in-depth interviews explored experiences with mammography counseling and SDM. PARTICIPANTS Women ages 40-54 with limited health literacy and no history of breast cancer or mammogram in the prior 9 months were approached before a primary care visit at a Boston academic, safety-net hospital. PCPs practicing at this site were eligible for PCP interviews. APPROACH Interviews were audio-recorded and transcribed verbatim. A set of deductive codes for each stakeholder group was developed based on literature and the interview guide. Inductive codes were generated during codebook development. Codes were compared within and across patient and PCP interviews to create themes relevant to mammography decision-making. KEY RESULTS The average age of 25 interviewed patients was 46.5; 18 identified as black, 3 as Hispanic, 2 as non-Hispanic white, and 2 had no recorded race or ethnicity. Of 20 PCPs, 15 were female; 12 had practiced for >5 years. Patients described a lack of technical (appropriate tests and what they do) and process (what happens during a mammogram visit) knowledge, viewing these as necessary for decision-making. PCPs were reluctant to engage patients with limited health literacy in SDM due to time constraints and feared that increased information might confuse patients or deter them from having mammograms. Both groups felt pre-visit education would facilitate mammography-related SDM during clinical visits. CONCLUSION Both patients and PCPs perceived a need for tools to relay technical and process knowledge about mammography prior to clinical encounters to address the scope of information that patients with limited health literacy desired.
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Affiliation(s)
- Christine M Gunn
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA.
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Ariel Maschke
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
| | - Michael K Paasche-Orlow
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Nancy R Kressin
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Mara A Schonberg
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tracy A Battaglia
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
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Maschke A, Paasche-Orlow MK, Kressin NR, Schonberg MA, Battaglia TA, Gunn CM. Discussions of Potential Mammography Benefits and Harms among Patients with Limited Health Literacy and Providers: "Oh, There are Harms?". JOURNAL OF HEALTH COMMUNICATION 2020; 25:951-961. [PMID: 33455518 PMCID: PMC8062298 DOI: 10.1080/10810730.2020.1845256] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Starting breast cancer screening at age 40 versus 50 may increase potential harms frequency with a small mortality benefit. Younger women's screening decisions, therefore, may be complex. Shared decision-making (SDM) is recommended for women under 50 and may support women under 55 for whom guidelines vary. How women with limited health literacy (LHL) approach breast cancer screening decision-making is less understood, and most SDM tools are not designed with their input. This phenomenological study sought to characterize mammography counseling experiences among women with LHL and primary care providers (PCPs). Women ages 40-54 with LHL who had no history of breast cancer or mammogram within 9 months were approached before a primary care visit at a safety-net hospital. PCPs at this site were invited to participate. Qualitative interviews explored mammography counseling experiences. Patients also reviewed sample information materials. A constant comparison technique generated four themes salient to 25 patients and 20 PCPs: addressing family history versus comprehensive risk assessment; potential mammography harms discussions; information delivery preferences; and integrating pre-visit information tools. Findings suggest that current counseling techniques may not be responsive to patient-identified needs. Opportunities exist to improve how mammography information is shared and increase accessibility across the health literacy spectrum.
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Affiliation(s)
- Ariel Maschke
- Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA, USA
| | - Michael K Paasche-Orlow
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Nancy R Kressin
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Mara A Schonberg
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tracy A Battaglia
- Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA, USA
| | - Christine M Gunn
- Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA, USA
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Lam JH, Pickles K, Stanaway FF, Bell KJL. Why clinicians overtest: development of a thematic framework. BMC Health Serv Res 2020; 20:1011. [PMID: 33148242 PMCID: PMC7643462 DOI: 10.1186/s12913-020-05844-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Medical tests provide important information to guide clinical management. Overtesting, however, may cause harm to patients and the healthcare system, including through misdiagnosis, false positives, false negatives and overdiagnosis. Clinicians are ultimately responsible for test requests, and are therefore ideally positioned to prevent overtesting and its unintended consequences. Through this narrative literature review and workshop discussion with experts at the Preventing Overdiagnosis Conference (Sydney, 2019), we aimed to identify and establish a thematic framework of factors that influence clinicians to request non-recommended and unnecessary tests. METHODS Articles exploring factors affecting clinician test ordering behaviour were identified through a systematic search of MedLine in April 2019, forward and backward citation searches and content experts. Two authors screened abstract titles and abstracts, and two authors screened full text for inclusion. Identified factors were categorised into a preliminary framework which was subsequently presented at the PODC for iterative development. RESULTS The MedLine search yielded 542 articles; 55 were included. Another 10 articles identified by forward-backward citation and content experts were included, resulting in 65 articles in total. Following small group discussion with workshop participants, a revised thematic framework of factors was developed: "Intrapersonal" - fear of malpractice and litigation; clinician knowledge and understanding; intolerance of uncertainty and risk aversion; cognitive biases and experiences; sense of medical obligation "Interpersonal" - pressure from patients and doctor-patient relationship; pressure from colleagues and medical culture; "Environment/context" - guidelines, protocols and policies; financial incentives and ownership of tests; time constraints, physical vulnerabilities and language barriers; availability and ease of access to tests; pre-emptive testing to facilitate subsequent care; contemporary medical practice and new technology CONCLUSION: This thematic framework may raise awareness of overtesting and prompt clinicians to change their test request behaviour. The development of a scale to assess clinician knowledge, attitudes and practices is planned to allow evaluation of clinician-targeted interventions to reduce overtesting.
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Affiliation(s)
- Justin H Lam
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia.
| | - Kristen Pickles
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
| | - Fiona F Stanaway
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
| | - Katy J L Bell
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
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Seaman K, Dzidic PL, Castell E, Saunders C, Breen LJ. Subject positions in screening mammography and implications for informed choice. Psychol Health 2020; 36:478-495. [PMID: 32404016 DOI: 10.1080/08870446.2020.1766043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Screening mammography has potential benefits as well as harms, but these are not always communicated to women. We therefore explored how women discuss screening mammography, the subject positions made available in their discourse, and the implications of these for informed choice. Design: We conducted 16 individual interviews with women aged 44-72 years who were attenders (n = 11) and non-attenders (n = 5) of screening, and analysed transcripts through Foucauldian Discourse Analysis. Main Outcome Measures: A semi-structured interview guide, informed by literature and researcher expertise, was used to collect data. Results: The women constructed screening mammography as either helpful or potentially harmful. We identified three subject positions-The Responsible Woman (who attends screening), The Irresponsible Woman (who does not attend screening), and the Judicious Woman (who engages in alternate breast health practices). Conclusion: These subject positions have the potential to limit women's choices, constrain shared decision-making with health professionals, and restrict women's engagement in risk-reducing behaviours. An expanded range of options ultimately offers an alternate future in which women's autonomy to control their own bodies is better supported.
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Affiliation(s)
- Kristen Seaman
- School of Psychology, Curtin University, Perth, Western Australia, Australia
| | - Peta L Dzidic
- School of Psychology, Curtin University, Perth, Western Australia, Australia
| | - Emily Castell
- School of Psychology, Curtin University, Perth, Western Australia, Australia
| | - Christobel Saunders
- School of Medicine, Division of Surgery, The University of Western Australia, Crawley, Western Australia, Australia
| | - Lauren J Breen
- School of Psychology, Curtin University, Perth, Western Australia, Australia
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Cohen EO, Weaver OO, Tso HH, Gerlach KE, Leung JWT. Breast Cancer Screening via Digital Mammography, Synthetic Mammography, and Tomosynthesis. Am J Prev Med 2020; 58:470-472. [PMID: 31732323 DOI: 10.1016/j.amepre.2019.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/02/2019] [Accepted: 09/03/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Ethan O Cohen
- Department of Diagnostic Imaging, Unit 1350, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Olena O Weaver
- Department of Diagnostic Imaging, Unit 1350, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hilda H Tso
- Department of Diagnostic Imaging, Unit 1350, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Karen E Gerlach
- Department of Diagnostic Imaging, Unit 1350, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jessica W T Leung
- Department of Diagnostic Imaging, Unit 1350, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Puzhko S, Gagnon J, Simard J, Knoppers BM, Siedlikowski S, Bartlett G. Health professionals' perspectives on breast cancer risk stratification: understanding evaluation of risk versus screening for disease. Public Health Rev 2019; 40:2. [PMID: 30858992 PMCID: PMC6394012 DOI: 10.1186/s40985-019-0111-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 02/12/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Younger women at higher-than-population-average risk for breast cancer may benefit from starting screening earlier than presently recommended by the guidelines. The Personalized Risk Stratification for Prevention and Early Detection of Breast Cancer (PERSPECTIVE) approach aims to improve the prevention of breast cancer through differential screening recommendations based on a personal risk estimate. In our study, we used deliberative stakeholder consultations to engage health professionals in an in-depth dialog to explore the feasibility of the proposed implementation strategies for this new personalized breast cancer screening approach. METHODS Deliberative stakeholder consultation is a qualitative descriptive study design used to engage health professionals in the discussion, while the mediators play a more passive role. A purposeful sample of 11 health professionals (family physicians and genetic counselors) working in Montreal was used. The deliberations were organized in two phases, including small group deliberations according to the deliberants' health profession and a mixed group deliberation combining participants from the small groups. Inductive thematic content analysis was performed on the transcripts by two coders to create the deliberative and analytic outputs. Quality of deliberations was assessed quantitatively using the de Vries method and qualitatively using participant observation. RESULTS One of our key findings was that health professionals lacked understanding of the two steps of the screening approach: risk stratification "screening," which is an evaluation for the level of risk and screening for disease. As part of this confusion, the main topic of concern was a justification of program implementation as a population-wide screening, based on their uncertainty that it will be beneficial for women with near-population risks. Despite the noted difficulties concerning implementation, health professionals acknowledged the substantial benefits of the proposed PERSPECTIVE program. CONCLUSIONS Our study was the first to evaluate the perspectives of health professionals on the implementation and benefits of a new program for breast cancer risk stratification with the purpose of personalizing screening for disease. This new multi-step approach to screening requires more clarity in communication with health professionals. To implement and maintain effective screening, engagement of family physicians with other health professionals or even development of a centralized public health system may be needed.
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Affiliation(s)
- Svetlana Puzhko
- 1Department of Family Medicine, Faculty of Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges, Suite 300, Montréal, Québec H3S 1Z1 Canada
| | - Justin Gagnon
- 1Department of Family Medicine, Faculty of Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges, Suite 300, Montréal, Québec H3S 1Z1 Canada
| | - Jacques Simard
- 2Genomics Center, CHU de Québec-Université Laval Research Center, Room R4-4787, 2705 Laurier Blvd, Québec, Québec G1V 4G2 Canada
- 4Department of Molecular Medicine, Faculty of Medicine, Université Laval, Québec, Canada
| | - Bartha Maria Knoppers
- 3Genome Quebec Innovation Centre of Genomics and Policy, Department of Human Genetics, Faculty of Medicine, McGill University, 3640 University Street, Room W-315, 740 Dr. Penfield Ave, 5214, Montréal, Québec H3A 0C7OG1 Canada
| | - Sophia Siedlikowski
- 1Department of Family Medicine, Faculty of Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges, Suite 300, Montréal, Québec H3S 1Z1 Canada
| | - Gillian Bartlett
- 1Department of Family Medicine, Faculty of Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges, Suite 300, Montréal, Québec H3S 1Z1 Canada
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