Improved Decision Making in Breast Reconstruction: A Validated Option Grid<!--EndFragment-->
Carrie Stern, MD1, Thomas Del Guercio, MD1, Jenny Q. Zhang, BA1, Fran Bullard, BA1, Marie-anne Durand, MSc, MPhil, PhD, CPsychol2, Oren Tepper, MD1, Evan Garfein, MD3, Vishal Thanik, MD4, Katie Weichman, MD1.
1Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY, USA, 2The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA, 3Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA, 4Institute of Reconstructive Plastic Surgery,, New York, NY, USA.
Despite improvements in breast cancer survival, disparities in treatments offered, chosen, and received still persist. The decision regarding type of breast reconstruction is multifaceted and involves shared decision-making between patients and physician. Patients of low socioeconomic status have several impediments to effective shared decision making including, low literacy, low numeracy, and limited access to secondary resources. Encounter decision aids have been shown to improve outcomes in controlled settings. Based on the limitations associated with low socioeconomic patients the use of pictorial representations in decisions aids have been shown to improve understanding, compliance, and recall of health related information. We sought to develop a pictorial option grid (decision aid) to help aid in the decision making in patients undergoing breast reconstruction after mastectomy.
An option grid (IRB 3025-2016), addressing frequently asked questions regarding no reconstruction, implant reconstruction, and autologous reconstruction was developed. Questions were developed with the help of various health care providers. Once the questions and evidence-based answers had been constructed, an artist created pictorial representations of each answer. Translations from English to Spanish and Mandarin Chinese were then performed and checked with two native speakers for confirmation.
Using a Community-Based Participatory Research (CBPR) approach we tested the usability of the picture option grid version 1.0 using think aloud protocol and semi-structured interviews on target users. We tested prototype at two sites, Montefiore Medical Center and Bellevue Hospital Center, on Spanish speaking patients and English speaking patients who were greater than 18 years of age and had considered breast reconstruction in the previous 3 years. Thematic analysis of responses to semi-structured interviews was performed and based on feedback from these interviews Version 2.0 was developed.
In the development of version 1.0 of the picture option grid a total of 12 questions were chosen and 12 evidence-based answers were developed. A total of 29 women (15 Spanish, 14 English) were given the Picture Option Grid 1.0 in order to test the response. A total of two rounds of pilot testing were performed with women who represented the target patient population. The first round included 10 women (5 Spanish and 5 English) and a total of 12 questions. The picture grid was modified to 10 questions using first round of feedback and additional expert opinion. Nineteen women (10 Spanish and 9 English) were included in the second pilot, and concluded when saturation of responses during the semi-structured interview was reached.
Conclusions: Using CBPR approach, we developed and tested the usability of a Picture Option Grid for breast reconstruction. Additional modifications were performed and Picture Option Grid 2.0 was created. Preliminary data from our pilot study of women of low SES and health professionals, confirm the usability of a Picture Option Grid for breast reconstruction. Ongoing studies include a pilot randomized control trial to determine the acceptability and efficacy of a Picture Option Grid for breast reconstruction.
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