Moving towards patient-reported outcomes as a vital sign: implementation lessons from the BREAST-Q
Jacqueline J. Chu, BA1, Jonas A. Nelson, MD, MPH1, Stefan Dabic, MPH1, Elizabeth O. Kenworthy, MD1, Meghana G. Shamsunder, MPH1, Colleen McCarthy, MD, MHS1; Babak J. Mehrara, MD1, Andrea L. Pusic, MD, MHS 2
1Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 2Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA
Background: The BREAST-Q is the gold standard patient-reported outcome measure (PROM) of health-related quality of life and patient satisfaction following breast reconstruction. However, the routine, longitudinal implementation of the BREAST-Q has been challenging, so the BREAST-Q remain underutilized in patient care. This study describes our institution’s quality improvement initiative for increasing BREAST-Q utilization in clinical practice and the characteristics of BREAST-Q non-responders.
Methods: In 2011, the BREAST-Q was instituted as part of routine care. In 2018, our institution began a quality improvement initiative to increase BREAST-Q completion rates for post-mastectomy breast reconstruction patients. The BREAST-Q was administered at every clinic visit via an institutional patient portal or an in-clinic tablet, with a one-month lockout period between BREAST-Qs. Patient scores were integrated into the electronic health record for immediate data availability at clinic visits. High clinical staff engagement was encouraged by assigning “BREAST-Q Champions” and by using digital dashboard technologies for improved integration of the BREAST-Q into clinical workflows and real-time accountability. The outcome of interest was annual BREAST-Q completion rate for assessments requested within 2-years of reconstructive surgery, which was determined for 2011 through 2019. Annual completion rates prior to quality-improvement intervention were compared to those after intervention. Other outcomes of interest included number of BREAST-Qs completed each year, method of BREAST-Q administration, and patient characteristics of BREAST-Q responders and non-responders.
Results: Out of 109,435 requested BREAST-Qs, 41,981 BREAST-Qs were completed. Of BREAST-Qs requested within 2-years of surgery, the average annual BREAST-Q completion rate increased from 42.8% in 2011–2017 to 87.6% in 2019, the last full year of our study period. High completion rates were maintained January–July 2020; however, a significantly larger proportion of BREAST-Qs were completed at home in 2020 versus the same period in 2019 (49.7% vs. 38.8%, p<0.001), potentially due to the COVID-19 pandemic. Compared with non-responders, responders were younger (49.7 vs. 52.2 years, p<0.001), more likely to be white (76.9% vs. 73.6%, p<0.001), and have private insurance (79.4% vs. 69.8%, p<0.001).
Conclusion:: Our quality improvement initiative shifted the paradigm for PROMs administration by implementing the BREAST-Q as a vital sign, a measurement collected at every clinical encounter as an indicator for patient wellbeing and satisfaction. Our initiative was successful at increasing BREAST-Q completion rates, and we recommend the use of similar implementation techniques at other institutions interested in incorporating PROMs into routine care.
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