Team Science Principles Enhance Cancer Care Delivery Quality Improvement: Interdisciplinary Implementation of Breast Cancer Screening Shared Decision Making.

PURPOSE: Implementing shared decision making (SDM), recommended in screening mammography by national guidelines for women age 40-49 years, faces challenges that innovations in quality improvement and team science (TS) are poised to address. We aimed to improve the effectiveness, patient-centeredness, and efficiency of SDM in primary care for breast cancer screening. METHODS: Our interdisciplinary team included primary and specialty care, psychology, epidemiology, communication science, engineering, and stakeholders (patients and clinicians). Over a 6-year period, we executed two iterative cycles of plan-do-study-act (PDSA) to develop, revise, and implement a SDM tool using TS principles. Patient and physician surveys and retrospective analysis of tool performance informed our first PDSA cycle. Patient and physician surveys, toolkit use, and clinical outcomes in the second PDSA cycle supported SDM implementation. We gathered team member assessments on the importance of individual TS activities. RESULTS: Our first PDSA cycle successfully generated a SDM tool called Breast Cancer Risk Estimator, deemed valuable by 87% of patients surveyed. Our second PDSA cycle increased Breast Cancer Risk Estimator utilization, from 2,000 sessions in 2017 to 4,097 sessions in 2019 while maintaining early-stage breast cancer diagnoses. Although TS activities such as culture, trust, and communication needed to be sustained throughout the project, shared goals, research/data infrastructure support, and leadership were more important earlier in the project and persisted in the later stages of the project. CONCLUSION: Combining rigorous quality improvement and TS principles can support the complex, interdependent, and interdisciplinary activities necessary to improve cancer care delivery exemplified by our implementation of a breast cancer screening SDM tool.

Patient-provider communication while using a clinical decision support tool: explaining satisfaction with shared decision making for mammography screening.

BACKGROUND: Clinical decision aids may support shared decision-making for screening mammography. To inform shared decision-making between patients and their providers, this study examines how patterns of using an EHR-integrated decision aid and accompanying verbal patient-provider communication predict decision-making satisfaction. METHODS: For 51 patient visits during which a mammography decision aid was used, linguistic characteristics of patient-provider verbal communication were extracted from transcribed audio recordings and system logs automatically captured uses of the decision aid. Surveys assessed patients' post-visit decisional satisfaction and its subcomponents. Linear mixed effects models assessed how patients' satisfaction with decision making was related to patterns of verbal communication and navigation of the decision aid. RESULTS: The results indicate that providers' use of quantitative language during the encounter was positively associated with patients' overall satisfaction, feeling informed, and values clarity. Patients' question-asking was negatively associated with overall satisfaction, values clarity, and certainty perception. Where system use data indicated the dyad had cycled through the decision-making process more than once ("looping" back through pages of the decision aid), patients reported improved satisfaction with shared decision making and all subcomponents. Overall satisfaction, perceived support, certainty, and perceived effectiveness of decision-making were lowest when a high number of navigating clicks occurred absent "looping." CONCLUSIONS: Linguistic features of patient-provider communication and system use data of a decision aid predict patients' satisfaction with shared decision making. Our findings have implications for the design of decision aid tools and clinician training to support more effective shared decision-making for screening mammography.

Rationale for targeted rather than population based screening with C-reactive protein using the National Health and Nutrition Examination Survey (1999 to 2002).

C-reactive protein (CRP) is the most well-studied inflammatory marker for the prediction of coronary artery disease. It was hypothesized that population-wide screening would have minimal impact but that a target population might be identified for whom CRP testing could be appropriate. The National Health and Nutrition Examination Survey (NHANES; 1999 to 2002) included 7,399 subjects who represented 171 million United States residents aged 20 to 79 years. Subjects were risk stratified according to National Cholesterol Education Program Adult Treatment Panel III guidelines. Subjects with CRP levels >3 mg/L then had their risk profiles adjusted by adding 1 risk factor and multiplying their Framingham risk scores by 1.5. Subjects had their low-density lipoprotein (LDL) cholesterol goals adjusted as necessary and were then recategorized as above or below their CRP-adjusted LDL cholesterol goal. LDL cholesterol goals were met initially by 67.8% (116 +/- 8 million) of United States residents, and 64.8% (111 +/- 8 million) achieved their LDL cholesterol goals after CRP adjustment. Thus, 5.3 +/- 1.1 million of the population (3.1 +/- 0.1%) had their risk modified in a clinically meaningful way by CRP adjustment. Targeting the screening to 2 groups, those with 1 risk factor and LDL cholesterol levels 130 to 159 mg/dl and those with moderately high risk and LDL cholesterol levels 100 to 129 mg/dl, we were able to identify all 5.3 million by screening only 14.8 million, achieving a screening yield of 35%. In conclusion, population-based screening with CRP provided a clinical impact for only 3.1% of United States residents. Patients with 1 risk factor and LDL cholesterol levels of 130 to 159 mg/dl and those with moderately high risk and LDL cholesterol levels of 100 to 129 mg/dl represent high-yield subgroups for routine CRP screening.

Ultrasound-detected carotid plaque as a screening tool for advanced subclinical atherosclerosis.

BACKGROUND: There is great need for a simple, noninvasive tool that can be used in an office setting to screen for subclinical atherosclerosis. In patients referred for cardiovascular (CV) risk assessment, we evaluated the ability of ultrasound screening for carotid plaque to identify patients with advanced subclinical atherosclerosis. METHODS: Consecutive asymptomatic patients without vascular disease referred by their physician for measurement of the ankle-brachial pressure index and carotid intima-media thickness (CIMT) were included. Carotid intima-media thickness was measured using the standardized ultrasound protocol from the Atherosclerosis Risk in Communities (ARIC) study. Advanced atherosclerosis was defined as CIMT > or = 75th percentile for age, sex, and race in ARIC. RESULTS: The mean age of the 327 subjects was 55.4 years (SD 7.7 years). The 10-year Framingham CV risk was 5.1% (4.8%). In a multiple logistic regression model that included Framingham CV risk, ankle-brachial pressure index, and use of lipid-lowering medications, plaque presence significantly predicted advanced atherosclerosis (odds ratio 3.08, 95% CI 1.91-4.96, P < .001). In stepwise regression models that included age, body mass index, current tobacco use, family history of premature CV disease, fasting glucose, sex, systolic blood pressure, total/high-density lipoprotein cholesterol ratio, and use of antihypertensive and lipid-lowering medications, plaque presence independently predicted advanced atherosclerosis (P < .001). CONCLUSION: Ultrasound detection of carotid plaque helped identify asymptomatic patients with advanced subclinical atherosclerosis. Screening for carotid plaque is easier than determination of CIMT and may help detect asymptomatic patients at increased CV risk.

Cardiovascular disease prevention.

In this chapter, we have reviewed many of the steps necessary for effective CHD risk reduction. The first step in the office setting is to assess the individual CHD risk. This combines the evaluation of current CHD or a "secondary risk equivalent" with the counting of risk factors and in many cases, the absolute risk calculation. The next steps are to consider each of the major modifiable risk factors (hypertension, dyslipidemia, diabetes mellitus, smoking status) to set goals for each and then work to achieve those goals through lifestyle changes and medication therapy. We reviewed each of these risk factors in detail and then turned to a discussion of emerging risk factors that may help "fine-tune" the risk assessment in some borderline cases. We also discussed additional non-invasive testing that is available to the clinician to help refine the assessment of current burden of disease. Finally, we discuss some of the barriers that exist on both a global and local level to effective treatment of CHD risk factors.