Mapping the Decision-Making Process for Adjuvant Endocrine Therapy for Breast Cancer: The Role of Decisional Resolve.

BACKGROUND: Studies show adjuvant endocrine therapy increases survival and decreases risk of breast cancer recurrence for hormone receptor-positive tumors. Yet studies also suggest that adherence rates among women taking this therapy may be as low as 50% owing largely to adverse side effects. Despite these rates, research on longitudinal patient decision making regarding this therapy is scant. OBJECTIVE: We sought to map the decision-making process for women considering and initiating adjuvant endocrine therapy, paying particular attention to patterns of uncertainty and decisional change over time. METHODS: A longitudinal series of semistructured interviews conducted at a multispecialty health care organization in Northern California with 35 newly diagnosed patients eligible for adjuvant endocrine therapy were analyzed. Analysis led to the identification and indexing of 3 new decision-making constructs-decisional phase, decisional direction, and decisional resolve-which were then organized using a visual matrix and examined for patterns characterizing the decision-making process. RESULTS: Our data reveal that most patients do not make a single, discrete decision to take or not take hormone therapy but rather traverse multiple decisional states, characterized by 1) phase, 2) direction, and 3) strength of resolve. Our analysis tracks these decisional states longitudinally using a grayscale-coded matrix. Our data show that decisional resolve wavers not just when considering therapy, as the existing concept of decisional conflict suggests, but even after initiating it, which may signal future decisions to forgo therapy. CONCLUSIONS: Adjuvant endocrine therapy, like other chronic care decisions, has a longer decision-making process and implementation period. Thus, theoretical, empirical, and clinical approaches should consider further exploring the new concept and measurement of decisional resolve, as it may help to improve subsequent medication adherence.

Surgical site infection rates at the Pontiac Health Care Centre, a rural community hospital.

INTRODUCTION: The prevalence of surgical site infections (SSIs) at the Pontiac Health Care Centre, a rural hospital, was compared with rates obtained by large multicentre studies. Postoperative nosocomial infection (NI) rates were also calculated. METHODS: A review of all surgical interventions involving an incision, excluding ophthalmological procedures, performed between October 2001 and March 2003 (n = 831) was undertaken. Various clinical parameters were recorded. Infection rates were calculated. Data were analyzed using either the chi2 or Student's t test. RESULTS: The overall SSI rate was 5.54%: 3.50% in clean cases (C), 6.77% in clean-contaminated cases (CC), and 14.58% in contaminated or dirty cases (D). The postoperative NI rate was 6.62% (C, 3.68%; CC, 9.90%; D, 16.67%). The mean duration of surgery was significantly higher among patients with SSIs and with NIs than those without infections for CC (133 +/- 95 v. 78 +/- 60 min, p < 0.05, and 129 +/- 82 v. 77 +/- 60 min, p < 0.001 respectively) and D (130 +/- 96 v. 82 +/- 62 min, p < 0.001, and 136 +/- 92 v. 80 +/- 60 min, p < 0.001 respectively). There were significantly higher SSI and NI rates among patients with combined American Society of Anesthesiologists (ASA) scores II and III than those with ASA score I in D (chi2 = 5.06 and chi2 = 6.34 respectively). There was also significantly higher SSI and NI rates among patients with combined Comorbidity Scale score 1-6 than those with no comorbid factors in CC (chi2 = 4.14 and chi2 = 4.42 repectively) and D (not significant and chi2 = 4.04 respectively). CONCLUSION: SSI rates at the Pontiac Health Care Centre were comparable to multicentre rates. Wound contamination category, type of surgery, duration of surgery, ASA score and Comorbidity Scale score were associated with SSI and NI rates. Studies have shown that examining NI rates decreases these rates by raising awareness; thus, we suggest that rural hospitals implement protocols to survey their postoperative NI rates.