Implementing a Breast Reconstruction Decision Support Tool in Diverse Practice Settings

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Using the BREASTChoice clinical decision support tool improves a patient’s understanding of breast reconstruction options, timing, and possible complications, with the potential to significantly enhance their ability to make informed decisions about their reconstruction surgery based on their preference and risk factors.

Project Details -
Completed

Breast reconstruction includes a series of surgical procedures to create a breast shape after patients undergo mastectomy. For patients opting for a mastectomy, the choice of immediate or delayed breast reconstruction is crucial for restoring body image and enhancing quality of life. However, disparities exist in receipt of reconstruction by age and race, and immediate reconstruction poses a significant risk, with a complication rate around 23 percent, higher than many elective procedures. Lack of adequate risk information often leaves patients and surgeons uncertain during decision-making discussions. Currently, there are no reliable methods to personalize these discussions with patient-specific data. Insufficiently informed patients may experience decision regret due to unforeseen complications and additional procedures.

Researchers previously developed BREASTChoice to educate patients about breast reconstruction, estimate personalized risk for complications from immediate mastectomy reconstruction, aid patients in exploring preferences, and inform clinicians about patients' risks and preferences.

The specific aims of the research were as follows:

  • Elicit stakeholder input and evaluate the implementation potential of BREASTChoice.
  • Optimize and modify BREASTChoice based on stakeholder input and usability testing, and plan for implementation into routine care.
  • Evaluate the effects of the updated BREASTChoice on decision quality, decisional conflict, and treatment choice in a randomized controlled trial in diverse sites.

Researchers used mixed methods to refine BREASTChoice and test the enhanced tool’s effectiveness, including semi-structured qualitative interviews, usability interviews, surveys, questionnaires, use of existing validated tools, and a multisite randomized trial. Refinements included simplifying its accessibility and usability for patients and clinicians within their regular routines and workflows. Participants randomized to the BREASTChoice tool showed enhanced knowledge about breast reconstruction, including type, timing, and complication risks, with older adults and those from racially minoritized backgrounds especially benefitting. In addition, fewer women at increased risk for complications opted for immediate breast reconstruction, a procedure associated with higher risk, suggesting a potential for significant improvement in decision quality and alignment between patients’ surgery choice and clinical risks and preferences. The enhanced tool garnered high usability, feasibility, and acceptance among both patients and clinicians, and seamlessly integrated into the electronic health record (EHR) and patient portal, retrieving risk factors from the EHR and allowing patients to input missing or inaccurate data for risk prediction. Of significance, investigators believe BREASTChoice is the first breast reconstruction decision support tool integrating personalized risk prediction, evidence-based patient education, and CDS.