Christine M. Gunn

Content, Readability, and Understandability of Dense Breast Notifications by State

Additional Contributions: We thank the following site principal investigators: Stephen L. Rose, MD (TOPS Comprehensive Breast Center); Linda N. Greer, MD (John C. Lincoln Breast Health and Research Center); Mary K. Hayes, MD (Radiology Associates of Hollywood); Ingrid L. Ott, MD (Washington Radiology Associates); Kara L. Carlson, MD (Evergreen Breast Health Center); Thomas M. Cink, MD (Edith Sanford Breast Health Institute); Lora D. Barke, DO (Invision Sally Jobe Breast Center). We also acknowledge Anne Marie McCarthy, PhD (Massachusetts General Hospital), for data analysis and David Pasta, MS, and Faith Beery, MS (both from ICON), for statistical analysis of the results. Drs Rose, Greer, Hayes, Ott, Carlson, Cink, and Barke received a research grant for their contributions in this study from Hologic. All other contributors did not receive compensation for their contribution aside from their salaries.

An assessment of patient navigator activities in breast cancer patient navigation programs using a nine-principle framework.

OBJECTIVE To determine how closely a published model of navigation reflects the practice of navigation in breast cancer patient navigation programs. DATA SOURCE Observational field notes describing patient navigator activities collected from 10 purposefully sampled, foundation-funded breast cancer navigation programs in 2008-2009. STUDY DESIGN An exploratory study evaluated a model framework for patient navigation published by Harold Freeman by using an a priori coding scheme based on model domains. DATA COLLECTION Field notes were compiled and coded. Inductive codes were added during analysis to characterize activities not included in the original model. PRINCIPAL FINDINGS Programs were consistent with individual-level principles representing tasks focused on individual patients. There was variation with respect to program-level principles that related to program organization and structure. Program characteristics such as the use of volunteer or clinical navigators were identified as contributors to patterns of model concordance. CONCLUSIONS This research provides a framework for defining the navigator role as focused on eliminating barriers through the provision of individual-level interventions. The diversity observed at the program level in these programs was a reflection of implementation according to target population. Further guidance may be required to assist patient navigation programs to define and tailor goals and measurement to community needs.

Knowledge and Perceptions of Family Leave Policies Among Female Faculty in Academic Medicine

OBJECTIVE The purpose of this research was to examine the knowledge and perceptions of family leave policies and practices among senior leaders including American Association of Medical College members of the Group on Women in Medicine and Science (GWIMS) to identify perceived barriers to career success and satisfaction among female faculty. METHODS In 2011 and 2012, GWIMS representatives and senior leaders at 24 medical schools were invited to participate in an interview about faculty perceptions of gender equity and overall institutional climate. An inductive, thematic analysis of the qualitative data was conducted to identify themes represented in participant responses. The research team read and reviewed institutional family leave policies for concordance with key informant descriptions. FINDINGS There were 22 GWIMS representatives and senior leaders in the final sample. Participants were all female; 18 (82%) were full professors with the remainder being associate professors. Compared with publicly available policies at each institution, the knowledge of nine participants was consistent with policies, was discrepant for six, with the remaining seven acknowledging a lack of knowledge of policies. Four major themes were identified from the interview data: 1) Framing family leave as a personal issue undermines its effect on female faculty success; 2) poor communication of policies impairs access and affects organizational climate; 3) discrepancies in leave implementation disadvantage certain faculty in terms of time and pay; and 4) leave policies are valued and directly related to academic productivity. CONCLUSIONS Family leave policies are an important aspect of faculty satisfaction and academic success, yet policy awareness among senior leaders is lacking. Further organizational support is needed to promote equitable policy creation and implementation to support women in medical academia.

Shared Decision Making and the Use of Screening Mammography in Women Younger Than 50 Years of Age

Current breast cancer screening guidelines promote the use of shared decision making for women younger than 50 years of age, yet their effect on mammography utilization is largely unknown. This study aimed to examine the effect of two elements of shared decision making on the use of mammogram screening: patient-perceived choice and patient–provider communication. Data were obtained from HINTS 4, a nationally representative survey of the U.S. population, administered from 2011 to 2013. Choice was measured with the question “Has a doctor ever told you that you could choose whether or not to have a mammogram?” Communication was measured using a 7-item scale (range: 7–28; higher scores denote better communication). Binary logistic regression models assessed the effect of patient choice and communication on ever having a mammogram using weighted sample data. The sample included 1,085 women younger than 50 years of age: 31% of women perceived having a choice to undergo mammography. The mean patient–provider communication score was 22.8. Those who thought they were given a choice regarding mammography were more likely to have a mammogram relative to those who did not think a choice was given by the provider. Patient–provider communication had no significant association with mammography utilization. Patient perceived choice, but not patient-provider communication, is positively associated with mammography utilization in women younger than 50 years of age.

Women’s perceptions of dense breast notifications in a Massachusetts safety net hospital: “So what is that supposed to mean?”

OBJECTIVE Currently, 30 US states mandate that radiologists notify women when dense breast tissue is found on mammography. Little is understood about how notifications are perceived by recipients. This qualitative study sought to understand how dense breast notifications (DBNs) impact womens perceptions and their participation in follow-up care. METHODS We assessed rates of DBN recall and conducted semi-structured telephone interviews with 30 English-speaking women ages 40 to 74 after receiving a DBN from a Massachusetts hospital. Content coding characterized womens recall of the notification content, perceptions of breast density, and planned or actual participation in follow-up care. RESULTS Most women (81%) recalled receiving a DBN, but few could recall specific content. Women described struggling to understand the meaning of breast density and created their own explanatory models of dense breasts that differed from medical explanations. Many women planned to or did talk with their doctors about breast density as a result of receiving the notification. CONCLUSIONS Women receiving DBNs have limited knowledge and many misperceptions about the implications of having dense breasts. PRACTICE IMPLICATIONS Educational support is needed to promote informed decision- making about breast cancer screening that incorporates personal risk in the setting of dense breast legislation.

What Makes Patient Navigation Most Effective: Defining Useful Tasks and Networks

Abstract:Given the momentum in adopting patient navigation into cancer care, there is a need to understand the contribution of specific navigator activities to improved clinical outcomes. A mixed-methods study combined direct observations of patient navigators within the Patient Navigation Research Program and outcome data from the trial. We correlated the frequency of navigator tasks with the outcome of rate of diagnostic resolution within 365 days among patients who received the intervention relative to controls. A focused content analysis examined those tasks with the strongest correlations between navigator tasks and patient outcomes. Navigating directly with specific patients (r = 0.679), working with clinical providers to facilitate patient care (r = 0.643), and performing tasks not directly related to their diagnostic evaluation for patients were positively associated with more timely diagnosis (r = 0.714). Using medical records for non-navigation tasks had a negative association (r = –0.643). Content analysis revealed service provision directed at specific patients improved care while systems-focused activities did not.

Social Network Structures of Breast Cancer Patients and the Contributing Role of Patient Navigators

BACKGROUND Minority women in the U.S. continue to experience inferior breast cancer outcomes compared with white women, in part due to delays in care delivery. Emerging cancer care delivery models like patient navigation focus on social barriers, but evidence demonstrating how these models increase social capital is lacking. This pilot study describes the social networks of newly diagnosed breast cancer patients and explores the contributing role of patient navigators. MATERIALS AND METHODS Twenty-five women completed a one hour interview about their social networks related to cancer care support. Network metrics identified important structural attributes and influential individuals. Bivariate associations between network metrics, type of network, and whether the network included a navigator were measured. Secondary analyses explored associations between network structures and clinical outcomes. RESULTS We identified three types of networks: kin-based, role and/or affect-based, or heterogeneous. Network metrics did not vary significantly by network type. There was a low prevalence of navigators included in the support networks (25%). Network density scores were significantly higher in those networks without a navigator. Network metrics were not predictive of clinical outcomes in multivariate models. CONCLUSION Patient navigators were not frequently included in support networks, but provided distinctive types of support. If navigators can identify patients with poorly integrated (less dense) social networks, or who have unmet tangible support needs, the intensity of navigation services could be tailored. Services and systems that address gaps and variations in patient social networks should be explored for their potential to reduce cancer health disparities. IMPLICATIONS FOR PRACTICE This study used a new method to identify the breadth and strength of social support following a diagnosis of breast cancer, especially examining the role of patient navigators in providing support. While navigators were only included in one quarter of patient support networks, they did provide essential supports to some individuals. Health care providers and systems need to better understand the contributions of social supports both within and outside of health care to design and tailor interventions that seek to reduce health care disparities and improve cancer outcomes.

Challenges in Recruiting, Retaining and Promoting Racially and Ethnically Diverse Faculty

BACKGROUND Despite individual and institutional awareness of the inequity in retention, promotion and leadership of racially and ethnically underrepresented minority faculty in academic medicine, the number of such faculty remains unacceptably low. The authors explored challenges to the recruitment, retention and promotion of underrepresented faculty among a sample of leaders at academic medical centers. METHODS Semi-structured interviews were conducted from 2011 to 2012 with 44 senior faculty leaders, predominantly members of the Group on Diversity and Inclusion (GDI) and/or the Group on Women in Medical Sciences (GWIMS), at the 24 randomly selected medical schools of the National Faculty Survey of 1995. All institutions were in the continental United States and balanced across public/private status and geographic region. Interviews were audio-taped, transcribed, and organized into content areas before conducting inductive thematic analysis. Themes expressed by multiple informants were studied for patterns of association. RESULTS The climate for underrepresented minority faculty was described as neutral to positive. Three consistent themes were identified regarding the challenges to recruitment, retention and promotion of underrepresented faculty: 1) the continued lack of a critical mass of minority faculty; 2) the need for coordinated programmatic efforts and resources necessary to address retention and promotion; and 3) the need for a senior leader champion. CONCLUSION Despite a generally positive climate, the lack of a critical mass remains a barrier to recruitment of racially and ethnically underrepresented faculty in medicine. Programs and resources committed to retention and promotion of minority faculty and institutional leadership are critical to building a diverse faculty.

A Qualitative Study of Spanish-Speakers’ Experience with Dense Breast Notifications in a Massachusetts Safety-Net Hospital

BackgroundLegislation requiring mammography facilities to notify women if they have dense breast tissue found on mammography has been enacted in 34 US states. The impact of dense breast notifications (DBNs) on women with limited English proficiency (LEP) is unknown.ObjectiveThis study sought to understand Spanish-speaking women’s experience receiving DBNs in a Massachusetts safety-net hospital.DesignEligible women completed one audio-recorded, semi-structured interview via telephone with a native Spanish-speaking research assistant trained in qualitative methods. Interviews were professionally transcribed verbatim and translated. The translation was verified by a third reviewer to ensure fidelity with audio recordings.ParticipantsNineteen Spanish-speaking women ages 40–74 who received mammography with a normal result and recalled receiving a DBN.ApproachUsing the verified English transcripts, we conducted a content analysis to identify women’s perceptions and actions related to receiving the notification. A structured codebook was developed. Transcripts were independently coded and assessed for agreement with a modification of Cohen’s kappa. Content codes were grouped to build themes related to women’s perceptions and actions after receiving a DBN.Key ResultsNineteen Spanish-speaking women completed interviews. Nine reported not receiving the notification in their native language. Four key themes emerged: (1) The novelty of breast density contributed to notification-induced confusion; (2) women misinterpreted key messages in the notification; (3) varied actions were taken to seek further information; and (4) women held unrealized expectations and preferences for follow-up.ConclusionsNot having previous knowledge of breast density and receiving notifications in English contributed to confusion about its meaning and inaccurate interpretations of key messages by Spanish speakers. Tools that promote understanding should be leveraged in seeking equity in risk-based breast cancer screening for women with dense breasts.

Explaining Breast Density Recommendations: An Introductory Workshop for Breast Health Providers

Introduction High breast density is an independent risk factor for breast cancer and can decrease the sensitivity of mammography. However, evidence surrounding recommendations for patient risk stratification and supplemental screening is evolving, and providers receive limited training on breast density counseling. Methods We implemented an introductory, interactive workshop about breast density including current evidence behind supplemental screening and risk stratification. Designed for providers who counsel women on breast health, this workshop was evaluated with internal medicine providers, primary care residents, and radiology residents. We surveyed participants about knowledge and attitudes at baseline, postintervention (residents and providers), and 3-month follow-up (providers only). We compared baseline and postintervention scores and postintervention and 3-month follow-up scores using paired t tests and McNemars tests. Results Internal medicine providers had significant gains in knowledge when comparing baseline to postintervention surveys (6.5–8.5 on a 10-point scale, p < .0001), with knowledge gains maintained when comparing postintervention to 3-month follow-up surveys (p = .06). Primary care and radiology residents also had significant gains in knowledge when comparing baseline to postintervention surveys (p < .004 for both). All learner groups reported increases in their confidence regarding counseling women about breast density and referring for supplemental screening. Discussion Through this breast density session, we showed trends for increased knowledge and change in attitudes for multiple learner groups. Because we aim to prepare providers with the best currently available recommendations, these materials will require frequent updating as breast density evidence and national consensus evolve.