Sylvia Lambrechts

The Voice of the Patient Methodology: A Novel Mixed-Methods Approach to Identifying Treatment Goals for Men with Prostate Cancer

BackgroundMany guidelines advocate the use of shared decision making for men with newly diagnosed prostate cancer. Decision aids can facilitate the process of shared decision making. Implicit in this approach is the idea that physicians understand which elements of treatment matter to patients. Little formal work exists to guide physicians or developers of decision aids in identifying these attributes. We use a mixed-methods technique adapted from marketing science, the ‘Voice of the Patient’, to describe and identify treatment elements of value for men with localized prostate cancer.MethodsWe conducted semi-structured interviews with 30 men treated for prostate cancer in the urology clinic of the West Los Angeles Veteran Affairs Medical Center. We used a qualitative analysis to generate themes in patient narratives, and a quantitative approach, agglomerative hierarchical clustering, to identify attributes of treatment that were most relevant to patients making decisions about prostate cancer.ResultsWe identified five ‘traditional’ prostate cancer treatment attributes: sexual dysfunction, bowel problems, urinary problems, lifespan, and others’ opinions. We further identified two novel treatment attributes: a treatment’s ability to validate a sense of proactivity and the need for an incision (separate from risks of surgery).ConclusionsApplication of a successful marketing technique, the ‘Voice of the Customer’, in a clinical setting elicits non-obvious attributes that highlight unique patient decision-making concerns. Use of this method in the development of decision aids may result in more effective decision support.

Decisional Quality in Patients With Small Renal Masses

OBJECTIVE To measure decisional quality in patients being counseled on treatment for small renal masses and identify potential areas of improvement. MATERIALS AND METHODS A total of 73 patients diagnosed with small renal masses at the University of California, Los Angeles Health completed an instrument measuring decisional conflict, patient satisfaction with care, disease-specific knowledge, and patient impression that shared decision-making occurred in the visit after counseling by a specialist. Participant characteristics were compared between those with high and low decisional conflict using chi-square or Student t test (or Wilcoxon rank-sum test). RESULTS Participants were mostly older (mean age 63.5), white (84%), in a relationship (61%), and unemployed or retired (63%). Mean knowledge score was 59% correct. The mean (standard deviation) decisional conflict score was 16.4 (18.4) indicating low levels of decisional conflict but with a wide range of scores. Comparing participants with high decisional conflict with those with low decisional conflict, there were significant differences in knowledge scores (Wilcoxon P = .0069), patient satisfaction with care (P = .0011), and perceived shared decision-making (P <.0001). CONCLUSION Patients with small renal masses generally have low levels of decisional conflict and can identify a preferred treatment after a physician visit. However, both groups lack overall knowledge about their disease even after counseling, and thus may be heavily influenced by paternalistic care. Those patients with decisional conflicts are less likely to perceive their care as satisfactory and are less likely to be involved in decision-making.

PD06-02 DECISIONAL QUALITY AND THE IMPACT OF SHARED DECISION MAKING AMONG PATIENTS WITH UROLOGIC STONE DISEASE

INTRODUCTION AND OBJECTIVES: To assess the contemporary knowledge of Human Papillomavirus (HPV) and its association with penile cancer in a nationwide cohort from the US. METHODS: We utilized the Health Information National Trends Survey (HINTS), a cross-sectional telephone survey performed in the US initiated by the National Cancer Institute. Themost recent iteration, HINTS 4Cycle4,wasconducted inmail formatbetweenAugust 19andNovember 17, 2014. Primary endpoints included knowledge of HPV and its causal relationship to penile cancer. Baseline characteristics included sex, age, education, race&ethnicity, income, residency, personal or family history of cancer, health insurance status, and internet use. Multivariable logistic regression assessed predictors of HPV and penile cancer knowledge. RESULTS: An unweighted sample of 3,376 respondents was extracted from the HINTS 4, Cycle 4. Whereas 64.4% of respondents had heard of HPV, only 29.5% of these were aware that it could cause penile cancer. Men were significantly less likely to have heard of HPV than women (OR 0.32 95% CI 0.24-0.43). Older age; African-American, Asian, and “other race”; being married; from a lower education bracket; having a personal cancer history; and those without internet access were significantly less likely to have heard of HPV. None of our examined variables were independent predictors for the knowledge of the association of penile cancer and HPV. CONCLUSIONS: Our analysis of a large, nationally representative survey demonstrates that the majority of the American public is familiar with HPV but lack a meaningful understanding between this virus and penile cancer. Primary care providers and specialists should be encouraged to intensify counseling about this significant association as a primary preventive measure of this potentially fatal disease.

PD09-07 THE IMPACT OF SHARED DECISION MAKING SOFTWARE ON DECISIONAL QUALITY OF MEN UNDERGOING TREATMENT FOR BPH: AN INTERIM ANALYSIS

INTRODUCTION AND OBJECTIVES: Physicians need practical methods to accurately estimate life expectancy when counseling older men with comorbidities regarding treatment of prostate cancer. Although numerous nomograms exist for prediction of life expectancy (LE), few are used in practice due to the difficulty of integration into busy clinical workflows. We sought to determine if survival could be accurately predicted if reduced to a count of several common comorbidities that pose a high risk to mortality. In selecting these comorbidities, we aimed to balance frequency and risk in order to maximize identification of men at risk for overtreatment based on <10-year LE. METHODS: We sampled 1,598 men with newly diagnosed prostate cancer at two Southern California Veterans Affairs Medical Centers from 1998 to 2004. We created rank-ordered lists of comorbidities organized by frequency and highest risk of mortality. Separate ranked lists were then created by differentially weighting comorbidities by frequency to risk ratios: 1:6, 1:4, 1:2, 1:1, 2:1, 4:1, and 6:1. By successively adding comorbidities from highestto tenth highestranked, a set of 10 candidate comorbidity indices was constructed for each list. Using competing risks regression analysis, we determined cindex, the number of men with <10-year LE, and the number of men with <10-year LE treated with surgery or radiation for each index. RESULTS: Candidate comorbidity indices heavily weighted by frequency were poor at identifying men with <10-year LE, while indices heavily weighted by risk of mortality failed to identify men who were overtreated. Six candidate indices each found more than 300 men with <10-year LE (range 303-392); all six were weighted either 2:1, 1:1, or 1:2 by frequency to risk ratio and included highly similar comorbidities. Two of the six indices identified more than 200 men with <10-year LE overtreated with surgery or radiation (range 173-203). The candidate index with the highest number overtreated was weighted 1:1 by frequency to risk and included six comorbidities: 1) chronic obstructive pulmonary disease 2) congestive heart failure 3) peripheral vascular disease 4) stroke 5) myocardial infarction 6) exertional angina. C-index for this index was 0.66. CONCLUSIONS: A simple count of six comorbidities predicts the risk of 10-year other-cause mortality and robustly identifies men who are overtreated for early stage prostate cancer. Simplifying estimation of life expectancy may be key to operationalizing this critical variable for prostate cancer decision-making.

Decisional Quality of Women Choosing a Contraceptive Method in an Urban Gynecology Practice [8O]

INTRODUCTION: Women have an array of birth control options to choose from. Little is known about the decisional quality of choices made in reproductive health. METHODS: A cross-sectional survey of women in a high-volume Obstetrics/Gynecology clinic was conducted. Eligible participants were English speaking women of reproductive age that completed a discussion with their provider regarding contraceptive options. Familiarity for contraceptive options was measured using a 5-point Likert scale; Decisional conflict was measured using the SURE (4-item) validated scale. Questionnaire content also included items for satisfaction with care, shared decision making, and health literacy. RESULTS: Participants (N=105) were most familiar with condoms (97%) and the birth control pill (96%), and were least familiar with tubal ligation (36%) and the sponge (34%). Most women chose the birth control pill (44%) as their contraceptive choice. Women with low decisional conflict (84%; SURE=4), stated that they were more likely to stick to their decision (90% versus 73%), and were more satisfied with their decision (98% versus 50%). Those satisfied with their decision were more likely to be younger, not employed full-time (40% versus 69%), more likely to have made a choice of method both before (91% versus 69%) and after seeing the doctor (98% versus 54%), and had lower decisional conflict. CONCLUSION: Increased decisional conflict is associated with lower patient satisfaction and a lowered patient predicted adherence to birth control strategy. Methods to improve decisional conflict, such as shared decision making, may improve decision quality for women choosing from various contraceptive methods.

Improving Decisional Quality on Labor and Delivery: What Do Women Know About Cesarean Delivery? [23K]

INTRODUCTION: We aim to describe decisional quality (defined by decision-specific knowledge, decisional conflict and patient satisfaction) for women whose gestational age indicated that they should have been counseled regarding birthing options. We also aim to understand how confident patients are regarding their birthing choice and predictors of decisional conflict. METHODS: A convenience sample of antepartum patients receiving care at University based clinics was selected. Patients were P0, 35 weeks or greater gestation, and without medical indication for cesarean delivery. Knowledge was measured using a new instrument developed by a multi-stakeholder panel. The SURE scale was used to measure decisional conflict. Satisfaction with care, shared decision-making, and sources of information regarding treatment decision-making was also measured. RESULTS: 91% of respondents (N=81) planned on a vaginal delivery, 7% reported they were undecided and a single respondent reported they planned to have a cesarean delivery. Overall knowledge score was 52%. Knowledge scores individually and overall did not correlate with decisional conflict, however those with lower knowledge scores were less sure that they would stay with their decision (OR 5.6). Most patients report “friends and family” as their most influential source (63%), however this was also associated with higher decisional conflict (P=.035). Patients whose providers had asked them about delivery preferences had lower decisional conflict (P=.01). CONCLUSION: This initiative provided a comprehensive assessment of knowledge areas that were deemed important for a woman in making the choice between cesarean and vaginal delivery as well as factors predictive of choice certainty. Future work to improve decisional quality is warranted.