Medical Decision Making Expanding the reach of decision and communication aids in a breast care center: A quality improvement study Jeffrey K. Belkora *, Alexandra Teng, Shelley Volz, Meredith K. Loth, Laura J. Esserman University of California, San Francisco, USA 1. Introduction Many women diagnosed with breast cancer wish to be well informed and to participate actively in treatment decisions [1,2]. In addition, a legal and ethical doctrine of informed consent holds that patients should be informed of treatment risks and benefits and actively consent to treatment [3]. Knowledge and active participation in cancer decision making may also be associated with psychological and physical health benefits [4]. The Cochrane Collaboration has conducted systematic reviews of interventions aimed at helping people become well-informed participants in medical decision making [5–7]. These interventions include decision and communication aids. Decision aids are print or multimedia materials that present focused information about treatment options and their outcomes. Communication aids include question-listing, audio-recording, and note-taking services. Ques- tion-listing involves helping patients develop and write down a list of questions. Audio-recording and note-taking involves providing patients with recordings and written summaries of the doctor’s answers to their questions. Decision aids are associated with increased patient knowledge [5], while communication aids are associated with increased question-asking [6] and information recall [7]. Therefore, in order to promote patient knowledge and participation, in 2005 we translated into practice these proven patient-centered interventions. Specifically, we implemented decision aids, question-listing, audio-recording, and note-taking at the UCSF Breast Care Center. In pilot studies, we found that patients and physicians reported increased satisfaction with consultations that featured communication aids compared to those that did not, as well as attenuated communication barriers, improved quality of decision making, and improved agreement on the quality of decision making [8,9]. We monitored our ongoing implementation in early 2007 and found further evidence of effectiveness consistent with Cochrane reviews of these interventions. Responding to surveys before and after using the communication aids, patients reported improve- ments in decision self-efficacy and decisional conflict [10]. Before and after reviewing decision aids, patients reported high satisfac- tion (mean of 4.2 out of a maximum of 5, n = 163), increases in knowledge (51–72% items correct, n = 100) and reductions in mean Patient Education and Counseling 83 (2011) 234–239 ARTICLE INFO Article history: Received 28 November 2009 Received in revised form 30 May 2010 Accepted 3 July 2010 Keywords: Shared decision making Decision aids Questions Audio-recordings Notes Summaries Professional-patient communications Implementation Reach ABSTRACT Objective: One academically based breast cancer clinic implements decision and communication aids as part of routine clinical care. This quality improvement study aimed to expand reach of these supportive materials and services with budget-neutral program changes. Methods: We used program theory and continuous quality improvement to design changes to our program. We calculated reach as the number of new patient visits for which we administered decision and communication aids. We compared reach before and after the program changes. Results: Program changes included: reassigning program outreach tasks from over-committed to under- utilized personnel; deploying personnel in floating rather than fixed schedules; and creating a waitlist so service delivery was dynamically reallocated from overbooked to underbooked personnel. Before these changes, we reached 208 visitors with decision aids, and 142 visitors with communication aids. Changes were associated with expanded reach, culminating in program year 2008 with the delivery of 936 decision aids and 285 communication aids. Conclusions: We observed over a fourfold increase in decision aid reach and a twofold increase in communication aid reach. We attribute increases to recent program changes. Practice implications: This study illustrates how program theory and quality improvement methods can contribute to expanded reach of decision and communication aids. ß 2010 Elsevier Ireland Ltd. All rights reserved. * Corresponding author at: 3333 California Street, Suite 265, San Francisco, CA 94118, USA. Tel.: +1 650 533 6965; fax: +1 415 651 8574. E-mail address: jeff.belkora@ucsfmedctr.org (J.K. Belkora). Contents lists available at ScienceDirect Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou 0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.07.003