Patient-Reported Outcomes As A Clinical Vital Sign: Breast-Q Implementation Lessons And Clinical Reference Values
Jonas A. Nelson, MD, MPH1, Jacqueline J. Chu, BA1, Stefan Dabic, MPH1, Meghana G. Shamsunder, MPH1, Elizabeth O. Kenworthy, MD1, Carrie S. Stern, MD1, Colleen M. McCarthy, MD1, Andrea L. Pusic, MD, MHS2, Babak J. Mehrara, MD1.
1Memorial Sloan Kettering Cancer Center, New York, NY, USA, 2Brigham and Women's Hospital, Boston, MA, USA.
Background: BREAST-Q has been challenging to implement for routine patient care. We describe our institution's improvements to BREAST-Q clinical implementation through increasing patient engagement and creating reference values. Methods: We reviewed BREAST-Qs completed by postmastectomy breast reconstruction patients at Memorial Sloan Kettering Cancer Center (MSK) in 2011-2019. In 2018, we began implementing BREAST-Q as a vital sign; BREAST-Qs were automatically administered before every encounter through an online patient portal. Clinics had a "BREAST-Q Champion" to troubleshoot implementation issues, assisted by a digital dashboard that tracked response rates. We examined annual BREAST-Q completion rates for 2011-2019. Based on 2011-2017 scores, we used descriptive statistics to create longitudinal reference values from pre-op to 2-years post-op. Patient characteristics and BREAST-Q scores were compared to those of the Mastectomy Reconstruction Outcomes Consortium (MROC) cohort for external validation. Results: In 2018-2019, we collected 9495 BREAST-Qs from patients within 2-years post-op, compared to 15,126 in 2011-2017. Annual completion rate was 87.6% in 2019, compared to an average of 42.8% in 2011-2017. Reference values were based on 3268 MSK patients (2932 implant, 336 autologous) and validated with 2814 MROC patients (1958 implant, 856 autologous). Few clinically meaningful and statistical differences were found during validation. We created the Real-time Engagement and Communication Tool (REACT) for implant and autologous patients. REACT presents 25th, 50th, and 75th percentile score trajectories from pre-op to 2 years post-op. Conclusion: Sustained, routine implementation of BREAST-Q is possible, and REACT adds to the clinical applicability of BREAST-Q by providing context to a numerical score.
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