InternetBased Patient Education: Facilitating Shared DecisionMaking Between Plastic Surgeons and Wom

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Internet-Based Patient EducationFacilitating
Shared Decision-MakingBetween Plastic Surgeons
and Women Seeking Breast ReconstructionAfter
MastectomyTopics in Womens HealthAPHA Poster
Session 4076.0, Board 5, 11/18/03

• Elizabeth Steinberger RN, MA, MPH
• UNC School of Public Health
• Edwin Wilkins MD, MS
• University of Michigan Section of Plastic Surgery

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Abstract
The Internet makes it possible to provide
especially up-to-date, low-cost, and accessible
health education interventions. Shared
decision-making theory was used to construct a
web site designed to give breast cancer patients
complete, balanced, easy-to-understand information
about breast reconstruction options after
mastectomy. In 2000, a pilot prospective
cohort study (n51) evaluated the acceptability
and impact of the site. In one clinic, women
viewed the web site before seeing the plastic
surgeon. In a second clinic, women were given a
brochure and a pencil talk while consulting the
same surgeon. The groups did not vary by age,
race, or computer literacy. Knowledge of breast
reconstruction options decision-making anxiety
and desire for information and satisfaction with
the provider, length of provider visit, and
quality of care likewise did not vary
significantly between groups. However, the web
group reported feeling more comfortable using
computers (plt0.01) and web sites (plt0.009).
Moreover, women using the web site reported
significantly higher satisfaction with the
quality of information (plt0.026) and spent an
average of 14.7 minutes less with the surgeon
(plt0.0005). The Web is an acceptable
educational venue for breast cancer patients.
Internet-based interventions can facilitate
shared decision-making between doctors and
patients by saving physician time while providing
higher quality health information to
patients. Breast Reconstruction Options After
Mastectomy A Consumers Guide http//www.surgery
.med.umich.edu/breastrecon.htm
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What is MBROS?
The Michigan Breast Reconstruction Outcome Study
(MBROS) is a six-year study (1994-2000) of
multiple aspects of breast reconstruction
outcomes. During the lifetime of the study,
MBROS has assessed a total of 397 actively
participating patients from 11 medical centers in
the U.S. and Canada. Patients are followed for
two years from the date of their breast
reconstruction surgeries to determine long-term
outcomes of breast reconstruction. MBROS is
supported by a grant from the Department of
Defense, United States Army Medical Research and
Material Command, DAMD 17-94-J-4044. Studies
have been completed on Psychosocial
outcomes of breast reconstruction by procedure
and timing of reconstruction. Patient
satisfaction with aesthetic results by procedure
type (implants vs. pedicle TRAMS vs. free
TRAMS). Objective, computerized assessments
of symmetry of breast reconstruction results by
procedure type. Physical functioning one
year after surgery by procedure type.
Mammography after TRAM flap reconstruction.
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Web Site DevelopmentPurposes and Sources
Purposes 1) Provide thorough, accurate,
easy-to-understand information about available
breast reconstruction options after
mastectomy. 2) Facilitate shared
decision-making between plastic surgeons and
women seeking post-mastectomy breast
reconstruction. Sources Breast Reconstruction
Information Unpublished University of
Michigan Hospital patient manual on Breast
reconstruction (Wilkins, 1996) Published
patient education brochures on breast
reconstruction Existing web sites on breast
cancer surgery Input from Former Breast
Reconstruction Patients Focus group (n5) to
assess text drafts for relevance and
readability. Interviews (n4) to gather
personal vignettes of breast reconstruction.
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Web Site Development Design
The web site was organized according to the
decision tree that must be traversed by patients
considering breast reconstruction
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Construction
All options portrayed include discussions of
equipment and procedures, advantages and
disadvantages, risks, and an options summary.
Some also include vignettes of the personal
experiences of former breast reconstruction
patients.
HOME PAGE
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Construction (2)
TRAM (Transverse Rectus Abdominus Muscle) Flap Rec
onstruction page, showing procedure, outcome
photos, and a vignette.
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Construction (3)
Implant risk page, listing and describing complica
tions of implants.
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Construction (4)
Table summarizing breast replacement options after
mastectomy
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Evaluation Background

• Shared medical decision-making theory (Mulley,
  Lindbergh--prostate cancer surgery). Provide
  patients with all of the information needed to
  understand the options, then allow them to choose
  their treatment in partnership with the doctor.
• Patients are more likely to be satisfied with the
  outcome of treatment because
• 1) they are invested in the decision-making
  process
• 2) they re better informed about the options
  and
• 3) the option chosen is more likely to suit
  their values and lifestyle.
• At the time of creation (1999)
• 1) No site existed that was solely dedicated to
  educating patients about breast reconstruction.
• 2) The feasibility of using Web-based materials
  to facilitate decision-making about surgery in
  clinical settings had not yet been tested.
• (Now sites on breast augmentation also exist and
  have been evaluated.)

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Methods
From January through June 2000, a pilot
prospective cohort study (n51) evaluated the
acceptability and impact of the site. An
experimental group of 34 pre-mastectomy breast
cancer patients attending the breast cancer
clinic at the University of Michigan Hospital
were instructed to view the web site online in
the patient education center or clinic thirty
minutes before their scheduled appointment with
the plastic surgeon. A fesearch assistant taught
those who were unfamiliar with computers or the
Internet how to use the site. A control group of
17 pre-mastectomy patients attending a private
breast reconstruction clinic were given a popular
brochure on breast reconstruction options in the
waiting room and a pencil talk explaining the
options from the same surgeon. Each patients
consultation with the plastic surgeon was timed
to the nearest minute. All patients were then
given an exit survey to assess their basic
knowledge of breast reconstruction options their
satisfaction with materials, provider, and length
of visit their anxiety regarding breast
reconstruction and their use of computers and
the Internet. Responses were recorded on
five-point Likert scales. After completing the
survey, patients were given a copy of the
Consumers Guide to Breast Reconstruction
Options after Mastectomy in booklet form to refer
to at home.
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Research Design
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Results
Demographics
Experimental Group (Web)
Control Group (Brochure)
Significance
47.3
Age
51.5
plt0.156
Educational Level
4.0 (college graduate)
3.1 (some college)
plt0.0015
85.3 White, 8.8 Black
75.6 White, 17.6 Black
plt0.597
Race
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Results (2)
Computer and Internet use
Experimental Group (Web)
Control Group (Brochure)
Significance
Use computer at home or work
76.4
70.5
plt0.690
Use Internet at home or work
70.5
70.6
plt0.961
Comfortable using computers
1.44
2.29
plt0.010
Comfortable using Internet
1.47
2.38
plt0.009
1 is high on a 1-5 scale
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Results (3)
Knowledge, Anxiety, Satisfaction Knowledge of
breast reconstruction options decision-making
anxiety and desire for information and
satisfaction with the provider, length of
provider visit, and quality of care did not vary
significantly between groups. Significant
Results
Experimental Group (Web)
Control Group (Brochure)
Significance
Satisfaction with information
plt0.026
1.24
2.00
Comfort using Internet
2.38
plt0.009
1.47
Minutes spent with provider
40.0
54.7
plt0.0005
1 is high on a 1-5 scale
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Significant Results 1. Satisfaction with
Information
I received very good explanations of my options
for replacing or replacing my breast(s) after
mastectomy.
Experimental (Web) group more satisfied with
information (plt0.026)
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Significant Results 2. Comfort Using Internet
I feel comfortable using web sites.
Experimental (Web) group more comfortable using
web sites (plt0.009). Experimental (Web) group
also more comfortable using computers (plt0.010).
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Significant Results 3. Time Spent With
Provider
Time spent with plastic surgeon
Experimental (Web) group spent less time with
plastic surgeon (40.0 minutes vs. 54.7 minutes,
plt0.0005)
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Conclusions
Limitations of the study 1) Small sample size
(n51) 2) Not randomized to conditions 3)
Possible confounders Study setting
(hospital vs. private clinic) Educational
level (higher for Web group) Conclusions 1)
It is feasible to use web-based educational
materials in a clinical setting. 2) Web-based
materials provide higher quality information than
brochures while saving physician time spent in
explanation of options.
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Contact Information
For further information contact Elizabeth
Steinberger RN, MA, MPH UNC School of Public
Health Rosenau Hall 308, CB7440 Chapel Hill,
NC 27599-7440 steinber_at_email.unc.edu Edwin
Wilkins MD, MS Section of Plastic
Surgery University of Michigan Hospital 2130
Taubman Center 1500 East Medical Center
Drive Ann Arbor, MI 48109-0340 ewilkins_at_umich.e
du