Why do hospital mastectomy rates vary? Differences in the decision-making experiences of women with breast cancer.

BACKGROUND: Hospital mastectomy rates vary. This study explores the relationship between mastectomy rates and breast cancer patients' consultation and decision-making experiences with specialist clinicians. METHODS: Qualitative semi-structured interviews were conducted with 65 patients from three purposively selected breast units from a single UK region. Patients provided with a choice of breast cancer surgery (breast conservation therapy (BCT) or mastectomy) were purposively recruited from high, medium and low case-mix-adjusted mastectomy rate units. RESULTS: Low mastectomy rate unit patients' consultation and decision-making experiences were markedly different to those of the medium and high mastectomy rate breast units. Treatment variation was associated with patients' perception of the most reassuring and least disruptive treatment; the content and style of information provision (equipoise or directed); level of patient participation in decision making; the time and process of decision making and patient autonomy in decision making. The provision of more comprehensive less directive information and greater autonomy, time and support of independent decision making were associated with a lower uptake of BCT. CONCLUSION: Variation in hospital mastectomy rates was associated with differences in the consultation and decision-making experiences of breast cancer patients. Higher mastectomy rates were associated with the facilitation of more informed autonomous patient decision making.

Changing trends in the decision-making preferences of women with early breast cancer.

BACKGROUND: Previous studies have indicated a predominance of passive decision-making styles among women with early-stage breast cancer in the UK offered a choice between breast-conserving surgery (BCS) and mastectomy. The aim of this study was to determine current decision-making styles and establish their association with operation choice and breast unit mastectomy rate. METHODS: A questionnaire survey was conducted among women from three specialist breast units representing high, medium and low case mix-adjusted mastectomy rates. RESULTS: Of 697 consecutive patients, 356 (51.1 per cent) completed the questionnaire, a mean of 6.9 (range 1.3-48.6) weeks after surgery. Some 262 women (73.6 per cent) underwent BCS and 94 (26.4 per cent) had a mastectomy. Some 218 patients (61.2 per cent) achieved their preferred decision-making style. The proportions of women achieving an active decision-making style were high, particularly for those choosing mastectomy (83 versus 58.0 per cent for BCS; P < 0.001) and in the high mastectomy rate unit (79.6 versus 53 and 52.2 per cent for medium and low rate units respectively; P < 0.001). CONCLUSION: More women chose an active decision-making style than in previous UK studies. The provision of greater treatment selection autonomy to women suitable for BCS may not reduce mastectomy rates.

Case-mix fails to explain variation in mastectomy rates: management of screen-detected breast cancer in a UK region 1997-2003.

Wide variation in the surgical management of breast cancer exists at hospital, regional, national and international level. To demonstrate whether variation in surgical practice observed at aggregate level between breast units persists following adjustment for case-mix, individual patient-level data from the Trent Breast Screening Programme Quality Assurance database (1997-2003) was analysed. Expected case-mix adjusted mastectomy rates were derived by logistic regression using the variables tumour size, site and grade, patient age and year of presentation, employing the region's overall case-mix adjusted practice as the reference population. The region's 11 breast screening units detected 5109 (3989 invasive) surgically managed primary breast cancers over the 6-year period. A total of 1828 mastectomies (Mx) were performed (Mx rate 35.8%, 95% confidence interval: 34.5-37.1%). Significant variation in mastectomy rates were observed between units (range 25-45%, P<0.0001), and persists following case-mix adjustment (P<0.0001). Two-fold variation in observed to expected unit mastectomy rate coefficient is demonstrated overall (range 0.66-1.36), increasing to almost four-fold variation in cancers less than 15 mm diameter (range 0.55-1.95). Significant variation in surgery for screen-detected primary breast cancer is not explained by case-mix. Further research is required to investigate potential patient and professional causative factors.

Selecting performance assessment methods for experienced physicians.

BACKGROUND: While much is now known about how to assess the competence of medical practitioners in a controlled environment, less is known about how to measure the performance in practice of experienced doctors working in their own environments. The performance of doctors depends increasingly on how well they function in teams and how well the health care system around them functions. METHODS: This paper reflects the combined experiences of a group of experienced education researchers and the results of literature searches on performance assessment methods. CONCLUSION: Measurement of competence is different to measurement of performance. Components of performance could be re-conceptualised within a different domain structure. Assessment methods may be of a different utility to that in competence assessment and, indeed, of different utility according to the purpose of the assessment. An exploration of the utility of potential performance assessment methods suggests significant gaps that indicate priority areas for research and development.

Is insight important? measuring capacity to change performance.

BACKGROUND: Some doctors who perform poorly appear not to be aware of how their performance compares with accepted practice. The way that professionals maintain their existing expertise and acquire new knowledge and skills - that is, maintain their 'currency' of practice - requires a capacity to change. This capacity to change probably requires the individual doctor to possess insight into his or her performance as well as motivation to change. There may be a range of levels of insight in different individuals. At some point this reaches a level which is inadequate for effective self-regulation. Insight and performance may be critically related and there are instances where increasing insight in the presence of decreasing performance can also cause difficulties. OBJECTIVE: This paper presents an exploration into the nature of insight, its relationship to professional performance and its measurement as part of performance, reflecting the combined experiences of a group of experienced education researchers and the results of literature searches on insight and performance. CONCLUSION: There may be individuals in whom insight is so lacking that they are beyond remediation. If there is a dichotomy between adequate and inadequate levels of insight, testing this could be a cost-effective way of determining where efforts for remediation should be focussed.