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Patient-reported Outcomes As A Clinical Vital Sign: BREAST-Q Implementation Lessons And Clinical Reference Values
Jacqueline J. Chu, BA1, Jonas A. Nelson, MD1, Colleen McCarthy, MD1, Carrie S. Stern, MD1, Meghana G. Shamsunder, MPH1, Andrea L. Pusic, MD2, Babak J. Mehrara, MD1.
1Memorial Sloan Kettering Cancer Center, New York, NY, USA, 2Brigham and Women's Hospital, Boston, MA, USA.

BACKGROUND: The BREAST-Q is the gold standard patient-reported outcome measure (PROM) of health-related quality of life and patient satisfaction following breast reconstruction. However, the routine, longitudinal implementation of the BREAST-Q has been challenging, so the BREAST-Q remain underutilized in patient care. We describe our institutionís 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. Annual completion rates prior to quality-improvement intervention were compared to those after intervention. Based on 2011-2017 scores, descriptive statistics were used to create reference values for BREAST-Q satisfaction subscales at preoperative and 6 months, 1 year, and 2 years after surgery and for BREAST-Q quality-of-life subscales at preoperative and 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Separate reference values were generated for implant and autologous patients. Reference values were externally validated by comparing patient characteristics and BREAST-Q scores between the MSK and the Mastectomy Reconstruction Outcomes Consortium (MROC) study cohorts.
RESULTS: Out of 109,435 requested BREAST-Qs, 41,981 BREAST-Qs were completed. Of BREAST-Qs requested within 2-years of surgery, the average annual BREAST-Q completion rate increased from 42.8% in 2011-2017 to 87.6% in 2019, the last full year of our study period. High completion rates were maintained January-July 2020; however, a significantly larger proportion of BREAST-Qs were completed at home in 2020 versus the same period in 2019 (49.7% vs. 38.8%, p<0.001), potentially due to the COVID-19 pandemic. Reference values were based on 3268 MSK patients (2932 implant, 336 autologous) and validated with 2814 MROC patients (1958 implant, 856 autologous). Overall, few timepoint comparisons between the datasets reached clinically meaningful and statistical difference. Clinically important differences between MSK and MROC cohorts were most prevalent at 3 months after surgery, with MSK cohort patients having higher Psychosocial Wellbeing (Implants: +9.4 points, p<0.001; Autologous: +4.7 points, p=0.019) and Sexual Wellbeing (Implants: +6.1 points, p<0.001). By 1 year after surgery, differences between MSK and MROC cohorts diminished. Reference values were used to create the BREAST-Q Reconstruction Engagement and Communication Tool (REACT) for implant and autologous patients.
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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