Research Article
Perception of Healthcare Providers Regarding Breast Reconstruction “Women’s Health and Cancer Rights Act “(1998) Through Evaluation of Continuing Medical Education Conference
CRachael Essig2 and Cristiane M. Ueno1*
1Department of Surgery, Division of Plastic, Hand & Reconstructive Surgery, West Virginia University, USA
2West Virginia University - School of Medicine, USA
*Corresponding author: Cristiane M. Ueno, Department of Surgery, Division of Plastic, Reconstructive and Hand Surgery, West Virginia University, PO Box 9238, Morgantown, WV 26505-9238, USA
Published: 30 Nov, 2016
Cite this article as: Essig R, Ueno CM. Perception of
Healthcare Providers Regarding Breast
Reconstruction “Women’s Health and
Cancer Rights Act “(1998) Through
Evaluation of Continuing Medical
Education Conference. Clin Surg. 2016;
1: 1180.
Abstract
Purpose: Studies have shown increase in breast reconstruction after the federal 1998 Women’s Health and Cancer Rights Act, however, disparities in breast reconstruction remain. Reconstruction
disparities are multifactorial: including demographics, comorbidities, access to information and
knowledge of available procedures. The aim of this study is to: assess the perception of Breast
Reconstruction Coverage as a Federal Law amongst health care providers in West Virginia.
Methods: Data was collected in two consecutive conferences in 2015 and 2016. During both
conferences attendants received a lecture on breast reconstruction options with emphasis in
education of the “Women’s Health and Cancer Rights Act”. Perception was measured through pre
and post questionnaire in an Annual Continuing Medical Education (CME) Conference.
Results: In 2015, eighty-one attendants completed both questionnaires. Initially 42% answered the
correct answer and post-conference 61.7% of the providers were aware that insurance would cover
reconstruction.
In 2016, one hundred and nineteen attendants completed both questionnaires. Before conference
37.82% of providers were aware that patients could receive their breast reconstruction covered by
insurance and it changed to 69.7% after conference.
An effectiveness score was designed to evaluate perception of providers pre and post-conference.
The effectiveness score did not show statistically significant change in 2015, whereas in 2016 it
showed statistically significant change in perception of WHCRA. (p< 0.001). When comparing 2015
and 2016, there is a positive impact of the conference education and positive perception change
from 2015 to 2016.
Conclusion: Although this is a survey limited to a few number of participants, it shows that
there are still limitations regarding healthcare provider’s perception of breast reconstruction
possibilities for patients and timing of referral. It highlights the need for continuous education of
physician/providers to increase breast reconstruction awareness. Intervening in patient-physician
communication can result in breast reconstruction surgery rates more consistent with the overall
population (urban and rural), overcome the negative effects of racial/ethnic disparities in breast
reconstruction and improve quality of life among the underserved patient population.
Keywords: Breast reconstruction; Breast cancer; Mastectomy
Background
A United States of America female’s lifetime risk of developing invasive breast cancer is
approximated to be 12% or 1 in 8 females during their lifetime [1-2]. It is estimated that about
240,000 women will be diagnose with breast cancer per year. Of these diagnoses, it is projected that
60% of patients will undergo breast-conserving therapy, while 40% will undergo mastectomy [1].
The diagnosis and treatment of breast cancer can inflict significant stress on patients, while breast
reconstruction can lead to improve of body image, sexuality and self-confidence [3-5].
In 1998, the Women’s Health and Cancer Rights Act (WHCRA) was passed which mandates that
all insurance carriers cover post-mastectomy breast reconstruction
[6-7]. Additionally in 2001, there was a legislation that placed
penalties for insurance companies who were noncompliant with the
WHCRA [7-8].
With the placement of this legislation it was presumed that
women would have greater access to post-mastectomy breast
reconstruction. In a recent study, Xie et al. [8] analyzed the different
rates in post-mastectomy breast reconstruction from 1998 to 2007.
The period of analysis included a year previous to the WHCRA in
statement and many years following. Between 1999 and 2000 in the
states, that did not have laws regarding insurance coverage prior to
the WHCRA, utilization of post-mastectomy breast reconstruction
rates rose between 31-36% [8]. During the entire study period 1999-
2007, the states increased breast reconstruction after mastectomies by
50% [8]. After the institution of the Women’s Health Care Rights Act
significant improvements were observed in quality of life amongst
women that underwent post-mastectomy breast reconstruction
compared with women that underwent mastectomy and no
reconstruction [3-5,9,10].
Nonetheless, increase in post-mastectomy breast reconstruction
and changes in healthcare policies promoting insurance coverage for
reconstruction after mastectomy, did not eliminate disparities in breast
reconstruction. Barriers to breast reconstruction after mastectomy still
persist. The reasons are multifactorial: low socioeconomic status, lack
of insurance, low literacy level, language barrier, race, comorbidities,
type of hospital are amongst the identified factors for disparities in
treatment of breast cancer [3,5,8]. Additionally, patients may not be
informed of the option of breast reconstruction, may not be referred
to a plastic surgeon or may accept that their insurance will not cover
a “cosmetic” procedure. The dissemination of the information related
to breast reconstruction policies may have different penetrance
depending on socioeconomic status [3].
TChung et al. [9] evaluated a New York State database between
1998 and 2006 with aims to study the racial/ethnic insurance
variation in breast reconstruction and the affect of implementation
of WHCRA in 1998. Interestingly immediate post-mastectomy breast
reconstruction increased amongst all women during the period,
however, the racial/ethnic gap between white and minority became
greater between 1998 and 2006. It suggested that health education
materials and documents explaining patient’s rights and benefits can
be too confusing to many patients without college degrees and breast
reconstruction is an elective subspecialty procedure that patients with
lower level of health literacy may not have a complete understanding
of its benefits [11].
Currently there is research and database information on
women and post-mastectomy reconstruction, but unfortunately
there is a lack of information on physician/providers perceptions/
recommendations [11-12]. Breast reconstruction is an elective and
subspecialty procedure and it is important to discuss perception of
physician/providers that are educating patients in treatment of breast
cancer as they have an influence on patient’s decision regarding
breast reconstruction.
Tseng showed that patients in near-metro and rural areas are less
likely o undergo breast reconstruction [11]. Their observations are
probably due to presence of less plastic surgeons in rural communities,
difficulty of traveling to more urban areas and presence of providers
that are less likely to refer patients for reconstruction [12].
Based on that conclusion, we conducted a pre- and postconference
questionnaire to the participants of the Annual West
Virginia University Breast Cancer Conference. The main objective
was to: 1. determine if there is a need to increase education to
providers in West Virginia regarding delivery of information in
breast reconstruction to breast cancer patients. 2. Assess healthcare
provider perception of breast reconstruction rights (WHCRA 1998)
pre and after conference.
Table 1
Table 1
The question placed on the pre and post conference questionnaire regarding post-mastectomy breast reconstruction and the WHCRA. The correct answer is D. Patient should be referred to a plastic surgeon as she wishes and breast reconstruction is covered under WHCRA 1998.
Methods
Study design and setting
The data for this paper was collected from pre and post-conference
questionnaire at the Annual West Virginia University Breast Cancer
Conference in 2015 and later repeated in 2016. A pre and postconference
questionnaire had to be filled and returned in order
to receive Continuing Medical Education (CME) hours. A single
question was added to conference questionnaire that specifically
assessed if participants had any knowledge of the WHCRA mandating
coverage for post-mastectomy breast reconstruction (Table 1).
A question was formulated where an insured patient asks to be
referred to a plastic surgeon pre-mastectomy and the answers ranged
from:
- Patient is too old to undergo breast reconstruction.
- Provider refers to a plastic surgeon, but advises patient that insurance will not cover breast reconstruction.
- Breast reconstruction is an elective procedure and patient should focus on breast cancer treatment first.
- Provider will refer to a plastic surgeon and breast reconstruction is covered by insurance.
- Patient is not a candidate for reconstruction as she will undergo radiation therapy.
Data was collected from the questionnaire including demographics of the conference attendants including: county of residence, practice type (private or academic), and position in the practice (physicians, Advanced Practice Practitioners, Registered Nurses, etc.). Eighty-one participants completed both the pre and post conference questionnaire in 2015 and ninety-eight in 2016. During the conference attendants received a thirty-minute lecture on breast reconstruction options and information regarding WHCRA (1998). The responses to the pre-conference questionnaire were collected prior to lecture and post-conference questionnaire collected at the end of conference.
Statistical analysis
A score was defined to evaluate the improvement of healthcare
provider in perception of breast reconstruction. The score was
divided as a combination of three components:
- Providers whose perception improved after the lecture. They selected the wrong answer pre-conference and the correct answer post-conference ((θιc).
- Providers whose perception worsened after lecture. They selected the correct answer pre-conference and changed to a different answered post-conference (θci).
- Providers whose perception remained incorrect. They selected wrong answer pre-conference and post-conference (θii).
Results from 2015 and 2016 questionnaire were analyzed through a likelihood ratio test to estimate if perception of breast reconstruction changed amongst providers.
Results
Participants demographics
In 2015, amongst the 133 conference attendants there were: 21
physicians, 36 registered nurses, 19 advanced practice practitioners,
2 social workers amongst others (Figure 1). Between them: 85
practitioners practice in a hospital facility and 23 in outpatient clinics
(Figure 1).
There were 17 out of 55 countries from WV represented (Figure
1). In addition, there were participants from: Pennsylvania, Ohio,
Virginia and Maryland (Figure 1). We collected 81 completed pre and
post-conference questionnaires.
Attendants’ perception pre-conference: The pre-conference
form showed that 26% of attendants believed that patients referred
to a Plastic Surgeon would have to pay for their reconstruction, 42%
believed that patients could receive their reconstruction covered by
insurance, 28.4% believed that patient should think about their cancer
treatment before considering seeing a plastic surgeon (Table 2). This
shows a lack of information and/or decreased importance of breast
reconstruction discussion during the initials encounters–reiterating
that plastic surgery is an elective and subspecialty referral.
Attendants’ perception post-conference: After conference 61.7%
believed that insurance would cover reconstruction, 11% believed
that insurance would not cover reconstruction, 27% believed that
patients should undergo mastectomy, radiation, and chemotherapy
before seeing a plastic surgeon (Table 2). Those results showed that
although lecture improved education of the WHCRA, it may not have
affected their perception in regards to when in the cancer treatment a
patient should be referred to a plastic surgeon.
Participants demographics: In 2016, amongst the 147 attendants
there were: 24 physicians, 19 advanced practice practitioners, 36
registered nurses amongst other providers including: social workers,
PhDs, physical therapists, medical assistants, licensed practical
nurses, etc. We collected 119 completed pre and post-conference
questionnaires.
Attendants’ perception pre-conference: The pre-conference form
showed that 30.3% of attendants believed that patients referred to
a Plastic Surgeon would have to pay for their reconstruction, 47%
believed that patients could receive their reconstruction covered by
insurance, 19.3% believed that patient should focus on their cancer
treatment before considering seeing a plastic surgeon (Table 3). This
shows a lack of information in regards breast reconstruction options
and 1998 Women’s Health and Cancer Rights Act (WHCRA), but
suggests that attendants are more willing to refer patients to a plastic
surgeon in the initial encounters (47% will refer to a plastic surgeon).
Attendants perception post-conference: After conference: 69.7%
believed that insurance would cover reconstruction, 3.4% believed
that insurance would not cover reconstruction, 9.2% believed that
patients should undergo mastectomy, radiation, and chemotherapy
before seeing a plastic surgeon (Table 3). Those results showed
that lecture improved education of the WHCRA and attendants’
perception of importance of referring patient to a plastic surgeon
during the initial encounters as part of overall breast cancer care.
Figure 1
Figure 1
Demographics of participants at the West Virginia University Breast Conference 2015 and 2016, respectively.
Table 2
Table 2
Counts and proportions for Question in 2015. The ”effectiveness score”
in 2015 was 24.7-33.3-4.9= -13.6%. This score is NOT statistically significant different from zero at a 5% significance level (p-value = 0.116).
Table 3
Table 3
Counts and proportions for Question in 2016. The ”effectiveness score”
in 2016 was 40.6-12.5-3.1= +25%. This score is statistically significant different from zero at a 5% significance level (p-value< 0.001).
Table 4
Table 4
The ”effectiveness score” is defined as the proportion of providers
who transitioned from an incorrect to the correct answer minus the proportion of
providers who gave an incorrect answer post course (transitioning from either an
incorrect or the correct answer). The conference lecture appeared to be much
more effective in 2016 than 2015 (not formally tested).
Figure 2
Statistical Analysis
Since the same providers are tested pre and post-conference,
the test results are correlated. Rather than comparing the
proportion of correctspre and post-conference, the effectiveness
of the lecture is evaluated by considering the transitions between
correct and incorrectanswers. An ”effectiveness score” is defined
as the difference between the proportion of providers transitioning
from an incorrect to the correct answer (θic) and the sum of the
proportions of providersmoving from incorrect or correctanswers
to an incorrectanswer (θii and θci respectively). A statistical test of
hypothesis is used to evaluate whether this ”effectiveness score” is
significantly different from zero (H0 θιχ−θχι−θii = 0 vs. H1: θιχ −θχι
−θii ≠ 0). The counts shown in (Tables 2 and 3) form multinomial
distribution and the hypothesis of interest can thus be tested by
means of a likelihood ratio test. The results are shown in (Table 4).
The effectiveness score shows significant change in perception in
the year of 2016, statistically significant (p< 0.001). Although it did
not show a statistically significance between pre and post-conference
perception in 2015, when compared 2015 and 2016 there is a positive
impact of the conference from 2015 to 2016 (Table 4).
Table 4: the ”effectiveness score” is defined as the proportion of
providerswhotransitioned from an incorrect to the correctanswer
minus the proportion of providerswho gave an incorrectanswer post
course (transitioning from either an incorrect or the correctanswer).
The conferencelectureappeared to bemuch more effective in 2016
than 2015 (not formally tested).
Discussion
Rates of reconstruction vary from study to study and it can
range from 8% to 81%. Patient’s demographic characteristics, age,
ethnicity, minority, low income and low health literacy play a role
in the likelihood of post-mastectomy breast reconstruction. Lack of
information and inability to involve patients in their decision are also
identified barriers to breast reconstruction.
From our data, there was a change in healthcare providers’
education of the WHCRA and perception of importance of referral
for breast reconstruction changed from 42% to 61.7% in 2015 and
from 47% to 69.7% in 2016; respectively before and after a CME
educational intervention (Figure 2).
Financial restraint related to insurance coverage and accesses
to plastic surgeons are also responsible for differences in breast
reconstruction in the rural population. There are studies supporting
the difference in breast reconstruction showing that uninsured or
Medicaid patients receive less breast reconstruction. This could
be due to language barrier, lack of information, access to breast
reconstruction, and low income patients may find more difficult to
spend time away from work [5,9].
It is clear that in many states there is an overall increase in
utilization of post-mastectomy breast reconstruction [8]; however,
in rural states such as West Virginia there are barriers to providing
this capacity of care. Our population of attendees was limited to
mostly WV and then within the state of WV only 17 counties were
represented. These 17 counties were also centralized to the region
surrounding West Virginia University, which as an academic center
allows for more access to healthcare-Institution type impacts the rate
of post-mastectomy reconstruction. Those patients who complete
their care at an academic hospital traveled twofold the distance of
women who received treatment at a community center; however,
the patients treated at academic center underwent reconstruction at
significantly higher rates than at the community hospital [13]. The lack
of representation of more rural areas in the state such as the Southern
portion is likely due to the barriers of travel for these providers. This
geographical isolation can play a role in patients’ access to a complete
range of healthcare services. It has been demonstrated that patients
that undergo a mastectomy followed by immediate reconstruction
must travel significantly larger distances that have increased over
time, to care than those that do not complete reconstruction [13].
Furthermore, an improvement of healthcare provider and
patient awareness regarding the psychological benefits of breast
reconstruction and additional reconstructive options can cause an
impact on increase of breast reconstruction.
Some studies observed an increase of immediate breast
reconstruction after the WHCRA with relative increase in utilization
of immediate breast reconstruction in Medicare and Medicaid
patients suggesting a larger impact on underserved populations.
However, private insured patients are still more likely to undergo
immediate reconstruction suggesting that breast surgeons are more
likely to refer a privately insured patient to a plastic surgeon [4].
Research from survivors underscores critical skills such as:
information, communication, and problem solving. It is important
to remember that insurance alone does not ensure access, quality,
cultural competency, diversity within the provider workforce [5].
Benefits of insurance in regards to breast reconstruction also needs
active promotion of patient and provider education.
Studies have shown that patient’s preferences, cultural beliefs
and knowledge about breast reconstruction and its benefits strongly
influence the decision for breast reconstruction [9,11]. Therefore, it is
possible that women with higher income, greater level of education
are positively associated with health literacy and knowledge of
benefits of breast reconstruction. This implies in a greater use of
breast reconstruction services by this patient population. Similarly,
lack of effective communication between patients and physicians,
especially regarding elective, subspecialty procedures such as breast
reconstruction can lead to a decrease of use and awareness of those
services [9-11].
Education through Continuing Medical Education (CME) hours
has been the standard of post-medical school and residency graduate
education. There has been a recognized pattern that increased
medical knowledge as assessed via testing does not always equate to
a better practice of medicine based on the newly acquired theoretical
knowledge [13]. A study has shown that CME affects physicians’
practices at the minimum for 6 months [13]. Other studies support
that the addition of testing increases the retention of information
and leads to a better application of the knowledge in the future
[13]. Although testing is not the best assessment for application of
knowledge it is still the gold standard for evaluating the effectiveness
of CME [13]. Using both the pre and post conference questionnaire
as a requirement for receiving CME hours at the conference increased
the number of attendants that completed the questionnaire. Having
both a pre and post assessment showed that the quality of CME at
the conference was effective in increasing education to a number of
attendants about the WHCRA.
Conclusion
Using pre and post-conference questionnaires demonstrated an
increase in healthcare providers’ education of the WHCRA at the
2015 and 2016 West Virginia University Breast Cancer Conference.
Continuing Medical Education (CME) became more and more
important in changing education in medical practices. It is important
to promote further outreach programs and clinics in WV, and
tracking the number of post-mastectomy breast reconstruction in the
coming years to evaluate for a long term effectiveness of the WHCRA
education.
Several studies suggest that patients and providers are influenced
by financial considerations, which indicates a need to increase
education of available coverage and evaluate barriers to breast
reconstruction among patients, particularly minority women [9].
Availability to insurance coverage often is not enough to
assure equal access to health care. A higher level of education and
communication amongst providers and vulnerable populations is
required [11]. Additionally, patient-physician interactions vary by
race and ethnic differences in trust and communication. Physician’s
play a critical role in discussing procedures and recommendations
with patients and even impact how women will make decision to
pursue reconstruction.
Post-mastectomy is shown to improve psychological outcomes in
women undergoing mastectomy [4-13] and efforts to increase access
to breast reconstruction such as the New York State law of 2010 [10]
mandating physicians to discuss options for breast reconstruction
before surgery are continuing. Disparities in health care remain a
topic of discussion in the United States. Breast reconstruction is an
elective procedure and despite innumerous studies showing benefit
in patients that underwent mastectomy, improvements in referral
and breast reconstruction is one of those inequalities in health
care. The widening in health care can be improved if physician/
providers continue to concentrate efforts towards mitigation of those
differences by increasing recognition, providing equal information
and understandable communication between patients and providers.
Decision for breast reconstruction is a process influenced by
clinical factors such as cancer staging, patient’s comorbidities, health
care system and provider’s biases. The process of decision-making
relies on an informed interaction between patient and physician/
provider and studies have shown that under informed patients and
lack of communication constitute obstacles for women to receive
breast reconstruction despite the WHCRA of 1998 [6].
An improvement of patient-physician communication can
potentially improve quality of life after diagnosis and treatment of
breast cancer.
Future research can be directed towards development of
communication skills, training as well as cultural sensitive
materials for providers other than plastic surgeons who appear to
be the primary information givers to this population. Additionally,
research should be directed towards development of interventions
to measure physician giving information and patient health literacy
improvement.
Acknowledgement
The authors thank Jenny R. Ostien, MS for her assistance with obtaining data from conference questionnaires and Guilherme V. Rocha, PhD for his invaluable contribution with the statistical analysis of this manuscript.
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