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Purpose “Patient-centred care” is widely promoted as an ideal goal of health care systems, but is often difficult to achieve in practice. This article has three aims: to develop an original set of generalisable patient-centred care principles (PCCPs); to identify barriers to the implementation of these principles in a real-world setting, using breast reconstruction (BR) services in Australia as a case study; and to document examples of successful patient-centred care in relation to BR. Methods Semi-structured interviews ( n  = 90) were conducted with 31 breast and plastic reconstructive surgeons, 37 breast cancer health professionals and 22 women who underwent mastectomy as part of their breast cancer treatment and were dissatisfied with their BR experiences. Results Ten broad PCCPs were derived from our participant interviews. These principles comprised the following: maximising patient choice, access to services, patient and family support and appropriateness of information; minimising patient costs and physical and psychosocial morbidity; and facilitating informed decision-making, interdisciplinary patient management and evidence-informed practice. While the major barriers to the implementation of these PCCPs in relation to BR were resource driven, surgeon-related factors were also identified. Conclusions These PCCPs highlight areas of need but also provide examples of high quality patient-centred care. They may help to guide a national discussion about minimum standards of BR practice, while allowing for some necessary regional and cultural variation. They also have the potential to be applied more widely to the provision of a range of health services within Australia or internationally.

Purpose The potential quality of life benefits of breast reconstruction (BR) for women who have undergone mastectomy for breast cancer have long been recognised. While many women will not want to have BR, international best-practice guidance mandates that all should be given the choice. The aim of this article is to highlight potential policies to support patients’ informed discussion of BR options and to improve access to BR for women living in underserved locations. Methods Ninety semi-structured interviews were conducted from May 2015 to May 2017 with a convenience sample of 31 breast reconstructive surgeons, 37 breast cancer health professionals and a purposive sample of 22 women who underwent mastectomy as part of their breast cancer treatment. Breast, plastic reconstructive surgeons and health professionals based in major cities also provided information about how they cared for patients from more remote areas. Results Analysis of interview data revealed a range of barriers that were grouped into four major categories describing issues for women living outside major cities: population characteristics associated with lower socioeconomic status; locational barriers including limited health services resources and distance; administrative barriers such as hospital policies and inadequate support for women who need to travel; and surgical workforce recruitment barriers. Conclusions Suggestions for potential solutions included the following: greater geographical centralisation of BR services within major cities; the creation of designated breast centres with minimum caseload requirements similar to the UK’s system; and a buddy system, whereby smaller hospitals network with multidisciplinary teams based in larger hospitals.

In Australia, the rate of breast reconstruction after mastectomy for breast cancer has unacceptable variation between socioeconomically and geographically similar areas. While some centres offer a full range of options and contemporary best practice, others do not give women information about options that should be available for all. General practitioners (GPs) have a key role to play by ensuring their patients have the opportunity for an informed discussion with multidisciplinary teams (MDTs) that offer choice.

Purpose Many studies have explored women's reasons for choosing or declining a particular type of breast reconstruction (BR) following mastectomy for breast cancer. This systematic review synthesises women's reasons for choosing a range of BR options, including no BR, in different settings and across time. Methods Thirteen databases were systematically searched, with 30 studies (4269 participants), meeting the selection criteria. Information on study aim and time frame, participation rate, design/methods, limitations/bias, reasons and conclusions, as well as participant clinical and demo-graphic information, was reported. An overall quality score was generated for each study. Reasons were grouped into eight domains. Results While study methodology and results were heterogeneous, all reported reasons were covered by the eight domains: Feeling/looking normal; Feeling/looking good; Being practical; Influence of others; Relationship expectations; Fear; Timing; and Unnecessary. We found a strong consistency in reasons across studies, ranging from 52% of relevant publications citing relationship expectations as a reason for choosing BR, up to 91% citing fear as a reason for delaying or declining BR. Major thematic findings were a lack of adequate information about BR, lack of genuine choice for women and additional access limitations due to health system barriers. Conclusions Understanding women's reasons for wanting or not wanting BR can assist clinicians to help women make choices most aligned with their individual values and needs. Our thematic findings have equity implications and illustrate the need for surgeons to discuss all clinically appropriate BR options with mastectomy patients, even if some options are not available locally.

Background: In their landmark report on the “Principles and Practice of Screening for Disease” (1968), Wilson and Jungner noted that the practice of screening is just as important for securing beneficial outcomes and avoiding harms as the formulation of principles. Many jurisdictions have since established various kinds of “screening governance organizations” to provide oversight of screening practice. Yet to date there has been relatively little reflection on the nature and organization of screening governance itself, or on how different governance arrangements affect the way screening is implemented and perceived and the balance of benefits and harms it delivers. Methods: An international expert policy workshop convened by Sturdy, Miller and Hogarth. Results: While effective governance is essential to promote beneficial screening practices and avoid attendant harms, screening governance organizations face enduring challenges. These challenges are social and ethical as much as technical. Evidence-based adjudication of the benefits and harms of population screening must take account of factors that inform the production and interpretation of evidence, including the divergent professional, financial and personal commitments of stakeholders. Similarly, when planning and overseeing organized screening programs, screening governance organizations must persuade or compel multiple stakeholders to work together to a common end. Screening governance organizations in different jurisdictions vary widely in how they are constituted, how they relate to other interested organizations and actors, and what powers and authority they wield. Yet we know little about how these differences affect the way screening is implemented, and with what consequences. Conclusions: Systematic research into how screening governance is organized in different jurisdictions would facilitate policy learning to address enduring challenges. Even without such research, informal exchange and sharing of experiences between screening governance organizations can deliver invaluable insights into the social as well as the technical aspects of governance.

Background There are many test options available for colorectal cancer screening. The choice of test relates to the objectives of those offering or considering screening. Discussion While all screening programs aim to detect disease early in order to improve the length and/or quality of life for the individual, some organizations and individuals prefer screening tests that offer the opportunity for cancer prevention. Others favor maximizing participation or the opportunity for shared decision-making, including discussion of information on test quality and availability. We propose three additional objectives for screening: minimizing harms, optimizing economic efficiency and maximizing equity of access to screening. Summary Applying these objectives to colorectal cancer screening, we advocate the use of immunochemical FOBTs as the preferred screening strategy, as it satisfies all three of these important objectives.

Purpose Breast reconstruction (BR) makes an important positive contribution to the quality of life of many women who have undergone mastectomy for breast cancer. The purpose of this article is to evaluate the evidence for possible relationships between women’s expectations of BR and their satisfaction with outcomes to inform and facilitate improved communication about BR options prior to initial surgery. Methods A systematic review of the literature reporting expectations of BR published between 1 January 1994 and 6 March 2017 identified 2107 initial search results. Twenty-one publications, reporting 20 studies (2288 participants), satisfied the selection criteria. Information on study aim and time frame, participation rate, design/methods, limitations/bias, results and conclusions, as well as participant clinical and demographic information, was reported. An overall quality score was generated for each study. Results Four of five studies that quantified expectations and satisfaction found a positive relationship between the two. This may indicate a possible trend, but as 16 of the 21 included publications did not provide quantifiable data, no firm conclusions are possible. Conclusion Our findings have important implications for policy and practice which are applicable to medical decision-making more broadly. There is a clear need to utilise accurate and consistent measures of patient-reported expectations and to educate both patients and health practitioners about the importance of informed discussion about treatment options. This is particularly salient for women facing a choice about BR, a major breast cancer survivorship decision. Routine use of an expectations checklist in pre-operative consultations may be useful.

Bowel cancer is a serious health problem in developed countries. Australia, the United Kingdom (UK) and New Zealand (NZ) reviewed the same randomised controlled trial evidence on the benefits and harms of population-based bowel cancer screening. Yet only NZ, with the highest age standardised rate of bowel cancer mortality, decided against introducing a bowel cancer screening programme. This case study of policy making explores the unique resource, ethical, institutional and political environments in which the evidence was considered. It highlights the centrality of context in assessing the relative worth of evidence in policy making and raises questions about the suitability of knowledge utilisation strategies.

Objectives: The aim of this study was to determine the role of community preference information from discrete choice studies of colorectal cancer (CRC) screening in health technology assessment (HTA) reports and subsequent policy decisions. Methods: We undertook a systematic review of discrete choice studies of CRC screening. Included studies were reviewed to assess the policy context of the research. For those studies that cited a recent or pending review of CRC screening, further searches were undertaken to determine the extent to which community preference information was incorporated into the HTA decision-making process. Results: Eight discrete choice studies that evaluated preferences for CRC screening were identified. Four of these studies referred to a national or local review of CRC screening in three countries: Australia, Canada, and the Netherlands. Our review of subsequently released health policy documents showed that while consideration was given to community views on CRC, policy was not informed by discrete choice evidence. Conclusions: Preferences and values of patients are increasingly being considered “evidence” to be incorporated into HTA reports. Discrete choice methodology is a rigorous quantitative method for eliciting preferences and while as a methodology it is growing in profile, it would appear that the results of such research are not being systematically translated or integrated into HTA reports. A formalized approach is needed to incorporate preference literature into the HTA decision-making process.

Much of the evidence translation literature focuses narrowly on the use of evidence in the initial policy formulation stages, and downplays the crucial role of institutions and the inherently political nature of policy making. More recent approaches acknowledge the importance of institutional and political factors, but make no attempt to incorporate their influence into new models of evidence translation. To address this issue, this article uses data from a comparative case study of bowel cancer screening policy in Australia, the United Kingdom and New Zealand, to propose alternative models of evidence incorporation which apply to all stages of the policy process.