Levorphanol as a Second Line Opioid in Cancer Patients Presenting to an Outpatient Supportive Care Center: An Open-label Study

CONTEXT

Levorphanol is a potent opioid agonist and NMDA receptor blocker with minimal drug interactions, and there are few reports of its use in cancer patients.

OBJECTIVES

We aimed to determine the frequency of successful opioid rotation (OR) to levorphanol and the median opioid rotation ratio (ORR) from Morphine Equivalent Daily Dose (MEDD).

METHODS

This is a prospective, single-group, interventional study. Cancer outpatients requiring an OR and receiving a MEDD of 60-300 mg were rotated to levorphanol using a ratio of 10:1 and assessed daily for 10-day. Successful OR was defined as a 2-point improvement in the Edmonton Symptom Assessment System (ESAS) pain score on day 10 or achieving the personalized pain goal between days 3-10 in patients with uncontrolled pain or resolution of opioid side effects (OSE) in those undergoing OR for OSE alone. The ORR to levorphanol was calculated using net-MEDD (MEDD before OR minus the MEDD of the breakthrough opioid used along with levorphanol after OR).

RESULTS

Forty patients underwent OR to levorphanol, and uncontrolled pain 35/40 (87.5%) was the most common indication. The median net-MEDD and levorphanol doses were 95 and 10 mg, respectively, and 33/40 (82.5%) had a successful OR with a median (IQR) ORR of 8.56 (7.5-10). Successful OR was associated with significant improvement in ESAS and OSE scale scores. There was a strong association between MEDD and levorphanol dose.

CONCLUSION

This study provided preliminary data that cancer patients could be successfully rotated to levorphanol using an ORR of 8.5. Levorphanol was associated with improved pain and symptom control and was well- tolerated.

Impact of an Interdisciplinary Goals-of-Care Program Among Medical Inpatients at a Comprehensive Cancer Center During the COVID-19 Pandemic: A Propensity Score Analysis

PURPOSE

Many hospitals have established goals-of-care programs in response to the coronavirus disease 2019 pandemic; however, few have reported their outcomes. We examined the impact of a multicomponent interdisciplinary goals-of-care program on intensive care unit (ICU) mortality and hospital outcomes for medical inpatients with cancer.

METHODS

This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at the MD Anderson Cancer Center, TX, during the 8-month preimplementation (May 1, 2019-December 31, 2019) and postimplementation period (May 1, 2020-December 31, 2020). The primary outcome was ICU mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of care plan documentation. Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment score.

RESULTS

This study involved 12,941 hospitalized patients with cancer (pre n = 6,977; post n = 5,964) including 1,365 ICU admissions (pre n = 727; post n = 638). After multicomponent goals-of-care program initiation, we observed a significant reduction in ICU mortality (28.2% v 21.9%; change -6.3%, 95% CI, -9.6 to -3.1; P = .0001). We also observed significant decreases in length of ICU stay (mean change -1.4 days, 95% CI, -2.0 to -0.7; P < .0001) and in-hospital mortality (7% v 6.1%, mean change -0.9%, 95% CI, -1.5 to -0.3; P = .004). The proportion of hospitalized patients with an in-hospital do-not-resuscitate order increased significantly from 14.7% to 19.6% after implementation (odds ratio, 1.4; 95% CI, 1.3 to 1.5; P < .0001), and do-not-resuscitate order was established earlier (mean difference -3.0 days, 95% CI, -3.9 to -2.1; P < .0001).

CONCLUSION

This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent goals-of-care intervention.

Practice Patterns on the Incorporation of Integrative Medicine Into the Oncologic Care of Patients With Cancer

BACKGROUND

With rising interest in complementary approaches to symptom management, awareness of real-world practice patterns in the incorporation of integrative oncology (IO) into cancer care is limited. Therefore, we examined the reasons for referral, symptom burdens, and clinical outcomes for cancer patients who underwent initial IO consultations.

METHODS

The records of adult patients with cancer who underwent initial outpatient IO consultations at our cancer center for a representative 10-day period at the start of each month for 12 months starting January 1, 2017, were reviewed retrospectively. Patient demographic and medical characteristics and outpatient IO consultation details, including patient-reported outcome measures of symptom burden, were extracted. Descriptive summary statistics and logistic regression were used to analyze the data.

RESULTS

Among the 473 study patients, 71% were women, breast cancer (42%) was the most common cancer type, and 31% had metastatic cancer. Referring clinicians listed an integrative approach (57%) as the most common reason for referral, followed by diet (26%), pain (19%), discussion of herbs and supplements (18%), and stress (18%). In comparison, patients listed their primary concerns as diet (16%), pain (15%), and an integrative approach to overall health (11%). After the IO consultations, the highest likelihood of subsequent recommendations were acupuncture for hot flashes (odds ratio [OR], P = .002) or peripheral neuropathy (OR = 6.59, P < .001), oncology massage for pain (OR = 3.04, P < .001), psychology referral for patient's self-reported anxiety (OR = 2.35, P < .001), and mind-body therapies for stress (OR = 2.57, P < .001).

CONCLUSION

Cancer patients' top concerns regarding IO consultation may not always match providers' reasons for referral. Longitudinal data analysis is needed to determine the effect of integrative interventions on symptom burden.

Schizencephaly in Hereditary Hemorrhagic Telangiectasia

BACKGROUND AND PURPOSE

The presence of malformations of cortical development in patients with hereditary hemorrhagic telangiectasia has been reported on previous occasions. We evaluated a sample of adults with hereditary hemorrhagic telangiectasia for the presence of malformations of cortical development, spatial coincidence of malformations of cortical development and AVMs, and the coincidence of brain and pulmonary AVMs.

MATERIALS AND METHODS

A total of 141 patients 18 years of age or older who were referred to the Augusta University hereditary hemorrhagic telangiectasia clinic and underwent brain MR imaging between January 19, 2018, and December 3, 2020, were identified. MR imaging examinations were reviewed retrospectively by 2 experienced neuroradiologists, and the presence of malformations of cortical development and AVMs was confirmed by consensus. Demographic and clinical information was collected for each case, including age, sex, hereditary hemorrhagic telangiectasia status by the Curacao Criteria, mutation type, presence of malformations of cortical development, presence of brain AVMs, presence of pulmonary AVMs, and a history of seizures or learning disabilities.

RESULTS

Five of 141 (3.5%) patients with hereditary hemorrhagic telangiectasia had malformations of cortical development. Two of the 5 patients with polymicrogyria also had closed-lip schizencephaly. One of the patients had a porencephalic cavity partially lined with heterotopic GM. The incidence of spatially coincident polymicrogyria and brain AVMs was 40% (2/5 cases). Of the patients with hereditary hemorrhagic telangiectasia and malformations of cortical development, 4/5 (80%) had pulmonary AVMs and 2/5 (40%) had brain AVMs.

CONCLUSIONS

To our knowledge, we are the first group to report the presence of schizencephaly in patients with hereditary hemorrhagic telangiectasia. The presence of schizencephaly and porencephaly lends support to the hypothesis of regional in utero cerebral hypoxic events as the etiology of malformations of cortical development in hereditary hemorrhagic telangiectasia.

Interdisciplinary intervention for the management of nonmedical opioid use among patients with cancer pain

BACKGROUND

Few studies have assessed interventions aimed at managing nonmedical opioid use (NMOU) behavior among patients with cancer. The authors developed the Compassionate High-Alert Team (CHAT) intervention to manage patients receiving opioids for cancer pain who demonstrate NMOU behavior. The objective of this study was to determine the change in frequency of NMOU behaviors, pain intensity, and opioid requirements among those who received the intervention.

METHODS

A total of 130 patients receiving opioids for cancer pain that had documented evidence of NMOU and received the CHAT intervention were reviewed. Demographic and clinical information such as NMOU behaviors, pain scores, and morphine equivalent daily dose at baseline, 3, and 6 months post-intervention was obtained.

RESULTS

NMOU behaviors significantly decreased from a median (interquartile range) of 2 (1-3) at baseline to 0 (0-1) at both 3 and 6 months post-intervention (p < .001). A total of 45 of 75 (60%) and 31 of 50 (62%) of CHAT recipients achieved complete response to the intervention at 3 and 6 months, respectively. Higher baseline number of NMOU behaviors was independently associated with patient response to the intervention (odds ratio [OR], 1.97; 95% confidence interval [CI],1.09-4.28, p = .049 at 3 months; OR, 2.5; 95% CI, 1.20-6.47, p = .03 at 6 months). The median pain score decreased from 7 at baseline to 6 at both 3 and 6 months (p = .01). Morphine equivalent daily dose did not significantly change during that same period (143 mg/day vs. 139 mg/day, p = .13).

CONCLUSIONS

Most patients who received the CHAT intervention improved in their NMOU behaviors and pain intensity scores 3 and 6 months post-intervention. These preliminary findings support the efficacy of CHAT in managing patients receiving opioids for cancer pain who demonstrate NMOU behavior.

Opioid Rotation and Conversion Ratios Used by Palliative Care Professionals: An International Survey

Background: The opioid rotation ratios (ORRs) and conversion ratios (CRs) used worldwide among palliative care (PC) professionals to perform opioid rotations (ORs) and route conversions may have a wide variation. Methods: We surveyed PC professionals on opioid ratios used through email to the Multinational Association of Supportive Care in Cancer's PC study group and Twitter and Facebook posts between September and November 2020. Results: We received 370 responses from respondents from 53 countries: 276 (76%) were physicians, 46 (13%) advanced practice providers, 39 (11%) pharmacists, and 9 respondents did not report their profession. There were statistically significant variations in median CR from intravenous (IV) to oral morphine (2-3), IV to oral hydromorphone (2-4.5), ORR from IV hydromorphone to oral morphine (10-20), and ORR from transdermal fentanyl mcg/hour to oral morphine (2-3.5) across various groups. Conclusion: This survey highlights the wide variation in ORRs and CRs among PC clinicians worldwide and the need for further research to standardize practice.

454 Sinus of Valsalva Rupture

Background

Sinus of Valsalva (SVA) rupture is a rare cardiac pathology which is important to recognise and diagnose early.

Case Summary

This case report details a 30-year-old gentleman who presented with a 3-day history of dyspnoea and palpitations on a background of previous congenital heart disease. The patient's examination highlighted a continuous harsh pan-systolic murmur as well as an ECG finding of sinus tachycardia. Transthoracic echocardiography identified a ruptured Sinus of Valsalva. The patient was transferred to a cardiothoracic surgery centre and definitively treated with an aortic root and ventricular septal defect repair.

Discussion

This case highlights the clinical findings of a patient with an acute left to right shunt and the importance of early diagnosis and urgent surgery. This case emphasises the factors required to decide which surgical approach is appropriate such as the presence of aortic valvular pathology size, size of Sinus of Valsalva aneurysm, any simultaneous cardiac anomaly and the cardiac chamber involved.

Learning Points

Three-Appointment Technique to Fabricate Duplicate Denture From Patients Existing Denture

The duplicating procedure copies most of the features of the existing denture. When a patient gets accustomed to the old dentures, it becomes difficult to adjust to the new set of dentures. That’s the time fabricating duplicate dentures helps. This article describes an easy, cost-effective technique to make duplicate dentures with materials readily available in dental setup. The intaglio surface of the denture was intact which increased patient satisfaction. The reduced vertical dimension was corrected with a new set of teeth. Dentures were delivered to the patient superfast within three days. The patient was totally satisfied with the copy dentures.

A quantitative study to explore functional outcomes following laparoscopic ventral mesh rectopexy for rectal prolapse

INTRODUCTION

Rectal prolapse is a life-altering problem and laparoscopic ventral mesh rectopexy (LVMR) is emerging as the surgical intervention of choice. However, the literature is ambiguous on its effect on bowel function and sparse as regards bladder and sexual function. This study assesses short-term functional outcomes following LVMR.

MATERIALS AND METHODS

This quantitative retrospective study with a pretest-post-test design included 130 adults who had undergone LVMR from October 2010 to December 2018 in a tertiary centre. Analysis with paired-samples t-test and Wilcoxon matched pairs test was done using SPSS (v26).

RESULTS

The median age was 58 years (interquartile range, 48-74 years); 123 (94.6%) were female. The median length of stay was two days (interquartile range, 1-2 days). A total of 104 (80%) sets of medical notes were reviewed. One patient had recurrence of rectal prolapse. Synthetic mesh was used in 24 patients (23.1%) and biological mesh in 80 (76.9%). One patient had extrusion of a synthetic mesh and required surgery; 31(23.8%) completed the Electronic Patient Assessment Questionnaire for Pelvic Floor. Overall, the improvement in bladder function was not statistically significant (p = 0.670). A statistically significant improvement was seen for all bowel symptoms (p = 0.002) excluding constipation (p = 0.295). Irritable bowel symptoms associated with rectal prolapse improved significantly following LVMR (p = 0.001). Vaginal prolapse (p < 0.0005), dyspareunia (p = 0.001) and bowel symptoms affecting sexual intercourse (p = 0.01) improved, but improvement in overall sexual function was not statistically significant (p = 0.081).

CONCLUSIONS

LVMR improves bowel function overall, although it can worsen constipation. It has the potential to improve sexual function but makes negligible difference to bladder function.

Bullying victimization in children and adolescents and its impact on academic outcomes

Introduction

Bullying is a serious problem in schools because of the negative impact on a child’s educational outcomes, especially academic achievement. However, the underlying mechanisms and causes are unknown.

Objectives

To evaluate the educational outcomes, and psychiatric comorbidities in children and adolescents who are victims of bullying

Methods

We used 2018–2019 Nationwide Survey of Children’s Health (NSCH) dataset for the study. The participants were children and adolescents (age: 6-17 years, n = 42,790). Data was stratified into two groups: 1) never bullied 2) bullied more than once. Prevalence of different educational outcomes were compared between the groups.

Results

In the never bullied group 21,015 participants were included, and in the bullied more than once group 21,775 participants were included. More females were in the bullied group compared to never bullied group (50.4% vs 47.5%, p=0.006). More White non- Hispanic individuals were in bullied group in contrast to never bullied group (56.7% vs 43.9%, p< 0.001). Individuals whose health status was fair, or poor were bullied more (2.4% vs 1.4%, p=<0.001). Individuals in bullied group were more likely to be repeating the grades compared to the never bullied group (7.1% vs 5.9%, p:0.039). Individuals who were missing >=11 school days, and sometimes or never engaged in school were observed more in bullied group compared to never bullied group (5.9% vs 3.2% and 20.3% vs 10.6% p < 0.001).

Conclusions

Our findings suggest that bullying victimization could be a risk factor and associated with decreased academic outcomes.

Disclosure

No significant relationships.

Bright Light Therapy for MDD in Children and Adolescents: a narrative review of literature

Introduction

Major Depressive Disorder (MDD) is a common mood disorder diagnosed in children and adolescents. Bright light therapy has been effective for seasonal affective disorders, however its role in the treatment of MDD is under studied.

Objectives

Our objective is to evaluate if bright light therapy (BLT) is a practical approach in treating Child and Adolescents having MDD.

Methods

We performed an extensive literature search using a wide range of MeSH terms in PubMed, PubMed Central and Google Scholar. We reviewed the literature for studies (published between 1983-2021) assessing the efficacy of BLT in the treatment of MDD in children and adolescents.

Results

The final search results yielded 8 randomized clinical trials and 1 case report from 1983 to 2021. BLT showed a superior effect in children and adolescents with MDD compared to the control group in the majority of the randomized trials and a case report. In six studies BLT showed good effect, however in a study by Magnusson et al. and Sonis et al., found a milder degree of improvement in depression symptoms when compared to the control group. In the majority of the studies, patients’ age range was 7 years 18 and in most of the studies, patients were not on antidepressants.

Conclusions

The use of BLT in children and adolescents suffering from MDD can be a promising alternative method of biological treatment, which is effective as well as well tolerated. Future long-term studies on large sample size are necessary in this field.

Disclosure

No significant relationships.

Telemedicine and Its Past, Present, and Future Roles in Providing Palliative Care to Advanced Cancer Patients

Simple Summary

The health care delivery model has dramatically changed due to the emergence of the global pandemic coronavirus disease (COVID-19). This can be seen in the innovative adoption of telemedicine in the delivery of palliative care to patients with advanced cancer. We provide an update on the adoption, delivery, benefits, and challenges faced in this model of health care delivery.

Abstract

The landscape of healthcare delivery has considerably changed due to the emergence of coronavirus disease 2019 (COVID-19). This is nowhere more evident than in the care of advanced cancer patients receiving palliative care. This population is susceptible to the severe complications of COVID-19, and immediate measures had to be taken to ensure their safety. Thus, the adoption of telemedicine as a health care delivery model emerged. This model provides many benefits, such as improved access to care while maintaining social distancing; however, there exist challenges to this model, including health care disparities, reimbursement, and monitoring of opioids in high-risk populations. This narrative review provides an overview of the unique benefits and barriers of telemedicine in palliative care patients.

Residential radon exposure and cancer

Radon is an established human lung carcinogen naturally released as an odorless, colorless gas from soil and rocks. It is a major environmental source of ionizing radiation and can cause oxidative damage to DNA, increasing the risk of lung cancer. Although the association between radon and lung cancer is well established, the association between radon and other cancers is not. Based on reported studies, there is no consistent evidence indicating an association between radon and non-solid and solid cancers, but limited literature, heterogenous study design, and confounding variables preclude definitive conclusions. More research is needed to evaluate the association between residential radon and non-lung cancers, particularly with regard to skin cancer, central nervous system (CNS) cancer, renal, and stomach cancer, in which existing literature suggests potential associations with residential radon may exist. However, the literature largely demonstrates that lung cancer is the primary concern associated with residential radon exposure; the lack of association with nonlung cancers could reflect the lack of studies which have an adequate sample size, establish accurate levels of radon exposure, and control for confounders. These results should be considered in residential radon mitigation efforts which should focus on smokers with high radon exposures.

Eco-epidemiological scaling of Leptospirosis: Vulnerability mapping and early warning forecasts

Infectious disease epidemics are plaguing the world and a lot of research is focused on the development of models to reproduce disease dynamics for eco-environmental and biological investigation, and disease management. Leptospirosis is an example of a neglected zoonosis strongly mediated by ecohydrological dynamics with emerging endemic and epidemic patterns worldwide in both animal and human populations. By accounting for large heterogeneities of affected areas we show how exponential endemics and scale-free epidemics are largely predictable and linked to common socio-environmental features via scaling laws with different exponents that inform about vulnerability factors. This led to the development of a novel pattern-oriented integrated model that can be used as an early-warning signal (EWS) tool for endemic-epidemic regime classification, risk determinant attribution, and near real-time forecast of outbreaks. Forecasts are grounded on expected outbreak recurrence time dependent on exceedance probabilities and statistical EWS that sense outbreak onset. A stochastic spatially-explicit model is shown to comprehensively predict outbreak dynamics (early sensing, timing, magnitude, decay, and eco-environmental determinants) and derive a spreading factor characterizing endemics and epidemics, where average over maximum rainfall is the critical factor characterizing disease transitions. Dynamically, case cross-correlation considering neighboring communities senses 2-weeks in advance outbreaks. Eco-environmental scaling relationships highlight how predicted host suitability and topographic index can be used as epidemiological footprints to effectively distinguish and control Leptospirosis regimes and areas dependent on hydro-climatological dynamics as the main trigger. The spatio-temporal scale-invariance of epidemics - underpinning persistent criticality and neutrality or independence among areas - is emphasized by the high accuracy in reproducing sequence and magnitude of cases via reliable surveillance. Further investigations of robustness and universality of eco-environmental determinants are required; nonetheless a comprehensive and computationally simple EWS method for the full characterization of Leptospirosis is provided. The tool is extendable to other climate-sensitive zoonoses to define vulnerability factors and predict outbreaks useful for optimal disease risk prevention and control.

Prevalence and clinical impact of atrioventricular conduction disease in patients with idiopathic pulmonary arterial hypertension

Background

Although bradycardia-related sudden death is common in patients with idiopathic pulmonary arterial hypertension (IPAH), the prevalence and prognostic significance of atrioventricular (AV) conduction disease in this patient group is not well-established.

Objectives

– Determine the prevalence of AV conduction disorders in patients with IPAH

– Investigate the relationship between AV block and functional outcomes and mortality.

Method

12-lead electrocardiograms (ECGs) of patients with IPAH were analysed. Patients were categorised according to the presence or absence of AV block. Demographic, pulmonary haemodynamic, cardiac structural characteristics and expression of genes associated with cardiac conduction were compared and functional and mortality outcomes analysed between groups.

Student's t-tests and χ2 tests were used to compare data. Survival was estimated using Kaplan-Meier analyses. Initial exploratory covariates were included in a univariate analysis and those terms with P-value of &lt;0.1 were then used to generate a Cox proportional-hazards multivariate model.

Results

135 IPAH patients (mean age 55±16 years, 28.1% male) were eligible for analysis. Median follow up was 9 years (interquartile range 4–14 years).

AV block was seen in 34.8% of patients with IPAH compared to 10.8% of matched comparators (p&lt;0.001), drawn from patients attending hospital for non-PAH related reasons.

IPAH patients with conduction disease were more likely to be older (59±16 vs 53±17 years, p=0.038). AV block was associated with more severe right ventricular (RV) basal dilatation (5.1±1.0 vs 4.3±0.7cm, p=0.013) and worse RV function (fractional area change 26±9% vs 31±9%, p=0.14). Pulmonary haemodynamics, right atrial size and resting and exertional oxygen saturations were not significantly different. Expression of HCN1, HCN2, SCN1B, SCN5A, CAV1, and KCN2 genes in peripheral blood from a subcohort was similar between those with and without AV block.

Lower 6 minute walk distances (344±153 vs 408±140m, p=0.035) and worse CAMPHOR scores across all 3 domains were seen in those with AV block (figure 1), and mortality was significantly higher (36.2 vs 13.6%, p=0.002) (figure 2). On multivariate analysis the presence of bundle branch block (BBB) was independently associated with a 2.1-fold increased risk of death (95% CI 1.89–4.85, p=0.045).

Conclusions

AV conduction disorders are more prevalent in IPAH than the general population, and are associated with worse prognosis and functional status. Prospective study is required to validate this finding.

In our cohort AV block could not be explained by hypoxia, differences in pulmonary haemodynamics nor, in a small subgroup, by differential expression of specific transmembrane ion channels implicated in cardiac conduction. More detailed investigation into causal mechanisms of AV block in IPAH could establish whether improved prognosis could be achieved by treatment of AV block.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Association Between Acupoint Selection, Target Symptoms, and Traditional Chinese Medicine Diagnosis in Real-Time Clinical Practice in a Comprehensive Cancer Center

Background: Acupuncture intervention in actual practice is rarely reported and may be different from that applied in acupuncture research. Objectives: To review acupuncture practice in an integrative medicine clinic and characterize the association between targeted symptoms, traditional Chinese medicine (TCM) diagnosis, and acupoint selection. Methods: We reviewed outpatient acupuncture records from March 2016 to April 2018. Statistical analyses were applied to characterize referral symptoms and associated TCM diagnosis as well as acupoint selection. Results: The final analysis included 5393 acupuncture records (1264 patients). Twelve TCM diagnosis components were identified in the referral symptoms of pain, neuropathy, xerostomia, and hot flashes. Pain was associated with 78 different TCM diagnoses (combinations of TCM diagnosis components). Total of 217 different acupoints were used in the acupuncture treatments (1739) for neuropathy. The acupoint yintang was used in 73.8% of the visits for neuropathy, yet only in 26.5% (P < .001) of the treatments when patients had a TCM diagnosis of qi deficiency, qi stagnation, and blood stagnation. Similarly, both consistencies and variations were seen in acupoint selection with each targeted symptom and its associated TCM diagnoses. Conclusions: TCM diagnosis was not homogeneous among acupuncture treatments for a single referral symptom. In contrast to most of the research on acupuncture for symptom control, there were considerable variations in acupoint selection among treatments for the same symptom in a clinical setting. Future research is needed to examine the clinical relevance of a fixed intervention structure in acupuncture research and the value of individualized acupuncture treatment.

Oncology patients' perception of physicians who use an integrated electronic health record (EHR) during clinic visits: PRIME-EHR double-blind, randomized controlled trial

BACKGROUND

Patients with cancer prefer and positively perceive physicians who communicate face-to-face without the use of a computer. However, the use of electronic health records (EHRs) in the examination room remains a practical necessity. On the basis of existing literature, the authors developed and tested an integration model, PRIME-EHR, that focuses on the best-practice guidelines. To their knowledge, no randomized controlled trials (RCTs) have been conducted to test the effectiveness of such models.

METHODS

In this double-blind, crossover RCT, 120 eligible patients with cancer were enrolled between April 1, 2019 and February 15, 2020 at The University of Texas MD Anderson Cancer Center. The objectives were to compare patients' perceptions of physicians' skills and their overall preference after they watched 2 standardized, scripted video vignettes of physicians: 1 portraying the use of a standard EHR and the other portraying the use of a PRIME-EHR. Actors and patients were blinded to the purpose of the study. Investigators were blinded to the sequence of videos watched by the patients. Validated questionnaires to rate physicians' compassion (0 = best, 50 = worst), communication skills (14 = poor, 70 = excellent), and professionalism (4 = poor, 20 = very good) were used.

RESULTS

PRIME-EHR, compared with the standard EHR, resulted in better scores for physician compassion (median score, 5 [interquartile range, 0-10] vs 12 [interquartile range, 4-25]; P = .0009), communication skills (median score, 69 [interquartile range, 63-70] vs 61 [interquartile range, 50-69]; P = .0026), and professionalism (median score, 20 [interquartile range, 18-20] vs 18 [interquartile range, 14-20]; P = .0058). The majority of patients preferred physicians who used PRIME-EHR (n = 70 [77%] vs n = 21 [23%]; P < .0001).

CONCLUSIONS

The PRIME-EHR approach significantly improved patients' perceptions of and preference for the physicians. This integrated model of health care delivery has the potential to improve communication and compassion in cancer care.