Impact of cognitive function on communication in patients with primary or secondary brain tumours

Communication support tools (CST) improve patient outcomes in oncology including: knowledge, satisfaction, self-management, and adherence to planned treatment. Little is known about communication support tools use in patients with primary or secondary brain tumours. We aimed to explore cognitive function and communication support tool use in this population. This prospective survey involved patients, caregivers and health professionals. Questionnaires were completed after initial brain radiotherapy consultation and 1-2 weeks later. Patients completed the Montreal Cognitive Assessment (MoCA). Descriptive statistics are reported. Fifty-three patients participated, median age 62 years, ECOG status 0-2 (90 %), with 75 % having secondary brain metastasis. 21/53 (40 %) patients reported needing help reading medical information. Only 28 % patients had normal cognition (MoCA score ≥ 26/30). Initially, 82 % of patients and 87 % of caregivers reported the consultation was 'extremely/quite clear, and 69 % of their health professionals thought consultation 'extremely/quite clear' to patient. At follow-up, fewer patients (75 %) reported health professionals' explanation as 'extremely/quite clear'. Although patients recalled discussed illness and treatment details, 82 % recalled treatment-related side effects and management thereof by 46 %. CST use was reported by 22 % patients, 19 % caregivers, and 27 %health professionals. When used, tools improved understanding according to 92 % patients, 100 % caregivers, and 91 % health professionals. The majority of patients have some level of cognitive impairment. Information discussed appears clear to most patients, but this is not sustained, and recall of treatment toxicity management is poor. Few CSTs are used in consultations, but when used, are reported as helpful by all.

Incorporating health literacy in education for socially disadvantaged adults: an Australian feasibility study

Background

Adult education institutions have been identified as potential settings to improve health literacy and address the health inequalities that stem from limited health literacy. However, few health literacy interventions have been tested in this setting.

Methods

Feasibility study for an RCT of the UK Skilled for Health Program adapted for implementation in Australian adult education settings. Implementation at two sites with mixed methods evaluation to examine feasibility, test for change in participants’ health literacy and pilot test health literacy measures.

Results

Twenty-two socially disadvantaged adults with low literacy participated in the program and received 80–90 hours of health literacy instruction. The program received institutional support from Australia’s largest provider of vocational education and training and was feasible to implement (100 % participation; >90 % completion; high teacher satisfaction). Quantitative results showed improvements in participants’ health literacy skills and confidence, with no change on a generic measure of health literacy. Qualitative analysis identified positive student and teacher engagement with course content and self-reported improvements in health knowledge, attitudes, and communication with healthcare professionals.

Conclusions

Positive feasibility results support a larger RCT of the health literacy program. However, there is a need to identify better, multi-dimensional measures of health literacy in order to be able to quantify change in a larger trial. This feasibility study represents the first step in providing the high quality evidence needed to understand the way in which health literacy can be improved and health inequalities reduced through Australian adult education programs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-016-0373-1) contains supplementary material, which is available to authorized users.

Evaluation of an Australian health literacy training program for socially disadvantaged adults attending basic education classes: study protocol for a cluster randomised controlled trial

BACKGROUND

People with low literacy and low health literacy have poorer health outcomes. Literacy and health literacy are distinct but overlapping constructs that impact wellbeing. Interventions that target both could improve health outcomes.

METHODS/DESIGN

This is a cluster randomised controlled trial with a qualitative component. Participants are 300 adults enrolled in basic language, literacy and numeracy programs at adult education colleges across New South Wales, Australia. Each adult education institute (regional administrative centre) contributes (at least) two classes matched for student demographics, which may be at the same or different campuses. Classes (clusters) are randomly allocated to receive either the health literacy intervention (an 18-week program with health knowledge and skills embedded in language, literacy, and numeracy training (LLN)), or the standard Language Literacy and Numeracy (LLN) program (usual LLN classes, specifically excluding health content). The primary outcome is functional health literacy skills - knowing how to use a thermometer, and read and interpret food and medicine labels. The secondary outcomes are self-reported confidence, more advanced health literacy skills; shared decision making skills, patient activation, health knowledge and self-reported health behaviour. Data is collected at baseline, and immediately and 6 months post intervention. A sample of participating teachers, students, and community health workers will be interviewed in-depth about their experiences with the program to better understand implementation issues and to strengthen the potential for scaling up the program.

DISCUSSION

Outcomes will provide evidence regarding real-world implementation of a health literacy training program with health worker involvement in an Australian adult education setting. The evaluation trial will provide insight into translating and scaling up health literacy education for vulnerable populations with low literacy.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616000213448 .

Validation of a Health Literacy Measure for Adolescents and Young Adults Diagnosed with Cancer

Health literacy can influence long-term health outcomes. This study aimed to validate an adapted version of the Functional, Communicative and Critical Health Literacy measure for adolescent and young adult (AYA) cancer patients and survivors (N = 105; age 12-24 years). Exploratory factor analysis was used to validate the measure, and indicated that a slightly modified item structure better fit the results. Furthermore, item response theory analysis highlighted location and discrimination parameter differences among items. Acceptability of the measure was high. This is the first validation of a health literacy measure among AYAs with an illness such as cancer.

Development and field testing of a consumer shared decision-making training program for adults with low literacy

OBJECTIVE

Given the scarcity of shared decision-making (SDM) interventions for adults with low literacy, we created a SDM training program tailored to this population to be delivered in adult education settings.

METHODS

Formative evaluation during program development included a review of the problem and previous efforts to address it, qualitative interviews with the target population, program planning and field testing.

RESULTS

A comprehensive SDM training program was developed incorporating core SDM elements. The program aimed to improve students' understanding of SDM and to provide them with the necessary skills (understanding probabilistic risks and benefits, personal values and preferences) and self-efficacy to use an existing set of questions (the AskShareKnow questions) as a means to engage in SDM during healthcare interactions.

CONCLUSIONS

There is an ethical imperative to develop SDM interventions for adults with lower literacy. Generic training programs delivered direct-to-consumers in adult education settings offer promise in a national and international environment where too few initiatives exist.

PRACTICE IMPLICATIONS

Formative evaluation of the program offers practical insights into developing consumer-focused SDM training. The content of the program can be used as a guide for future efforts to engage consumers in SDM.

Can consumers learn to ask three questions to improve shared decision making? A feasibility study of the ASK (AskShareKnow) Patient-Clinician Communication Model(®) intervention in a primary health-care setting

Objective

To test the feasibility and assess the uptake and acceptability of implementing a consumer questions programme, AskShareKnow, to encourage consumers to use the questions ‘1. What are my options; 2. What are the possible benefits and harms of those options; 3. How likely are each of those benefits and harms to happen to me?’ These three questions have previously shown important effects in improving the quality of information provided during consultations and in facilitating patient involvement.

Methods

This single‐arm intervention study invited participants attending a reproductive and sexual health‐care clinic to view a 4‐min video‐clip in the waiting room. Participants completed three questionnaires: (T1) prior to viewing the intervention; (T2) immediately after their consultation; and (T3) two weeks later.

Results

A total of 121 (78%) participants viewed the video‐clip before their consultation. Eighty‐four (69%) participants asked one or more questions, and 35 (29%) participants asked all three questions. For those making a decision, 55 (87%) participants asked one or more questions, while 27 (43%) participants asked all three questions. Eighty‐seven (72%) participants recommended the questions. After two weeks, 47 (49%) of the participants recalled the questions.

Conclusions

Enabling patients to view a short video‐clip before an appointment to improve information and involvement in health‐care consultations is feasible and led to a high uptake of question asking in consultations.

Practice Implications

This AskShareKnow programme is a simple and feasible method of training patients to use a brief consumer‐targeted intervention that has previously shown important effects in improving the quality of information provided during consultations and in facilitating patient involvement and use of evidence‐based questions.

Which information source is best? Concordance between patient report, clinician report and medical records of patient co-morbidity and adjuvant therapy health information

RATIONALE, AIM AND OBJECTIVES

Previous studies investigating agreement between data sources for co-morbidity and adjuvant therapy information have suggested agreement varies depending on how the information is collected. The aim of this study was to compare agreement among three data sources: patient report, clinician report and medical record.

METHOD

Data were collected as part of a nurse-delivered telephone intervention (the CONNECT programme). Patient report was collected using a self-administered questionnaire. Clinician report was collected from the patient's treating surgeon. Medical record information was extracted by a member of the research team. The proportion of specific agreement [positive (PA) and negative agreement (NA)] and Kappa statistics were calculated.

RESULTS

The study sample comprised 756 surgical patients with colorectal cancer. For the majority of co-morbidities the lowest level of agreement was found between the patient and clinician (PA 0.29-0.64, Kappa values ranged from 0.22 to 0.58). The highest agreement and Kappa values for co-morbidities were generally found between the patient report and medical record (PA 0.36-0.80 and NA 0.92-0.99; Kappa 0.34-0.77). There was good agreement between patient and clinician reports for receipt adjuvant therapy {Kappa 0.78 [confidence interval (CI) 0.72-0.84] and 0.84 [CI 0.80-0.88], respectively; PA 0.87 and 0.92, respectively}. No consistent pattern in the predictors of non-agreement was found.

CONCLUSION

Given there was higher agreement between patient report and medical record review, the use of patient self-report questionnaires to ascertain co-morbid conditions remains a valid method for health services research.

Identifying indicators of colorectal cancer care coordination: a Delphi study

AIM

Care coordination is an important aspect of the quality of cancer care but is difficult to evaluate due to the lack of valid and reliable measures. This study was conducted to identify a set of objective measures of colorectal cancer care coordination that could be included in a medical record audit tool.

METHOD

A two-stage Delphi study was conducted to gain consensus among a national panel of experts about the validity of 41 potential indicators of colorectal cancer care coordination that had been identified during a literature review. The expert panel comprised 20 members from the National Health and Medical Research Colorectal Cancer Guidelines Working Party plus representatives from cancer nursing/coordination, general practice and cancer consumers.

RESULTS

Consensus was reached on the validity of 15 of 41 potential indicators, including those that focused on practical aspects of communication (legibility, clarity, content and timeliness of hospital discharge letters, documentation of outcomes of multidisciplinary team meetings) and appropriateness (documentation of preoperative consultation with a stoma therapist, discussions and referrals for adjuvant therapy for appropriate patients, and treatment by an experienced colorectal surgeon). There was lack of consensus on the validity of indicators relating to access to and efficiency of services.

CONCLUSION

The study has identified a core set of measures considered to be valid indicators of colorectal cancer care coordination. A medical record audit based on these measures could be used to monitor adequacy of cancer care coordination and will complement subjective measures based on self-reported experiences of patients and carers.

Physician-patient-companion communication and decision-making: a systematic review of triadic medical consultations

OBJECTIVE

To systematically review quantitative and qualitative studies exploring physician-adult patient-adult companion (triadic) communication and/or decision-making within all medical encounters.

METHODS

Studies were identified via database searches and reference lists. One author assessed eligibility of studies, verified by two co-authors. Data were extracted by one author and cross-checked for accuracy. Two authors assessed the quality of included articles using standardized criteria.

RESULTS

Of the 8409 titles identified, 52 studies were included. Summary statements and tables were developed for each of five identified themes. Results indicated companions regularly attended consultations, were frequently perceived as helpful, and assumed a variety of roles. However, their involvement often raised challenges. Patients with increased need were more often accompanied. Some companion behaviours were felt to be more helpful (e.g. informational support) and less helpful (e.g. dominating/demanding behaviours), and preferences for involvement varied widely.

CONCLUSION

Triadic communication in medical encounters can be helpful but challenging. Based on analysis of included studies, preliminary strategies for health professionals are proposed.

PRACTICE IMPLICATIONS

Preliminary strategies for health professionals include (i) encourage/involve companions, (ii) highlight helpful companion behaviours, (iii) clarify and agree upon role preferences of patient/companions. Future studies should develop and evaluate specific strategies for optimizing triadic consultations.

Three questions that patients can ask to improve the quality of information physicians give about treatment options: a cross-over trial

OBJECTIVE

To test the effect of three questions (what are my options? what are the benefits and harms? and how likely are these?), on information provided by physicians about treatment options.

METHODS

We used a cross-over trial using two unannounced standardized patients (SPs) simulating a presentation of mild-moderate depression. One SP was assigned the intervention role (asking the questions), the other the control role. An intervention and control SP visited each physician, order allocated randomly. The study was conducted in family practices in Sydney, Australia, during 2008-09. Data were obtained from consultation audio-recordings. Information about treatment options and patient involvement were analyzed using the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool and the OPTION tool.

RESULTS

Thirty-six SP visits were completed (18 intervention, 18 control). Scores were higher in intervention consultations than controls: ACEPP scores 21.4 vs. 16.6, p<0.001, difference 4.7 (95% CI 2.3-7.0) and OPTION scores 36 vs. 25, p=0.001, difference 11.5 (95% CI 5.1-17.8), indicating greater information provision and behavior supporting patient involvement.

CONCLUSION

Asking these three questions improved information given by family physicians and increased physician facilitation of patient involvement. Practice implications. These questions can drive evidence-based practice, strengthen patient-physician communication, and improve safety and quality.

Factors which motivate cancer doctors to involve their patients in reaching treatment decisions

OBJECTIVE

Cancer patients increasingly expect to be involved in treatment decision-making. We investigated factors that motivate cancer doctors to involve their patients in treatment decisions.

METHODS

We conducted 22 telephone interviews with doctors treating breast, colorectal, gynaecological, haematological or prostate/urological cancer. Interviews probed doctors for attitudes to shared decision-making (SDM), views of when patient involvement is appropriate and what motivated them to encourage involvement. Interviews were audio-recorded. Themes were identified using framework analysis.

RESULTS

Cancer doctors described disease, patient, doctor and societal influences on their support for patient involvement in treatment decisions. Treatment recommendations were described as 'clear-cut' or 'grey'. When treatment options were clear-cut, the impact of treatment on patients' quality of life and self-image and the influence of consumer groups motivated doctors' support of patient involvement.

CONCLUSION

Australian cancer doctors express differing support of patient involvement in decision-making dependent on context, impact and effect that involvement may have. Doctors described meeting patient involvement preferences as a challenge, and needing to identify different characteristics, anxiety levels and levels of understanding to guide them to involve patients in decisions.

PRACTICE IMPLICATIONS

Models of shared decision-making may warrant refinement to better guide doctors to elicit and discuss information and involvement preferences.

Supporting Treatment Decision Making in Advanced Cancer: A Randomized Trial of a Decision Aid for Patients With Advanced Colorectal Cancer Considering Chemotherapy

Purpose

Decision making in advanced cancer is increasingly complex. We developed a decision aid (DA) for patients with advanced colorectal cancer who are considering first-line chemotherapy and reviewing treatment options, prognostic information, and toxicities. We examined its impact on patient understanding, treatment decisions, decisional conflict, decision making, consultation satisfaction, anxiety, and quality of life by using a randomized trial design.

Patients and Methods

In all, 207 patients with colorectal cancer who were considering first-line chemotherapy for metastatic disease were randomly assigned to receive a standard medical oncology consultation or a consultation in which the DA (take-home booklet with audio recording, reviewed by an oncologist) was used. Participants completed questionnaires postconsultation, postdecision, and 1 month later.

Results

In this study, 100 patients were randomly assigned to the control arm, and 107 received the DA. Median age of the sample was 62 years, 58% were male, 89% had a performance status of 0 or 1, and 36% had received prior adjuvant chemotherapy. Patients receiving the DA demonstrated a greater increase in understanding of prognosis, options, and benefits, with higher overall understanding (P < .001). Decisional conflict, treatment decisions, and achievement of involvement preferences were similar between the groups. Anxiety was similar across groups and decreased over time. Most patients were confident in a decision during the first consultation; 74% chose chemotherapy, 7% supportive care alone, and 10% observation.

Conclusion

This randomized trial of a decision aid in advanced cancer showed that its use in advanced colorectal cancer improved patient understanding of prognosis, treatment options, risks, and benefits without increasing anxiety. DAs can improve informed consent and can be tested through randomized trials even in the advanced cancer setting.

Enhancing international collaboration among early career researchers

OBJECTIVE

The European Association of Communication in Healthcare (EACH) Early Career Researchers Network (ECRN) aims are to (1) promote international collaboration among young investigators and (2) provide a support network for future innovative communication research projects. In October 2009, Miami, USA at a workshop facilitated by the ECRN at the International Conference on Communication in Healthcare (ICCH) hosted by the American Academy of Communication in Healthcare we explored common facilitators and challenges faced by early career researchers in health communication research.

METHODS

Attendees introduced themselves, their research area(s) of interest, and listed one facilitator and one barrier for their career development. EACH ECRN members then led a discussion of facilitators and challenges encountered in communication research projects and career development. We discussed potential collaboration opportunities, future goals, and activities.

RESULTS

Having supportive collegial relationships, institutional support, job security, and funding are critical facilitators for early career investigators. Key challenges include difficulty with time management and prioritizing, limited resources, and contacts.

CONCLUSION

International collaboration among early career researchers is a feasible and effective means to address important challenges, by increasing opportunities for professional support and networking, problem-solving, discussion of data, and ultimately publishing.

PRACTICE IMPLICATIONS

Future AACH-EACH Early Career Researcher Networks should continue to build collaborations by developing shared research projects, papers, and other scholarly products.

Physician-Identified Factors Affecting Patient Participation in Reaching Treatment Decisions

Purpose

Cancer physicians report high comfort with shared decision making but a lower frequency of using this approach in practice. Information regarding physicians’ perceptions of what helps and what hinders patient involvement in decision making may facilitate understanding of this discrepancy.

Methods

We surveyed 604 Australian cancer physicians treating breast, colorectal, gynecologic, hematologic, or urologic cancer to investigate barriers and facilitators to reaching treatment decisions with their patients and their support of strategies to encourage patient involvement and reflection on treatment options. Factor analysis and regression analyses were used to investigate relationships between variables and identify predictors of greater reporting of barriers to sharing treatment decisions with patients.

Results

Insufficient information at the first consultation (28.9%) and insufficient time (28.4%) were the most frequently reported barriers to reaching treatment decisions with patients. Multivariate analysis revealed that less experienced physicians more commonly reported system barriers (P = .00). Patients trusting their physician and being accompanied at the consultation were most helpful to reaching a treatment decision. Providing written information about treatment options, making a further appointment to reach a decision, encouraging the patient to speak with their family physician and treatment team, and the presence of a third person during the consultation were felt to encourage involvement and reflection on treatment decisions.

Conclusion

Cancer physicians experience difficulties when reaching treatment decisions with their patients. Interventions and strategies that physicians support are required to enhance patient involvement in reaching a treatment decision.

The context influences doctors' support of shared decision-making in cancer care

Most cancer patients in westernised countries now want all information about their situation, good or bad, and many wish to be involved in decision-making. The attitudes to and use of shared decision-making (SDM) by cancer doctors is not well known. Australian cancer clinicians treating breast, colorectal, gynaecological, haematological, or urological cancer were surveyed to identify their usual approach to decision-making and their comfort with different decision-making styles when discussing treatment with patients. A response rate of 59% resulted in 624 complete surveys, which explored usual practice in discussing participation in decision-making, providing information, and perception of the role patients want to play. Univariate and multivariate analyses were performed to identify predictors of use of SDM. Most cancer doctors (62.4%) reported using SDM and being most comfortable with this approach. Differences were apparent between reported high comfort with SDM and less frequent usual practice. Multivariate analysis showed that specialisation in breast or urological cancers compared to other cancers (AOR 3.02), high caseload of new patients per month (AOR 2.81) and female gender (AOR 1.87) were each independently associated with increased likelihood of use of SDM. Barriers exist to the application of SDM by doctors according to clinical situation and clinician characteristics.

Shared decision-making in Australia

This paper describes the current position of shared decision-making (SDM) within the Australian health care system. Australian health care includes a mixture of public and private practice governed by both regional and national policy. Support for SDM exists through guidelines and support for interventions to increase participation. However, there is no clear overall policy framework for SDM in Australia. The result is recognition that consumer involvement is important yet there are limited resources and infrastructure, and no clear strategy to support implementation. Barriers to SDM at the macro, meso and micro levels of health care are described. Efforts to support consumer involvement to date have been targeted to the supply side of health care. There is now awareness of the need to target the demand side by educating consumers to ask for information and involvement in their health care.

Evaluation of constructed wetland treatment performance for winery wastewater

Rapid expansion of wineries in rural California during the past three decades has created contamination problems related to winery wastewater treatment and disposal; however, little information is available about performance of on-site treatment systems. Here, the project objective was to determine full-scale, subsurface-flow constructed wetland retention times and treatment performance through assessment of water quality by daily sampling of total dissolved solids, pH, total suspended solids, chemical oxygen demand (COD), tannins, nitrate, ammonium, total Kjeldahl nitrogen, phosphate, sulfate, and sulfide across operating systems for winery wastewater treatment. Measurements were conducted during both the fall crush season of heavy loading and the spring following bottling and racking operations at the winery. Simple decay model coefficients for these constituents as well as COD and tannin removal efficiencies from winery wastewater in bench-scale reactors are also determined. The bench-scale study used upward-flow, inoculated attached-growth (pea-gravel substrate) reactors fed synthetic winery wastewater. Inlet and outlet tracer studies for determination of actual retention times were essential to analyses of treatment performance from an operational subsurface-flow constructed wetland that had been overloaded due to failure to install a pretreatment system for suspended solids removal. Less intensive sampling conducted at a smaller operational winery wastewater constructed wetland that had used pretreatment suspended solids removal and aeration indicated that the constructed wetlands were capable of complete organic load removal from the winery wastewater.

Time-dependent retardation model for chemical oxygen demand removal in a subsurface-flow constructed wetland for winery wastewater treatment

The relative success of chemical oxygen demand (COD) removal models to describe measured rates of COD removal in a pilot-scale constructed wetland designed for treatment of high-strength winery wastewater are evaluated using retention times determined from tracer studies. Not surprisingly, two-parameter residual and retardation models better fit the measured removal data than single-parameter, first-order decay models for wastewater at average COD loadings up to nearly 5000 mg/L. The residual and retardation models yielded nearly equivalent fits to the measured data. However, the retardation model had more consistent parameters for COD removal data across different depth levels in the constructed wetland and at different loadings, and a slightly smaller sum of least-squared errors. The retardation model seems to be appropriate for constructed wetland design because it allows a steady decrease in COD with increased treatment time rather than a constant residual COD (C*) value. From the least-squares optimization procedure used to estimate model parameters (a volumetric rate constant, Kv, range of 3 to 12 d(-1)), nonrealistic, or physically meaningless, large C* values (C* range of 23 to 450 mg COD/L) that were dependent on COD loading were obtained, potentially underestimating the constructed wetland system's actual winery wastewater treatment potential. The optimal parameters for the retardation model applied to the pilot-scale constructed wetland ranged from 9 to 12 d(-1) for the initial degradation rate constant, Ko, and 2 to 5 d(-1) for the time-based retardation coefficient, b. These values should be verified for full-scale field systems based on field measurements currently underway.