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Shields CG, Griggs JJ, Fiscella K, Elias CM, Christ SL, Colbert J, Henry SG, Hoh BG, Hunte HER, Marshall M, Mohile SG, Plumb S, Tejani MA, Venuti A, Epstein RM. The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment. J Gen Intern Med 2019; 34:435-442. [PMID: 30632104 PMCID: PMC6420510 DOI: 10.1007/s11606-018-4785-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 08/30/2018] [Accepted: 11/19/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer. OBJECTIVE To examine the effect of race on physicians' pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation. DESIGN Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles-a 62-year-old man with advanced lung cancer and uncontrolled pain-differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions. PARTICIPANTS Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians' mean age was 52 years (SD = 27.17), 59% male, and 64% white. MAIN MEASURES Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment. KEY RESULTS SPs completed 181 covertly audio-recorded visits that had complete data for the model covariates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81). CONCLUSIONS Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain. TRIAL REGISTRATION NCT01501006.
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Affiliation(s)
- Cleveland G Shields
- Center for Cancer Research, Purdue University, West Lafayette, IN, USA
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, USA
- Human Development & Family Studies, Purdue University, West Lafayette, IN, USA
| | - Jennifer J Griggs
- Department of Internal Medicine, Hematology/ Oncology Division, and Health Management and Policy, University of Michigan School of Medicine, Ann Arbor, MI, USA
- Department of Health Management & Policy, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Kevin Fiscella
- Center for Communication and Disparities Research, University of Rochester School of Medicine, Rochester, NY, USA
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, NY, USA
| | - Cezanne M Elias
- Human Development & Family Studies, Purdue University, West Lafayette, IN, USA
| | - Sharon L Christ
- Human Development & Family Studies, Purdue University, West Lafayette, IN, USA
- Department of Statistics, Purdue University, West Lafayette, IN, USA
| | - Joseph Colbert
- Department of Biostatistics, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Stephen G Henry
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Beth G Hoh
- Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY, USA
| | - Haslyn E R Hunte
- School of Public Health, Department of Social and Behavioral Sciences, West Virginia University, Morgantown, WV, USA
| | - Mary Marshall
- Human Development & Family Studies, Purdue University, West Lafayette, IN, USA
| | - Supriya Gupta Mohile
- James P Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, NY, USA
| | - Sandy Plumb
- Center for Communication and Disparities Research, University of Rochester School of Medicine, Rochester, NY, USA
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA
- James P Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, NY, USA
| | - Mohamedtaki A Tejani
- James P Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, NY, USA
| | - Alison Venuti
- Center for Communication and Disparities Research, University of Rochester School of Medicine, Rochester, NY, USA
| | - Ronald M Epstein
- Center for Communication and Disparities Research, University of Rochester School of Medicine, Rochester, NY, USA.
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA.
- Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY, USA.
- James P Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, NY, USA.
- Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA.
- Family Medicine Research Programs, University of Rochester, Rochester, NY, USA.
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Affiliation(s)
- Ronald M Epstein
- University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
| | - Michael R Privitera
- University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
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Babu DS, Gerbino N, Fiscella K, Shields C, Griggs JJ, Epstein RM, Tejani MA. Communication of prognostic information between oncologists and patients with advanced lung cancer. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.34_suppl.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
29 Background: A critical domain of patient-provider communication is helping cancer patients understand their prognosis, as well as the efficacy of treatment options. In this qualitative study, we explored the ways oncology providers approached prognostic discussions during initial office visits with patients with metastatic lung cancer. Methods: Transcripts of initial visits between unannounced standardized patients portraying metastatic non-small cell lung cancer and their oncologists were recorded at multiple practice sites in community and academic settings, as part of a large NIH-funded study. Thematic analysis was conducted on a subset of these recorded visits from one study site. In this secondary analysis, three coders (one medical oncologist, one palliative care physician and one research assistant) reviewed transcripts independently to extract quotes related to prognosis, meeting regularly to review selected quotes and to decide on codes. This process repeated until saturation of themes was achieved (n = 15). Results: Discussions of prognosis were found in all 15 transcripts reviewed. Three main themes were identified: (1) Vagueness, in which best-case/worst-case scenarios were presented without an estimate of life expectancy; (2) Statistical Reliance, in which complex statistical data were presented to the patient; and (3) Emotional Support, in which the discussion was infused with emotional reassurance which was contextually appropriate. A fourth identified theme was (4) Minimizing of Supportive Care, as discussions of management options did not always elaborate on best supportive care. Conclusions: Our qualitative analysis of initial office visits among simulated patients with metastatic lung cancer revealed that providers often frame prognostic information in vague terms without a realistic estimate of life expectancy, sometimes give patients complex statistical data, and tend to accompany their discussions with emotional reassurance. Best supportive care is not always fully explained when management options are reviewed. More work is needed to determine optimal ways to convey prognostic and management information during clinic visits for patients with advanced cancer.
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Affiliation(s)
| | - Nicholas Gerbino
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
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Loh KP, Mohile SG, Epstein RM, McHugh C, Flannery MA, Culakova E, Lei L, Wells M, Gilmore N, Babu DS, Conlin AK, Thomas MB, Berenberg JL, Duberstein P. Willingness to bear adversity and beliefs about the curability of advanced cancer. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.34_suppl.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
20 Background: Older patients with advanced cancer who are certain that they could be cured pose unique challenges for physicians who wish to help them prepare for death. By estimating the prevalence of absolute certainty about curability (ACC) and examining its correlates we aim to inform the development of interventions to improve end of life care. We hypothesized that patients who report greater willingness to bear adversity in exchange for longevity will be more likely to demonstrate ACC. Methods: This is a cross-sectional analysis of a nationwide geriatric assessment trial. Patients were asked: “What are the chances the cancer will go away and never come back with treatment [100% (ACC), > 50%, 50/50, < 50%, 0%, or unclear].” We assessed willingness to bear adversity using two types of trade-off questions. For trade-offs between treatment-related adverse reactions and survival, five statements on specific adverse reactions (nausea/vomiting, assistance with activities, bedbound state, confusion, worsening memory) were administered. For trade-off preferences between quality of life (QoL) and survival, patients answered the following statement: “Maintaining my QoL is more important to me than living longer”. Logistic regression was used to assess the independent associations of patient trade-off preferences with ACC, after controlling for covariates. Results: 349 older patients were included; 8.0% had ACC. 7.4% of respondents disagreed/strongly disagreed with the statement “Maintaining my QoL is more important than living longer.” Patients who were willing to trade QoL for survival were more likely to demonstrate ACC (AOR 4.43, 95% CI 1.13-17.42). Trade-off preferences between adverse reactions and survival were not associated with ACC. Non-white race, < high school education, lower household income, lack of social support, intact functional status, and no polypharmacy were associated with ACC (p < 0.05). Conclusions: Patients with advanced cancer who are more willing to accept a decreased QoL for survival are more likely to be certain that they will be cured. Beyond sharing prognosis, clinicians might help patients improve prognostic understanding by helping them identify and articulate their values and beliefs.
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Affiliation(s)
- Kah Poh Loh
- University of Rochester Medical Center, Rochester, NY
| | | | | | - Colin McHugh
- University of Rochester Medical Center, Rochester, NY
| | | | - Eva Culakova
- University of Rochester Medical Center, Rochester, NY
| | - Lianlian Lei
- University of Rochester Medical Center, Rochester, NY
| | - Megan Wells
- University of Rochester Medical Center, Rochester, NY
| | | | | | | | - Melanie B. Thomas
- Southeast Clinical Oncology Research Consortium (SCOR), Charleston, SC
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De Sola-Smith KM, Bell J, Tancredi DJ, Kravitz RL, Duberstein P, Epstein RM, Fenton JJ. Hits and misses: A longitudinal examination of congruence between patient-reported quality-of-life concerns in advanced cancer and discussions with oncologists. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.34_suppl.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
22 Background: Quality of life (QOL) support is critical to high quality advanced cancer care and is associated with improved patient outcomes, but most patients report unmet supportive care needs. To understand supportive care provision in routine oncology, we examined the agreement, or congruence, between patients’ self-reported symptoms and topics discussed with oncologists over an extended interval of care. Prior research suggests that patient-provider rapport and overall QOL influence discussion of patient concerns, therefore we estimated effects of two predictors of interest: therapeutic alliance between patient and oncologist, and global QOL. Methods: We conducted a secondary analysis of data collected in the VOICE study. Patients with advanced cancer (n=196) completed measures of symptoms (e.g., pain, nausea, emotional concerns) and QOL, as well as an inventory of topics discussed with oncologists over the prior 3 months. Data were collected at quarterly intervals for up to 48 months, resulting in 901 paired reports of patients’ symptoms and discussions with oncologists. We constructed congruence as a multinomial outcome with four discrete categories: congruence (symptom reported/discussed), unaddressed concern (symptom reported/not discussed), surveillance (symptom not reported/discussed), and no supportive care concern (symptom not reported/not discussed). We then estimated effects of global QOL and therapeutic alliance using multi-level logistic regression. Results: Congruence was most common for pain (49.9%), while emotional concerns were most likely to be unaddressed (50.5%). Higher therapeutic alliance with oncologists was associated with lower odds of unaddressed pain (OR 0.94, CI 0.89-1.00) and emotional concerns (OR 0.95, CI 0.91-0.98). Higher global QOL was associated with higher odds of unaddressed emotional concerns (OR 1.11, CI 1.02-1.20). Congruence outcomes were stable over time. Conclusions: Oncologists may improve congruence by strengthening therapeutic alliance, by more consistently discussing emotional concerns, and by prioritizing topics for discussion according to patients’ needs.
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Affiliation(s)
| | - Janice Bell
- University of California Davis, Sacramento, CA
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Rogers HL, Dumenci L, Epstein RM, Siminoff LA. Impact of Patient Gender and Race and Physician Communication on Colorectal Cancer Diagnostic Visits in Primary Care. J Womens Health (Larchmt) 2018; 28:612-620. [PMID: 30489201 DOI: 10.1089/jwh.2018.6961] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Patient gender and race, and physician-patient communication are associated with clinical outcomes. Aim: To understand the role of these factors in the diagnosis of colorectal cancer (CRC) during primary care visits as measured by appropriate outcome. Materials and Methods: Caucasian and African American unannounced standardized patients (USPs) of both genders presented to 207 primary care physicians (PCPs) from community and academic practices in Ohio and Virginia as new patients with CRC symptoms. PCPs were blinded to the diagnosis. Physician subjects consented to audiotaping the encounter. Medical records were obtained. Communication elements were coded by trained observers and appropriate visit outcomes were coded from the medical record and audiofiles, defined as (1) recommendation for colonoscopy/sigmoidoscopy/fecal occult blood test (FOBT) or (2) referral to gastroenterologist. Results: A total of 141 of 367 USP visits (38%) resulted in appropriate clinical outcomes. Patient race was not associated with outcome, but being a male USP was (χ2 = 4.12, p = 0.04). Relational communication was represented as a latent variable with seven indicators (alpha = 0.84) and was independently associated with outcome (beta = 0.15; p = 0.025). After controlling for clustered sampling, relational communication, and race, structural equational modeling indicated that female USPs were less likely to have an appropriate clinical visit outcome (beta = -0.13; p = 0.033). Conclusions: Using a novel and innovative methodology capturing PCP behaviors during real-time clinician-patient interaction, appropriate clinical outcome was independently associated with being male and PCP relational communication factors such as encouraging patient communication, being engaged and expressive in the physician-patient conversation, and appearing friendly and sincere. There are persistent biases in the delivery of health care to female patients and further research into targeted communication skills programs may be warranted.
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Affiliation(s)
- Heather L Rogers
- 1 BioCruces Bizkaia Health Research Institute, Barakaldo, Spain.,2 IKERBASQUE, Basque Foundation for Science, Bilbao, Spain
| | - Levent Dumenci
- 3 Department of Social and Behavioral Sciences, Temple University College of Public Health, Philadelphia, Pennsylvania
| | - Ronald M Epstein
- 4 Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Laura A Siminoff
- 3 Department of Social and Behavioral Sciences, Temple University College of Public Health, Philadelphia, Pennsylvania
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Saeed F, Xing G, Tancredi DJ, Epstein RM, Fiscella KA, Norton SA, Duberstein PR. Is Annual Income a Predictor of Completion of Advance Directives (ADs) in Patients With Cancer. Am J Hosp Palliat Care 2018; 36:402-407. [PMID: 30477311 DOI: 10.1177/1049909118813973] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
CONTEXT: Completion of advance directives (ADs) enhances the likelihood of receiving goal-concordant treatments near the end of life. Previous research on community samples have shown that completion of ADs is less common in lower socioeconomic status demographic group; there is a paucity of such research in patients with cancer. OBJECTIVES: To study the effect of income and education on the completion of ADs. HYPOTHESIS: Patients with cancer having lower incomes and education levels would be less likely to report completing ADs. METHODS: We conducted cross-sectional analyses of data provided by patients (n = 265) enrolled in the Values and Options in Cancer Care clinical trial. Patients with advanced cancer reported whether they had (1) completed a living will or (2) designated a health-care proxy. Response options for both questions were yes (scored 1), no (scored 0), and unsure (scored 0). We studied the association of lower household income (≤US$20 000) and education level (never attended college) with AD scores. RESULTS: Patients with lower annual incomes had lower AD scores (estimate -0.44; confidence intervals [CI]: -0.71 to -0.16, P = .001); the association between higher educational attainment (some college or more) and completion of ADs was not statistically significant (estimate 0.04, CI: -0.16 to 0.24, P = .70). CONCLUSION: Interventions to promote completion of ADs among lower income patients with serious illnesses are needed.
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Affiliation(s)
- Fahad Saeed
- 1 Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,2 Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,3 Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Guibo Xing
- 4 Center for Healthcare Policy and Research, University of California, Davis, CA, USA
| | - Daniel J Tancredi
- 5 Department of Pediatrics, University of California, Davis, CA, USA
| | - Ronald M Epstein
- 2 Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,6 Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,7 Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Kevin A Fiscella
- 3 Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,7 Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sally A Norton
- 8 University of Rochester School of Nursing, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Paul R Duberstein
- 6 Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,9 Department of Health Behavior, Disparities, and Policy, Rutgers School of Public Health, Rochester, NY, USA
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Trevino KM, Maciejewski PK, Shen MJ, Prigerson HG, Mohile S, Kamen C, Epstein RM, Duberstein P. How much time is left? Associations between estimations of patient life expectancy and quality of life in patients and caregivers. Support Care Cancer 2018; 27:2487-2496. [PMID: 30387051 PMCID: PMC6494724 DOI: 10.1007/s00520-018-4533-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 10/26/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE It is unclear whether life-expectancy estimates of patients with advanced cancer and their caregivers are associated with patient existential, social, or emotional quality of life (QOL) or caregiver emotional QOL. METHODS Patients with advanced cancer and their caregivers (n = 162 dyads) reported estimates of the chance the patient would live for 2 years or more from 0% (most pessimistic) to 100% (most optimistic). They also completed self-report measures of QOL. RESULTS Adjusting for sociodemographic confounds and multiple comparisons, more pessimistic caregiver and patient life-expectancy estimates were associated with worse caregiver emotional QOL and worse patient existential QOL. Discrepancies between patient and caregiver estimates were not associated with patient or caregiver QOL. CONCLUSIONS Pessimistic life-expectancy estimates are associated with worse existential QOL in patients and worse emotional QOL in caregivers. Prospective research to establish causal relationships is needed, and interventions to address the relationship between beliefs about life expectancy and existential and emotional QOL should be considered. Providing these interventions to patients and caregivers receiving information on life expectancy may mitigate the negative impact of life-expectancy information on patient existential quality of life.
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Affiliation(s)
- Kelly M Trevino
- Weill Cornell Medicine, 525 E. 68th St., Box 39, New York, NY, 10065, USA.
| | - Paul K Maciejewski
- Weill Cornell Medicine, 525 E. 68th St., Box 39, New York, NY, 10065, USA
| | - Megan Johnson Shen
- Weill Cornell Medicine, 525 E. 68th St., Box 39, New York, NY, 10065, USA
| | - Holly G Prigerson
- Weill Cornell Medicine, 525 E. 68th St., Box 39, New York, NY, 10065, USA
| | - Supriya Mohile
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Charles Kamen
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Ronald M Epstein
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Paul Duberstein
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
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Norton SA, Wittink MN, Duberstein PR, Prigerson HG, Stanek S, Epstein RM. Family caregiver descriptions of stopping chemotherapy and end-of-life transitions. Support Care Cancer 2018; 27:669-675. [PMID: 30056528 DOI: 10.1007/s00520-018-4365-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 07/18/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE The purpose of this study was to describe family caregivers' perspectives of the final month of life of patients with advanced cancer, particularly whether and how chemotherapy was discontinued and the effect of clinical decision-making on family caregivers' perceptions of the patient's experience of care at the end of life (EOL). METHODS Qualitative descriptive design using semi-structured interviews collected from 92 family caregivers of patients with end-stage cancer enrolled in a randomized clinical trial. We used a phased approach to data analysis including open coding, focused coding, and within and across analyses. RESULTS We identified three patterns of transitions characterizing the shift away from active cancer treatment: (1) "We Pretty Much Knew," characterized by explicit discussions about EOL care, seemingly shared understanding about prognosis and seamless transitions from disease-oriented treatment to comfort-oriented care, (2) "Beating the Odds," characterized by explicit discussions about disease-directed treatment and EOL care options, but no shared understanding about prognosis and often chaotic transitions to EOL care, and (3) "Left to Die," characterized by no recall of EOL discussions with transitions to EOL occurring in crisis. CONCLUSIONS As communication and palliative care interventions continue to develop to improve care for patients with advanced cancer, it is imperative that we take into account the different patterns of transition and their unique patient and caregiver needs near the end of life. Our findings reveal considerable, and potentially unwarranted, variation in transitions from active treatment to death.
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Affiliation(s)
- S A Norton
- School of Nursing, University of Rochester, Rochester, NY, USA. .,Department of Medicine, Division of Palliative Care, University of Rochester, Rochester, NY, USA.
| | - M N Wittink
- Department of Family Medicine, University of Rochester, Rochester, NY, USA.,Department of Psychiatry, University of Rochester, Rochester, NY, USA
| | - P R Duberstein
- Department of Medicine, Division of Palliative Care, University of Rochester, Rochester, NY, USA.,Department of Family Medicine, University of Rochester, Rochester, NY, USA.,Department of Psychiatry, University of Rochester, Rochester, NY, USA
| | - H G Prigerson
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - S Stanek
- School of Nursing, University of Rochester, Rochester, NY, USA
| | - R M Epstein
- Department of Medicine, Division of Palliative Care, University of Rochester, Rochester, NY, USA.,Department of Family Medicine, University of Rochester, Rochester, NY, USA.,Department of Psychiatry, University of Rochester, Rochester, NY, USA.,Wilmot Cancer Center, University of Rochester, Rochester, NY, USA
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Saeed F, Hoerger M, Norton SA, Guancial E, Epstein RM, Duberstein PR. Preference for Palliative Care in Cancer Patients: Are Men and Women Alike? J Pain Symptom Manage 2018; 56:1-6.e1. [PMID: 29581034 PMCID: PMC6015521 DOI: 10.1016/j.jpainsymman.2018.03.014] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 03/02/2018] [Accepted: 03/13/2018] [Indexed: 11/21/2022]
Abstract
CONTEXT Men and those with low educational attainment are less likely to receive palliative care. Understanding these disparities is a high priority issue. OBJECTIVES In this study of advanced cancer patients, we hypothesized that men and those with lower levels of educational attainment would have less favorable attitudes toward palliative care. METHODS We performed a cross-sectional analysis of data collected from 383 patients at study entry in the Values and Options in Cancer Care (VOICE) clinical trial. Patients were asked about their preferences for palliative care if their oncologist informed them that further treatment would not be helpful. Palliative care was defined as "comfort care" that focuses on "quality of life, but not a cure." Response options were definitely no, possibly no, unsure, possibly yes, and definitely yes. Those preferring palliative care (definitely or possibly yes) were compared to all others. Predictors were patient gender and education level. Covariates included age, race, disease aggressiveness, and financial strain. RESULTS Women were more likely [odds ratio (95% CI)] than men to prefer palliative care [3.07 (1.80-5.23)]. The effect of education on preferences for palliative care was not statistically significant [0.85 (0.48-1.48)]. CONCLUSION Significant gender differences in patients' preferences for palliative care could partially account for gender disparities in end-of-life care. Interventions to promote palliative care among men could reduce these disparities.
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Affiliation(s)
- Fahad Saeed
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
| | - Michael Hoerger
- Department of Psychology, Tulane University, New Orleans, Louisiana
| | - Sally A Norton
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; School of Nursing, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Elizabeth Guancial
- Division of Hematology Oncology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ronald M Epstein
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Paul R Duberstein
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Mohile SG, Epstein RM, Hurria A, Heckler CE, Duberstein P, Canin BE, Gilmore N, Wells M, Xu H, Culakova E, Lowenstein LM, Flannery MA, Magnuson A, Loh KP, Mustian KM, Hopkins JO, Liu J, Melnyk N, Morrow GR, Dale W. Improving communication with older patients with cancer using geriatric assessment (GA): A University of Rochester NCI Community Oncology Research Program (NCORP) cluster randomized controlled trial (CRCT). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.18_suppl.lba10003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
LBA10003 Background: GA includes validated measures that assess age-related health domains (e.g., function, cognition) known to increase adverse outcomes. In this PCORI and NCI funded CRCT, we evaluated if providing a GA summary and recommendations for GA-guided interventions improves communication about age-related concerns for older patients (pts) with cancer. Methods: Pts aged ≥ 70 with advanced solid tumors or lymphoma and at least 1 impaired GA domain were enrolled. Oncology practices were randomized to intervention (oncologists received GA summary) or usual care (no summary provided). The primary outcomes were: 1) number of discussions about age-related concerns (the clinic visit after GA was audio-recorded and transcribed; 2 blinded coders evaluated quality of communication and plan for follow-up interventions) and 2) telephone surveys of patient satisfaction (modified Health Care Climate Questionnaire [HCCQ-age] scored 7-35). Outcomes were analyzed using linear mixed models with arm as the fixed effect, controlling for practice. Results: From 2014-17, 544 pts (295 in GA) were enrolled from 31 practices. There were no differences in demographics by arm (mean age 77 yrs; 49% female). More patients in usual care had impaired physical performance (96% vs 92%, p = 0.03) and social support (33% vs 25%, p = 0.05). In 530 evaluable pts, the overall mean number of discussions was 6.3 (SD: 4.0). The GA arm had 3.5 more discussions about age-related concerns (95%CI: 2.28-4.72, p = 10-6; intraclass correlation coefficient [ICC] = 0.24) compared to usual care; of these, in the GA arm, 2.0 more discussions on average had higher quality communication (95%CI: 1.20-2.69; p = 6x10-6) and 1.9 more led to interventions (95% CI: 1.14-2.73; p = 1.6x10-5). The GA arm had significantly more discussions for almost all GA domains. In 511 pts with HCCQ-age, the mean score was 22.9 (SD 4.5); the score was 1.12 points higher in the GA arm (95%CI: 0.23-2.03; p = .027; ICC = 0.02). Conclusions: Providing a GA summary to oncologists increases the number and quality of discussions about age-related concerns and improves pt satisfaction. Clinical trial information: NCT02107443.
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Affiliation(s)
| | | | - Arti Hurria
- City of Hope National Medical Center, Duarte, CA
| | | | | | | | | | - Megan Wells
- University of Rochester Medical Center, Rochester, NY
| | - Huiwen Xu
- University of Rochester Medical Center, Rochester, NY
| | - Eva Culakova
- University of Rochester Medical Center, Rochester, NY
| | | | | | | | - Kah Poh Loh
- University of Rochester Medical Center, Rochester, NY
| | | | - Judith O. Hopkins
- NRG Oncology/NSABP, and SCOR NCORP and the Forsyth Regional Cancer Center, Winston Salem, NC
| | | | - Nataliya Melnyk
- Rutgers Robert Wood Johnson Medcl School, East Brunswick, NJ
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Freytag J, Street RL, Xing G, Duberstein PR, Fiscella K, Tancredi DJ, Fenton JJ, Kravitz RL, Epstein RM. The ecology of patient and caregiver participation in consultations involving advanced cancer. Psychooncology 2018; 27:1642-1649. [PMID: 29575388 DOI: 10.1002/pon.4710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To identify predictors of participation of patients with advanced cancer in clinical encounters with oncologists and to assess the impact of patient and caregiver participation on perceptions of physician support. METHODS This is a secondary data analysis from the Values and Options in Cancer Care study, a cluster randomized clinical trial of a patient-centered communication intervention. Patients and caregivers completed pre-visit and post-visit health and communication measures. Audio recorded patient-caregiver (when present)-physician encounters were coded for active patient/caregiver participation behaviors (eg, question asking, expressing concern) and for physicians' facilitative communication (eg, partnership-building, support). Mixed linear regression models were used to identify patient, physician, and situational factors predicting patient and patient plus caregiver communication behaviors and post-visit outcomes. RESULTS Physician partnership building predicted greater expressions of concern and more assertive responses from patients and patient-caregiver pairs. Patients' perceptions of greater connectedness with their physician predicted fewer patient expressions of concern. Patient perceptions of physician respect for their autonomy were lower among patients accompanied by caregivers. Caregiver perceptions of physician respect for patient autonomy decreased with increasing patient age and varied by site. CONCLUSIONS In advanced cancer care, patient and caregiver communication is affected by ecological factors within their consultations. Physicians can support greater patient participation in clinical encounters through facilitative communication such as partnership-building and supportive talk. The presence of a caregiver complicates this environment, but partnership building techniques may help promote patient and caregiver participation during these visits.
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Affiliation(s)
| | | | - Guibo Xing
- University of California, Davis, Davis, CA, USA
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Abstract
Oncology clinician burnout has become a noteworthy issue in medical oncology directly affecting the quality of patient care, patient satisfaction, and overall organizational success. Due to the increasing demands on clinical time, productivity, and the evolving medical landscape, the oncology clinician is at significant risk for burnout. Long hours in direct care with seriously ill patients/families, limited control over daily responsibilities, and endless electronic documentation, place considerable professional and personal demands on the oncologist. As a result, the oncology clinician's wellness is adversely impacted. Physical/emotional exhaustion, cynicism, and feelings of ineffectiveness evolve as core signs of burnout. Unaddressed burnout may affect cancer clinician relationships with their patients, the quality of care delivered, and the overall physical and emotional health of the clinician. Oncology clinicians should be encouraged to build upon their strengths, thrive in the face of adversity and stress, and learn to positively adapt to the changing cancer care system. Fostering individual resilience is a key protective factor against the development of and managing burnout. Empowering clinicians at both the individual and organizational level with tailored resilience strategies is crucial to ensuring clinician wellness. Resilience interventions may include: burnout education, work-life balance, adjustment of one's relationship to work, mindful practice, and acceptance of the clinical work environment. Health care organizations must act to provide institutional solutions through the implementation of: team-based oncology care, communication skills training, and effective resiliency training programs in order to mitigate the effects of stress and prevent burnout in oncology.
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Affiliation(s)
- Fay J Hlubocky
- From the Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, IL; Department of Adult Psychiatry, Michigan State University, East Lansing, MI; University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Miko Rose
- From the Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, IL; Department of Adult Psychiatry, Michigan State University, East Lansing, MI; University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Ronald M Epstein
- From the Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, IL; Department of Adult Psychiatry, Michigan State University, East Lansing, MI; University of Rochester School of Medicine and Dentistry, Rochester, NY
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Fenton JJ, Duberstein PR, Kravitz RL, Xing G, Tancredi DJ, Fiscella K, Mohile S, Epstein RM. Impact of Prognostic Discussions on the Patient-Physician Relationship: Prospective Cohort Study. J Clin Oncol 2017; 36:225-230. [PMID: 29148892 DOI: 10.1200/jco.2017.75.6288] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose Some research has suggested that discussion of prognosis can disrupt the patient-physician relationship. This study assessed whether physician discussion of prognosis is associated with detrimental changes in measures of the strength of the patient-physician relationship. Methods This was a longitudinal cohort study of 265 adult patients with advanced cancer who visited 38 oncologists within community- and hospital-based cancer clinics in Western New York and Northern California. Prognostic discussion was assessed by coding transcribed audio-recorded visits using the Prognostic and Treatment Choices (PTCC) scale and by patient survey at 3 months after the clinic visit. Changes in the strength of the patient-physician relationship were computed as differences in patient responses to The Human Connection and the Perceived Efficacy in Patient-Physician Interactions scales from baseline to 2 to 7 days and 3 months after the clinic visit. Results Prognostic discussion was not associated with a temporal decline in either measure. Indeed, a one-unit increase in PTCC during the audio-recorded visit was associated with improvement in The Human Connection scale at 2 to 7 days after the visit (parameter estimate, 0.10; 95% CI, -0.02 to 0.23) and 3 months after the visit (parameter estimate, 0.18; 95% CI, 0.02 to 0.35) relative to baseline. Standardized effect sizes (SES) associated with an increase of two standard deviations in the PTCC at each time point were consistent with small beneficial effects (SES, 0.14 [95% CI, -0.02 to 0.29] at 2 to 7 days; SES, 0.24 [95% CI, 0.02 to 0.45] at 3 months), and lower bounds of CIs indicated that substantial detrimental effects of prognostic discussion were unlikely. Conclusion Prognostic discussion is not intrinsically harmful to the patient-physician relationship and may even strengthen the therapeutic alliance between patients and oncologists.
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Affiliation(s)
- Joshua J Fenton
- Joshua J. Fenton, Richard L. Kravitz, Guibo Xing, and Daniel J. Tancredi, University of California, Davis, Sacramento, CA; Paul R. Duberstein, Kevin Fiscella, and Ronald M. Epstein, University of Rochester; Supriya Mohile and Ronald M. Epstein, UR Medicine Wilmot Cancer Institute, Rochester, NY
| | - Paul R Duberstein
- Joshua J. Fenton, Richard L. Kravitz, Guibo Xing, and Daniel J. Tancredi, University of California, Davis, Sacramento, CA; Paul R. Duberstein, Kevin Fiscella, and Ronald M. Epstein, University of Rochester; Supriya Mohile and Ronald M. Epstein, UR Medicine Wilmot Cancer Institute, Rochester, NY
| | - Richard L Kravitz
- Joshua J. Fenton, Richard L. Kravitz, Guibo Xing, and Daniel J. Tancredi, University of California, Davis, Sacramento, CA; Paul R. Duberstein, Kevin Fiscella, and Ronald M. Epstein, University of Rochester; Supriya Mohile and Ronald M. Epstein, UR Medicine Wilmot Cancer Institute, Rochester, NY
| | - Guibo Xing
- Joshua J. Fenton, Richard L. Kravitz, Guibo Xing, and Daniel J. Tancredi, University of California, Davis, Sacramento, CA; Paul R. Duberstein, Kevin Fiscella, and Ronald M. Epstein, University of Rochester; Supriya Mohile and Ronald M. Epstein, UR Medicine Wilmot Cancer Institute, Rochester, NY
| | - Daniel J Tancredi
- Joshua J. Fenton, Richard L. Kravitz, Guibo Xing, and Daniel J. Tancredi, University of California, Davis, Sacramento, CA; Paul R. Duberstein, Kevin Fiscella, and Ronald M. Epstein, University of Rochester; Supriya Mohile and Ronald M. Epstein, UR Medicine Wilmot Cancer Institute, Rochester, NY
| | - Kevin Fiscella
- Joshua J. Fenton, Richard L. Kravitz, Guibo Xing, and Daniel J. Tancredi, University of California, Davis, Sacramento, CA; Paul R. Duberstein, Kevin Fiscella, and Ronald M. Epstein, University of Rochester; Supriya Mohile and Ronald M. Epstein, UR Medicine Wilmot Cancer Institute, Rochester, NY
| | - Supriya Mohile
- Joshua J. Fenton, Richard L. Kravitz, Guibo Xing, and Daniel J. Tancredi, University of California, Davis, Sacramento, CA; Paul R. Duberstein, Kevin Fiscella, and Ronald M. Epstein, University of Rochester; Supriya Mohile and Ronald M. Epstein, UR Medicine Wilmot Cancer Institute, Rochester, NY
| | - Ronald M Epstein
- Joshua J. Fenton, Richard L. Kravitz, Guibo Xing, and Daniel J. Tancredi, University of California, Davis, Sacramento, CA; Paul R. Duberstein, Kevin Fiscella, and Ronald M. Epstein, University of Rochester; Supriya Mohile and Ronald M. Epstein, UR Medicine Wilmot Cancer Institute, Rochester, NY
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Gilligan T, Coyle N, Frankel RM, Berry DL, Bohlke K, Epstein RM, Finlay E, Jackson VA, Lathan CS, Loprinzi CL, Nguyen LH, Seigel C, Baile WF. Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline. J Clin Oncol 2017; 35:3618-3632. [PMID: 28892432 DOI: 10.1200/jco.2017.75.2311] [Citation(s) in RCA: 304] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Purpose To provide guidance to oncology clinicians on how to use effective communication to optimize the patient-clinician relationship, patient and clinician well-being, and family well-being. Methods ASCO convened a multidisciplinary panel of medical oncology, psychiatry, nursing, hospice and palliative medicine, communication skills, health disparities, and advocacy experts to produce recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, and randomized controlled trials published from 2006 through October 1, 2016. Results The systematic review included 47 publications. With the exception of clinician training in communication skills, evidence for many of the clinical questions was limited. Draft recommendations underwent two rounds of consensus voting before being finalized. Recommendations In addition to providing guidance regarding core communication skills and tasks that apply across the continuum of cancer care, recommendations address specific topics, such as discussion of goals of care and prognosis, treatment selection, end-of-life care, facilitating family involvement in care, and clinician training in communication skills. Recommendations are accompanied by suggested strategies for implementation. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .
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Affiliation(s)
- Timothy Gilligan
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nessa Coyle
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Richard M Frankel
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Donna L Berry
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kari Bohlke
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ronald M Epstein
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Esme Finlay
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vicki A Jackson
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher S Lathan
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles L Loprinzi
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lynne H Nguyen
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carole Seigel
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Walter F Baile
- Timothy Gilligan, Cleveland Clinic, Cleveland, OH ; Nessa Coyle, Memorial Sloan Kettering Cancer Center, New York; Ronald M. Epstein, University of Rochester School of Medicine, Rochester, NY; Richard M. Frankel, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN; Donna L. Berry and Christopher S. Lathan, Dana-Farber Cancer Institute, Harvard Medical School; Vicki A. Jackson, Massachusetts General Hospital, Harvard Medical School, Boston; Carole Seigel, Patient/Advocacy Representative, Brookline, MA; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Esme Finlay, University of New Mexico School of Medicine, Albuquerque, NM; Charles L. Loprinzi, Mayo Clinic, Rochester, MN; and Lynne H. Nguyen and Walter F. Baile, The University of Texas MD Anderson Cancer Center, Houston, TX
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Affiliation(s)
- Louise Locock
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England
| | - Richard Lehman
- Institute of Applied Health Research, University of Birmingham, Birmingham, England.,Cochrane UK, Oxford, England
| | - Ronald M Epstein
- Department of Family Medicine Research, University of Rochester, Rochester, New York
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Elias CM, Shields CG, Griggs JJ, Fiscella K, Christ SL, Colbert J, Henry SG, Hoh BG, Hunte HER, Marshall M, Mohile SG, Plumb S, Tejani MA, Venuti A, Epstein RM. The social and behavioral influences (SBI) study: study design and rationale for studying the effects of race and activation on cancer pain management. BMC Cancer 2017; 17:575. [PMID: 28841847 PMCID: PMC6389115 DOI: 10.1186/s12885-017-3564-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 08/17/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Racial disparities exist in the care provided to advanced cancer patients. This article describes an investigation designed to advance the science of healthcare disparities by isolating the effects of patient race and patient activation on physician behavior using novel standardized patient (SP) methodology. METHODS/DESIGN The Social and Behavioral Influences (SBI) Study is a National Cancer Institute sponsored trial conducted in Western New York State, Northern/Central Indiana, and lower Michigan. The trial uses an incomplete randomized block design, randomizing physicians to see patients who are either black or white and who are "typical" or "activated" (e.g., ask questions, express opinions, ask for clarification, etc.). The study will enroll 91 physicians. DISCUSSION The SBI study addresses important gaps in our knowledge about racial disparities and methods to reduce them in patients with advanced cancer by using standardized patient methodology. This study is innovative in aims, design, and methodology and will point the way to interventions that can reduce racial disparities and discrimination and draw links between implicit attitudes and physician behaviors. TRIAL REGISTRATION https://clinicaltrials.gov/ , #NCT01501006, November 30, 2011.
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Affiliation(s)
- Cezanne M. Elias
- Department of Statistics, West Lafayette, Purdue University, Human Development & Family Studies, Indiana, 47906 USA
| | - Cleveland G. Shields
- Purdue University Center for Cancer Research, Regenstrief Center for Healthcare Engineering, Human Development & Family Studies, Fowler Memorial House, 1200 W State Street, West Lafayette, IN 47906 USA
| | - Jennifer J. Griggs
- Department of Internal Medicine, Hematology & Oncology Division and Department of Health Management & Policy Ann Arbor, University of Michigan School of Medicine, Ann Arbor, MI 48109-0419 USA
| | - Kevin Fiscella
- Department of Public Health Sciences, University of Rochester School of Medicine, Family Medicine, Rochester, NY 14642 USA
| | - Sharon L. Christ
- Department of Statistics, West Lafayette, Purdue University, Human Development & Family Studies, Indiana, 47906 USA
| | - Joseph Colbert
- Biostatistics Department, School of Public Health, University of Michigan, Ann Arbor, MI 48109, 14642 USA
| | - Stephen G. Henry
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, University of Rochester Medical Center, Rochester, NY USA
| | - Beth G. Hoh
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, University of Rochester Medical Center, Rochester, NY USA
| | - Haslyn E. R. Hunte
- West Virginia University, Robert C. Byrd Health Sciences Center, Morgantown, West VA 26506 USA
| | - Mary Marshall
- Department of Statistics, West Lafayette, Purdue University, Human Development & Family Studies, Indiana, 47906 USA
| | - Supriya Gupta Mohile
- Center for Communication and Disparities Research, University of Rochester School of Medicine, Family Medicine, James P Wilmot Cancer Center, Rochester, NY 14642 USA
| | - Sandy Plumb
- University of Rochester School of Medicine, Family Medicine, Rochester, NY 14642 USA
| | - Mohamedtaki A. Tejani
- James P Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY 14642 USA
| | - Alison Venuti
- University of Rochester School of Medicine, Family Medicine, Rochester, NY 14642 USA
| | - Ronald M. Epstein
- Center for Communication and Disparities Research, University of Rochester School of Medicine, Family Medicine, James P Wilmot Cancer Center, Rochester, NY 14642 USA
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Affiliation(s)
- Ronald M Epstein
- Center for Communication and Disparities Research, Departments of Family Medicine, Psychiatry, Medicine, and Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, 1381 South Ave., Rochester, NY, 14620, USA.
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Hlubocky FJ, Rose M, Epstein RM. Mastering Resilience in Oncology: Learn to Thrive in the Face of Burnout. Am Soc Clin Oncol Educ Book 2017. [PMID: 28561649 DOI: 10.14694/edbk_173874] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Oncology clinician burnout has become a noteworthy issue in medical oncology directly affecting the quality of patient care, patient satisfaction, and overall organizational success. Due to the increasing demands on clinical time, productivity, and the evolving medical landscape, the oncology clinician is at significant risk for burnout. Long hours in direct care with seriously ill patients/families, limited control over daily responsibilities, and endless electronic documentation, place considerable professional and personal demands on the oncologist. As a result, the oncology clinician's wellness is adversely impacted. Physical/emotional exhaustion, cynicism, and feelings of ineffectiveness evolve as core signs of burnout. Unaddressed burnout may affect cancer clinician relationships with their patients, the quality of care delivered, and the overall physical and emotional health of the clinician. Oncology clinicians should be encouraged to build upon their strengths, thrive in the face of adversity and stress, and learn to positively adapt to the changing cancer care system. Fostering individual resilience is a key protective factor against the development of and managing burnout. Empowering clinicians at both the individual and organizational level with tailored resilience strategies is crucial to ensuring clinician wellness. Resilience interventions may include: burnout education, work-life balance, adjustment of one's relationship to work, mindful practice, and acceptance of the clinical work environment. Health care organizations must act to provide institutional solutions through the implementation of: team-based oncology care, communication skills training, and effective resiliency training programs in order to mitigate the effects of stress and prevent burnout in oncology.
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Affiliation(s)
- Fay J Hlubocky
- From the Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, IL; Department of Adult Psychiatry, Michigan State University, East Lansing, MI; University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Miko Rose
- From the Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, IL; Department of Adult Psychiatry, Michigan State University, East Lansing, MI; University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Ronald M Epstein
- From the Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, IL; Department of Adult Psychiatry, Michigan State University, East Lansing, MI; University of Rochester School of Medicine and Dentistry, Rochester, NY
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Hoerger M, Perry LM, Gramling R, Epstein RM, Duberstein PR. Does educating patients about the Early Palliative Care Study increase preferences for outpatient palliative cancer care? Findings from Project EMPOWER. Health Psychol 2017; 36:538-548. [PMID: 28277698 PMCID: PMC5444973 DOI: 10.1037/hea0000489] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Randomized controlled trials, especially the Early Palliative Care Study (Temel et al., 2010), have shown that early outpatient palliative cancer care can improve quality of life for patients with advanced cancer or serious symptoms. However, fear and misconceptions drive avoidance of palliative care. Drawing from an empowerment perspective, we examined whether educating patients about evidence from the Early Palliative Care Study would increase preferences for palliative care. METHOD A sample of 598 patients with prostate, breast, lung, colon/rectal, skin, and other cancer diagnoses completed an Internet-mediated experiment using a between-group prepost design. Intervention participants received a summary of the Early Palliative Care Study; controls received no intervention. Participants completed baseline and posttest assessments of preferences of palliative care. Analyses controlled for age, gender, education, cancer type, presence of metastases, time since diagnosis, and baseline preferences. RESULTS As hypothesized, the intervention had a favorable impact on participants' preferences for outpatient palliative cancer care relative to controls (d = 1.01, p < .001), while controlling for covariates. Intervention participants came to view palliative care as more efficacious (d = 0.79, p < .001) and less scary (d = 0.60, p < .001) and exhibited stronger behavioral intentions to utilize outpatient palliative care if referred (d = 0.60, p < .001). Findings were comparable in patients with metastatic disease, those with less education, and those experiencing financial strain. CONCLUSIONS Educating patients about the Early Palliative Care Study increases preferences for early outpatient palliative care. This research has implications for future studies aimed at improving quality of life in cancer by increasing palliative care utilization. (PsycINFO Database Record
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Kamen CS, Duberstein P, Prigerson HG, Mohile SG, Asare M, Janelsins MC, Mustian KM, Peppone LJ, Epstein RM. Agreement about end-of-life (EOL) care among advanced cancer patients and their caregivers: Associations with care received. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.10021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10021 Background: Patients with advanced cancer and their caregivers often have different preferences regarding patients’ EOL care. Disagreement in a patient-caregiver dyad can increase stress and result in suboptimal care. Understanding factors that promote agreement, as well as the effect of agreement on care received at EOL, can inform interventions to improve communication and EOL decision-making for patients and caregivers. Methods: 205 patients (Stage III or IV cancer plus limited prognosis) and their caregivers were recruited to a randomized controlled trial of a communication intervention for patients, caregivers, and providers (Cancer Communication Study, PI: Epstein). Before intervention, patients completed the Preferences for Life-Extending Treatment questionnaire, which asked their preference regarding experimental treatment, life support, and palliative care; caregivers were asked about patients’ preferences. Binomial logistic regressions analyses modeled agreement in preferences as a function of patient and caregiver demographic characteristics and EOL care received as a function of patient-caregiver agreement. Results: The majority of patient-caregiver dyads agreed about experimental treatment (60.3%), life support (63.4%), and palliative care (70.7%). Dyads were more likely to agree about palliative care when patients were female (OR = 1.94, p = .03) and non-Hispanic white (OR = 2.10, p = .07) and when caregivers were college educated (OR = 2.04, p = .03). Of the 82 patients who died during study follow-up, 57 (69.5%) received EOL care congruent with their preferences. In 19 of the 38 (50%) cases where patient-caregiver dyads disagreed, caregivers’ preferences predicted EOL care received. Dyadic agreement about life support was associated with increased odds of patients receiving/not receiving life support congruent with their preference (OR = 3.02, p = .02). Conclusions: Facilitating agreement between patients and caregivers could improve receipt of patient-centered care. A communication intervention designed to increase dyadic agreement by helping patients and caregivers discuss challenging EOL decisions might improve EOL care delivery. Clinical trial information: NCT01485627.
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Affiliation(s)
| | | | | | | | - Matthew Asare
- University of Rochester Medical Center, Rochester, NY
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Epstein RM, Duberstein PR, Fenton JJ, Fiscella K, Hoerger M, Tancredi DJ, Xing G, Gramling R, Mohile S, Franks P, Kaesberg P, Plumb S, Cipri CS, Street RL, Shields CG, Back AL, Butow P, Walczak A, Tattersall M, Venuti A, Sullivan P, Robinson M, Hoh B, Lewis L, Kravitz RL. Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer: The VOICE Randomized Clinical Trial. JAMA Oncol 2017; 3:92-100. [PMID: 27612178 DOI: 10.1001/jamaoncol.2016.4373] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Observational studies demonstrate links between patient-centered communication, quality of life (QOL), and aggressive treatments in advanced cancer, yet few randomized clinical trials (RCTs) of communication interventions have been reported. Objective To determine whether a combined intervention involving oncologists, patients with advanced cancer, and caregivers would promote patient-centered communication, and to estimate intervention effects on shared understanding, patient-physician relationships, QOL, and aggressive treatments in the last 30 days of life. Design, Setting, and Participants Cluster RCT at community- and hospital-based cancer clinics in Western New York and Northern California; 38 medical oncologists (mean age 44.6 years; 11 (29%) female) and 265 community-dwelling adult patients with advanced nonhematologic cancer participated (mean age, 64.4 years, 146 [55.0%] female, 235 [89%] white; enrolled August 2012 to June 2014; followed for 3 years); 194 patients had participating caregivers. Interventions Oncologists received individualized communication training using standardized patient instructors while patients received question prompt lists and individualized communication coaching to identify issues to address during an upcoming oncologist visit. Both interventions focused on engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information. Control participants received no training. Main Outcomes and Measures The prespecified primary outcome was a composite measure of patient-centered communication coded from audio recordings of the first oncologist visit following patient coaching (intervention group) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QOL, and aggressive treatments and hospice use in the last 30 days of life. Results Data from 38 oncologists (19 randomized to intervention) and 265 patients (130 intervention) were analyzed. In fully adjusted models, the intervention resulted in clinically and statistically significant improvements in the primary physician-patient communication end point (adjusted intervention effect, 0.34; 95% CI, 0.06-0.62; P = .02). Differences in secondary outcomes were not statistically significant. Conclusions and Relevance A combined intervention that included oncologist communication training and coaching for patients with advanced cancer was effective in improving patient-centered communication but did not affect secondary outcomes. Trial Registration clinicaltrials.gov Identifier: NCT01485627.
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Affiliation(s)
- Ronald M Epstein
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York3Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York4James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Paul R Duberstein
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York3Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Joshua J Fenton
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento6UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento7Department of Family and Community Medicine, University of California, Davis, Sacramento
| | - Kevin Fiscella
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York8Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York9Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Michael Hoerger
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York10Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana11Tulane Cancer Center, Tulane University, New Orleans, Louisiana
| | - Daniel J Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento12Department of Pediatrics, University of California, Davis, Sacramento
| | - Guibo Xing
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Robert Gramling
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York8Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York13School of Nursing, University of Rochester, Rochester, New York14Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Supriya Mohile
- James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York15Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Peter Franks
- Department of Family and Community Medicine, University of California, Davis, Sacramento
| | - Paul Kaesberg
- UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento16Department of Internal Medicine, University of California, Davis, Sacramento
| | - Sandy Plumb
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Camille S Cipri
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Richard L Street
- Department of Communication, Texas A & M University, College Station18Houston Center for Healthcare Innovation, Quality, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas19Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Cleveland G Shields
- Human Development and Family Studies Department, Purdue University, West Lafayette, Indiana21Purdue University Center for Cancer Research, Purdue University, West Lafayette, Indiana22Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana23Center on Poverty and Health Inequities, Purdue University, West Lafayette, Indiana24College of Health of Human Sciences, Purdue University, West Lafayette, Indiana
| | - Anthony L Back
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle26Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Phyllis Butow
- Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, Australia28Psycho-oncology Co-operative Research Group, University of Sydney, Sydney, Australia
| | - Adam Walczak
- Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, Australia29School of Psychology, University of Sydney, Sydney, Australia
| | - Martin Tattersall
- Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, Australia30Sydney Medical School, University of Sydney, Sydney, Australia31Royal Prince Alfred Hospital, Sydney, Australia
| | - Alison Venuti
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Peter Sullivan
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Mark Robinson
- University of California, Davis School of Medicine, University of California, Davis, Sacramento
| | - Beth Hoh
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York34Department of Social Work, Strong Memorial Hospital, Rochester, New York
| | - Linda Lewis
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Richard L Kravitz
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento6UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento35Division of General Medicine, University of California, Davis, Sacramento
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Gramling R, Fiscella K, Xing G, Hoerger M, Duberstein P, Plumb S, Mohile S, Fenton JJ, Tancredi DJ, Kravitz RL, Epstein RM. Determinants of Patient-Oncologist Prognostic Discordance in Advanced Cancer. JAMA Oncol 2017; 2:1421-1426. [PMID: 27415765 DOI: 10.1001/jamaoncol.2016.1861] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Patients with advanced cancer often report expectations for survival that differ from their oncologists' expectations. Whether patients know that their survival expectations differ from those of their oncologists remains unknown. This distinction is important because knowingly expressing differences of opinion is important for shared decision making, whereas patients not knowing that their understanding differs from that of their treating physician is a potential marker of inadequate communication. Objective To describe the prevalence, distribution, and proportion of prognostic discordance that is due to patients' knowingly vs unknowingly expressing an opinion that differs from that of their oncologist. Design, Setting, and Participants Cross-sectional study conducted at academic and community oncology practices in Rochester, New York, and Sacramento, California. The sample comprises 236 patients with advanced cancer and their 38 oncologists who participated in a randomized trial of an intervention to improve clinical communication. Participants were enrolled from August 2012 to June 2014 and followed up until October 2015. Main Outcomes and Measures We ascertained discordance by comparing patient and oncologist ratings of 2-year survival probability. For discordant pairs, we determined whether patients knew that their opinions differed from those of their oncologists by asking the patients to report how they believed their oncologists rated their 2-year survival. Results Among the 236 patients (mean [SD] age, 64.5 [11.4] years; 54% female), 161 patient-oncologist survival prognosis ratings (68%; 95% CI, 62%-75%) were discordant. Discordance was substantially more common among nonwhite patients compared with white patients (95% [95% CI, 86%-100%] vs 65% [95% CI, 58%-73%], respectively; P = .03). Among 161 discordant patients, 144 (89%) did not know that their opinions differed from that of their oncologists and nearly all of them (155 of 161 [96%]) were more optimistic than their oncologists. Conclusions and Relevance In this study, patient-oncologist discordance about survival prognosis was common and patients rarely knew that their opinions differed from those of their oncologists.
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Affiliation(s)
- Robert Gramling
- School of Nursing, University of Rochester, Rochester, New York2Division of Palliative Medicine, University of Vermont, Burlington3Department of Family Medicine, University of Vermont, Burlington4Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York5Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York6Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York7Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Kevin Fiscella
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York5Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York6Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York8Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Guibo Xing
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Michael Hoerger
- Department of Psychology, Tulane University, New Orleans, Louisiana11Tulane Cancer Center, Tulane University, New Orleans, Louisiana12Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Paul Duberstein
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York6Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York12Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Sandy Plumb
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Supriya Mohile
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York14James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Joshua J Fenton
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento15Department of Family and Community Medicine, University of California, Davis, Sacramento16UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento
| | - Daniel J Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento17Department of Pediatrics, University of California, Davis, Sacramento
| | - Richard L Kravitz
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento16UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento18Division of General Medicine, University of California, Davis, Sacramento
| | - Ronald M Epstein
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York6Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York7Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York12Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York14James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Rodenbach RA, Brandes K, Fiscella K, Kravitz RL, Butow PN, Walczak A, Duberstein PR, Sullivan P, Hoh B, Xing G, Plumb S, Epstein RM. Promoting End-of-Life Discussions in Advanced Cancer: Effects of Patient Coaching and Question Prompt Lists. J Clin Oncol 2017; 35:842-851. [PMID: 28135140 DOI: 10.1200/jco.2016.68.5651] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To build on results of a cluster randomized controlled trial (RCT) of a combined patient-oncologist intervention to improve communication in advanced cancer, we conducted a post hoc analysis of the patient intervention component, a previsit patient coaching session that used a question prompt list (QPL). We hypothesized that intervention-group participants would bring up more QPL-related topics, particularly prognosis-related topics, during the subsequent oncologist visit. Patients and Methods This cluster RCT with 170 patients who had advanced nonhematologic cancer (and their caregivers) recruited from practices of 24 participating oncologists in western New York. Intervention-group oncologists (n = 12) received individualized communication training; up to 10 of their patients (n = 84) received a previsit individualized communication coaching session that incorporated a QPL. Control-group oncologists (n = 12) and patients (n = 86) received no interventions. Topics of interest identified by patients during the coaching session were summarized from coaching notes; one office visit after the coaching session was audio recorded, transcribed, and analyzed by using linear regression modeling for group differences. Results Compared with controls, more than twice as many intervention-group participants brought up QPL-related topics during their office visits (70.2% v 32.6%; P < .001). Patients in the intervention group were nearly three times more likely to ask about prognosis (16.7% v 5.8%; P =.03). Of 262 topics of interest identified during coaching, 158 (60.3%) were QPL related; 20 (12.7%) addressed prognosis. Overall, patients in the intervention group brought up 82.4% of topics of interest during the office visit. Conclusion A combined coaching and QPL intervention was effective to help patients with advanced cancer and their caregivers identify and bring up topics of concern, including prognosis, during their subsequent oncologist visits. Considering that most patients are misinformed about prognosis, more intensive steps are needed to better promote such discussions.
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Affiliation(s)
- Rachel A Rodenbach
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
| | - Kim Brandes
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Fiscella
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard L Kravitz
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
| | - Phyllis N Butow
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
| | - Adam Walczak
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
| | - Paul R Duberstein
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter Sullivan
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
| | - Beth Hoh
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
| | - Guibo Xing
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
| | - Sandy Plumb
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
| | - Ronald M Epstein
- Rachel A. Rodenbach, Kevin Fiscella, Paul R. Duberstein, Peter Sullivan, Beth Hoh, Sandy Plumb, and Ronald M. Epstein, Center for Communication and Disparities Research; Rachel A. Rodenbach and Ronald M. Epstein, University of Rochester School of Medicine and Dentistry; Kevin Fiscella and Paul R. Duberstein, University of Rochester Medical Center, Rochester, NY; Rachel A. Rodenbach, University of Pittsburgh Medical Center, Pittsburgh, PA; Kim Brandes, University of Amsterdam, Amsterdam, the Netherlands; Richard L. Kravitz and Guibo Xing, University of California Davis, Sacramento, CA; and Phyllis N. Butow and Adam Walczak, The University of Sydney, Sydney, New South Wales, Australia
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Affiliation(s)
- Ronald M Epstein
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA; Family Medicine Research, University of Rochester, Rochester, NY 14610, USA.
| | - Michael R Privitera
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
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Fenton JJ, Kravitz RL, Duberstein P, Tancredi DJ, Xing G, Epstein RM. A cluster randomized trial of a patient-centered communication intervention in advanced cancer: The Values and Options In Cancer Care (VOICE) study. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.26_suppl.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2 Background: Observational studies demonstrate links between patient-centered communication, prognosis discordance, quality of life (QoL) and aggressive treatments near the end of life, yet there are few randomized evaluations of communication interventions in advanced cancer. Methods: We completed a cluster randomized controlled trial in cancer clinics in Western NY and Northern CA with medical oncologists (n = 38 randomized to intervention or control) and their community-dwelling adult patients with advanced non-hematologic cancer (n = 265; 194 with enrolled caregivers). Interventions foroncologists (individualized communication training using Standardized Patient Instructors) and patients/caregivers (individualized coaching using question prompt lists) were directed towards enhancing patient engagement in consultations, oncologists’ response to emotions, and provision of balanced information about prognosis and treatment choices. Oncologists and patients randomized to control received no interventions. Primary outcome was a composite of 4 communication measures coded from audio-recorded oncologist visits shortly after patient coaching (intervention) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QoL, and utilization of aggressive treatments and hospice in the last 30 days of life. Results: In fully-adjusted models, the intervention significantly improved mean composite communication scores [0.34, 95% CI (0.06, 0.62), p = 0.017]. Effects on secondary outcomes were not significant. Conclusions: Oncologist communication training combined with coaching for patients with advanced cancer and available caregivers promoted patient-centered communication. Nevertheless, we did not observe changes in QoL and utilization, suggesting that more intensive, psychologically-oriented or longitudinal interventions may be needed, along with support and incentives for clinicians to participate. Clinical trial information: NCT01485627.
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Affiliation(s)
| | | | | | | | - Guibo Xing
- University of California, Davis, Sacramento, CA
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Carroll JK, Flocke SA, Sanders MR, Lowenstein L, Fiscella K, Epstein RM. Effectiveness of a clinician intervention to improve physical activity discussions in underserved adults. Fam Pract 2016; 33:488-91. [PMID: 27234988 PMCID: PMC5022124 DOI: 10.1093/fampra/cmw036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Physical activity (PA) counselling is challenging in primary care. It is unknown whether clinician training on the 5As (Ask, Advise, Agree, Assist, Arrange) improves PA counselling skills. OBJECTIVE To evaluate the effect of a clinician training intervention on PA counselling for underserved adults using the 5As framework. METHODS Pragmatic pilot clinical trial was used in the study. Clinicians (n = 13) were randomly assigned to two groups. Each group received the intervention consisting of four 1-hour training sessions to teach the 5As for PA counselling. Patient-clinician visits (n = 325) were audio recorded at baseline, immediately post-intervention, and at 6 months. Outcomes were the frequency and quality of PA discussions using the 5As, assessed by blinded coders. RESULTS Patients' mean age was 44 years; 75% were African American. PA was discussed in 37% (n = 119) of visits overall and did not change from baseline to follow-up. When PA discussions occurred, the frequency of 5As increased from baseline to follow-up for Advise (51-54%), Agree (11-26%), and Assist (11-17%); however, none of the 5As had a statistically significant increase. For Agree, exploration of patient willingness to engage in PA increased from 23% at baseline to 50% at follow-up. CONCLUSION A clinician-directed intervention to improve PA counselling increased the frequency of Advise, Agree and Assist, and the quality of Ask and Agree statements, though the absolute numbers were small and only Agree reached statistical significance. Future research is needed to understand the factors that affect the optimal uptake and approach to 5As counselling.
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Affiliation(s)
| | - Susan A Flocke
- Department of Family Medicine, Case Western Reserve University, Cleveland, OH, USA, Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH, USA
| | - Mechelle R Sanders
- Department of Family Medicine, Family Medicine Research Programs, University of Rochester Medical Center, Rochester, NY, USA and
| | - Lisa Lowenstein
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kevin Fiscella
- Department of Family Medicine, Family Medicine Research Programs, University of Rochester Medical Center, Rochester, NY, USA and
| | - Ronald M Epstein
- Department of Family Medicine, Family Medicine Research Programs, University of Rochester Medical Center, Rochester, NY, USA and
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Rodenbach RA, Rodenbach KE, Tejani MA, Epstein RM. Relationships between personal attitudes about death and communication with terminally ill patients: How oncology clinicians grapple with mortality. Patient Educ Couns 2016; 99:356-363. [PMID: 26519993 PMCID: PMC5955702 DOI: 10.1016/j.pec.2015.10.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 10/01/2015] [Accepted: 10/12/2015] [Indexed: 05/02/2023]
Abstract
OBJECTIVE Clinician discomfort with death may affect care of patients but has not been well-studied. This study explores oncology clinicians' attitudes surrounding their own death and how these attitudes both affect and are affected by their care of dying patients and their communication with them. METHODS Qualitative interviews with physicians (n=25), nurse practitioners (n=7), and physician assistants (n=1) in medical or hematologic oncology clinical practices about communication styles, care of terminally ill patients, and personal perspectives about mortality. RESULTS Clinicians described three communication styles used with patients about death and dying: direct, indirect, or selectively direct. Most reported an acceptance of their mortality that was "conditional," meaning that that they could not fully know how they would respond if actually terminally ill. For many clinicians, caring for dying patients affected their outlook on life and death, and their own perspectives on life and death affected their approach to caring for dying patients. CONCLUSION An awareness of personal mortality may help clinicians to discuss death more openly with patients and to provide better care. PRACTICE IMPLICATIONS Efforts to promote self-awareness and communication training are key to facilitating clear communication with and compassionate care of terminally ill patients.
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Affiliation(s)
- Rachel A Rodenbach
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642, USA.
| | - Kyle E Rodenbach
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642, USA
| | - Mohamedtaki A Tejani
- Department of Medicine, Hematology/Oncology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642, USA
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, USA
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Fenton JJ, Kravitz RL, Jerant A, Paterniti DA, Bang H, Williams D, Epstein RM, Franks P. Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial. JAMA Intern Med 2016; 176:191-7. [PMID: 26640973 DOI: 10.1001/jamainternmed.2015.6840] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Low-value diagnostic tests have been included on primary care specialty societies' "Choosing Wisely" Top Five lists. OBJECTIVE To evaluate the effectiveness of a standardized patient (SP)-based intervention designed to enhance primary care physician (PCP) patient-centeredness and skill in handling patient requests for low-value diagnostic tests. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 61 general internal medicine or family medicine residents at 2 residency-affiliated primary care clinics at an academic medical center in California. INTERVENTIONS Two simulated visits with SP instructors portraying patients requesting inappropriate spinal magnetic resonance imaging for low back pain or screening dual-energy x-ray absorptiometry. The SP instructors provided personalized feedback to residents regarding use of 6 patient-centered techniques to address patient concerns without ordering low-value tests. Control group physicians received SP visits without feedback and were emailed relevant clinical guidelines. MAIN OUTCOMES AND MEASURES The primary outcome was whether resident PCPs ordered SP-requested low-value tests during up to 3 unannounced SP clinic visits over 3 to 12 months follow-up, with patients requesting spinal magnetic resonance imaging, screening dual-energy x-ray absorptiometry, or headache neuroimaging. Secondary outcomes included PCP patient-centeredness and use of targeted techniques (both coded from visit audiorecordings), and SP satisfaction with the visit (0-10 scale). RESULTS Of 61 randomized resident PCPs (31 control group and 30 intervention group), 59 had encounters with 155 SPs during follow-up. Compared with control PCPs, intervention PCPs had similar patient-centeredness (Measure of Patient-Centered Communication, 43.9 [95% CI, 42.0 to 45.7] vs 43.7 [95% CI, 41.8 to 45.6], adjusted mean difference, -0.2 [95% CI, -2.9 to 2.5]; P = .90) and used a similar number of targeted techniques (5.4 [95% CI, 4.9 to 5.8] vs 5.4 [95% CI, 4.9 to 5.8] on a 0-9 scale, adjusted mean difference, 0 [95% CI, -0.7 to 0.6]; P = .96). Residents ordered low-value tests in 41 SP encounters (26.5% [95% CI, 19.7%-34.1%]) with no significant difference in the odds of test ordering in intervention PCPs relative to control group PCPs (adjusted odds ratio, 1.07 [95% CI, 0.49-2.32]). Rates of test ordering among intervention and control PCPs were similar for all 3 SP cases. The SPs rated visit satisfaction higher among intervention than control PCPs (8.5 [95% CI, 8.1-8.8] vs 7.8 [95% CI, 7.5-8.2], adjusted mean difference, 0.6 [95% CI, 0.1-1.1]). CONCLUSIONS AND RELEVANCE An SP-based intervention did not improve the patient-centeredness of SP encounters, use of targeted interactional techniques, or rates of low-value test ordering, although SPs were more satisfied with intervention than control residents. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01808664.
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Affiliation(s)
- Joshua J Fenton
- Department of Family and Community Medicine, University of California-Davis, Sacramento2Center for Healthcare Policy and Research, University of California-Davis, Sacramento
| | - Richard L Kravitz
- Center for Healthcare Policy and Research, University of California-Davis, Sacramento3Department of Internal Medicine, University of California-Davis, Sacramento
| | - Anthony Jerant
- Department of Family and Community Medicine, University of California-Davis, Sacramento2Center for Healthcare Policy and Research, University of California-Davis, Sacramento
| | - Debora A Paterniti
- Center for Healthcare Policy and Research, University of California-Davis, Sacramento4Department of Sociology, University of California-Davis, Sacramento
| | - Heejung Bang
- Division of Public Health Sciences, University of California-Davis, Sacramento
| | - Donna Williams
- Department of Internal Medicine, University of California-Davis, Sacramento
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester, Rochester, New York7Center for Communications and Disparities Research, University of Rochester, Rochester, New York
| | - Peter Franks
- Department of Family and Community Medicine, University of California-Davis, Sacramento2Center for Healthcare Policy and Research, University of California-Davis, Sacramento
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Affiliation(s)
- Ronald M Epstein
- Departments of Family Medicine, Psychiatry, and Oncology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Anthony L Back
- Department of Medicine, Division of Oncology, University of Washington, Seattle
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Shepherd HL, Barratt A, Jones A, Bateson D, Carey K, Trevena LJ, McGeechan K, Del Mar CB, Butow PN, Epstein RM, Entwistle V, Weisberg E. 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. Health Expect 2015; 19:1160-8. [PMID: 26364752 PMCID: PMC5152736 DOI: 10.1111/hex.12409] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2015] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Heather L Shepherd
- Centre for Medical Psychology and Evidence-based Decision-making, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.
| | - Alexandra Barratt
- Centre for Medical Psychology and Evidence-based Decision-making, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Anna Jones
- Centre for Medical Psychology and Evidence-based Decision-making, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Deborah Bateson
- Family Planning NSW, Sydney, NSW, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Sydney, NSW, Australia
| | - Karen Carey
- Health Consumers Council, Perth, WA, Australia
| | - Lyndal J Trevena
- Centre for Medical Psychology and Evidence-based Decision-making, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Kevin McGeechan
- Centre for Medical Psychology and Evidence-based Decision-making, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Chris B Del Mar
- Centre for Research in Evidence Based Practice, Bond University, Robina, QLD, Australia
| | - Phyllis N Butow
- Centre for Medical Psychology and Evidence-based Decision-making, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Ronald M Epstein
- Center for Communication and Disparities Research, University of Rochester Medical Center, Rochester, NY, USA
| | - Vikki Entwistle
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Edith Weisberg
- Family Planning NSW, Sydney, NSW, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Sydney, NSW, Australia
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Abstract
Given that presence is ineffable yet real and universal, it is no surprise that it has historically been the domain of mystics. However, presence and its cousins—shared mind, love, and compassion—have now become of intense interest among members of the scientific community under the banners of interpersonal neurobiology and social neuroscience (Decety & Lamm, 2009; Epstein & Street, 2011; Klimecki, Leiberg, Lamm, & Singer, 2013; Zlatev, Racine, Sinha, & Itkonen, 2008). This may seem obvious to readers of Families Systems, and Health, but it is not the basis for medical practice or psychotherapy in general.
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Abstract
George Engel's biopsychosocial vision was simultaneously scientific and humanistic. He passionately presented an approach to clinical care to correct the progressive distancing of clinical care and research from the lived experience of the patient. Yet, while science provides ever greater evidence for the linkages between subjectively-reported experience and health outcomes, trainees and practicing clinicians struggle to realize a biopsychosocial vision in a pragmatic way. These challenges are magnified by the mandate for greater patient autonomy and participation in care, increased access to information, and overlaps and omissions as multiple professionals try to address the whole person. Importantly, trainees and clinicians get stuck implementing the biopsychosocial model partly because they have not developed the capacity for resilience, self-awareness, and self-monitoring. These capacities must accompany efforts to help clinicians engage more deeply with their patients; otherwise, they risk emotional distress, empathic failure, premature closure, and withdrawal from effective connections with patients. This article will explore ways in which Engel's biopsychosocial vision can be realized through building the capacities of clinicians to become more self-aware and resilient, and engage in compassionate action.
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Brandes K, Butow PN, Tattersall MHN, Clayton JM, Davidson PM, Young J, Epstein RM, Walczak A. Advanced cancer patients' and caregivers' use of a Question Prompt List. Patient Educ Couns 2014; 97:30-37. [PMID: 25023487 DOI: 10.1016/j.pec.2014.06.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 05/13/2014] [Accepted: 06/19/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The objective of this study was to provide insight into how advanced cancer patients and their caregivers use a Question Prompt List (QPL) during a consultation and for preparation for future consultations. METHODS Audiotaped consultations and follow-up phone calls of 28 advanced cancer patients were coded and content analyzed. Questions asked and concerns expressed in consultations were coded for initiator, content, inclusion in the QPL and exact wording. Patients' reported and future use of the QPL were coded from the phone calls. RESULTS The majority of patients reported that they used the QPL. Questions asked by patients and caregivers predominately coincided with questions from the prognosis section of the QPL. Questions were rarely asked literally from the QPL, instead questions were tailored to patients' own circumstances. CONCLUSION QPLs are useful to stimulate discussion on prognosis among advanced cancer patients and caregivers. Patients tailored questions from the QPL to their own circumstances which may suggest high involvement and engagement. The development of more specific tailored communication interventions for advanced cancer patients is warranted. PRACTICE IMPLICATIONS Implementation of QPLs in the advanced cancer setting may be beneficial for patients, caregivers and healthcare providers to facilitate discussion of topics such as prognosis.
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Affiliation(s)
- Kim Brandes
- Amsterdam School of Communication Research (ASCoR), University of Amsterdam, Amsterdam, The Netherlands; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, Australia.
| | - Phyllis N Butow
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, Australia
| | - Martin H N Tattersall
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, Australia
| | - Josephine M Clayton
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, Australia; Hammond Care Palliative and Supportive Care Service, Greenwich Hospital, Sydney, Australia
| | - Patricia M Davidson
- Cardiovascular and Chronic Care Centre, University of Technology, Sydney, Australia
| | - Jane Young
- School of Public Health, University of Sydney, Sydney, Australia
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Centre, USA
| | - Adam Walczak
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, Australia
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Walczak A, Henselmans I, Tattersall MHN, Clayton JM, Davidson PM, Young J, Bellemore FA, Epstein RM, Butow PN. A qualitative analysis of responses to a question prompt list and prognosis and end-of-life care discussion prompts delivered in a communication support program. Psychooncology 2014; 24:287-93. [PMID: 25079976 DOI: 10.1002/pon.3635] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 07/02/2014] [Accepted: 07/06/2014] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Discussing end-of-life (EOL) care is challenging when death is not imminent, contributing to poor decision-making and EOL quality-of-life. A communication support program (CSP) targeting these issues may facilitate discussions. We aimed to qualitatively explore responses to a nurse-led CSP, incorporating a question prompt list (QPL-booklet of questions patients/caregivers can ask clinicians), promoting life expectancy and EOL-care discussions. METHODS Participants met a nurse-facilitator to explore an EOL-focussed QPL. Prognosis and advance care planning (ACP) QPL content was highlighted. Thirty-one transcribed meetings were analysed using thematic text analysis before reaching data saturation. RESULTS Thirty-one advanced cancer patients (life expectancy <12 months) and 11 family caregivers were recruited from six medical oncology clinics in Sydney, Australia. Intent to use the QPL related to information needs, involvement in care and readiness to discuss EOL issues. Many participants did not want life expectancy estimates, citing unreliable estimates, unknown treatment outcomes, or coping by not looking ahead. Most displayed interest in ACP, often motivated by a loved one's EOL experiences, clear treatment preferences, concerns about caregivers or recognition that ACP is valuable regardless of life expectancy. Timing emerged as a reason not to discuss EOL issues; many maintaining it was too early. CONCLUSION Patients and caregivers appear ambivalent about acknowledging approaching death by discussing life expectancy but value ACP. Given heterogeneity in responses, individualised approaches are required to guide EOL discussion conduct and content. Further exploration of the role of prognostic discussion in ACP is warranted.
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Affiliation(s)
- Adam Walczak
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, Australia
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87
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Mazer BL, Cameron RA, DeLuca JM, Mohile SG, Epstein RM. "Speaking-for" and "speaking-as": pseudo-surrogacy in physician-patient-companion medical encounters about advanced cancer. Patient Educ Couns 2014; 96:36-42. [PMID: 24862913 PMCID: PMC4101377 DOI: 10.1016/j.pec.2014.05.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 04/19/2014] [Accepted: 05/01/2014] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To examine using audio-recorded encounters the extent and process of companion participation when discussing treatment choices and prognosis in the context of a life-limiting cancer diagnosis. METHODS Qualitative analysis of transcribed outpatient visits between 17 oncologists, 49 patients with advanced cancer, and 34 companions. RESULTS 46 qualifying companion statements were collected from a total of 28 conversations about treatment choices or prognosis. We identified a range of companion positions, from "pseudo-surrogacy" (companion speaking as if the patient were not able to speak for himself), "hearsay", "conflation of thoughts", "co-experiencing", "observation as an outsider", and "facilitation". Statements made by companions were infrequently directly validated by the patient. CONCLUSION Companions often spoke on behalf of patients during discussions of prognosis and treatment choices, even when the patient was present and capable of speaking on his or her own behalf. PRACTICE IMPLICATIONS The conversational role of companions as well as whether the physician checks with the patient can determine whether a companion facilitates or inhibits patient autonomy and involvement. Physicians can reduce ambiguity and encourage patient participation by being aware of when and how companions may speak on behalf of patients and by corroborating the companion's statement with the patient.
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Affiliation(s)
- Benjamin L Mazer
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA.
| | - Rachel A Cameron
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Jane M DeLuca
- School of Nursing, Clemson University, Clemson, SC, USA
| | - Supriya G Mohile
- Department of Medicine, James Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Ronald M Epstein
- Departments of Family Medicine, Psychiatry, Oncology, and Nursing, University of Rochester Medical Center, Rochester, NY, USA
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Walczak A, Butow PN, Clayton JM, Tattersall MHN, Davidson PM, Young J, Epstein RM. Discussing prognosis and end-of-life care in the final year of life: a randomised controlled trial of a nurse-led communication support programme for patients and caregivers. BMJ Open 2014; 4:e005745. [PMID: 24969786 PMCID: PMC4078787 DOI: 10.1136/bmjopen-2014-005745] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Timely communication about life expectancy and end-of-life care is crucial for ensuring good patient quality-of-life at the end of life and a good quality of death. This article describes the protocol for a multisite randomised controlled trial of a nurse-led communication support programme to facilitate patients' and caregivers' efforts to communicate about these issues with their healthcare team. METHODS AND ANALYSIS This NHMRC-sponsored trial is being conducted at medical oncology clinics located at/affiliated with major teaching hospitals in Sydney, Australia. Patients with advanced, incurable cancer and life expectancy of less than 12 months will participate together with their primary informal caregiver where possible. Guided by the self-determination theory of health-behaviour change, the communication support programme pairs a purpose-designed Question Prompt List (QPL-an evidence-based list of questions patients/caregivers can ask clinicians) with nurse-led exploration of QPL content, communication challenges, patient values and concerns and the value of early discussion of end-of-life issues. Oncologists are also cued to endorse patient and caregiver question asking and use of the QPL. Behavioural and self-report data will be collected from patients/caregivers approximately quarterly for up to 2.5 years or until patient death, after which patient medical records will be examined. Analyses will examine the impact of the intervention on patients' and caregivers' participation in medical consultations, their self-efficacy in medical encounters, quality-of-life, end-of-life care receipt and quality-of-death indicators. ETHICS AND DISSEMINATION Approvals have been granted by the human ethics review committee of Royal Prince Alfred Hospital and governance officers at each participating site. Results will be reported in peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry ACTRN12610000724077.
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Affiliation(s)
- Adam Walczak
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Phyllis N Butow
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Josephine M Clayton
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
- HammondCare Palliative and Supportive Care Service, Greenwich Hospital, Greenwich, New South Wales, Australia
| | - Martin H N Tattersall
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Patricia M Davidson
- Cardiovascular and Chronic Care Centre, Curtin University of Technology, Sydney, New South Wales, Australia
| | - Jane Young
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Centre, Rochester, New York, USA
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Elwyn G, Dehlendorf C, Epstein RM, Marrin K, White J, Frosch DL. Shared decision making and motivational interviewing: achieving patient-centered care across the spectrum of health care problems. Ann Fam Med 2014; 12:270-5. [PMID: 24821899 PMCID: PMC4018376 DOI: 10.1370/afm.1615] [Citation(s) in RCA: 166] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 10/12/2013] [Accepted: 11/19/2013] [Indexed: 12/14/2022] Open
Abstract
Patient-centered care requires different approaches depending on the clinical situation. Motivational interviewing and shared decision making provide practical and well-described methods to accomplish patient-centered care in the context of situations where medical evidence supports specific behavior changes and the most appropriate action is dependent on the patient's preferences. Many clinical consultations may require elements of both approaches, however. This article describes these 2 approaches-one to address ambivalence to medically indicated behavior change and the other to support patients in making health care decisions in cases where there is more than one reasonable option-and discusses how clinicians can draw on these approaches alone and in combination to achieve patient-centered care across the range of health care problems.
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Affiliation(s)
- Glyn Elwyn
- The Dartmouth Center for Health Care Delivery Science, Hanover, New Hampshire
| | - Christine Dehlendorf
- Departments of Family & Community Medicine, Obstetrics, Gynecology & Reproductive Sciences, and Epidemiology & Biostatistics, UCSF, San Francisco, California
| | - Ronald M. Epstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
| | - Katy Marrin
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Heath Park, United Kingdom
| | - James White
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Heath Park, United Kingdom
| | - Dominick L. Frosch
- Gordon and Betty Moore Foundation, Palo Alto, California
- Department of Health Services Research, Palo Alto Medical Foundation Research Institute, Palo Alto, California
- Department of Medicine, University of California, Los Angeles, Los Angeles, California
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Hoerger M, Chapman BP, Prigerson HG, Fagerlin A, Mohile SG, Epstein RM, Lyness JM, Duberstein PR. Personality Change Pre- to Post- Loss in Spousal Caregivers of Patients with Terminal Lung Cancer. Soc Psychol Personal Sci 2014; 5:722-729. [PMID: 25614779 DOI: 10.1177/1948550614524448] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Personality is relatively stable in adulthood but could change in response to life transitions, such as caring for a spouse with a terminal illness. Using a case-control design, spousal caregivers (n=31) of patients with terminal lung cancer completed the NEO-FFI twice, 1.5 years apart, before and after the patient's death. A demographically-matched sample of community controls (n=93) completed the NEO-FFI on a similar timeframe. Based on research and theory, we hypothesized that bereaved caregivers would experience greater changes than controls in interpersonal facets of extraversion (sociability), agreeableness (prosocial, nonantagonistic), and conscientiousness (dependability). Consistent with hypotheses, bereaved caregivers experienced an increase in interpersonal orientation, becoming more sociable, prosocial, and dependable (Cohen's d = .48-.67), though there were no changes in nonantagonism. Changes were not observed in controls (ds ≤ .11). These initial findings underscore the need for more research on the effect of life transitions on personality.
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Affiliation(s)
- Michael Hoerger
- Tulane Cancer Center, New Orleans, LA, USA, University of Rochester Medical Center, Rochester, NY, USA
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91
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Asuero AM, Queraltó JM, Pujol-Ribera E, Berenguera A, Rodriguez-Blanco T, Epstein RM. Effectiveness of a mindfulness education program in primary health care professionals: a pragmatic controlled trial. J Contin Educ Health Prof 2014; 34:4-12. [PMID: 24648359 DOI: 10.1002/chp.21211] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
INTRODUCTION Burnout is a very prevalent type of stress among health professionals. It affects their well-being, performance, and attitude toward patients. This study assessed the effectiveness of a training program for primary health care professionals designed to reduce burnout and mood disturbance, increase empathy, and develop mindfulness. METHODS Pragmatic randomized controlled trial with pre- and postintervention measurements of 68 primary health care professionals (43 in the intervention and 25 in the control group) in Spain. The intervention consisted of presentations of clinically relevant topics, mindfulness-based coping strategies, mindfulness practice, yoga, and group discussions (8 sessions of 2.5 hours per week plus a 1-day session of 8 hours). Outcome measures included the Maslach Burnout Inventory, Profile of Mood States, Jefferson Scale of Physician Empathy, Baer's Five Facets Mindfulness Questionnaire, and a questionnaire on changes in personal habits and mindfulness practice. Measurements were performed at baseline and after 8 weeks. RESULTS The intervention group improved in the 4 scales measured. The magnitude of the change was large in total mood disturbance (difference between groups -7.1; standardized effect-size [SES] 1.15) and mindfulness (difference between groups 11; SES 0.9) and moderate in the burnout (difference between groups -7; SES 0.74) and empathy scales (difference between groups 5.2; SES 0.71). No significant differences were found in the control group. DISCUSSION Our study supports the use of mindfulness-based programs as part of continuing professional education to reduce and prevent burnout, promote positive attitudes among health professionals, strengthen patient-provider relationships, and enhance well-being.
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92
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Cameron RA, Mazer BL, DeLuca JM, Mohile SG, Epstein RM. In search of compassion: a new taxonomy of compassionate physician behaviours. Health Expect 2013; 18:1672-85. [PMID: 24305037 DOI: 10.1111/hex.12160] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Compassion has been extolled as a virtue in the physician-patient relationship as a response to patient suffering. However, there are few studies that systematically document the behavioural features of physician compassion and the ways in which physicians communicate compassion to patients. OBJECTIVE To develop a taxonomy of compassionate behaviours and statements expressed by the physician that can be discerned by an outside observer. DESIGN Qualitative analysis of audio-recorded office visits between oncologists and patients with advanced cancer. SETTING AND PARTICIPANTS Oncologists (n = 23) and their patients with advanced cancer (n = 49) were recruited in the greater Rochester, New York, area. The physicians and patients were surveyed and had office visits audio recorded. MAIN OUTCOME MEASURES Audio recordings were listened to for qualitative assessment of communication skills. RESULTS Our sensitizing framework was oriented around three elements of compassion: recognition of the patient's suffering, emotional resonance and movement towards addressing suffering. Statements of compassion included direct statements, paralinguistic expressions and performative comments. Compassion frequently unfolded over the course of a conversation rather than being a single discrete event. Additionally, non-verbal linguistic elements (e.g. silence) were frequently employed to communicate emotional resonance. DISCUSSION AND CONCLUSIONS This study is the first to systematically catalogue instances of compassionate communication in physician-patient dialogues. Further refinement and validation of this preliminary taxonomy can guide future education and training interventions to facilitate compassion in physician-patient interactions.
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Affiliation(s)
- Rachel A Cameron
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, SC, USA
| | - Benjamin L Mazer
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, SC, USA
| | - Jane M DeLuca
- School of Nursing, Clemson University, Clemson, SC, USA
| | - Supriya G Mohile
- Department of Medicine, James Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Ronald M Epstein
- Departments of Family Medicine, Psychiatry, Oncology, and Nursing, Center for Communication and Disparities Research, University of Rochester Medical Center, Rochester, NY, USA
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93
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Kravitz RL, Franks P, Feldman MD, Tancredi DJ, Slee CA, Epstein RM, Duberstein PR, Bell RA, Jackson-Triche M, Paterniti DA, Cipri C, Iosif AM, Olson S, Kelly-Reif S, Hudnut A, Dvorak S, Turner C, Jerant A. Patient engagement programs for recognition and initial treatment of depression in primary care: a randomized trial. JAMA 2013; 310:1818-28. [PMID: 24193079 PMCID: PMC4493759 DOI: 10.1001/jama.2013.280038] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment. OBJECTIVE To determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire-9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California. INTERVENTIONS DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control). MAIN OUTCOMES AND MEASURES Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome); depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted. RESULTS Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5% for DEV, 26% for IMCP, and 16.3% for control (DEV vs control, 1.1 [95% CI, -6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95% CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8 measured depression score at the 12-week follow-up: DEV vs control, -0.2 (95% CI, -1.2 to 0.8); IMCP vs control, 0.9 (95% CI, -0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control, -2.2 [90% CI, -8.0 to 3.49], P = .0499 for noninferiority; IMCP vs control, -3.3 [90% CI, -9.1 to 2.4], P = .02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control, 0.9 [90% CI, -4.9 to 6.7], P = .23 for noninferiority; IMCP vs control, 0.3 [90% CI, -5.1 to 5.7], P = .16 for noninferiority). CONCLUSIONS AND RELEVANCE A tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-week follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01144104.
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Affiliation(s)
- Richard L Kravitz
- Division of General Medicine, University of California at Davis, Sacramento2Center for Healthcare Policy and Research, University of California at Davis, Sacramento
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94
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Beach MC, Roter D, Korthuis PT, Epstein RM, Sharp V, Ratanawongsa N, Cohn J, Eggly S, Sankar A, Moore RD, Saha S. A multicenter study of physician mindfulness and health care quality. Ann Fam Med 2013; 11:421-8. [PMID: 24019273 PMCID: PMC3767710 DOI: 10.1370/afm.1507] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Mindfulness (ie, purposeful and nonjudgmental attentiveness to one's own experience, thoughts, and feelings) is associated with physician well-being. We sought to assess whether clinician self-rated mindfulness is associated with the quality of patient care. METHODS We conducted an observational study of 45 clinicians (34 physicians, 8 nurse practitioners, and 3 physician assistants) caring for patients infected with the human immunodeficiency virus (HIV) who completed the Mindful Attention Awareness Scale and 437 HIV-infected patients at 4 HIV specialty clinic sites across the United States. We measured patient-clinician communication quality with audio-recorded encounters coded using the Roter Interaction Analysis System (RIAS) and patient ratings of care. RESULTS In adjusted analyses comparing clinicians with highest and lowest tertile mindfulness scores, patient visits with high-mindfulness clinicians were more likely to be characterized by a patient-centered pattern of communication (adjusted odds ratio of a patient-centered visit was 4.14; 95% CI, 1.58-10.86), in which both patients and clinicians engaged in more rapport building and discussion of psychosocial issues. Clinicians with high-mindfulness scores also displayed more positive emotional tone with patients (adjusted β = 1.17; 95% CI, 0.46-1.9). Patients were more likely to give high ratings on clinician communication (adjusted prevalence ratio [APR] = 1.48; 95% CI, 1.17-1.86) and to report high overall satisfaction (APR = 1.45; 95 CI, 1.15-1.84) with high-mindfulness clinicians. There was no association between clinician mindfulness and the amount of conversation about biomedical issues. CONCLUSIONS Clinicians rating themselves as more mindful engage in more patient-centered communication and have more satisfied patients. Interventions should determine whether improving clinician mindfulness can also improve patient health outcomes.
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96
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Carroll JK, Fiscella K, Epstein RM, Sanders MR, Winters PC, Moorhead SA, van Osch L, Williams GC. Physical activity counseling intervention at a federally qualified health center: improves autonomy-supportiveness, but not patients' perceived competence. Patient Educ Couns 2013; 92:432-436. [PMID: 23932756 PMCID: PMC3862290 DOI: 10.1016/j.pec.2013.06.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 06/20/2013] [Accepted: 06/29/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To assess the effect of a pilot intervention to promote clinician-patient communication about physical activity on patient ratings of their perceived competence for physical activity and their clinicians' autonomy-supportiveness. METHODS Family medicine clinicians (n=13) at two urban community health centers were randomized to early or delayed (8 months later) communication training groups. The goal of the training was to teach the 5As (Ask, Advise, Agree, Assist, Arrange) for physical activity counseling. Outcome measures were changes in patient perceptions of autonomy support (modified Health Care Climate Questionnaire, mHCCQ) and perceived competence (Perceived Competence Scale for physical activity, PCS) completed via surveys at baseline, post-intervention and six-month follow-up. RESULTS Patients (n=326) were mostly female (70%) and low income. Using a generalized estimating equations model (GEE) with patients nested within clinician, patient perceived autonomy support increased at post-intervention compared to baseline (mean HCCQ scores 3.68-4.06, p=0.03). There was no significant change in patient perceived competence for physical activity. CONCLUSIONS A clinician-directed intervention increased patient perceptions of clinician autonomy support but not patient perceived competence for physical activity. PRACTICE IMPLICATIONS Clinicians working with underserved populations can be taught to improve their autonomy supportiveness, according to patient assessments of their clinicians.
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Affiliation(s)
- Jennifer K Carroll
- University of Rochester Medical Center, Department of Family Medicine, Family Medicine Research Programs, Rochester, NY 14620, USA.
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97
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Walczak A, Mazer B, Butow PN, Tattersall MHN, Clayton JM, Davidson PM, Young J, Ladwig S, Epstein RM. A question prompt list for patients with advanced cancer in the final year of life: development and cross-cultural evaluation. Palliat Med 2013; 27:779-88. [PMID: 23630055 DOI: 10.1177/0269216313483659] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clinicians and patients find prognosis and end-of-life care discussions challenging. Misunderstanding one's prognosis can contribute to poor decision-making and end-of-life quality of life. A question prompt list (booklet of questions patients can ask clinicians) targeting these issues may help overcome communication barriers. None exists for end-of-life discussions outside the palliative care setting. AIM To develop/pilot a question prompt list facilitating discussion/planning of end-of-life care for oncology patients with advanced cancer from Australia and the United States and to explore acceptability, perceived benefits/challenges of using the question prompt list, suggestions for improvements and the necessity of country-specific adaptations. DESIGN An expert panel developed a question prompt list targeting prognosis and end-of-life issues. Australian/US semi-structured interviews and one focus group elicited feedback about the question prompt list. Transcribed data were analysed using qualitative methods. SETTING/PARTICIPANTS Thirty-four patients with advanced cancer (15 Australian/19 US) and 13 health professionals treating such patients (7 Australian/6 US) from two Australian and one US cancer centre participated. RESULTS Most endorsed the entire question prompt list, though a minority queried the utility/appropriateness of some questions. Analysis identified four global themes: (1) reinforcement of known benefits of question prompt lists, (2) appraisal of content and suggestions for further developments, (3) perceived benefits and challenges in using the question prompt list and (4) contrasts in Australian/US feedback. These contrasts necessitated distinct Australian/US final versions of the question prompt list. CONCLUSIONS Participants endorsed the question prompt list as acceptable and useful. Feedback resulted in two distinct versions of the question prompt list, accommodating differences between Australian and US approaches to end-of-life discussions, highlighting the appropriateness of tailoring communication aides to individual populations.
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Affiliation(s)
- Adam Walczak
- School of Psychology, University of Sydney, Sydney, NSW, Australia.
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98
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Hoerger M, Epstein RM, Winters PC, Fiscella K, Duberstein PR, Gramling R, Butow PN, Mohile SG, Kaesberg PR, Tang W, Plumb S, Walczak A, Back AL, Tancredi D, Venuti A, Cipri C, Escalera G, Ferro C, Gaudion D, Hoh B, Leatherwood B, Lewis L, Robinson M, Sullivan P, Kravitz RL. Values and options in cancer care (VOICE): study design and rationale for a patient-centered communication and decision-making intervention for physicians, patients with advanced cancer, and their caregivers. BMC Cancer 2013; 13:188. [PMID: 23570278 PMCID: PMC3637237 DOI: 10.1186/1471-2407-13-188] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 03/26/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Communication about prognosis and treatment choices is essential for informed decision making in advanced cancer. This article describes an investigation designed to facilitate communication and decision making among oncologists, patients with advanced cancer, and their caregivers. METHODS/DESIGN The Values and Options in Cancer Care (VOICE) Study is a National Cancer Institute sponsored randomized controlled trial conducted in the Rochester/Buffalo, NY and Sacramento, CA regions. A total of 40 oncologists, approximately 400 patients with advanced cancer, and their family/friend caregivers (one per patient, when available) are expected to enroll in the study. Drawing upon ecological theory, the intervention uses a two-pronged approach: oncologists complete a multifaceted tailored educational intervention involving standardized patient instructors (SPIs), and patients and caregivers complete a coaching intervention to facilitate prioritizing and discussing questions and concerns. Follow-up data will be collected approximately quarterly for up to three years. DISCUSSION The intervention is hypothesized to enhance patient-centered communication, quality of care, and patient outcomes. Analyses will examine the effects of the intervention on key elements of physician-patient-caregiver communication (primary outcomes), the physician-patient relationship, shared understanding of prognosis, patient well-being, and health service utilization (secondary outcomes). TRIAL REGISTRATION Clinical Trials Identifier: NCT01485627.
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Affiliation(s)
- Michael Hoerger
- Rochester Healthcare Decision-Making Group, University of Rochester Medical Center, Rochester, New York, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, 300 Crittenden Blvd, Rochester, NY, USA
| | - Ronald M Epstein
- Rochester Healthcare Decision-Making Group, University of Rochester Medical Center, Rochester, New York, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Paul C Winters
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Kevin Fiscella
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Paul R Duberstein
- Rochester Healthcare Decision-Making Group, University of Rochester Medical Center, Rochester, New York, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Robert Gramling
- Rochester Healthcare Decision-Making Group, University of Rochester Medical Center, Rochester, New York, USA
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Phyllis N Butow
- Centre for Medical Psychology and Evidence-based Medicine, School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Paul R Kaesberg
- Department of Internal Medicine, University of California, Davis, Sacramento, California, USA
| | - Wan Tang
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York, USA
| | - Sandy Plumb
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Adam Walczak
- Centre for Medical Psychology and Evidence-based Medicine, School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Anthony L Back
- Department of Medicine, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Daniel Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA
| | - Alison Venuti
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Camille Cipri
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA
| | - Gisela Escalera
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA
| | - Carol Ferro
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Don Gaudion
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Beth Hoh
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Blair Leatherwood
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA
| | - Linda Lewis
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA
| | - Mark Robinson
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA
| | - Peter Sullivan
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Richard L Kravitz
- Department of Internal Medicine, University of California, Davis, Sacramento, California, USA
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA
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99
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Walczak A, Butow PN, Davidson PM, Bellemore FA, Tattersall MHN, Clayton JM, Young J, Mazer B, Ladwig S, Epstein RM. Patient perspectives regarding communication about prognosis and end-of-life issues: how can it be optimised? Patient Educ Couns 2013; 90:307-314. [PMID: 21920693 DOI: 10.1016/j.pec.2011.08.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 08/08/2011] [Accepted: 08/15/2011] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To explore patients' perspectives across two cultures (Australia and USA) regarding communication about prognosis and end-of-life care issues and to consider the ways in which these discussions can be optimised. METHODS Fifteen Australian and 11 US patients completed individual semi-structured qualitative interviews. A further 8 US patients participated in a focus group. Interviews and focus group recordings were transcribed verbatim and interpreted using thematic text analysis with an inductive, data-driven approach. RESULTS Global themes identified included readiness for and outcomes of discussions of prognosis and end-of-life issues. Contributing to readiness were sub themes including patients' adjustment to and acceptance of their condition (together with seven factors promoting this), doctor and patient communication skills, mutual understandings and therapeutic relationship elements. Outcomes included sub themes of achievement of control and ability to move on. A model of the relationships between these factors, emergent cross cultural differences, and how factors may help to optimise these discussions are presented. CONCLUSION Identified optimising factors illustrate Australian and US patients' perspectives regarding how prognosis and end-of-life issues can be discussed with minimised negative impact. PRACTICE IMPLICATIONS Recognition of factors promoting adjustment, acceptance and readiness and use of the communication skills and therapeutic relationship elements identified may assist in optimising discussions and help patients plan care, achieve more control of their situation and enjoy an optimal quality-of-life.
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Affiliation(s)
- Adam Walczak
- Centre for Medical Psychology and Evidence-based Decision-making, The University of Sydney, Australia.
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100
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Kravitz RL, Epstein RM, Bell RA, Rochlen AB, Duberstein P, Riby CH, Caccamo AF, Slee CK, Cipri CS, Paterniti DA. An academic-marketing collaborative to promote depression care: a tale of two cultures. Patient Educ Couns 2013; 90:411-419. [PMID: 21862274 PMCID: PMC3235260 DOI: 10.1016/j.pec.2011.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 06/29/2011] [Accepted: 07/08/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Commercial advertising and patient education have separate theoretical underpinnings, approaches, and practitioners. This paper aims to describe a collaboration between academic researchers and a marketing firm working to produce demographically targeted public service anouncements (PSAs) designed to enhance depression care-seeking in primary care. METHODS An interdisciplinary group of academic researchers contracted with a marketing firm in Rochester, NY to produce PSAs that would help patients with depressive symptoms engage more effectively with their primary care physicians (PCPs). The researchers brought perspectives derived from clinical experience and the social sciences and conducted empirical research using focus groups, conjoint analysis, and a population-based survey. Results were shared with the marketing firm, which produced four PSA variants targeted to gender and socioeconomic position. RESULTS There was no simple, one-to-one relationship between research results and the form, content, or style of the PSAs. Instead, empirical findings served as a springboard for discussion and kept the creative process tethered to the experiences, attitudes, and opinions of actual patients. Reflecting research findings highlighting patients' struggles to recognize, label, and disclose depressive symptoms, the marketing firm generated communication objectives that emphasized: (a) educating the patient to consider and investigate the possibility of depression; (b) creating the belief that the PCP is interested in discussing depression and capable of offering helpful treatment; and (c) modelling different ways of communicating with physicians about depression. Before production, PSA prototypes were vetted with additional focus groups. The winning prototype, "Faces," involved a multi-ethnic montage of formerly depressed persons talking about how depression affected them and how they improved with treatment, punctuated by a physician who provided clinical information. A member of the academic team was present and consulted closely during production. Challenges included reconciling the marketing tradition of audience segmentation with the overall project goal of reaching as broad an audience as possible; integrating research findings across dimensions of words, images, music, and tone; and dealing with misunderstandings related to project scope and budget. CONCLUSION Mixed methods research can usefully inform PSAs that incorporate patient perspectives and are produced to professional standards. However, tensions between the academic and commercial worlds exist and must be addressed. PRACTICE IMPLICATIONS While rewarding, academic-marketing collaborations introduce tensions which must be addressed.
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Affiliation(s)
- Richard L Kravitz
- Department of Internal Medicine, University of California at Davis, Sacramento, USA.
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