Enhancing patient participation in oncology consultations: a best evidence synthesis of patient-targeted interventions

The impact of patient engagement on patient safety in care transitions after cancer treatment: Protocol for a systematic review and meta-analysis

BACKGROUND

Transitions of care after cancer treatment pose a major challenge for patient safety as adverse events and unplanned healthcare utilization occur frequently. At this point, patient and family engagement (PFE) is particularly valuable since patients and their families experience various challenges along this pathway, such as changing roles and recurrent needs to navigate across structural gaps between different services. However, there is currently a lack of evidence on the impact of PFE on patient safety in transitions after cancer treatment.

OBJECTIVE

To systematically review and synthesize evidence on effects of different PFE interventions on patient safety in the transition of care after cancer treatment.

METHODS

This protocol for a systematic review with meta-analysis follows PRISMA-P guidelines. A comprehensive database search will be conducted in MEDLINE, EMBASE, CENTRAL, CINAHL, and APA PsycInfo. Trial registries and grey literature will be searched, forward and backward citation tracking will be performed. Trials with prospective, longitudinal, interventional study designs will be included if they evaluate PFE interventions on patient safety outcomes (primary outcomes: healthcare utilization, patient harm, adherence, patient experience; secondary: quality of life, distress); eligible studies need to survey patients with any oncological disease during or after transition following cancer treatment. Results will be synthesized narratively and meta-analytically using a random-effects model. Risk of bias will be assessed using the Cochrane RoB-2 and revised JBI critical appraisal tool. The certainty of evidence will be judged according to the GRADE approach.

DISCUSSION

Robust evidence of effectiveness is needed to establish PFE interventions for patient safety in care transitions for oncological patients. This review will allow evidence-based conclusions about types and effects of different PFE interventions for transitional safety in oncology care and inform stakeholders in designing sustainable PFE activities.

TRIAL REGISTRATION

PROSPERO (CRD42024546938), OSF (doi.org/10.17605/OSF.IO/9XAMU).

Patient-physician communication about cancer-related fatigue: a survey of patient-perceived barriers

PURPOSE

Cancer-related fatigue is a subjective, distressing, and common sequela of cancer which is often disregarded and underdiagnosed. Fatigue is assessed by self-report requiring communication between patient and physician. In this study, we investigated the patients' perspective on the patient-physician communication about fatigue.

METHODS

On average five months after diagnosis 1179 cancer patients, recruited in Germany, completed a survey as part of the LIFT project. The survey included questions on sociodemographic data, fatigue, depression, fatigue management, patient-physician communication, and communication barriers. Data were analyzed descriptively and using logistic regression analyses.

RESULTS

Half of the participants reported that their physician had never asked them whether they felt exhausted. Patients undergoing chemo-, radio-, or immunotherapy were more likely to be asked about fatigue, while older age and major depression decreased the likelihood. Sixty-four percent of the patients felt impeded by communication barriers. Common barriers were not knowing who to turn to for fatigue (39%), time constraints (31%), and the fear of being perceived as weak (22%). Almost half of the participants indicated that their physicians were not appreciative and did not deal adequately with fatigue-related questions.

CONCLUSION

This study revealed gaps in the patient-physician communication regarding cancer-related fatigue. Contrary to guideline recommendations a minority of physicians addressed fatigue. On the other hand, cancer patients felt reluctant to bring up this topic due to structural barriers and fears. Physicians should routinely address fatigue and adopt a communication style which encourages patients to likewise state their symptoms and raise their questions.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT04921644. Registered in June 2021.

Evaluation of a Novel Question Prompt List in Pediatric Surgical Oncology

INTRODUCTION

Parents of children with cancer describe interactions with clinicians as emotionally distressing. Patient engagement in treatment discussions decreases decisional conflict and improves decision quality which may limit such distress. We have shown that parents prefer to engage surgeons by asking questions, but parents may not know what to ask. Question Prompt Lists (QPLs), structured lists of questions designed to help patients ask important questions, have not been studied in pediatric surgery. We developed a QPL designed to empower parents to ask meaningful questions during pediatric surgical oncology discussions. We conducted a mixed methods analysis to assess the acceptability, appropriateness, and feasibility of using the QPL.

METHODS

Key stakeholders at an academic children's hospital participated in focus groups to discuss the QPL. Focus groups were recorded and transcribed. Participants were surveyed regarding QPL acceptability, appropriateness, and feasibility. Thematic content analysis of transcripts was performed.

RESULTS

Four parents, five nurses, five nurse practitioners, five oncologists, and four surgeons participated. Seven key themes were identified: (1) QPL as a tool of empowerment; (2) stick to the surgical details; (3) QPLs can impact discussion quality; (4) time consuming, but not overly disruptive; (5) parental emotion may impact QPL use; (6) provide QPLs prior to surgical consultation in both print and digital formats; and (7) expansion of QPLs to other disciplines. Over 70% of participants agreed that the QPL was acceptable, appropriate, and feasible.

CONCLUSIONS

Our novel QPL is acceptable, appropriate, and feasible to use with parents of pediatric surgical oncology patients.

Question prompt lists and caregiver question asking in pediatric specialty appointments: A randomized controlled trial

OBJECTIVE

Question prompt lists (QPLs) have been effective at increasing patient involvement and question asking in medical appointments, which is critical for shared decision making. We investigated whether pre-visit preparation (PVP), including a QPL, would increase question asking among caregivers of pediatric patients with undiagnosed, suspected genetic conditions.

METHODS

Caregivers were randomized to receive the PVP before their appointment (n = 59) or not (control, n = 53). Appointments were audio-recorded. Transcripts were analyzed to determine questions asked.

RESULTS

Caregivers in the PVP group asked more questions (MeanPVP = 4.36, SDPVP = 4.66 vs. Meancontrol = 2.83, SDcontrol = 3.03, p = 0.045), including QPL questions (MeanPVP = 1.05, SDPVP = 1.39 vs. Meancontrol = 0.36, SDcontrol = 0.81, p = 0.002). Caregivers whose child had insurance other than Medicaid in the PVP group asked more total and QPL questions than their counterparts in the control group (ps = 0.005 and 0.002); there was no intervention effect among caregivers of children with Medicaid or no insurance (ps = 0.775 and 0.166).

CONCLUSION

The PVP increased question asking but worked less effectively among traditionally underserved groups. Additional interventions, including provider-focused efforts, may be needed to promote engagement of underserved patients.

PRACTICE IMPLICATIONS

Patient/family-focused interventions may not be beneficial for all populations. Providers should be aware of potential implicit and explicit biases and encourage question asking to promote patient/family engagement.

Addressing multilevel barriers to clinical trial participation among Black and White men with prostate cancer through the PACCT study

BACKGROUND

Cancer clinical trial participation is low and inequitable. Partnering Around Cancer Clinical Trials (PACCT) addressed systemic and interpersonal barriers through an observational study of eligibility and an intervention to improve patient-physician communication and trial invitation rates.

METHODS

Physicians at two comprehensive cancer centers and Black and White men with prostate cancer participated. Patients were followed for 2 years to determine whether they became potentially eligible for an available therapeutic trial. Potentially eligible patients were randomized to receive a trials-focused Question Prompt List or usual care. Patient-physician interactions were video-recorded. Outcomes included communication quality and trial invitation rates. Descriptive analyses assessed associations between sociodemographic characteristics and eligibility and effects of the intervention on outcomes.

RESULTS

Only 44 (22.1%) of participating patients (n = 199) became potentially eligible for an available clinical trial. Patients with higher incomes were more often eligible (>$80,000 vs. <$40,000, adjusted OR = 6.06 [SD, 1.97]; $40,000-$79,000 vs. <$40,000, adjusted OR = 4.40 [SD, 1.81]). Among eligible patients randomized to the intervention (n = 19) or usual care (n = 25), Black patients randomized to the intervention reported participating more actively than usual care patients, while White intervention patients reported participating less actively (difference, 0.41 vs. -0.34). Intervention patients received more trial invitations than usual care patients (73.7% vs. 60.0%); this effect was greater for Black (80.0% vs. 30.0%) than White patients (80.0% vs. 66.7%).

CONCLUSIONS

Findings suggest the greatest enrollment barrier is eligibility for an available trial, but a communication intervention can improve communication quality and trial invitation rates, especially for eligible Black patients.

An interactive mobile application versus an educational booklet to promote job retention in women undergoing adjuvant chemotherapy for breast cancer: a randomized controlled trial

BACKGROUND

Job loss after a cancer diagnosis can lead to long-term financial toxicity and its attendant adverse clinical consequences, including decreased treatment adherence. Among women undergoing (neo)adjuvant chemotherapy for breast cancer, access to work accommodations (e.g., sick leave) is associated with higher job retention after treatment completion. However, low-income and/or minority women are less likely to have access to work accommodations and, therefore, are at higher risk of job loss. Given the time and transportation barriers that low-income working patients commonly face, it is crucial to develop an intervention that is convenient and easy to use.

METHODS

We designed an intervention to promote job retention during and after (neo)adjuvant chemotherapy for breast cancer by improving access to relevant accommodations. Talking to Employers And Medical staff about Work (TEAMWork) is an English/Spanish mobile application (app) that provides (1) suggestions for work accommodations tailored to specific job demands, (2) coaching/strategies for negotiating with an employer, (3) advice for symptom self-management, and (4) tools to improve communication with the medical oncology team. This study is a randomized controlled trial to evaluate the app as a job-retention tool compared to a control condition that provides the app content in an informational paper booklet. The primary outcome of the study is work status after treatment completion. Secondary outcomes include work status 1 and 2 years later, participant self-efficacy to ask an employer for accommodations, receipt of workplace accommodations during and following adjuvant therapy, patient self-efficacy to communicate with the oncology provider, self-reported symptom burden during and following adjuvant therapy, and cancer treatment adherence.

DISCUSSION

This study will assess the use of mobile technology to improve vulnerable breast cancer patients' ability to communicate with their employers and oncology providers, work during treatment and retain their jobs in the long term, thereby diminishing the potential consequences of job loss, including decreased treatment adherence, debt, and bankruptcy.

TRIAL REGISTRATION

ClincalTrials.gov NCT03572374 . Registered on 08 June 2018.

Question prompt lists to improve communication between cancer patients and healthcare professionals

PURPOSE OF REVIEW

This literature review sets out to summarize knowledge on the impact of question prompt lists (QPLs) on patient-physician communication in oncology and to provide an account of current research on the development, adaptation, and implementation of this type of communication tool.

RECENT FINDINGS

Provided with a QPL, patients seem to ask more questions, in particular on sensitive issues like those around the end-of-life period and they recall the information provided better. There is a need to adapt QPLs, taking account of divergences in attitudes towards illness, participation in decision-making, and discussions about the illness prognosis across cultures. QPLs may also need to be tailored to specific concerns of patients at the different stages in the care trajectory and to the particularities of each cancer type. These adaptations contribute to the effectiveness of the tool because they make it possible to tailor it to the challenges and constraints experienced in clinical practice.

SUMMARY

QPLs are designed to enhance patients' communication with their physicians. Further research is required to develop QPLs suited to each cultural and clinical setting, involving health professionals so as to facilitate the implementation of these tools in routine practice.

Helping Patients Communicate With Oncologists When Cancer Treatment Resistance Occurs to Develop, Test, and Implement a Patient Communication Aid: Sequential Collaborative Mixed Methods Study

BACKGROUND

Most cancer-related deaths result from disseminated diseases that develop resistance to anticancer treatments. Inappropriate communication in this challenging situation may result in unmet patient information and support needs. Patient communication aids such as question prompt lists (QPLs) may help.

OBJECTIVE

This study aims to develop and pilot-test a specific QPL in the following two contrasting clinical contexts in France after cancer resistance has developed: triple-negative and luminal B metastatic breast cancer (MBC) and metastatic uveal melanoma (MUM).

METHODS

A sequential study design with a mixed methods collaborative approach will be applied. The first step aims to build a specific QPL. Step 1a will explore oncologist-patient communication issues from oncology professionals' interviews (n=20 approximately). Step 1b will appraise information and support needs experienced by patients with MBC or MUM both quantitatively (n=80) and qualitatively (n=40 approximately). These data will be used to develop and pilot-test a QPL specific to patients with cancer experiencing initial or acquired resistance to treatment. We expect to obtain a core QPL that comprises questions and concerns commonly expressed by patients with resistant cancer and is complemented by specific issues for either MBC or MUM cancer sites. In step 1c, 2 focus groups of patients with any type of metastatic cancer (n=4) and health care professionals (n=4) will be conducted to revise the content of a preliminary QPL and elaborate an acceptable and feasible clinical implementation. In step 1d, the content of the QPL version 1 and implementation guidance will be validated using a Delphi process. Step 2 will pilot-test the QPL version 1 in real practice with patients with MBC or MUM (n=80). Clinical utility will be assessed by comparing responses to questionnaires administered in step 1b (QPL-naive historical control group) and step 2 (QPL intervention group).

RESULTS

This study received grants in March and December 2019 and was approved by the French national ethics committee in July 2019. As of October 2021, interviews with oncology professionals have been conducted and analyzed (N=26 to reach saturation), and 39 and 27 patients with MBC and MUM, respectively, have been recruited.

CONCLUSIONS

A clinically and culturally tailored QPL is expected to facilitate patients' participation in consultations, improve oncologists' responses to patients' information and support needs, and thus foster patients' psychological adjustment to the diagnosis and follow-up of cancer resistance to treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04118062; http://clinicaltrials.gov/ct2/show/NCT04118062.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/26414.

Effectiveness of individual feedback and coaching on shared decision-making consultations in oncology care: Study protocol for a randomized clinical trial (Preprint)

Background

Shared decision-making (SDM) is particularly important in oncology as many treatments involve serious side effects, and treatment decisions involve a trade-off between benefits and risks. However, the implementation of SDM in oncology care is challenging, and clinicians state that it is difficult to apply SDM in their actual workplace. Training clinicians is known to be an effective means of improving SDM but is considered time consuming.

Objective

This study aims to address the effectiveness of an individual SDM training program using the concept of deliberate practice.

Methods

This multicenter, single-blinded randomized clinical trial will be performed at 12 Dutch hospitals. Clinicians involved in decisions with oncology patients will be invited to participate in the study and allocated to the control or intervention group. All clinicians will record 3 decision-making processes with 3 different oncology patients. Clinicians in the intervention group will receive the following SDM intervention: completing e-learning, reflecting on feedback reports, performing a self-assessment and defining 1 to 3 personal learning questions, and participating in face-to-face coaching. Clinicians in the control group will not receive the SDM intervention until the end of the study. The primary outcome will be the extent to which clinicians involve their patients in the decision-making process, as scored using the Observing Patient Involvement–5 instrument. As secondary outcomes, patients will rate their perceived involvement in decision-making, and the duration of the consultations will be registered. All participating clinicians and their patients will receive information about the study and complete an informed consent form beforehand.

Results

This trial was retrospectively registered on August 03, 2021. Approval for the study was obtained from the ethical review board (medical research ethics committee Delft and Leiden, the Netherlands [N20.170]). Recruitment and data collection procedures are ongoing and are expected to be completed by July 2022; we plan to complete data analyses by December 2022. As of February 2022, a total of 12 hospitals have been recruited to participate in the study, and 30 clinicians have started the SDM training program.

Conclusions

This theory-based and blended approach will increase our knowledge of effective and feasible training methods for clinicians in the field of SDM. The intervention will be tailored to the context of individual clinicians and will target the knowledge, attitude, and skills of clinicians. The patients will also be involved in the design and implementation of the study.

Trial Registration

Netherlands Trial Registry NL9647; https://www.trialregister.nl/trial/9647

International Registered Report Identifier (IRRID)

DERR1-10.2196/35543

The DISCO App: A pilot test of a multi-level intervention to reduce the financial burden of cancer through improved cost communication☆

Objective

Financial toxicity affects 30–50% of people with cancer in the US. Although experts recommend patients and physicians discuss treatment cost, cost discussions occur infrequently. We pilot-tested the feasibility, acceptability and influence on outcomes of the DIScussions of COst (DISCO) App, a multi-level communication intervention designed to improve cost discussions and related outcomes.

Methods

While waiting to see their physician, patients (n = 32) used the DISCO App on a tablet. Physicians were given a cost discussion tip sheet. Clinic visits were video recorded and patients completed pre- and post-intervention measures of self-efficacy for managing costs, self-efficacy for interacting with physicians, cost-related distress, and perceptions of the DISCO App. Coders observed the recordings to determine the presence of cost discussions, initiators, and topics.

Results

Most patients reported needing ≤15 min to use the DISCO App, and that it made it easier to ask cost-related questions. Findings showed increased self-efficacy for managing treatment costs (p = .02) and for interacting with physicians (p = .001). All visits included a cost discussion.

Conclusions

Prompting patients to discuss costs may improve cost treatment discussions and related outcomes.

Innovation

An app-based and tailorable treatment-cost communication intervention is feasible, acceptable, and demonstrates promise in prompting cost discussions and improving outcomes.

Trial registration: Clinical Trials.gov registration number: NCT03676920 (September 19, 2018).

DISCO App: study protocol for a randomized controlled trial to test the effectiveness of a patient intervention to reduce the financial burden of cancer in a diverse patient population

Background

Financial toxicity, the material and psychological burden of the cost of treatment, affects 30–50% of people with cancer, even those with health insurance. The burden of treatment cost can affect treatment adherence and, ultimately, mortality. Financial toxicity is a health equity issue, disproportionately affecting patients who are racial/ethnic minorities, have lower incomes, and are < 65 years old. Patient education about treatment cost and patient-oncologist cost discussions are recommended as ways to address financial toxicity; however, research shows cost discussions occur infrequently (Altice et al. J Natl Cancer Inst 109:djw205, 2017; Schnipper et al. J Clin Oncol 34:2925-34, 2016; Zafar et al. Oncologist 18:381-90, 2013; American Cancer Society Cancer Action Network 2010). Our overall goal is to address the burden of financial toxicity and work toward health equity through a tailorable education and communication intervention, the DISCO App. The aim of this longitudinal randomized controlled trial is to test the effectiveness of the DISCO App on the outcomes in a population of economically and racially/ethnically diverse cancer patients from all age groups.

Methods

Patients diagnosed with breast, lung, colorectal, or prostate cancer at a NCI-designated comprehensive cancer center in Detroit, MI, will be randomized to one of three study arms: one usual care arm (arm 1) and two intervention arms (arms 2 and 3). All intervention patients (arms 2 and 3) will receive the DISCO App before the second interaction with their oncologist, and patients in arm 3 will receive an intervention booster. The DISCO App, presented on an iPad, includes an educational video about treatment costs, ways to manage them, and the importance of discussing them with oncologists. Patients enter socio-demographic information (e.g., employment, insurance status) and indicate their financial concerns. They then receive a tailored list of questions to consider asking their oncologist. All patients will have up to two interactions with their oncologist video recorded and complete measures at baseline, after the recorded interactions and at 1, 3, 6, and 12 months after the second interaction. Outcome measures will assess discussions of cost, communication quality, knowledge of treatment costs, self-efficacy for treatment cost management, referrals for support, short- and longer-term financial toxicity, and treatment adherence.

Discussion

If effective, this intervention will improve awareness of and discussions of treatment cost and alleviate the burden of financial toxicity. It may be especially helpful to groups disproportionately affected by financial toxicity, helping to achieve health equity.

Trial registration

ClinicalTrials.gov NCT04766190. Registered on February 23, 2021

A Review of Research on Disparities in the Care of Black and White Patients With Cancer in Detroit

Racial disparities in cancer incidence and outcomes are well-documented in the US, with Black people having higher incidence rates and worse outcomes than White people. In this review, we present a summary of almost 30 years of research conducted by investigators at the Karmanos Cancer Institute's (KCI's) Population Studies and Disparities Research (PSDR) Program focusing on Black-White disparities in cancer incidence, care, and outcomes. The studies in the review focus on individuals diagnosed with cancer from the Detroit Metropolitan area, but also includes individuals included in national databases. Using an organizational framework of three generations of studies on racial disparities, this review describes racial disparities by primary cancer site, disparities associated with the presence or absence of comorbid medical conditions, disparities in treatment, and disparities in physician-patient communication, all of which contribute to poorer outcomes for Black cancer patients. While socio-demographic and clinical differences account for some of the noted disparities, further work is needed to unravel the influence of systemic effects of racism against Black people, which is argued to be the major contributor to disparate outcomes between Black and White patients with cancer. This review highlights evidence-based strategies that have the potential to help mitigate disparities, improve care for vulnerable populations, and build an equitable healthcare system. Lessons learned can also inform a more equitable response to other health conditions and crises.

Effect of a multilevel implementation programme on shared decision-making in breast cancer care

BACKGROUND

Women with newly diagnosed breast cancer face multiple treatment options. Involving them in a shared decision-making (SDM) process is essential. The aim of this study was to evaluate whether a multilevel implementation programme enhanced the level of SDM behaviour of clinicians observed in consultations.

METHODS

This before-after study was conducted in six Dutch hospitals. Patients with breast cancer who were facing a decision on surgery or neoadjuvant systemic treatment between April 2016 and September 2017 were included, and provided informed consent. Audio recordings of consultations made before and after implementation were analysed using the five-item Observing Patient Involvement in Decision-Making (OPTION-5) instrument to assess whether clinicians adopted new behaviour needed for applying SDM. Patients scored their perceived level of SDM, using the nine-item Shared Decision-Making Questionnaire (SDM-Q-9). Hospital, duration of the consultation(s), age, and number of consultations per patient that might influence OPTION-5 scores were investigated using linear regression analysis.

RESULTS

Consultations of 139 patients were audiotaped, including 80 before and 59 after implementation. Mean (s.d.) OPTION-5 scores, expressed on a 0-100 scale, increased from 38.3 (15.0) at baseline to 53.2 (14.8) 1 year after implementation (mean difference (MD) 14.9, 95 per cent c.i. 9.9 to 19.9). SDM-Q-9 scores of 105 patients (75.5 per cent) (72 before and 33 after implementation) were high and showed no significant changes (91.3 versus 87.6; MD -3.7, -9.3 to 1.9). The implementation programme had an association with OPTION-5 scores (β = 14.2, P < 0.001), hospital (β = 2.2, P = 0.002), and consultation time (β = 0.2, P < 0.001).

CONCLUSION

A multilevel implementation programme supporting SDM in breast cancer care increased the adoption of SDM behaviour of clinicians in consultations.

Efficacy of a multimedia intervention in facilitating breast cancer patients' clinical communication about sexual health: Results of a randomized controlled trial

OBJECTIVE

Many women with breast cancer (BC) hesitate to raise sexual concerns clinically. We evaluated a multimedia intervention to facilitate BC patients' communication about sexual/menopausal health, called Starting the Conversation (STC).

METHODS

Female BC patients (N = 144) were randomly assigned to either STC (20-min video, workbook, and resource guide) or control (resource guide only). Audio-recorded dialogue from patients' next oncology clinic encounter was coded for patients' sexual health communication. Self-report surveys assessed patients' beliefs about sexual health communication, self-efficacy for clinical interactions, sexual function/activity, anxiety/depression symptoms, and quality of life at baseline, post-intervention, and 2-month follow-up. T-tests or mixed-effects logistic regression compared study arms.

RESULTS

Women in the STC arm were more likely to raise the topic of sexual health (51%; OR = 2.62 [1.02, 6.69], p = 0.04) and ask a sexual health question (40%; OR = 2.85 [1.27, 6.38], p = 0.01) during their clinic encounter than those in the control arm (30% and 19% for raise and ask, respectively). At follow-up, women in the STC arm showed greater improvements in sexual health communication self-efficacy (p = 0.009) and in anxiety symptoms (p = 0.03), and more women were sexually active at follow-up, compared to the control arm (OR = 1.5, 70% vs. 46%, p = 0.04).

CONCLUSIONS

The STC intervention facilitated women's clinical communication about sexual health and reduced women's anxiety, possibly due to increased confidence in expressing their medical needs. Helpful information gained from clinical discussions could have improved women's willingness or ability to engage in sexual activity. Future studies should identify aspects of the clinical encounter most critical to improving women's sexual outcomes.

Question Prompt List to Support Patient-Provider Communication in the Use of the 21-Gene Recurrence Test: Feasibility, Acceptability, and Outcomes

PURPOSE

The 21-gene recurrence score (RS) assay is used to guide breast cancer treatment decisions but can be poorly understood by patients. We examined the effects of a question prompt list (QPL) on knowledge, distress, and decisional conflict related to genomic testing and treatment in early-stage breast cancer.

METHODS

We describe the feasibility and acceptability of the QPL and the impact of the QPL on knowledge, distress, and decisional conflict before and after the receipt of the QPL (MEND 2, N = 65). We also compared distress and decisional conflict between women who received the QPL (MEND 2, N = 65) and a comparable group of women who did not receive the QPL who participated in an earlier observational study within the same clinics (MEND 1, N = 136).

RESULTS

MEND 2 participants indicated high acceptability and feasibility using the QPL. Knowledge increased post-QPL (P < .01) but did not decrease distress. Decisional conflict was lower among women in MEND 2 compared with those in MEND 1 (P < .01), with no statistically significant differences in distress.

CONCLUSION

The findings suggest that the QPL is feasible, acceptable, can improve knowledge and decrease decisional conflict in the large group of women deciding treatment while integrating RS test results.

Communicating treatment risks and benefits to cancer patients: a systematic review of communication methods

PURPOSE

Cancer patients are increasingly involved in decision-making processes. Hence, clinicians need to inform patients about the risks and benefits of different treatment options in order for patients to make well informed decisions. The aim of this review is to determine the effects of methods of communicating prognostic information about (1) disease progression (survival, progression, recurrence and remission), (2) side effects and complications and (3) health-related quality of life (HRQL) on cognitive, affective and behavioral outcomes in cancer patients.

METHODS

A literature search was performed to select articles that were published up to  November 2019 and that examined verbal and/or visual risk communication interventions in an oncological clinical setting.

RESULTS

The search yielded 14,875 studies; 28 studies were ultimately included. For disease progression information, we found that framing affects treatment choice. Furthermore, limiting the amount of progression information in a graphical display could benefit patients' understanding of risks and benefits. For prognostic information about side effects and complications, precise and defined risk information was better understood than information presented in words. When displaying HRQL data, no consensus was found on which graph type to use.

CONCLUSION

Great heterogeneity in the results and methodology and in the compared communication formats precluded us from drawing any further conclusions. Practical implications for clinicians are to consider the effects that different types of framing might have on the patient and to not rely exclusively on words to describe risks, but rather include at least some form of numbers or visualization.

The Effect of Prognostic Communication on Patient Outcomes in Palliative Cancer Care: a Systematic Review

BACKGROUND

While prognostic information is considered important for treatment decision-making, physicians struggle to communicate prognosis to advanced cancer patients. This systematic review aimed to offer up-to-date, evidence-based guidance on prognostic communication in palliative oncology.

METHODS

PubMed and PsycInfo were searched until September 2019 for literature on the association between prognostic disclosure (strategies) and patient outcomes in palliative cancer care, and its moderators. Methodological quality was reported.

RESULTS

Eighteen studies were included. Concerning prognostic disclosure, results revealed a positive association with patients' prognostic awareness. Findings showed no or positive associations between prognostic disclosure and the physician-patient relationship or the discussion of care preferences. Evidence for an association with the documentation of care preferences or physical outcomes was lacking. Findings on the emotional consequences of prognostic disclosure were multifaceted. Concerning disclosure strategies, affective communication seemingly reduced patients' physiological arousal and improved perceived physician's support. Affective and explicit communication showed no or beneficial effects on patients' psychological well-being and satisfaction. Communicating multiple survival scenarios improved prognostic understanding. Physicians displaying expertise, positivity and collaboration fostered hope. Evidence on demographic, clinical and personality factors moderating the effect of prognostic communication was weak.

CONCLUSION

If preferred by patients, physicians could disclose prognosis using sensible strategies. The combination of explicit and affective communication, multiple survival scenarios and expert, positive, collaborative behaviour likely benefits most patients. Still, more evidence is needed, and tailoring communication to individual patients is warranted.

IMPLICATIONS

Future research should examine the effect of prognostic communication on psychological well-being over time and treatment decision-making, and focus on individualising care.

The influence of a question prompt list on patient-oncologist information exchange in an African-American population

OBJECTIVES

Question Prompt Lists (QPL) increase patient active participation in oncology interactions, but questions remain regarding how QPLs influence patient-oncologist information exchange. We examined how a QPL influenced information exchange during oncology interactions with African-American patients.

METHODS

Data were self-reports and video recordings from a parent study testing the effects of a QPL in the outpatient clinics of two urban cancer hospitals. In this secondary analysis, we investigated which QPL questions patients identified as ones they wanted to ask their oncologists, how frequently patients/companions used patient active participation statements to seek information related to each QPL question, whether oncologists provided QPL-related information unprompted or prompted by patients/companions, and how frequently patients' QPL-related information needs were addressed or unaddressed.

RESULTS

The QPL influenced information exchange by increasing patients' and companions' (if present) prompting for QPL-related information from their oncologists. Patients/companions most often prompted for QPL-related information about side effects and patient experience.

CONCLUSION

This study builds on prior research on QPL interventions by expanding the object of study to information exchange and by analyzing patients' information needs.

PRACTICE IMPLICATIONS

This research demonstrates that a QPL supports patient/companion participation in oncology consultations by making information exchange more interactive.

Effect of a Skills Training for Oncologists and a Patient Communication Aid on Shared Decision Making About Palliative Systemic Treatment: A Randomized Clinical Trial

BACKGROUND

Palliative systematic treatment offers uncertain and often limited benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). This trial examined the independent and combined effect of an oncologist training and a patient communication aid on SDM.

METHODS

In this multicenter randomized controlled trial with four parallel arms (2016-2018), oncologists (n = 31) were randomized to receive SDM communication skills training or not. The training consisted of a reader, two group sessions, a booster session, and a consultation room tool (10 hours). Patients (n = 194) with advanced cancer were randomized to receive a patient communication aid or not. The aid consisted of education on SDM, a question prompt list, and a value clarification exercise. The primary outcome was observed SDM as rated by blinded observers from audio-recorded consultations. Secondary outcomes included patient-reported SDM, patient and oncologist satisfaction, patients' decisional conflict, patient quality of life 3 months after consultation, consultation duration, and the decision made.

RESULTS

The oncologist training had a large positive effect on observed SDM (Cohen's d = 1.12) and on patient-reported SDM (d = 0.73). The patient communication aid did not improve SDM. The combination of interventions did not add to the effect of training oncologists only. The interventions affected neither patient nor oncologist satisfaction with the consultation nor patients' decisional conflict, quality of life, consultation duration, or the decision made.

CONCLUSION

Training medical oncologists in SDM about palliative systemic treatment improves both observed and patient-reported SDM. A patient communication aid does not. The incorporation of skills training in (continuing) educational programs for medical oncologists is likely to stimulate the widely advocated uptake of shared decision making in clinical practice.

TRIAL REGISTRATION

Netherlands Trial Registry NTR 5489.

IMPLICATIONS FOR PRACTICE

Treatment for advanced cancer offers uncertain and often small benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). SDM is increasingly advocated for ethical reasons and for its beneficial effect on patient outcomes. Few initiatives to stimulate SDM are evaluated in robust designs. This randomized controlled trial shows that training medical oncologists improves both observed and patient-reported SDM in clinical encounters (n = 194). A preconsultation communication aid for patients did not add to the effect of training oncologists. SDM training effectively changes oncologists' practice and should be implemented in (continuing) educational programs.

Effects of a Proactive Interdisciplinary Self-Management Program on Patient Self-Efficacy and Participation During Practice Nurse Consultations: A Randomized Controlled Trial in Type 2 Diabetes

Background

Nowadays, patients with chronic conditions such as type 2 diabetes mellitus (T2DM) need and want to be more active participants in their health care. This study aimed to investigate the effects of the Proactive Interdisciplinary Self-Management (PRISMA) training program on participation during consultations with practice nurses and self-efficacy of patients with T2DM in general practice.

Methods

Within a randomized controlled trial, patients were followed for 6 months. They received either PRISMA in addition to usual care or usual care only. Self-efficacy was assessed using the 5-item Perceived Efficacy in Patient-Physician Interactions (PEPPI-5) scale. Consultations were video-recorded and analyzed using the Roter interaction analysis system. Multilevel analysis was carried out.

Results

No differences in the PEPPI-5 were found between the intervention (n = 101) and control groups (n = 102) (U = 1,737.5, z = -0.2, P = 0.8). In addition, the groups did not differ in patient participation. However, patients who attended the PRISMA program expressed more counselling utterances (B = 0.22; standard error (SE) = 0.09).

Conclusions

PRISMA did not result in higher self-efficacy or patient participation during the consultation with practice nurses at 6 months. Possibly, two training sessions are insufficient and a more powerful intervention might be needed. However, the study showed indications that patients counselled themselves more frequently during the consultation. Practice nurses could stimulate patients who are already engaged in self-counselling by further specifying their goals of behavior change.

Introducing a time out consultation with the general practitioner between diagnosis and start of colorectal cancer treatment: Patient-reported outcomes

Objective

To evaluate the introduction of a “time out consultation” with the general practitioner (GP) recommended to patients following the diagnosis of colorectal carcinoma (CRC) before start of treatment.

Methods

A prospective study using questionnaires to compare the number of GP consultations, with their content and outcomes before and after the introduction of an additional consultation with the GP to improve decision‐making and adequate support.

Results

72 patients before and 98 patients after the introduction of the “time out consultation” participated. Introduction of the consultation increased the number of patients to contact their GP from 67% to 80%, but did not change kind or content of the consultations. Patients felt the consultation was comforting and were more satisfied with the GP after the introduction. There was no difference in outcomes measured by the questionnaires in all patients combined, but men, older patients and patients with palliative treatment options only did improve on specific outcomes after the introduction.

Conclusion

The introduction of the “time out consultation” did not change the kind or content of GP consultations before start of CRC treatment, but patients did feel more comforted and satisfied. Subgroups of patients benefited on specific outcomes.

Scoping Review of Self-Advocacy Education Interventions to Improve Care

Self-advocacy is a client's ability to represent one's interests when managing disease or disability. Self-advocacy may increase one's ability to seek, evaluate, and use information to promote health, yet little is known about the role of occupational therapy in promoting self-advocacy. This scoping review aims to identify interventions within occupational therapists' scope of practice to improve self-advocacy. A literature search was conducted through Academic Search Complete to identify interventions within the scope of occupational therapy that promote self-advocacy. All levels of evidence were included, and articles were reviewed for inclusion by two authors. Included articles were charted for level of evidence, objectives, participants, and results. Fourteen articles met the criteria. Interventions included interactive multimedia interventions, peer-led educational groups, writing interventions, job counseling and advocacy, and disease-specific advocacy programs. Occupational therapists are well-equipped to intervene and promote self-advocacy through workplace modification, utilizing assistive technologies, and facilitating peer-led educational groups.

Promoting shared decision making in advanced cancer: Development and piloting of a patient communication aid

OBJECTIVE

To learn how to configure a patient communication aid (PCA) to facilitate shared decision-making (SDM) about treatment for advanced cancer.

METHODS

The PCA consists of education about SDM, a question prompt list, and values clarification methods. Study 1. A first version was presented to 13 patients, 8 relatives and 14 bereaved relatives in interviews. Study 2. A second version was used by 18 patients in a pilot study. Patients and oncologists were interviewed, patients were surveyed, and consultations were audio-recorded.

RESULTS

Respondents reported that the aid facilitated patient control over information, raised choice awareness and promoted elaboration. Risks were identified, most importantly that the aid might upset patients. Also, some respondents reported that the PCA did not, or would not support decision making because they felt sufficiently competent, did not perceive a role for themselves, or did not perceive that the decision required elaboration.

CONCLUSIONS

Opinions on the usefulness of the PCA varied. It was challenging to raise awareness about the presence of a choice, and to find a balance between comprehensive information and sensitivity.

PRACTICE IMPLICATIONS

A future study should demonstrate whether the PCA can improve SDM, and whether this effect is stronger when oncologists receive training.

The effects of persuasive messages on cancer patients' attitudes, norms and intention to express concerns

OBJECTIVE

To examine whether the use of persuasive messages in which cancer patients' attitudes and perceived social norms were either simultaneously or exclusively targeted can positively change patients' attitudes, perceived social norms and the intention to express concerns in consultations.

METHODS

Two online experiments were conducted. The first experiment had a pre-test and post-test measurements design with 4 conditions (attitudes message, social norms message, combined message, control message). The second experiment had a pre-test and post-test measurements design with 2 conditions (message and no message group).

RESULTS

The results of the first study showed small positive changes for patients who could potentially change, but there were no differences in effects between conditions. A second study was conducted to determine whether these effects could be attributed to exposure to the message or to the pre-test questionnaire. There were no differences between the conditions.

CONCLUSION

The results indicate that paying attention to the expression of concerns by patients might increase patients' intention to express further concerns.

PRACTICE IMPLICATIONS

Providers might be able to support patients' in their sharing of concerns through simple communication strategies such as explicitly mentioning that the expression of concerns is possible during a consultation.

Evaluation and Implementation of ListeningTime: A Web-Based Preparatory Communication Tool for Elderly Patients With Cancer and Their Health Care Providers

Background

Effective patient-provider communication is an important condition to deliver optimal care and it supports patients in coping with their disease. The complex and emotionally loaded setting of oncology care challenges both health care providers (HCPs) and patients in reaching effective communication. ListeningTime is developed for elderly patients with cancer and their oncological HCPs to help them (better) prepare the clinical encounter and overcome communication barriers. ListeningTime is a Web-based preparatory communication tool including modeling videos and has an audio-facility to listen back to recorded encounters.

Objective

This study aims to evaluate the usability, perceived usefulness, and actual use of ListeningTime, through the eyes of elderly patients with cancer and their oncological HCPs. If highly rated, the ultimate goal is to make ListeningTime publicly available.

Methods

First, members of a panel of elderly cancer survivors and patients (age ≥65 years) were approached to evaluate ListeningTime through a Web-based questionnaire. The usability and perceived usefulness were assessed. Second, ListeningTime was evaluated in real-life practice through a pilot study in 3 Dutch hospitals. In these hospitals, elderly patients with cancer and their oncological HCPs were approached to evaluate ListeningTime through a similar Web-based questionnaire, measuring the perceived usefulness. In addition, we examined log files and user statistics to get insight into how the program was used.

Results

A total of 30 cancer survivors or patients from the patient panel, and 17 patients and 8 HCPs from the hospitals, evaluated ListeningTime. Overall, both panel members and hospital patients were positive about the ListeningTime website, audio-facility, and video fragments. Some patients suggested improvements with respect to the actors’ performances in the video fragments and believed that ListeningTime is mainly suitable for non experienced patients. HCPs were also positive about ListeningTime; they valued the video fragments for patients and the audio-facility for patients and themselves. However, providers did not relisten their own recorded encounters. Patients did use the audio-facility to relisten their encounters.

Conclusions

ListeningTime was highly rated, both by patients and their oncological HCPs. As a result, the video fragments of ListeningTime are now made publicly available for elderly patients with cancer through the Dutch website “kanker.nl.”

Empowerment from patient's and caregiver's perspective in cancer care

The caregivers’ perceptions of the patients’ health condition may be biased and induce them to perceive higher needs than patients actually disclose. Our aim was to assess if the level of knowledge and awareness about cancer disease and treatment, and patient participation and assistance differs between caregivers and patients. A descriptive, cross-sectional study was conducted across five countries (Italy, United Kingdom, Spain, France and Germany) on a total of 510 participants who directly (patient) or indirectly (caregiver) faced a cancer diagnosis. Investigating this divergence could help to identify possible difficulties in patient–caregiver relationship, eventually improving patient empowerment.

A systematic evidence synthesis of interventions to engage children and young people in consultations about their long-term conditions

Children and young people with long-term conditions are not always provided with opportunities to engage fully in consultations. This systematic review examined the effectiveness or worth of methods used to engage children and young people with long-term conditions in their consultations. Searches were undertaken in October 2016 in eight databases and of the grey literature. Two reviewers independently screened the results, extracted data and assessed the quality of the studies using a validated and reliable checklist. A narrative synthesis of mixed method data was undertaken. Twelve studies were included in the review. Interventions used to engage children and young people mainly focused on face-to-face outpatient consultations, with an emphasis on diabetes and asthma. Most of the interventions focused on either improving health professionals' communication skills or encouraging children's and young people's engagement through providing condition-related information or a structured way to be included in consultations. Fewer interventions were child-led or directed towards developing children's and young people's skills to become key reporters of their condition. This review has demonstrated that interventions targeted at children and young people with long-term conditions can improve their levels of engagement in consultations. There is a need for more systematic development and robust evaluation of interventions to improve children's active participation in consultations.

Not "just" an intravenous line: Consumer perspectives on peripheral intravenous cannulation (PIVC). An international cross-sectional survey of 25 countries

Peripheral intravascular cannula/catheter (PIVC) insertion is a common invasive procedure, but PIVC failure before the end of therapy is unacceptably high. As PIVC failure disrupts treatment and reinsertion can be distressing for the patient, prevention of PIVC failure is an important patient outcome. Consumer participation in PIVC care to prevent failure is an untapped resource. This study aimed to understand consumers’ PIVC experience; establish aspects of PIVC insertion and care relevant to them; and to compare experiences of adult consumers to adult carers of a child. An international, web-based, cross-sectional survey was distributed via social media inviting adult consumers and adult carers of a child under 18 years who had experienced having a PIVC in the last five years (one survey each for adults and adult carers) to complete a 10-item survey. As such, sampling bias is a limitation and results should be carefully considered in light of this. There were 712 respondents from 25 countries, mainly female (87.1%) and adults (80%). A little over 50% of adults described insertion as moderately painful or worse, with level of insertion difficulty (0–10 scale) identified as moderate (median 4, IQR 1, 7). Adult carers reported significantly more pain during insertion and insertion difficulty (both p < 0.001). Rates of first insertion attempt failure were higher in children compared with adults (89/139 [64%] vs 221/554 [40%]; p < 0.001), and 23% of children required ≥ 4 attempts, compared with 9% of adults (p < 0.0001). Three themes from open-ended question emerged: Significance of safe and consistent PIVC care; Importance of staff training and competence; and Value of communication. The PIVC experience can be painful, stressful and frustrating for consumers. Priorities for clinicians and policy makers should include use of pain relief as standard practice to reduce the pain associated with PIVC insertion and developing strategies to increase first PIVC insertion attempt success particularly for children and older consumers.

A randomized controlled trial of a skills training for oncologists and a communication aid for patients to stimulate shared decision making about palliative systemic treatment (CHOICE): study protocol

BACKGROUND

Systemic treatment for advanced cancer offers uncertain and sometimes little benefit while the burden can be high. Hence, treatment decisions require Shared Decision Making (SDM). The CHOICE trial examines the separate and combined effect of oncologist training and a patient communication aid on SDM in consultations about palliative systemic treatment.

METHODS

A RCT design with four parallel arms will be adopted. Patients with metastatic or irresectable cancer with a median life expectancy <12 months who meet with a medical oncologist to discuss the start or continuation of palliative systemic treatment are eligible. A total of 24 oncologists (in training) and 192 patients will be recruited. The oncologist training consists of a reader, two group sessions (3.5 h; including modelling videos and role play), a booster feedback session (1 h) and a consultation room tool. The patient communication aid consists of a home-sent question prompt list and a value clarification exercise to prepare patients for SDM in the consultation. The control condition consists of care as usual. The primary outcome is observed SDM in audio-recorded consultations. Secondary outcomes include patient and oncologist evaluation of communication and decision-making, the decision made, quality of life, potential adverse outcomes such as anxiety and hopelessness, and consultation duration. Patients fill out questionnaires at baseline (T0), before (T1) and after the consultation (T2) and at 3 and 6 months (T3 and T4). All oncologists participate in two standardized patient assessments (before-after training) prior to the start of patient inclusion. They will fill out a questionnaire before and after these assessments, as well as after each of the recorded consultations in clinical practice.

DISCUSSION

The CHOICE trial will enable evidence-based choices regarding the investment in SDM interventions targeting either oncologists, patients or both in the advanced cancer setting. The trial takes into account the immediate effect of the interventions on observed communication, but also on more distal and potential adverse patient outcomes. Also, the trial provides evidence regarding the assumption that SDM about palliative cancer treatment results in less aggressive treatment and more quality of life in the final period of life.

TRIAL REGISTRATION

Netherlands Trial Registry number NTR5489 (prospective; 15 Sep 2015).

Partnering around cancer clinical trials (PACCT): study protocol for a randomized trial of a patient and physician communication intervention to increase minority accrual to prostate cancer clinical trials

BACKGROUND

Cancer clinical trials are essential for testing new treatments and represent state-of-the-art cancer treatment, but only a small percentage of patients ever enroll in a trial. Under-enrollment is an even greater problem among minorities, particularly African Americans, representing a racial/ethnic disparity in cancer care. One understudied cause is patient-physician communication, which is often of poor quality during clinical interactions between African-American patients and non-African-American physicians. Partnering Around Cancer Clinical Trials (PACCT) involves a transdisciplinary theoretical model proposing that patient and physician individual attitudes and beliefs and their interpersonal communication during racially discordant clinical interactions influence outcomes related to patients' decisions to participate in a trial. The overall goal of the study is to test a multilevel intervention designed to increase rates at which African-American and White men with prostate cancer make an informed decision to participate in a clinical trial.

METHODS/DESIGN

Data collection will occur at two NCI-designated comprehensive cancer centers. Participants include physicians who treat men with prostate cancer and their African-American and White patients who are potentially eligible for a clinical trial. The study uses two distinct research designs to evaluate the effects of two behavioral interventions, one focused on patients and the other on physicians. The primary goal is to increase the number of patients who decide to enroll in a trial; secondary goals include increasing rates of physician trial offers, improving the quality of patient-physician communication during video recorded clinical interactions in which trials may be discussed, improving patients' understanding of trials offered, and increasing the number of patients who actually enroll. Aims are to 1) determine the independent and combined effects of the two interventions on outcomes; 2) compare the effects of the interventions on African-American versus White men; and 3) examine the extent to which patient-physician communication mediates the effect of the interventions on the outcomes.

DISCUSSION

PACCT has the potential to identify ways to increase clinical trial rates in a diverse patient population. The research can also improve access to high quality clinical care for African American men bearing the disproportionate burden of disparities in prostate and other cancers.

TRIAL REGISTRATION

Clinical Trials.gov registration number: NCT02906241 (September 8, 2016).

Patient participation during oncological encounters: Barriers and need for supportive interventions experienced by elderly cancer patients

OBJECTIVE

To enhance patient participation during (oncological) encounters, this study aims to gain insight into communication barriers and supportive interventions experienced by elderly patients with cancer.

METHOD

A mixed method design, including both quantitative (secondary survey data analysis) and qualitative (interviews) methods Survey data were used to identify communication barriers and need for supportive interventions of elderly cancer patients, compared to younger patients. Next, interviews provided in-depth insight into elderly patients' experiences and underlying mechanisms.

RESULTS

A majority of the 70 participating elderly cancer patients (53%) felt confident in communicating and participating during medical encounters. However, 47% of patients experienced barriers to effectively communicate with their healthcare provider and felt the need for supportive interventions. The 14 interviewed patients mentioned barriers and facilitators related to attributes of themselves (e.g. feeling sick, self-efficacy), the provider (e.g. taking patient seriously) and the healthcare system (e.g. time constraints).

CONCLUSIONS

Although many elderly cancer patients feel confident, offering support to patients who feel less confident in communicating with their provider is recommended.

PRACTICE IMPLICATIONS

The outcomes of this study can be used as a first step for developing interventions for elderly cancer patients to overcome communication barriers, and help providers to facilitate this process.

ListeningTime; participatory development of a web-based preparatory communication tool for elderly cancer patients and their healthcare providers

OBJECTIVE

This paper outlines the participatory development process of a web-based preparatory communication tool for elderly cancer patients and their oncological healthcare providers (HCPs). This tool aims to support them to (better) prepare their encounters. An overarching aim of the project is to develop the tool in a participatory way to increase uptake and use.

METHODS

Scrum, a participatory framework originated from software development, was applied to develop the tool. Using constant feedback loops, elderly (former) cancer patients, oncological HCPs and their representatives were, as end-users, involved.

RESULTS

During six 'sprints', the communication tool 'ListeningTime' was developed with input from end-users. The use of scrum in developing an innovative tool was challenging in this context, because of time constraints of seriously-ill patients and busy HCPs and the co-creation involving non-profit scientific researchers and a for-profit development company.

CONCLUSIONS

The collaboration with end-users facilitated the development process of ListeningTime. Early involvement of end-users and flexibility in terms of planning and setup appear to be preconditions for creating a bottom-up inspired development procedure. Several challenges emerged from using scrum as participatory framework. Nevertheless, the 'pressure cooking situation', using scrum, resulted in a quick development process and a product ready for implementation.

PatientVOICE: Development of a Preparatory, Pre-Chemotherapy Online Communication Tool for Older Patients With Cancer

Background

Good communication around cancer treatment is essential in helping patients cope with their disease and related care, especially when this information is tailored to one’s needs. Despite its importance, communication is often complex, in particular in older patients (aged 65 years or older). In addition to the age-related deterioration in information and memory processing older patients experience, communication is also complicated by their required yet often unmet role of being an active, participatory patient. Older patients rarely express their informational needs and their contributions to consultations are often limited. Therefore, older patients with cancer need to be prepared to participate more actively in their care and treatment.

Objective

The objective of this paper was to report the development of PatientVOICE, an online, preparatory tool with audio facility aimed to enhance the participation of older patients during educational nursing encounters preceding chemotherapy and to improve their information recall.

Methods

PatientVOICE was developed by applying the following 6 steps of the intervention mapping framework that involved both patients and nurses: (1) needs assessment, (2) specifying determinants and change objectives, (3) reviewing and selecting theoretical methods and practical strategies, (4) developing intervention components, (5) designing adoption and implementation, and (6) making an evaluation plan.

Results

A careful execution of these consecutive steps resulted in the ready-to-use preparatory website. PatientVOICE provides pre-visit information about chemotherapy (ie, medical information, side effects, and recommendations of dealing with side effects), information about the educational nursing visit preceding chemotherapy (ie, aim, structure, and recommendations for preparation), techniques to improve patients’ communication skills using a question prompt sheet (QPS) and video-modeling examples showing “best practices”, and the opportunity to upload and listen back to an audio recording of a patient’s own nursing visit.

Conclusions

The development process resulted in PatientVOICE, a multi-component online intervention targeted to older patients with cancer. PatientVOICE contains information about the treatment as well as information about the role of the patient during treatment. Using different methods (QPS and audio facility), we hope to support these patients during their treatment. In the future, the utility and usability of this complex intervention will be evaluated in a group of older patients who receive or have received chemotherapy.

Does patient coaching make a difference in patient-physician communication during specialist consultations? A systematic review

OBJECTIVE

To systematically review the literature on the effectiveness of a patient coach intervention on patient - physician communication in specialists consultations.

METHODS

PubMed, Cochrane, PsycInfo, Cinahl and Embase were searched until November 2015. Included were papers describing interventions directed at adult outpatients in secondary care with a variety of somatic diseases. Outcomes had to be measured in communication effectivity from a patient's perspective.

RESULTS

Seventeen publications met the inclusion criteria (involving 3787 patients), describing 13 unique interventions. Most interventions were single one-on-one sessions taking between 20 and 40min before consultation. Research quality in ten studies was high. These studies showed significant improvement on immediate, intermediate and long term patient - physician communication.

CONCLUSION

We found limited evidence suggesting an improvement of patient - physician communication by having multiple patient coaching encounters during which questions are prepared and rehearsed and consultations are evaluated and reflected upon, sometimes supported by audio recording the consultation.

PRACTICE IMPLICATIONS

The results of this review contribute to the (re-)design of an effective model for patient coaching, a profile and training approach of patient coaches. Future research should aim at determining which patients will benefit most from coaching interventions.

Randomized trial of a question prompt list to increase patient active participation during interactions with black patients and their oncologists

OBJECTIVE

Communication during racially-discordant interactions is often of poor quality and may contribute to racial treatment disparities. We evaluated an intervention designed to increase patient active participation and other communication-related outcomes during interactions between Black patients and non-Black oncologists.

METHODS

Participants were 18 non-Black medical oncologists and 114 Black patients at two cancer hospitals in Detroit, Michigan, USA. Before a clinic visit to discuss treatment, patients were randomly assigned to usual care or to one of two question prompt list (QPL) formats: booklet (QPL-Only), or booklet and communication coach (QPL-plus-Coach). Patient-oncologist interactions were video recorded. Patients reported perceptions of the intervention, oncologist communication, role in treatment decisions, and trust in the oncologist. Observers assessed interaction length, patient active participation, and oncologist communication.

RESULTS

The intervention was viewed positively and did not increase interaction length. The QPL-only format increased patient active participation; the QPL-plus-Coach format decreased patient perceptions of oncologist communication. No other significant effects were found.

CONCLUSION

This QPL booklet is acceptable and increases patient active participation in racially-discordant oncology interactions. Future research should investigate whether adding physician-focused interventions might improve other outcomes.

PRACTICE IMPLICATIONS

This QPL booklet is acceptable and can improve patient active participation in racially-discordant oncology interactions.

Development and feasibility of a web-based question prompt sheet to support information provision of health-related quality of life topics after oesophageal cancer surgery

We developed a web-based question prompt sheet (QPS) to support information provision of health-related quality of life (HRQL) topics after oesophageal cancer surgery. The QPS was evaluated and updated in three consecutive studies. In Study 1, eight patients were guided in using the QPS. Feasibility was assessed by cognitive walkthrough, questionnaire and interview. We obtained 430 notes (217 negative, 213 positive) of patients' actions and or remarks, and 91 suggestions. With minor support, most patients were able to use the QPS. In Study 2, forty patients independently used and appraised a modified version of the QPS by questionnaire. All patients deemed the QPS to be usable and useful. In Study 3, 21 patients and three surgeons used the QPS in clinical practice. Clinical feasibility was assessed by the number of QPS sent to the researcher/surgeon. Patients and surgeons were surveyed and the follow-up consultation was audio-recorded. Surgeons were additionally interviewed. Twenty/fourteen patients sent their QPS to the researcher/surgeon. Five QPSs were read by the consultation surgeon. Patients considered the QPS usable and useful. Surgeons considered the QPS of added value and helpful in informing patients, but currently not clinically feasible due to increased consultation time.

Barriers to Clinical Trial Enrollment in Racial and Ethnic Minority Patients With Cancer

BACKGROUND

Clinical trials that study cancer are essential for testing the safety and effectiveness of promising treatments, but most people with cancer never enroll in a clinical trial - a challenge exemplified in racial and ethnic minorities. Underenrollment of racial and ethnic minorities reduces the generalizability of research findings and represents a disparity in access to high-quality health care.

METHODS

Using a multilevel model as a framework, potential barriers to trial enrollment of racial and ethnic minorities were identified at system, individual, and interpersonal levels. Exactly how each level directly or indirectly contributes to doctor-patient communication was also reviewed. Selected examples of implemented interventions are included to help address these barriers. We then propose our own evidence-based intervention addressing barriers at the individual and interpersonal levels.

RESULTS

Barriers to enrolling a diverse population of patients in clinical trials are complex and multilevel. Interventions focused at each level have been relatively successful, but multilevel interventions have the greatest potential for success.

CONCLUSION

To increase the enrollment of racial and ethnic minorities in clinical trials, future interventions should address barriers at multiple levels.

Communication during haematological consultations; patients' preferences and professionals' performances

Many patients with haematological malignancies experience barriers in clinical communication. Reaching effective communication is of great importance as it has been linked to a range of improved patient outcomes such as satisfaction, compliance to treatment, perceived quality of life and physical and mental health. To get a better understanding how communication in haematological consultations can be improved, the current study focussed on patients' preferences and perceived performances regarding the communicative behaviour of their health care professional. Secondly, the mediation of an online communication tool for patients was analysed. Within a controlled pre- post-test design, 78 datasets of clinical consultations could be analysed. Patients considered both affective and instrumental communication aspects important. The affective communication behaviour of the health care professional met the patients' pre-visit preferences well. In the information exchange, more variability and discrepancies were found. Overall, the online intervention did not seem to influence the patients' perceived communication performance of their health care professional much. To further improve the communication during clinical consultations, health care professionals should inquire about patients' expectations, especially during the exchange of information and advices. At the same time, patients should be supported to express their preferences at the start of the consultation. The study was registered in the Netherlands Trial Register, number 3779.

Patient-defined goals for the treatment of severe aortic stenosis: a qualitative analysis

Background

Patients with severe aortic stenosis (AS) at high risk for aortic valve replacement are a unique population with multiple treatment options, including medical therapy, surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR). Traditionally, in elderly populations, goals of treatment may favour quality of life over survival. Professional guidelines recommend that clinicians engage patients in shared decision making, a process that may lead to decisions more aligned with patient‐defined goals of care. Goals of care for high‐risk patients with AS are not well defined in the literature, and patient‐reported barriers to shared decision making highlight the need for explicit encouragement from clinicians for patient involvement.

Objective

The purpose of this study was to elicit and report patient‐defined goals from elderly patients facing treatment decisions for severe AS.

Methods

This analysis was conducted at Dartmouth‐Hitchcock Medical Center, an academic medical institution. In a retrospective manner, we qualitatively analysed goal statements reported by high‐risk, elderly patients with severe AS evaluated for TAVR between June 2012 and August 2014.

Results

Forty‐six patients provided treatment goals during consideration of TAVR and defined preferred outcomes as maintaining independence, staying alive, reducing symptoms or, most commonly, increasing their ability to do a specific activity or hobby.

Conclusions

In the high‐risk patient population considering TAVR, patient‐reported goals may be obtained with a simple question delivered during the clinical encounter. Encouraging patients to define their goals may lead to a greater degree of shared decision making, as advocated in current professional guidelines.

Patient agenda setting in respiratory outpatients: A randomized controlled trial

Soliciting a patient's agenda (the reason for their visit, concerns and expectations) is fundamental to health care but if not done effectively outcomes can be adversely affected. Forms to help patients consider important issues prior to a consultation have been tested with mixed results. We hypothesized that using an agenda form would impact the extent to which patients felt their doctor discussed the issues that were important to them. Patients were randomized to receive an agenda form to complete whilst waiting or usual care. The primary outcome measure was the proportion of patients agreeing with the statement 'My doctor discussed the issues that were important to me' rated on a four-point scale. Secondary outcomes included other experience and satisfaction measures, consultation duration and patient confidence. There was no significant effect of agenda form use on primary or secondary outcomes. Post hoc exploratory analyses suggested possible differential effects for new compared to follow-up patients. There was no overall benefit from the form and a risk of detrimental impact on patient experience for some patients. There is a need for greater understanding of what works for whom in supporting patients to get the most from their consultation.

Question Prompt Lists in health consultations: A review

OBJECTIVES

This review examines the use and effectiveness of Question Prompt Lists (QPL) as communication aids to enhance patient question asking, information provision to patients and patient participation in health and medical consultations.

METHODS

A systematic search was undertaken to identify relevant literature concerning QPLs including academic databases, Google-based and snowball searching. Forty-two relevant studies reporting 50 interventions were identified.

RESULTS

Although findings varied there was some evidence that a QPL endorsed by the physician increased total question asking. Using a QPL increased question asking concerning specific content areas (e.g. prognosis). There was some evidence that physicians provided more information during consultations. There were no consistent findings concerning effects on patient knowledge recall, anxiety and satisfaction or consultation time. Some interventions that increased question asking had longer consultation times.

CONCLUSION

There is evidence that an appropriate QPL, endorsed by the physician and provided immediately before the consultation, may increase patient question asking and lead to more information being provided by the physician.

PRACTICE IMPLICATIONS

There is increasing evidence to support QPL use in routine practice. Further trials might address the issues identified including an assessment of QPL optimal length and QPL adaptation for cultural and special needs groups.

Follow-up effects of a tailored pre-counseling website with question prompt in breast cancer genetic counseling

OBJECTIVE

Pre-counseling education helps counselees to prepare for breast cancer genetic counseling and might subsequently result in more positive experiences, improved cognitive outcomes and more experienced control. This study assessed the effects of a website with tailored information and a blank sheet to fill in questions (question prompt; QP), at 1 week and 1 year post-counseling.

METHODS

Consecutive counselees were randomized to the usual care group (UC) or the intervention group (UC+website+QP). Counselees completed questionnaires pre- and post-counseling and 1 year follow-up. We conducted multilevel regression analyses corrected for time.

RESULTS

Intervention group counselees (n = 103) were more satisfied about their final visit (β = .35; CI: .06-.65; P = .02; n = 156) than UC group counselees (n = 94). Intervention group counselees also reported more positive experiences with the counseling (β = .32; CI: .06-.59; P = .02; n = 188) and higher perceived personal control 1 year post-counseling (β = .51; CI: .18-.84; P = .002; n = 193). No significant effects were found on recall, knowledge, anxiety, cancer worry, risk perception alignment and adherence to breast surveillance advice.

CONCLUSION

This study shows that pre-counseling education providing tailored information and QP, might lead to improvements in experiences with the counseling and perceived personal control 1 year post-counseling.

PRACTICE IMPLICATIONS

Online pre-visit information is a feasible tool to enhance counselees' experiences.

Active patient participation in the development of an online intervention

Background

An important and challenging part of living with cancer relates to the repeated visits to the hospital. Since how patients cope between these post-diagnostic visits depends partly on the information and support received from their physician during the visits, it is important to make the most of them. Recent findings reinforce the importance of training not only the health care professionals in communication skills, but providing patients with support in communication as well. Delivering such supportive interventions online can have potential benefits in terms of accessibility, cost-effectiveness, and ability to tailor information to personal needs. However, problems with attrition (dropout, non-usage) during the test phase and poor uptake after implementation are frequently reported. The marginal level of engagement of the patient as end user seems to play a role in this. Therefore, recent research suggests integrating theory-based development methods with methods that promote involvement of the patient at an early stage. This paper describes a participatory protocol, used to let patients guide a theory-informed development process.

Objective

The objective of this project was to apply a bottom-up inspired procedure to develop a patient-centered intervention with corresponding evaluation and implementation plan.

Methods

The applied development protocol was based on the intervention mapping framework, combined with patient participatory methods that were inspired by the participation ladder and user-centred design methods.

Results

The applied protocol led to a self-directed online communication intervention aimed at helping patients gain control during their communications with health care professionals. It also led to an evaluation plan and an implementation plan. The protocol enabled the continuous involvement of patient research partners and the partial involvement of patient service users, which led to valuable insights and improvements.

Conclusions

The applied protocol realized patient participation on different levels throughout the entire project. Early involvement, involvement on different levels, and flexibility in terms of planning and setup seem to be preconditions to creating a bottom-up inspired development procedure with (seriously ill) patients. Further research is necessary to find out if a more patient-centered approach improves the implementation and uptake of eHealth interventions.

Trial Registration

Netherlands National Trial Register ID number: NTR3779; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3779 (Archived by WebCite at http://www.webcitation.org/6TdfALKxV).

Advanced cancer patients' and caregivers' use of a Question Prompt List

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.

Participation of chronic patients in medical consultations: patients' perceived efficacy, barriers and interest in support

AIMS

Chronic patients are increasingly expected to participate actively in medical consultations. This study examined (i) patients' perceived efficacy and barriers to participation in consultations, (ii) patients' interest in communication support and (iii) correlates of perceived efficacy and barriers, with an emphasis on differences across providers' disciplines.

METHODS

A representative panel of chronic patients (n = 1314) filled out the short Perceived Efficacy in Patient-Provider Interaction scale and were questioned about barriers to participation and interest in communication support. Potential correlates included socio-demographic (age, sex, education, living situation), clinical (discipline care provider, type of illness, comorbidity, illness duration, functional disabilities, health consultations in last year) and personal characteristics (information preference, health literacy, level of general patient activation).

RESULTS

Most patients felt efficacious in consultations, although 46% reported barriers to participation and 39% had an interest in support. Barriers most frequently recognized were 'not wanting to be bothersome', 'perception there is too little time' and 'remembering subjects only afterwards'. Patients most frequently endorsed relatively simple support. Patients perceived the least barriers and were least likely to endorse support when seeing a nurse. In multivariate models, consistent risk factors for low efficacy and perceived barriers were low health literacy and a low general patient activation.

CONCLUSIONS

Many chronically ill patients feel confident in medical interactions. Still, a significant number might benefit from support. Often this concerned more generally vulnerable patients, that is, the low literate and generally less activated. Relatively simple supportive interventions are likely to be endorsed and might overcome frequent barriers.

How can we explain physician accuracy in assessing patient distress? A multilevel analysis in patients with advanced cancer

OBJECTIVE

To examine the determinants of the accuracy with which physicians assess metastatic cancer patient distress, also referred to as their empathic accuracy (EA). Hypothesized determinants were physician empathic attitude, self-efficacy in empathic skills, physician-perceived rapport with the patient, patient distress and patient expressive suppression.

METHODS

Twenty-eight physicians assessed their patients' distress level on the distress thermometer, while patients (N=201) independently rated their distress level on the same tool. EA was the difference between both scores in absolute value. Hypothesized determinants were assessed using self-reported questionnaires. Multilevel analyses were carried out.

RESULTS

Little of the variance in EA was explained by physician variables. EA was higher with higher levels of patient distress. Physician-perceived quality of rapport was positively associated with EA. However, for highly distressed patients, good rapport was associated with lower EA. Patient expressive suppression was also related to lower EA.

CONCLUSION

This study adds to the understanding of EA in oncological settings, particularly in challenging the common assumption that EA depends largely on physician characteristics or that better rapport would always favor higher EA.

PRACTICE IMPLICATIONS

Physicians should ask patients for feedback regarding their emotions. In parallel, patients should be prompted to express their concerns.

Development of a question prompt list as a communication intervention to reduce racial disparities in cancer treatment

Racial disparities have been found in the use of chemotherapy as cancer treatment. These disparities may be, in part, due to well-documented differences in the quality of communication during clinical interactions with oncologists and Black versus White patients. In this study using a community-based participatory research approach, academic researchers, community members, and oncologists formed a partnership to develop a communication intervention to address racial disparities in cancer care. Partners developed a question prompt list (QPL), a simple tool that can be used to improve communication, and thus treatment, during clinical interactions in which oncologists and Black patients discuss chemotherapy. Partners endorsed the use of a QPL, provided specific suggestions for content and format, conducted and analyzed qualitative interviews with Black patients receiving chemotherapy, and approved the final version. The feasibility and effectiveness of the QPL that resulted from this research process are currently under evaluation in a separate study.