Evaluation of a blended-learning training concept to train oncology physicians to advise their patients about complementary and integrative medicine (KOKON-KTO): study protocol for a prospective, multi-center, cluster-randomized trial

Effects of training oncology physicians advising patients on complementary and integrative therapies on patient-reported outcomes: 2-year follow-up of the multi-center, cluster-randomized KOKON-KTO study

PURPOSE

Many cancer patients wish for complementary and integrative medicine (CIM) consultations led by their oncology physician. Within the KOKON-KTO study, oncology physicians in the intervention group were trained in a blended learning to provide CIM consultations to their cancer patients in addition to distributing a leaflet about CIM websites. Control oncology physicians only distributed the leaflet. The training showed positive effects on the patient-level. As of now, no consistent evidence exists on the long-term effects of such one-time-only CIM consultation during cancer treatment.

METHODS

In the KOKON-KTO follow-up study, cancer patients previously participating in the KOKON-KTO study (intervention group:IG and control group: CG) received, at least 24 months later, a follow-up questionnaire by post, evaluating long-term effects of the KOKON-KTO consultation using the measures provided in the original study (patient-physician communication (EORTC-QLQ-COMU2), satisfaction with cancer treatment (PS-CaTE), CIM disclosure with healthcare provider (HCP), and need for CIM consultation during cancer therapy).

RESULTS

In total, 102 cancer patients participated in the follow-up study (IG n = 62; CG n = 40). The overall reponse rate was around 36% (IG: 48.4%; CG: 23.7%). In the follow-up study, differences between groups had increased and were still shown (EORTC-QLQ-COMU26, 0-100 point scale, ≥10-point-group difference) in some subscales: patient's active behavior (in means; IG:73.6 (95% CI, 63.8-83.5); CG:61.1 (95% CI, 52.4-69.8)); clinician-patient relationship (IG:80.9 (95% CI, 71.8-90.0); CG:68.7 (95% CI, 59.3-78.0)). For some outcomes, differences decreased over time (e.g., EORTC-QLQ-COMU26 subscales "takes into account patient's preference" and "corrects misunderstandings"). More patients in the CG used CIM without oncology physicians' knowledge (IG: 13.7%, CG: 24.0%).

CONCLUSION

This study presents first findings that one-time-only CIM consultations may enhance patient-physican relationship and CIM disclosure long-term. To further support cancer patients' in their wish for CIM consultations, training programs should provide oncology physicians with CIM competencies for different cancer stages including cancer survivors.

Effects of blended learning training for oncology physicians to advise their patients about complementary and integrative therapies: results from the multicenter cluster-randomized KOKON-KTO trial

BACKGROUND

Many oncology physicians are confronted with the topic of complementary and integrative medicine (CIM) by cancer patients. This study examined whether a blended learning (e-learning and a workshop) to train oncology physicians in providing advice on CIM therapies to their cancer patients, in addition to distributing an information leaflet about reputable CIM websites, had different effects on physician-reported outcomes in regard to consultations compared with only distributing the leaflet.

METHODS

In a multicenter, cluster-randomized trial, 48 oncology physicians were randomly allocated to an intervention group (CIM consultation and an information leaflet) or a control group (information leaflet only). After the training, the oncology physicians conducted 297 consultations with their cancer patients. Measurements were assessed at oncology physician, physician-patient-interaction (measured by external reviewers), and patient levels. This analysis focused on the physician outcomes of stress reaction and perceived consultation skill competency. In addition, qualitative interviews were conducted with a subsample of oncology physicians who experienced both, the intervention and control condition.

RESULTS

The oncology physicians in the intervention group showed a lower stress reaction in all measured dimensions after CIM consultations than those in the control group. There was no significant difference between oncology physicians in the intervention and control groups regarding the perceived consultation skill competency (overburden: intervention 1.4 [95% CI: 0.7;2.1]; control 2.1 [95% CI: 1.4;2.7], tension: 1.3 [95% CI: 0.7;2.0] vs. 1.9 [95% CI: 1.3;2.5], and discomfort with consultation situations: 1.0 [95% CI: 0.4;1.7]; vs. 1.7 [95% CI: 1.2;2.3]). The qualitative data showed that only providing the leaflet seemed impersonal to oncology physicians, while the training made them feel well prepared to conduct a full conversation about CIM and provide the information leaflet.

CONCLUSIONS

In our exploratory study providing structured CIM consultations showed positive effects on the perceived stress of oncology physicians, and the training was subjectively experienced as an approach that improved physician preparation for advising cancer patients about CIM, however no effects regarding perceived consultation skill competency were found.

TRIAL REGISTRATION

The trial registration number of the KOKON-KTO study is DRKS00012704 in the German Clinical Trials Register (Date of registration: 28.08.2017).

Development, Implementation, and Evaluation of an e-Learning in Integrative Oncology for Physicians and Students Involving Experts and Learners: Experiences and Recommendations

In this project, an e-Learning program for complementary and integrative medicine in oncology was systematically developed, implemented, and evaluated in a stepwise procedure. Learning objectives and content were defined within the KOKON project network, considering the educational competencies for integrative oncology. To design a valuable e-Learning, experts were involved in all relevant steps of the process, as well as stakeholders from various target groups (undergraduates: medicine students, postgraduates: oncology physicians). We used mixed methods including quantitative surveys, progress tests, and qualitative focus groups. The developed e-Learning program led to a significant measurable knowledge gain about complementary and integrative medicine. In parallel, physicians and students were subjectively satisfied with the training. For the majority of e-Learning elements, the needs of both target groups are comparable. Furthermore, both groups emphasized the value of formative assessment tools for gaining knowledge. From the various surveys and experiences collected in this project, we derive recommendations for others developing e-Learning programs.

Development and Implementation of Situational Judgment Tests as an Evaluation Method for Training Oncology Physicians: Application in the KOKON-KTO Training

Situational judgment tests (SJTs) are often used in aptitude testing and present practice-specific challenges. Their implementation into online training programs provides the opportunity to assess learning progress and improve training quality. In this study, text-based SJTs for oncology physicians were developed, validated, and implemented into the KOKON-KTO training which uses a blended learning training format to teach oncology physicians how to consult cancer patients on complementary and integrative medicine (CIM). The SJT was implemented to measure the e-learning results. In the development and validation phase, a total of 15 SJTs (each SJT including 1 best choice answer based on training content and 4 distractors; 9 SJTs for oncologists and 6 SJTs for oncology gynecologists only) were developed by an interprofessional team (n=5) using real-case vignettes and applying an in-depth review process. Best answers were validated by experts (oncologists and oncology gynecologists) with experience in advising cancer patients on CIM. In the implementation and evaluation phase, SJTs were answered by KOKON-KTO training participants (n=19) pre- and post e-learning. Results were analyzed using descriptive measurements, item difficulties, and Cohen's d for effect size pre- and post-training. The experts (n=12, 49.8% gynecologists) agreed with best choice answers (69.4% for oncology gynecology; 81.5% for oncology) in 12 out of 15 SJTs. Comparing pre- and post-training scores, KOKON-KTO training participants were able to improve knowledge substantially (effect sizes for oncologists d=1.7; oncology gynecologists d= .71). Future studies need to increase the number of experts and SJTs in order to apply further psychometric measurements. As part of the KOKON-KTO study, this project is registered as DRKS00012704 on the "German Clinical Trials Register" (Date of registration: 28.08.2017).

A systematic review of communication about Complementary and Integrative Health (CIH) in global biomedical settings

OBJECTIVES

A systematic review to analyze communication rates of complementary and integrative health (CIH) and analyze how communication terms, such as "disclosure," are measured and operationalized.

METHODS

We searched seven databases for studies published between 2010 and 2018 with quantitative measurements of patients' communication of CIH to a biomedical clinician. We analyzed communication terms used to describe patients reporting CIH usage. We also examined the conceptual and operational definitions of CIH provided and whether those terms were explicitly operationalized. We aggregated the percentage, rate, or ratio of CIH users that communicated about CIH with their clinicians by disease type and geographical region.

RESULTS

7882 studies were screened and 89 included in the review. Studies used a wide range of conceptual and operational definitions for CIH, as well as 23 different terms to report communication related to reporting CIH usage. Usage varied by disease type and geographical region.

CONCLUSIONS

Studies of CIH and CIH communication may measure different kinds of social and communicative phenomena, which makes comparison across international studies challenging.

PRACTICE IMPLICATIONS

Future studies should employ standardized, replicable measures for defining CIH and for reporting CIH communication. Clinicians can incorporate questions about prior, current, and future CIH use during the medical visit.

Effects of training oncology physicians advising patients on complementary and integrative therapies on patient-reported outcomes: A multicenter, cluster-randomized trial

BACKGROUND

Many patients with cancer do not disclose complementary medicine use but want their physician's advice on this matter. This study evaluated whether using blended learning (e-learning plus a workshop) to train oncology physicians in providing advice on complementary and integrative medicine (CIM) therapies to their patients with cancer, in addition to distributing an information leaflet on reputable CIM websites, had different effects on patient-reported outcomes for the consultation than only distributing the leaflet.

METHODS

In this multicenter, cluster-randomized trial, patients from private practices/hospital departments, recruited by 48 oncology physicians randomly allocated to an intervention group (CIM consultation plus information leaflet) or a control group (information leaflet), received CIM information. Patient-reported outcomes included satisfaction (Patient Satisfaction With Information on Cancer Treatment), readiness to make a decision (Preparation for Decision Making), and physician-patient communication (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire and Communication 26 [EORTC QLQ-COMU26]) for the consultation. Qualitative interviews were conducted with a physician subsample.

RESULTS

A total of 291 patients (128 in the intervention group and 169 in the control group) advised by 41 physicians participated. Patients in the intervention group rated physician-patient communication higher on all EORTC QLQ-COMU26 scales (mean total score, 84.3 [95% CI, 79.5-89.2] vs 73.6 [95% CI, 69.3-78.0]; P = .002), were more satisfied with the advice (mean, 4.2 [95% CI, 4.0-4.4] vs 3.7 [95% CI, 3.5-3.8]; P < .001), and were readier to make a decision (mean, 63.5 [95% CI, 57.4-69.6] vs 53.2 [95% CI, 47.8-58.7]; P = .016) than the control group. Physicians who reported patients in both settings seemed satisfied with the advice given.

CONCLUSIONS

This study evaluated a novel education intervention for training oncology physicians in providing CIM advice in routine care. Providing structured CIM consultations had positive effects on patient satisfaction, readiness to make decisions, and physician-patient communication.

Dietary supplement use in ambulatory cancer patients: a survey on prevalence, motivation and attitudes

PURPOSE

Patients with cancer often believe dietary supplements (DS) such as micronutrients and botanical products to be health supporting and non-toxic despite growing concerns regarding potential pharmacological interactions. Studies on the prevalence of DS use among patients with cancer are heterogeneous and mainly conducted at university-based cancer centers. This survey focused on a particular cancer patient group treated in an ambulatory setting without regular access to professional nutritional counselling.

METHODS

Patients with a history of cancer or hematological malignancy were included in this survey. A self-reported questionnaire was used to evaluate the different aspects of DS use, changes in dietary habits and patients' demographic characteristics.

RESULTS

Almost every second patient reported using DS (47.2%). Women (56.3%), patients with an academic degree (56.0%) and non-smokers (84.8%) were more inclined to use DS. Along with magnesium (16.6%), calcium (14.3%), multivitamins (12.0%) and vitamin C (9.4%), use of herbal supplements (12.6%) was common. Women (84.8% vs. 74.9% of men, p =  < 0.001) and patients younger than 65 years (84.4% vs. 77.2% of patients > 65 y, p =  0.002) sought dietary advice more often. Support of the immune system was the main reason for DS use (26.4%) and a relevant number of patients (49.6%) reported to have changed their dietary habits following cancer diagnosis.

CONCLUSION

DS use is common among patients with cancer treated in an ambulatory setting. This finding should encourage oncologists to implement detailed questioning about DS use and dietary habits to prevent potential interactions and offer substantial advice.

Defining Criteria for Guiding Cancer Patients to Find a Reputable Complementary Medicine Provider: Results of a Literature Review and a Consensus Procedure

PURPOSE

Even in cases of positive evidence for complementary medicine (CM) therapies, it is still difficult for cancer patients to identify reputable providers. The aim of this study was to develop and evaluate a criteria list to provide guidance to cancer patients seeking a reputable CM provider.

METHODS

The design combined a literature review, an expert consensus procedure (n=15) and an assessment from three stakeholder perspectives (patients (n=18), CM providers (n=26) and oncology physicians (n=20)).

RESULTS

A total of 30 existing CM criteria were extracted from the literature, and 12 more were added by the experts. The main challenge was to define criteria that could easily be applied by the patients. A final comprehensive list of 8 criteria guiding cancer patients to find a reputable CM provider was developed.

CONCLUSION

Health professionals and cancer information services might find the criteria list helpful when aiming to strengthen patients' awareness of quality-related factors associated with CM providers. The criteria developed might be helpful when standards are established for quality assurance in CM in oncology.

KOKON: A Germany-Wide Collaborative Research Project to Identify Needs, Provide Information, Foster Communication and Support Decision-Making about Complementary and Alternative Medicine in Oncology

BACKGROUND

The German Cancer Aid set up a priority research programme with the intention to generate high-quality information based on evidence and to make this information easily accessible for health-care professionals and advisors, researchers, patients, and the general public.

SUMMARY

The Kompetenznetz Komplementärmedizin in der Onkologie (KOKON) received 2 funding periods within this programme. During the first funding period, KOKON assessed patients' and health-care professionals' informational needs, developed a consulting manual for physicians, developed an education programme for self-help groups, set up a knowledge database, and developed a pilot information website for patients. Funding period 2 continues with work that allows cancer patients and health-care professionals to make informed decisions about complementary and alternative medicine (CAM). For this aim, KOKON evaluates training programmes for physicians (oncology physicians, paediatric oncologists, and general practitioners) and for self-help groups. All training programmes integrate results from an analysis of the ethical, psychological, and medical challenges of CAM in the medical encounter, and the knowledge database is being extended with issues related to CAM for supportive and palliative care. Key Message: A Germany-wide collaborative research project to identify needs, provide information, foster communication, and support decision-making about CAM in oncology is being set up.