Effects of medical graphic narratives (patient comic) on Patient Reported Outcome Measures (PROMs) in patients undergoing coronary angiography and PCI

Background/Introduction

Increasing evidence suggests that patients scheduled for invasive cardiac procedures such as coronary angiography / PCI feel insufficiently informed about the planned procedure.

Purpose

To improve the Patient Informed Consent (IC) before coronary angiography by using “medical graphic narratives” (patient comic) that illustrate central IC-related aspects in a simple and understandable manner.

Methods

A patient comic illustrating central steps of the procedure, risks, treatment alternatives and behavioural measures was created in collaboration with professional scientific visual communicators. In a randomised, controlled, prospective trial, we included 121 patients undergoing coronary angiography/PCI. Patients were randomised to a group that was informed about the procedure using the usual Patient IC approach (official consent form and conversation with physician; Control group) or a group that additionally obtained a patient comic for reading (graphic illustrations of central IC aspects based on the official consent form; Comic group). Patient Reported Outcome Measures (PROMs), i.e. satisfaction with and perceived quality of the patient IC, were tested in both groups comparing single items of the Client Satisfaction Questionnaire-8 (CSQ-8) and self-designed single items in both IC groups. Differences were compared using the Fisher's exact test. A p-value <0.05 was considered statistically significant.

Results

PROMs showed significant benefits in favour of the Comic group: Quality of the patient IC was perceived to be “very good” in 45.0% of the Comic group compared to 24.9% of patients in the Control group (p=0.023). Only 23.0% of the patients in the Control group, compared to 40.0% in the Comic group, stated that the IC procedure completely met their expectations (p=0.012). 57.4% in the Control group and 76.7% in the Comic group stated that all of their questions were satisfactorily adressed before the procedure (p=0.015). 43.3% in the Comic group, in contrast to 18.0% in the Control group, declared to feel “very satisfied” with the obtained IC procedure (p=0.002). The acceptance of the patient comic was very high: no patient (0%) expressed feelings of not being taken seriously by reading the patient comic.

Conclusions

Our data confirm pronounced limitations of the usual Patient IC practice before coronary angiography. The use of a patient comic that narratively illustrates central steps of the procedure positively impacts on patient-centered endpoints and significantly improves the patient IC procedure.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Friede Springer Herz Stiftung

[Gender (role) aspects in doctor-patient communication]

Aspects of gender and gender roles are important factors influencing the interactions between physicians and their patients. On the one hand, gender roles have an impact on the behavior of the patients, such as in health care utilization or use of preventive examinations. On the other hand, gender issues influence doctors' actions with respect to communication, diagnosis, and treatment. Here, a gender bias may lead to misdiagnosis and inadequate treatment. In this paper certain pertinent aspects of gender roles in the doctor-patient relationship are discussed and illustrated by empirical findings.

Gender-specific predictors of early mortality after coronary artery bypass graft surgery

BACKGROUND

Female gender is a risk factor for early mortality after coronary artery bypass graft surgery (CABG). Yet, the causes for this excess mortality in women have not been fully explained.

OBJECTIVES

To analyse gender differences in early mortality (30 days post surgery) after CABG and to identify variables explaining the association between female gender and excess mortality, taking into account preoperative clinical and psychosocial, surgical and postoperative risk factors.

METHODS

A total of 1,559 consecutive patients admitted to the German Heart Institute Berlin (2005-2008) for CABG were included in this prospective study. A comprehensive set of prespecified preoperative, surgical and postoperative risk factors were examined for their ability to explain the gender difference in early mortality.

RESULTS

Early mortality after CABG was higher in women than in men (6.9 vs. 2.4 %, HR 2.91, 95 % CI 1.70-4.96, P < 0.001). Women were older than men (+4.7 years, P < 0.001), had lower self-assessed preoperative physical functioning (-16 points on a scale from 0 to 100, P < 0.001), and had higher rates of postoperative low cardiac output syndromes (6.6 vs. 3.3 %, P = 0.01), respiratory insufficiency (9.4 vs. 5.3 %, P = 0.006) and resuscitation (5.2 vs. 1.8 %, P = 0.001). The combination of these factors explained 71 % of the gender difference in early mortality; age and physical functioning alone accounted for 61 %. Adjusting for these variables, HR for female gender was 1.36 (95 % CI 0.77-2.41, P = 0.29).

CONCLUSIONS

Age, physical function and postoperative complications are key mediators of the overmortality of women after aortocoronary bypass surgery. Self-assessed physical functioning should be more seriously considered in preoperative risk assessment particularly in women.

Pre-operative renal arterial embolisation does not provide survival benefit in patients with radical nephrectomy for renal cell carcinoma

Currently, there is no widespread use of percutaneous renal artery embolisation (PRAE) as a pre-operative treatment in the management of renal cell carcinoma (RCC). There is also a scarcity of studies concerning the potential benefits of this procedure. All patients with RCC who underwent pre-operative PRAE before nephrectomy (n = 227) and all patients solely undergoing surgery (n = 607) at our institution from 1992 to 2006 were included. Information on techniques used, perioperative transfusion requirements, pathological and clinical variables, acute toxicity and complications were obtained from a retrospective review of medical records. Propensity modelling techniques were used to compare cancer-specific survival (CSS) and overall survival (OS) in both groups. Propensity scores were calculated from a logistic matching model including age, gender, clinical tumour size, grading, pN stage, cM stage, pT stage, histology and microvascular invasion. This resulted in 189 matches. The mean follow-up of the entire group of matched patients was 81 months. The 5-year actuarial CSS and OS for the total group of matched patients was 80.8% and 73.9%, respectively. CSS and OS did not show any significant differences between the matched treatment groups. There were no statistical differences in surgical complications between all patients treated with pre-operative PRAE (n = 227) and all patients without PRAE (n = 607), except for blood transfusion (61% vs 24%; p<0.01). Symptoms of post-embolization syndrome, including lumbar pain, fever, nausea, hypertension and macroscopic haematuria, were reported by 202 patients (89%), in most cases being mild and self-limited. There is no conclusive evidence that pre-operative PRAE provides survival benefits in the management of surgically resected RCC.

[Value of the postoperative Störkel score. Predict disease-free survival of patients with surgically resected renal cell carcinoma]

OBJECTIVE

To determine the value of clinical and pathological parameters defining the Störkel score in order to predict outcomes of patients with surgically treated renal cell carcinoma (RCC).

MATERIAL AND METHODS

A total of 834 consecutive patients having radical or partial nephrectomy were retrospectively reviewed. For each patient with RCC, the prognostic Störkel score was calculated according to the following variables: Robson stage, Thoenes nuclear grading, histological type, pattern of growth, and age. Based on the Störkel score, patients were divided into groups: those with good prognosis (GP), intermediate prognosis (IP), and poor prognosis (PP). Cancer-specific survival (CSS) and overall survival (OS) were estimated using the Kaplan-Meier method. The accuracy of prediction of CSS and OS with the Störkel score was analyzed using Kaplan-Meier analysis, proportional hazards regression, and graphic representation [(Kaplan-Meier curves, area under the curve (AUC)]. In 564 patients who were still alive, the median follow-up was 79 months (mean 84.8 months).

RESULTS

In the GP, IP, and PP groups, CSS after 8 years was 86.7%, 75.6%, and 13.7%, respectively (p<0.001). In the multiple analysis, only the Robson stage and Thoenes nuclear grading independently predicted CSS. Accordingly, the prognostic accuracy of the Störkel score (CSS prediction: AUC=0.744, 95% CI=0.70-0.79) was not better than with a reduced model that included the Robson stage and grading only (CSS prediction: AUC=0.765, 95%CI=0.72-0.81).

CONCLUSIONS

Of all parameters included in the Störkel score, only the Robson stage and nuclear grading are significant prognostic factors. Hence, we recommend an accordant modification of the score with additional variables.