Testing whether providing older patients with a list of questions to ask their surgeons improves decision making and well-being
Changing patient-doctor communication may be difficult without addressing clinician communication directly. LIMITATIONS: This study has limitations consistent with other studies of communication interventions that failed to demonstrate efficacy of primary outcomes. There are a range of outcomes and...
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| Format: | eBook |
| Language: | English |
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Washington, DC
Patient-Centered Outcomes Research Institute (PCORI)
[2020], 2020
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| Series: | Final research report
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| Online Access: | |
| Collection: | National Center for Biotechnology Information - Collection details see MPG.ReNa |
| Summary: | Changing patient-doctor communication may be difficult without addressing clinician communication directly. LIMITATIONS: This study has limitations consistent with other studies of communication interventions that failed to demonstrate efficacy of primary outcomes. There are a range of outcomes and care trajectories related to communication, where the signal and noise are difficult to discriminate. We used rigid definitions and categorical variables to avoid miscounting, which may have limited our ability to detect an effect. There were also unanticipated enrollment challenges, because eligible patients found study participation overwhelming. Finally, although we developed strict entry criteria, on post hoc review we found 59 enrolled patients who did not actually discuss major oncologic or vascular surgery with their surgeon We also interviewed a subset of patients who experienced serious surgical complications to explore their perceptions of postoperative conflict about additional aggressive treatments in the setting of an unwanted outcome. RESULTS: Of 1319 patients eligible for participation, 223 received the intervention procedure (ie, a QPL was sent to their address in advance of their visit), and 223 received usual care. On intention-to-treat analysis, there was no significant difference between intervention and usual care for all patient-reported primary outcomes. Effect estimates are given as odds ratios (ORs) (treatment relative to control) for the (ordinal) logistic models and as regression coefficients for treatment in the linear models; estimated effect on frequency of patients asking questions about options was 1.32 (95% CI, 0.73-2.40; P = .353), estimated effect on questions about expectations was 0.97 (95% CI, 0.56-1.70; P = .923), and estimated effect on questions about risks was 1.41 (95% CI, 0.78-2.53; P = .255). PEPPI-5 scores did not vary significantly by treatment group (effect estimate, −0.37; 95% CI, −1.29 to 0.55; P = .411) or family (effect estimate, −0.03; 95% CI, −1.14 to 1.07; P = .949). Regrets were not significantly different by treatment group (OR, 1.39; 95% CI, 0.64-3.00; P = .412). Mean MYCaW concerns of family members were larger in usual care (effect estimate, 1.51; 95% CI, 0.28-2.74; P = .008). We enrolled patients aged ≥60 years with at least 1 comorbidity and an oncologic or vascular (peripheral, neurologic, cardiac) problem that could be treated with major surgery. Family members were also enrolled. The index surgical visit was audio-recorded and transcribed. Primary patient engagement outcomes included number and type of questions asked during the surgical visit (specifically questions about options, expectations, risks, and advance directives) and patient-reported 5-item Perceived Efficacy in Patient-Physician Interactions (PEPPI-5) scores assessed after the surgical visit. Primary well-being outcomes included (1) the difference in patient's Measure Yourself Concerns and Wellbeing (MYCaW) scores reported after surgery and scores reported after the surgical visit, and (2) treatment-associated regret at 6 to 8 weeks after surgery. After completing patient recruitment, we interviewed surgeons regarding their experiences with the QPL. BACKGROUND: Poor preoperative communication can have serious consequences including unwanted treatment and postoperative conflict. OBJECTIVE: To compare the effectiveness of a question prompt list (QPL) intervention with usual care on patient engagement, well-being, and postoperative conflict. METHODS: The QPL brochure developed by patient and family stakeholders has 11 questions to ask a surgeon. It is sent with a surgeon's endorsement letter (in English and/or Spanish) to patients before their outpatient visit. In this cluster-randomized stepped-wedge trial, surgeons were randomly assigned within site to different start dates for the QPL intervention. Patients received the QPL intervention or usual care from 1 of 40 study-enrolled surgeons at 5 study sites based on whether their surgeon was in the control or the intervention phase of the stepped-wedge design. MYCaW concerns of patients were not significantly different (effect estimate, −0.15; 95% CI, −1.13 to 0.82; P = .645). When we (post hoc) restricted the intervention group to patients with clear evidence that they reviewed the QPL, we observed a nonsignificant increase in our effect size for frequency of patients asking questions about options (OR, 1.88; 95% CI, 0.81-4.35; P = .164), expectations (OR, 1.59; 95% CI, 0.67-3.80; P = .292), and risks (OR, 2.41; 95% CI, 1.04-5.59; P = .039) (nominal α = .01; Bonferroni correction for multiple comparisons). Surgeons strongly supported using the QPL in clinic, noting that it empowered patients to ask questions. Patients who experienced surgical complications did not report conflict about additional treatment postoperatively regardless of study group. CONCLUSIONS: The results of this study were null related to primary patient engagement and well-being outcomes. |
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| Physical Description: | 1 PDF file (69 pages) illustrations |