Evaluation of Question-Listing at the Cancer Support Community
University of California, San Francisco, 3333 California Street, Suite 265, San Francisco, CA 94118 USA. Translational Behavioral Medicine
06/2013; 3(2):162-71. DOI: 10.1007/s13142-012-0186-8
The Cancer Support Community (CSC) provides psychosocial support to people facing cancer in community settings. The purpose of this study was to evaluate the compatibility, effectiveness, and fidelity of the Situation-Choices-Objectives-People-Evaluation-Decisions (SCOPED) question-listing intervention at three CSC sites. Between August 2008 and August 2011, the Program Director at each CSC site implemented question-listing, while measuring patient distress, anxiety, and self-efficacy before and after each intervention. We analyzed the quantitative results using unadjusted statistical tests and reviewed qualitative comments by patients and the case notes of Program Directors to assess compatibility and fidelity. Program Directors implemented question-listing with 77 blood cancer patients. Patients reported decreased distress (p = 0.009) and anxiety (p = 0.005) and increased self-efficacy (p < 0.001). Patients and Program Directors endorsed the intervention as compatible with CSC's mission and approach and feasible to implement with high fidelity. CSC effectively translated SCOPED question-listing into practice in the context of its community-based psychosocial support services at three sites.
Available from: Jennifer Elston Lafata
- "Use of HRA instruments could potentially facilitate timely identification of patients who may benefit from counseling or other interventions, but they may also disrupt history taking, and their impact on cost and quality outcomes is not well understood (Dickey, Gemson, and Carney 1999). The use of patient-generated written lists may facilitate timely attention to the patient's agenda and has led to improvements in patients' psychosocial and health outcomes (Kaplan, Greenfield, and Ware 1989; Rost et al. 1991; Stewart 1995; Belkora et al. 2013). Yet these tools could interfere with patient–clinician rapport building or, as others have found, serve to slow the timely progression of office visits (Schrager and Gaard 2009). "
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The use of physician office-based tools such as electronic health records (EHRs), health risk appraisal (HRA) instruments, and written patient reminder lists is encouraged to support efficient, high-quality, patient-centered care. We evaluate the association of exam room use of EHRs, HRA instruments, and self-generated written patient reminder lists with patient–physician communication behaviors, recommended preventive health service delivery, and visit length.Research Methods
Observational study of 485 office visits with 64 primary care physicians practicing in a health system serving the Detroit metropolitan area. Study data were obtained from patient surveys, direct observation, office visit audio-recordings, and automated health system records. Outcome measures included visit length in minutes, patient use of active communication behaviors, physician use of supportive talk and partnership-building communication behaviors, and percentage of delivered guideline-recommended preventive health services for which patients are eligible and due. Simultaneous linear regression models were used to evaluate associations between tool use and outcomes. Adjusted models controlled for patient characteristics, physician characteristics, characteristics of the relationship between the patient and physician, and characteristics of the environment in which the visit took place.ResultsPrior to adjusting for other factors, visits in which the EHR was used on average were significantly (p < .05) longer (27.6 vs. 23.8 minutes) and contained fewer preventive services for which patients were eligible and due (56.5 percent vs. 62.7 percent) compared to those without EHR use. Patient written reminder lists were also significantly associated with longer visits (30.0 vs. 26.5 minutes), and less use of physician communication behaviors facilitating patient involvement (2.1 vs. 2.6 occurrences), but more use of active patient communication behaviors (4.4 vs. 2.6). Likewise, HRA use was significantly associated with increased preventive services delivery (62.1 percent vs. 57.0 percent). All relationships remained significant (p > .05) in adjusted models with the exception of that between HRA use and preventive service delivery.Dissemination and Implementation ImplicationsOffice-based tools intended to facilitate the implementation of desired primary care practice redesign are associated with both positive and negative cost and quality outcomes. Findings highlight the need for monitoring both intended and unintended consequences of office-based tools commonly used in primary care practice redesign.
Available from: Jennifer Elston Lafata
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ABSTRACT: Purpose: Little is known about the impact of environmental factors such as electronic medical records (EMRs), health risk appraisals (HRAs), and written patient reminders, on clinicians’ use of patient-centered communication. Controlling for physician and patient personal influences, we evaluate environmental influences on physicians’ patient-centered communication.
Method: Observational study of N=485 periodic health examinations to N=64 primary care physicians. Physician characteristics were obtained from administrative records and patient characteristics from a pre-visit survey. Research assistants completed observation checklist that recorded: time physician was present in examination room; physicians’ use of EMR and HRA; and patients’ use of written discussion topic reminders. Two physician office visit communication behaviors were obtained via audio-recordings: self-initiated partnership building and supportive talk.(Street, 2001) Three research assistants coded recordings by listening while reading transcripts. Inter-rater reliability was assessed with Cohen’s kappa and was 0.66 for physician partnership building and 0.74 for physician supportive talk. A structural equation model, that considered the hierarchical structure of the data, was fit to estimate the association of personal and environmental factors on physician use of self-initiated partnership building and supportive talk.
Result: Mean patient age was 59 years, 65% women, and 28% black; mean physician age was 50 years, 57% women, 14% black and 68% general internists; 81% of visits used the EMR, 13% an HRA, and 11% a patient written reminder. Physicians engaged in more supportive talk with patients reporting depressive symptoms and when HRAs were used, and less when patients brought written reminders. Physicians used more partnership building with more educated and black patients, and less when patients brought written reminders or had been seen recently. Visits with older physicians included more supportive talk, while those with black physicians used less partnership building. No other factors, including race and gender concordance, patient decision-making preference, EMR use, or how long after the scheduled time the appointment started were significantly associated with physicians’ use of patient-centered communication.
Conclusion: While patient-centered communication was associated with personal influences, environmental influences also played a role: HRAs had a positive and patient written reminders a negative influence on patient-centered communication. The impact of commonly present environmental factors on the quality of office visit communication needs to be continually monitored for both positive and negative consequences.
Available from: Sarah Murdoch (nee Scott)
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ABSTRACT: Background Men with prostate cancer face preference-sensitive decisions when choosing among treatments with similar survival outcomes but different procedures, risks and potential complications. A decision-support intervention, 'Decision Navigation' assists men with prostate cancer to prepare a question list (consultation plan) for their doctors and provides them with a consultation summary and audio recording. A randomised controlled trial of Decision Navigation showed advantages over usual care on quantitative measures including confidence in decision-making and regret. Objective
The aim of this study was to gain a qualitative understanding of patient's and doctor's perspectives on Decision Navigation. Methods Six patients who received Decision Navigation were purposively selected for interview out of 62 randomised controlled trial participants. All four doctors who consulted Navigated patients were interviewed. Interview data was analysed using framework analysis. Results Patients reported that planning for the consultation helped them to frame their questions, enabling them to participate in consultations and take responsibility for making decisions. They reported feeling more confident in the decisions made, having a written report of the key information and an audio recording. Patients considered routine information relating to side effects was inadequate. Doctors reported that consultation plans made them aware of patients' concerns and ensured comprehensive responses to questions posed. Doctors also endorsed implementing Decision Navigation as part of routine care. Conclusion Results suggest that Decision Navigation facilitated patients' involvement in treatment decision-making. Prostate patients engaging in preference-sensitive decision-making welcomed this approach to personalised tailored support.
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