Epstein Ronald M, Duberstein Paul R, Fenton Joshua J, Fiscella Kevin, Hoerger Michael, Tancredi Daniel J, Xing Guibo, Gramling Robert, Mohile Supriya, Franks Peter, Kaesberg Paul, Plumb Sandy, Cipri Camille S, Street Richard L, Shields Cleveland G, Back Anthony L, Butow Phyllis, Walczak Adam, Tattersall Martin, Venuti Alison, Sullivan Peter, Robinson Mark, Hoh Beth, Lewis Linda, Kravitz Richard L
Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York3Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York4James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York.
Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York3Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York.
JAMA Oncol. 2017 Jan 1;3(1):92-100. doi: 10.1001/jamaoncol.2016.4373.
Observational studies demonstrate links between patient-centered communication, quality of life (QOL), and aggressive treatments in advanced cancer, yet few randomized clinical trials (RCTs) of communication interventions have been reported.
To determine whether a combined intervention involving oncologists, patients with advanced cancer, and caregivers would promote patient-centered communication, and to estimate intervention effects on shared understanding, patient-physician relationships, QOL, and aggressive treatments in the last 30 days of life.
DESIGN, SETTING, AND PARTICIPANTS: Cluster RCT at community- and hospital-based cancer clinics in Western New York and Northern California; 38 medical oncologists (mean age 44.6 years; 11 (29%) female) and 265 community-dwelling adult patients with advanced nonhematologic cancer participated (mean age, 64.4 years, 146 [55.0%] female, 235 [89%] white; enrolled August 2012 to June 2014; followed for 3 years); 194 patients had participating caregivers.
Oncologists received individualized communication training using standardized patient instructors while patients received question prompt lists and individualized communication coaching to identify issues to address during an upcoming oncologist visit. Both interventions focused on engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information. Control participants received no training.
The prespecified primary outcome was a composite measure of patient-centered communication coded from audio recordings of the first oncologist visit following patient coaching (intervention group) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QOL, and aggressive treatments and hospice use in the last 30 days of life.
Data from 38 oncologists (19 randomized to intervention) and 265 patients (130 intervention) were analyzed. In fully adjusted models, the intervention resulted in clinically and statistically significant improvements in the primary physician-patient communication end point (adjusted intervention effect, 0.34; 95% CI, 0.06-0.62; P = .02). Differences in secondary outcomes were not statistically significant.
A combined intervention that included oncologist communication training and coaching for patients with advanced cancer was effective in improving patient-centered communication but did not affect secondary outcomes.
clinicaltrials.gov Identifier: NCT01485627.
观察性研究表明，以患者为中心的沟通、生活质量（QOL）与晚期癌症的积极治疗之间存在联系，但关于沟通干预的随机临床试验（RCT）报道较少。
确定一项涉及肿瘤学家、晚期癌症患者及其护理人员的联合干预措施是否能促进以患者为中心的沟通，并评估该干预措施对临终前30天内的共同理解、医患关系、生活质量和积极治疗的影响。
设计、地点和参与者：在纽约西部和北加利福尼亚州的社区及医院癌症诊所进行的整群随机对照试验；38名医学肿瘤学家（平均年龄44.6岁；11名[29%]为女性）和265名社区居住的晚期非血液系统癌症成年患者参与（平均年龄64.4岁，146名[55.0%]为女性，235名[89%]为白人；2012年8月至2014年6月入组；随访3年）；194名患者有参与的护理人员。
肿瘤学家接受使用标准化患者教员进行的个性化沟通培训，而患者则收到问题提示清单和个性化沟通指导，以确定在即将到来的肿瘤学家就诊期间要解决的问题。两种干预措施都侧重于让患者参与会诊、回应情绪、告知患者预后和治疗选择以及信息的平衡表述。对照组参与者未接受培训。
预先设定的主要结局是根据患者接受指导（干预组）或入组（对照组）后首次肿瘤学家就诊的录音编码得出的以患者为中心的沟通综合测量指标。次要结局包括医患关系、对预后的共同理解、生活质量、临终前30天内的积极治疗和临终关怀使用情况。
分析了来自38名肿瘤学家（19名随机分配至干预组）和265名患者（130名干预组）的数据。在完全调整模型中，干预措施在主要医患沟通终点上带来了临床和统计学上的显著改善（调整后的干预效果为0.34；95%可信区间为0.06 - 0.62；P = 0.02）。次要结局的差异无统计学意义。
一项包括肿瘤学家沟通培训和对晚期癌症患者进行指导的联合干预措施在改善以患者为中心的沟通方面有效，但未影响次要结局。
clinicaltrials.gov标识符：NCT01485627。
