Tai-Seale Ming, Cheung Michael, Vaida Florin, Ruo Bernice, Walker Amanda, Rosen Rebecca L, Hogarth Michael, Fisher Kimberly A, Singh Sonal, Yood Robert A, Garber Lawrence, Saphirak Cassandra, Li Martina, Chan Albert S, Yu Edward E, Kallenberg Gene, Longhurst Christopher A, Millen Marlene, Stults Cheryl D, Mazor Kathleen M
University of California, San Diego, School of Medicine, La Jolla.
University of California, San Diego, Herbert Wertheim School of Public Health and Human Longevity Science, La Jolla.
JAMA Health Forum. 2024 Dec 6;5(12):e244436. doi: 10.1001/jamahealthforum.2024.4436.
Despite various attempts to improve patient-clinician communication, there has been limited head-to-head comparison of these efforts.
To assess whether clinician coaching (mobile application or in-person) is more effective than reminder posters in examination rooms and whether mobile app use is noninferior to in-person coaching.
DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized clinical trial with 3 arms. A total of 21 primary care clinics participated in 3 health systems in the US; participants were patients and primary care clinicians with clinic visits between August 28, 2019, and December 31, 2021. Data were analyzed from August 4, 2022, to November 10, 2024. Data analysis was based on intention to treat.
In-person coaching of clinicians with standardized patient instructor training (high-touch), mobile application-based coaching (high-tech), and posters placed in examination rooms encouraging shared decision-making (AskShareKnow [ASK]). Before visits, patients in the high-touch and high-tech groups were prompted to inform their clinicians of the most important matter for discussion using online check-in.
The primary outcome was a patient engagement measure (CollaboRATE) of patient perceptions of communication and shared decision-making during the visit. Difference-in-differences mixed-effect regression with random intercepts for primary care clinician were used for analyses. Secondary outcomes included the net promoter score (patient's likelihood of recommending this clinician to others) and patient's confidence in managing their health.
Participants included 4852 patients with a median age of 54 years (IQR, 39-66 years); 63.6% were women. A total of 114 clinicians (median age range, 40-59 years; 48 were women [42.1%]) participated. The 3 interventions did not differ significantly in probability of CollaboRATE top score (marginal difference, high-tech vs ASK, -0.021; 95% CI, -0.073 to 0.030; high-touch vs ASK, -0.018, 95% CI, -0.069 to 0.033; high-tech vs high-touch, -0.003, 95% CI, -0.057 to 0.052; P = .14). Patients in the high-tech group were less likely to recommend their clinician to others than patients in the high-touch group (difference in marginal probability, -0.056; 95% CI, -0.118 to 0.019; P = .04). After 3 months, patients in the high-tech group had a significantly lower score than patients in the high-touch group (mean difference, -0.176; 95% CI, -0.341 to -0.011; P = .04) in confidence in managing their health.
This cluster randomized clinical trial found no evidence of intervention effects, although there were differences across systems. Some secondary outcomes suggested positive effect of clinicians receiving in-person coaching. Alternative outcome measures of patient engagement may be needed.
ClinicalTrials.gov Identifier: NCT03385512.
尽管人们为改善患者与临床医生之间的沟通进行了各种尝试，但对这些努力进行的直接比较却很有限。
评估临床医生培训（通过移动应用程序或面对面方式）是否比检查室中的提醒海报更有效，以及使用移动应用程序是否不劣于面对面培训。
设计、设置和参与者：一项有3个组的整群随机临床试验。美国3个医疗系统中的21家初级保健诊所参与其中；参与者为2019年8月28日至2021年12月31日期间就诊的患者和初级保健临床医生。数据于2022年8月4日至2024年11月10日进行分析。数据分析基于意向性分析。
对临床医生进行标准化患者指导培训的面对面培训（高接触）、基于移动应用程序的培训（高科技），以及在检查室张贴鼓励共同决策的海报（AskShareKnow [ASK]）。就诊前，高接触组和高科技组的患者被提示通过在线签到告知临床医生最重要的讨论事项。
主要结局是一项患者参与度指标（CollaboRATE），用于衡量患者对就诊期间沟通和共同决策的感知。分析采用了针对初级保健临床医生的具有随机截距的差分混合效应回归。次要结局包括净推荐值（患者向他人推荐该临床医生的可能性）和患者对自身健康管理的信心。
参与者包括4852名患者，中位年龄为54岁（四分位间距，39 - 66岁）；63.6%为女性。共有114名临床医生参与（中位年龄范围，40 - 59岁；48名女性[42.1%]）。在CollaboRATE获得高分的概率方面，这3种干预措施没有显著差异（边际差异，高科技组与ASK组，- 0.021；95%置信区间，- 0.073至0.030；高接触组与ASK组，- 0.018，95%置信区间，- 0.069至0.033；高科技组与高接触组，- 0.003，95%置信区间，- 0.057至0.052；P = 0.14）。高科技组的患者向他人推荐其临床医生的可能性低于高接触组（边际概率差异，- 0.056；95%置信区间，- 0.118至0.019；P = 0.04）。3个月后，高科技组患者在自身健康管理信心方面的得分显著低于高接触组（平均差异，- 0.176；95%置信区间，- 0.341至 - 0.011；P = 0.04）。
这项整群随机临床试验未发现干预效果的证据，尽管各系统之间存在差异。一些次要结局表明临床医生接受面对面培训有积极效果。可能需要采用其他患者参与度结局指标。
ClinicalTrials.gov标识符：NCT03385512。
