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NCI patient centered care in cancer patient

NCI patient centered care in cancer patient






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    NCI patient centered care in cancer patient NCI patient centered care in cancer patient Presentation Transcript

    • How Clinician-Patient Communication Can Improve Health Outcomes
      Richard L. Street, Jr.
      Texas A&M University
      June 8, 2010
    • The problem: How does one explain these findings?
      Kaplan et al (1988)
      Patient efforts to exert control—lower blood pressure and lower A1c 8-12 weeks after the consultation
      More equal dr-pt floortime—fewer functional limitations 8-12 weeks after visit
      Orth et al (1987)
      lower blood pressure at 2 weeks related to:
      Proportion of physician talk that was explaining/describing/reporting—
      Frequency of patient talk that expressed concerns/described symptoms—lower blood pressure at 2 weeks
    • Stewart et al (2000)
      Patient perception of dr patient-centeredness (e.g, exploring problem, finding common ground)—better emotional well-being 2 months after visit
      Street et al (1993)
      Less nurse controlling behavior—better A1c control at 2 months
      Ward et al (2003)
      More active patient participation among lupus pts—less organ damage at three years
    • But then what about these findings?
      Amount of dr. information—more functional limitations and lower self-reported health (Kaplan et al, 1988)
      Pt effort to participate in decision-making not related to subsequent A1c (Rost et al, 1991)
      Dr. patient-centered communication (partnership-building, supportive) not related to lupus patients’ outcomes (Ward et al, 2003)
      Negative affect related to better A1c (Kaplan et al., 1988) and poorer A1c (Street et al, 1993)
    • Or these?
      Observer coded PCC (exploring pt. problem, finding common ground) (Stewart et al., 2000):
      was not related to pt’s emotional well-being
      only modestly correlated with pt. perception of PCC
      Active pt. participation in deciding breast cancer treatment (Street et al, 1995):
      did not predict breast cancer patients’ emotional and functional well-being at 1 year following treatment
      did predict patient assuming responsibility for decision at 1 year which in turn predicted well-being
      PCC trained doctors and diabetes outcomes (Kinmonth et al, 1998)
      With trained drs, patients were happier and fatter
    • Theoretical pathways
      Patient Health
      Conceptual/Measurement challenges
    • 7
    • Patient-Centered COMMUNICATION:Six overlapping functions
      Epstein MR and Street RL. Patient-centered communication in cancer care:
      Promoting healing and reducing suffering. NCI, NIH publication #07-6225, Bethesda MD, 2007
    • Proximal Outcomes
      *feeling ‘known’
      *patient feels involved
      Intermediate Outcomes
      *access to care
      *quality medical decision
      *commitment to
      *trust in system
      *social support
      *self-care skills
      *emotional management
      Indirect (mediated) path
      Health outcomes
      *less suffering
      *emotional well-being
      *pain control
      *functional ability
      Direct path
    • Exploring pathways: A research agenda
      Identify the health outcome of interest
      Identify the mechanism for improved health
      Model the pathway through which communication can lead to improved health
      Select appropriate measures for communication variables, proximal outcomes, and intermediate outcomes
      • Develop intervention to target communication process to activate that mechanism
    • Pain Control in Cancer
      Outcome: Better pain control at 2 weeks
      Effective use of pain medication
      Proximal outcomes
      Change in pain medication (new medication, change in dose)
      Communication variables
      Active patient participation about pain (asking questions, expressing concern, being assertive)
      Intervention: patient activation coaching intervention
      Emphasize importance of patient involvement, educate about pain management, provide opportunities for practice talking to the doctor and feedback on performance
    • Coaching
      Pain control
      at 2 weeks
      Change in pain meds
    • Cancer Health Empowerment for Living without Cancer Pain (Ca-HELP) Study (R.L. Kravitz, PI)
      Research settings
      Patient of UC Davis Cancer Center, Kaiser Permanente oncology clinics in Sacramento and Roseville, Sacramento VA Health Care System
      Research participants
      Age 18-80
      Cancers: breast, prostate, lung, head/neck, pancreatic, colorectal, esophageal
      Worst pain of 4 or greater or worst pain of 3 with impairment of daily activities
      Not in hospice
      No more than one pain management consultation
    • Research measures
      Frequency measures (Street, 2001)
      Patient involvement-pain specific (frequency of patients’ questions, assertive statements, and concerns specific about pain) overall and pain-specific
      Ratings measures
      Coders’ ratings of participatory decision-making (Kaplan et al, 1995)
      Change in pain medication
      Patient self-report to question, “During the visit you just completed, did  the physician recommended any change in your pain medication? “ (Yes--new medicine,; Yes--change in dose or amount of a medicine; No)
    • Characteristics of the sample(N = 148)
    • Predictors of Active Patient Participation (Street et al., 2010)
    • Predictors of Pain Medication Adjustment
    • Coaching
      Pain control
      at 2 weeks
      Change in pain meds
    • Pain Control and Better Knee Function for Patients having Acupuncture for Osteoarthritis
      Outcome: Better pain control and function
      Placebo effect through beliefs about acupuncture
      Proximal outcomes
      Patient expectations that acupuncture will improve pain and function
      Communication Intervention
      Acupuncturists communicating high vs. neutral expectations for treatment success
    • The Houston Arthritis and Acupuncture Treatment Study (HAATS)
      (PI, M. Suarez-Almazor)
      For the first half of the trial half of the acupuncturists were randomly allocated to the high expectations communication style and the other half to the neutral style. In the second half the acupuncturists switched communication styles.
    • Communicating High vs Neutral Expectations
      High expectations
      “I’ve had a lot of success with patients with your kind of knee pain”
      “I’m optimistic this is going to work for you.”
      “You should start feeling better within 4 or 5 treatments”
      “Sometimes it just takes a little longer to work, but it usually does”
      Neutral expectations
      “It works for some patients and not for others.”
      “I am not sure if it’ll work. We just have to wait and see if it helps you”
      “It may be that it’s not working, maybe it will after a few more treatments”
    • Research measures
      Communication expectation measure
      Coders’ rating on 100mm scale at baseline visit
      Based on what you heard, rate this practitioner’s communication style when discussing treatment expectations for improvement.
      Neutral ___________________________________High
      Patient expectations (assessed at 4 weeks)
      For each condition (e.g., knee pain, stiffness), please choose how you would expect it to be 2 MONTHS from now after you have completed the Acupuncture Treatment. (Much worse, Worse, The same. Better, Much Better)
      Pain and Function measures
      WOMAC scale response at + 6 weeks and + 3 months
      Pain—How much pain do you have ‘walking on a flat surface,’ ‘going and down stairs,’ etc
      Function—What degree of difficulty do you have with ‘ascending stairs,’ ‘getting in/out of car,’
    • Baseline demographic and clinical characteristics
    • Results of Path Analysis
      Expectations Communicated
      Patient Expectations Acupuncture Effectiveness
      (4 weeks)
      3 months
      Patient Baseline Expectations
      All effects were significant, P < .05
      good overall model fit: chi-square=5.2, p=.39, RMSEA=.01
    • Another pathway? Shared Mind
      Epstein and Peters (2009)
      “Collaborative cognition depends on the physician being mindful not only of the patient’s values, thoughts, and feelings but also his or her own. Research exploring shared deliberation and shared mind must bridge cognitive science, decision research, and communication skills training and evaluate communication processes as well as patients’ experience of care” (p. 197).
    • Shared mind is a process:
      A way of thinking
      A way of talking
      A way of collaborating
      Shared mind is also an outcome
      Shared understanding of the problem
      Understanding the others’ perspective
      Reaching agreement on a course of action
    • Types of shared understanding
      Similar beliefs
      What physician believes coincides with what patient believes
      Perceived agreement (fantasy)
      What physician believes coincides with what physician believes patient believes
      Understanding of the other (perspective-taking)
      What physician believes the patient believes coincides with what the patient believes
    • PT
    • The CONNECT study (PI, P. Haidet)
      Determine how well physicians understand their patient’s health belief models
      Identify predictors of greater understanding (more accurate perspective taking)
      Communication factors—more active patient participation (asking questions, expressing concerns, stating opinion and preferences)
      Relationship factors—number of previous visits, racial/gender concordance
      Cultural factors—as assessed by physician-patient demographics
    • The CONNECT instrument: Six domains of health beliefs (*Haidet et al, Patient Education and Counseling 2008)
      To what extent:
      is there a biological cause to the patient’s health condition
      is the patient at fault for his/her health condition
      does the patient have control over his/her health condition
      does the condition have meaning for the patient
      can the patient’s health condition benefit from natural/alternative remedies
      does patient want a partnership with the doctor
    • Study Design: cross-sectional using pre- and post-visit surveys, audiotapes of primary care encounters
      Setting: 10 primary care clinics in Houston, TX
      Subjects: 272 adult patients receiving care from 29 physicians
    • The CONNECT Instrument*
      Six domains of explanatory models (cause, fault, control, meaning, alternative treatments, relationship)
      *Haidet et al, Patient Education and Counseling 2008
    • Data Analysis
      Summary scores for each CONNECT domain
      Compared domain sum scores between patient own and physician understanding
      Used multivariate models to examine predictors of greater physician udnerstanding
      Accounted for effect of patients nested within physicians
    • Results: Study Population
      Patients (n=272)
      Physicians (n=29)
    • Differences between patients’ model , physician models, and physician
      beliefs about the patients’ models
    • Associations With Better Physician Understanding*
      Greater Patient Participation
      Meaning, Control, Alternative Treatments, Relationship (p = 0.01-0.05)
      Race Concordance
      Control (p = 0.02)
      Lower Patient Education
      Control (p = 0.008)
      Male Physician
      Control, Relationship (p = 0.004, 0.05)
      *Lower absolute difference between
      patient own and physician understanding score
    • Association With Poorer Physician Understanding*
      African American Patients (compared w/ Caucasian)
      Relationship (p = 0.02)
      Hispanic patients (compared with Caucasian)
      Meaning (p = O.06)
      *Greater absolute difference between
      patient own and physician understanding score
    • Conclusion
      Significant gaps in physician understanding of patient perspectives in routine primary care settings
      Certain demographic factors may impact physician understanding
      Active patient participation improved understanding in multiple domains
    • Questions?
    • References
      Epstein RM, Street RL, Jr. Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. Bethesda, MD: National Cancer Institute; 2007. Report No.: NIH Publication No. 07-6225.
      P. Haidet, K.J. O’Malley, B.F. Sharf, A.P. Gladney, A.J. Greisinger, & R.L. Street Jr. (2008) Characterizing explanatory models of illness in healthcare: Development and validation of the CONNECT instrument. Patient Education and Counseling, 73, 232-239.
      Kaplan SH, Greenfield S, Ware JE, Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989; 27:S110-S127.
      Street, R. L., Jr. (2001). Active patients as powerful communicators. In W. P. Robinson, & H. Giles (Eds.), The new handbook of language and social psychology (pp.541-560). New York: John Wiley & Sons.
      R.L. Street, Jr.,C. Slee, D. K. Kalauokalani,D.E. Dean, D. J. Tancredi, & R. L. Kravitz (2010) press) Improving physician-patient communication about cancer pain with a tailored education-coaching intervention. Patient Education and Counseling, 80, 42-47.
      M.M. Ward, S. Sundaramurthy, D. Lotstein, T. Bush, C.M. Neuwelt, & R.L. Street, Jr. (2003). Participatory patient-physician communication and morbidity in patients with systemic lupus erythematosus. Arthritis & Rheumatism, 49, 810-818.
    • HS Gordon, RL Street, Jr., BF Sharf, & J Souchek. (2006) Racial differences in doctors’ information-giving and patients’ participation. Cancer, 106, 1313-1320.
      Street, R. L., Jr. (2001). Active patients as powerful communicators. In W. P. Robinson, & H. Giles (Eds.), The new handbook of language and social psychology (pp.541-560). New York: John Wiley & Sons.
      R.L. Street, Jr, M.N. Richardson, V. Cox, and M.E. Suarez Almazor. (2009) (Mis)Understanding in patient-health care provider communication about total knee replacement. Arthritis Care and Research, 61, 100-107.