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Background: Financial toxicity, the burden of treatment cost, affects 30-50% of people with cancer in the US. Although experts recommend patients and oncologists discuss treatment ...cost to identify patients who need assistance, cost discussions occur in fewer than half of cancer treatment discussions. We pilot-tested the feasibility and efficacy of the Discussions of Cost (DISCO) App, a patient communication intervention designed to improve cost discussions and other financial toxicity-related outcomes during and following oncology treatment consultations. The DISCO App provides an individualized list of cost-related questions patients can ask their oncologist, specific to a patient’s economic situation. Methods: While waiting to see their oncologist, newly diagnosed patients with breast or lung cancer (n=32) used the DISCO App on an iPad. Clinic visits were videorecorded and patients completed pre- and post-intervention measures of self-efficacy for managing treatment costs, self-efficacy for interacting with oncologists, cost-related distress, and perceptions of the DISCO App. A trained coder observed the recordings to determine the presence of a cost discussion, the cost-related topic, and any emergent factors. Results: Findings showed increases in patients’ self-efficacy for managing treatment costs (p=.02) and interacting with oncologists (p=.001). Cost-related distress decreased but not significantly (p=.20). Patients reported the DISCO App was understandable (M=4.5 out of 5), useful as they talked with their oncologist (M=4.0), and 84% of patients reported needing less than 15 minutes to use the DISCO App. Most (94%) interactions were videorecorded (in two cases technical difficulties prevented videos from being collected); all (100%) of the videorecorded interactions included a cost discussion. The most frequently discussed topics were: insurance, time off from work, and financial navigation. Frequently, the oncologist asked the patient for his/her question list and discussed/answered the questions. Conclusions: Findings suggest the DISCO App is feasible to implement in the clinic and effective in improving patient-oncologist cost discussions and financial toxicity-related outcomes. Patient acceptance of the DISCO App and oncologist engagement suggested the intervention prompted cost discussions. Next steps include conducting a longitudinal randomized controlled trial to determine the effectiveness of the DISCO App on financial toxicity, and other outcomes. Clinical trial information: NCT03676920 .
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Background: Clinical communication is poorer with Black patients than with White patients, but most studies are limited to verbal communication. Nonverbal synchrony, the ...nonconscious coordination of movement between individuals, has been shown to reflect relationship quality. We investigated nonverbal synchrony’s association with patient and physician affect and rapport in cancer treatment discussions, and if those associations differed by patient race. Methods: We used motion detection software to measure overall synchrony and synchrony based on who is leading in the interaction (similar to leading in dancing) in video recordings of 68 Black patients and 163 White patients discussing treatment with their physicians. Naïve observers rated the interaction for six constructs: patient and physician positive and negative affect and patient-physician positive and negative rapport. We examined associations between patient race, nonverbal synchrony and the six constructs. Results: In interactions with Black patients, overall synchrony was positively associated with patients’ positive affect and positive patient-physician rapport and negatively associated with patients’ negative affect and negative patient-physician rapport. When the physician was leading, synchrony was positively associated with patients’ positive affect and positive patient-physician rapport and negatively associated with patients’ negative affect and negative patient-physician rapport. When the patient was leading, synchrony was positively associated with patients’ and physicians’ positive affect and positive patient-physician rapport, and negatively associated with patients’ negative affect and negative patient-physician rapport. In interactions with White patients, overall synchrony was positively associated with patient positive affect; when the physician was leading, synchrony was negatively associated with patient negative affect. Conclusions: This is the first study to use a dynamic, jointly-determined measure in patient-physician communication. Synchrony was related to patient and physician affect and rapport in interactions with Black patients, but only patient affect in interactions with White patients, suggesting nonverbal synchrony is particularly important in interactions with Black patients. Next, we will investigate associations with patient outcomes, such as satisfaction. Findings could contribute to physician training to enhance coordination and outcomes in oncology interactions.
Abstract Objective To investigate whether patient demographic characteristics and patients’ companions influence variation in patient question asking during cancer clinical interactions, thus ...representing a potential disparity in access to information. Methods Data included 109 oncologist–patient–companion interactions video recorded at a comprehensive cancer center. Interactions were observed and analyzed using the Karmanos Information Seeking Analysis System (K-ISAS). Results Significant relationships were found between patient race/ethnicity and question asking. Black patients asked fewer questions and a smaller proportion of direct questions (relative to the total frequency of questions) than White patients. Black patients were also less likely to have companions present during the interaction, which resulted in fewer questions asked on Black patients’ behalf. Conclusion Differences in question asking by Black and White patients suggest that Black patients may receive less information from their oncologists than White patients. Practice/research implications Patients should be encouraged to ask more questions and more direct questions and to bring a companion to the interaction to assist them in gaining information from their physician. Future research is needed to investigate ways to eliminate this potential source of disparities in access to information.
Information provided to parents in pediatric intensive care units (PICU) is often complex and uncertain. Our objective is to gain a better understanding of parents' informational needs regarding ...their child's critical illness, and their sources and mechanisms for gaining information.
Parents whose children were discharged from a Midwestern university-affiliated children's hospital PICU in the prior 30 days, and health professionals who worked in the PICU for at least one year were eligible. Semi-structured audio-recorded interviews were conducted, transcribed, and analyzed using established qualitative methods.
Of 40 participants, 28 were parents and 12 were health professionals. Types of information needed by parents included information related to their child's PICU stay and hospitalization (e.g., diagnosis, prognosis, treatment plans), and post-discharge care (e.g., home instructions, warning signs, emergency plans). Some parents reported wanting to know everything about their child's condition whereas others reported little to no need for information. Sources of information included health professionals, Internet, family, and other parents. Mechanisms of gaining information included interpersonal interactions between parents and health professionals (e.g., asking questions, rounds, family conferences, modeling, hands-on learning, knowledge testing) and materials that could be viewed independently (e.g., printed materials, parent diaries, videos, white boards, patient portals).
Types and amount of information needed by parents of critically ill children are wide ranging and include details of their child's immediate condition and long-term post-discharge care. Parents use many sources and mechanisms to gain health information and most parents use more than one source or mechanism.
•Types and amounts of information needed by parents in PICUs are wide ranging.•Information sources include health providers, Internet, family, and other parents.•Most parents use more than one source and mechanism to gain health information.•Parents informational needs can inform the development of educational resources.
To describe prostate cancer treatment decision making, focusing on knowledge and attitudes toward observation, known as watchful waiting (WW) or active surveillance (AS), and reasons for not choosing ...WW/AS.
Semistructured in-person interviews were conducted with 21 men (14 black; 7 white) with recently diagnosed localized prostate cancer.
All cancers were detected by prostate-specific antigen screening; 14 men had low-risk disease. Nineteen chose surgery or radiation treatment. The majority wanted to "get rid of" or "cure" the cancer by undergoing aggressive therapy, even with awareness of the potential for significant side effects. Most men seemed unaware of the uncertainty/controversies that aggressive treatment may not cure their cancer or improve their survival. Limited knowledge about WW/AS was common, and few remembered WW/AS being presented as a viable option. Rather, many men perceived it as "doing nothing." Some men, who initially were inclined toward WW/AS, yielded to pressure from family, physicians, or both to choose aggressive treatment. Lack of physician support was a significant barrier to WW/AS.
The observational strategy (WW/AS) was not viewed as a reasonable approach, even for those with low-risk cancer. The desire for aggressive therapy may reflect the complex psychology associated with receiving a diagnosis of cancer and the limited supportive counseling received. Further efforts to better understand and educate patients and physicians may help men make informed and appropriate treatment decisions to maximize quality of life without compromising survival.
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Background: Financial toxicity, the burden of treatment cost, affects 30-50% of people with cancer in the United States. Although experts recommend patients and oncologists ...discuss treatment cost to identify patients who need assistance, cost discussions occur in fewer than half of cancer treatment discussions. We pilot-tested the feasibility and efficacy of the Discussions of Cost (DISCO) App, a patient communication intervention designed to improve cost discussions and other financial toxicity-related outcomes during and following oncology treatment consultations. The DISCO App provides an individualized list of cost-related questions patients can ask their oncologist, specific to a patient’s economic situation. Methods: While waiting to see their oncologist, newly diagnosed patients with breast or lung cancer (n=32) used the DISCO App on an iPad. Clinic visits were videorecorded and patients completed pre- and post-intervention measures of self-efficacy for managing treatment costs, self-efficacy for interacting with oncologists, cost-related distress, and perceptions of the DISCO App. A trained coder observed the recordings to determine the presence of a cost discussion, the cost-related topic, and any emergent factors. Results: Findings showed increases in patients’ self-efficacy for managing treatment costs (p=.02) and interacting with oncologists (p=.001). Cost-related distress decreased but not significantly (p=.20). Patients reported the DISCO App was understandable (M=4.5 out of 5), useful as they talked with their oncologist (M=4.0), and 84% of patients reported needing less than 15 minutes to use the DISCO App. Most (94%) interactions were videorecorded (in two cases technical difficulties prevented videos from being collected); all (100%) of the videorecorded interactions included a cost discussion. The most frequently discussed topics were: insurance, time off from work, and financial navigation. Frequently, the oncologist asked the patient for his/her question list and discussed/answered the questions. Conclusions: Findings suggest the DISCO App is feasible to implement in the clinic and effective in improving patient-oncologist cost discussions and financial toxicity-related outcomes. Patient acceptance of the DISCO App and oncologist engagement suggested the intervention prompted cost discussions. Next steps include conducting a longitudinal randomized controlled trial to determine the effectiveness of the DISCO App on financial toxicity, and other outcomes. Clinical trial information: NCT03676920 .
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Background: Clinical communication is poorer with Black patients than with White patients, but most studies are limited to verbal communication. Nonverbal synchrony, the subtle, ...nonconscious coordination of movement between individuals, has been shown to reflect relationship quality. We investigated nonverbal synchrony’s association with patient and physician affect and rapport in cancer treatment discussions, and if those associations differed by patient race. Methods: We used motion detection software to measure overall synchrony and synchrony based on who is leading in the interaction (similar to leading in dancing) in video recordings of 68 Black patients and 163 White patients discussing treatment with their non-Black physicians. Additionally, naïve observers rated the interaction for six constructs: patient and physician positive and negative affect and patient-physician positive and negative rapport. We examined associations between nonverbal synchrony and the six constructs. Results: In interactions with Black patients, overall synchrony was positively associated with patients’ positive affect and positive patient-physician rapport and negatively associated with patients’ negative affect and negative patient-physician rapport. When the physician was leading, synchrony was positively associated with patients’ positive affect and positive patient-physician rapport and negatively associated with patients’ negative affect and negative patient-physician rapport. When the patient was leading, synchrony was positively associated with patients’ and physicians’ positive affect and positive patient-physician rapport, and negatively associated with patients’ negative affect and negative patient-physician rapport. In interactions with White patients, overall synchrony was positively associated with patient positive affect; when the physician was leading, synchrony was negatively associated with patient negative affect. Conclusions: This is the first study to use an innovative measure of dynamic communication in patient-physician cancer treatment discussions. Nonverbal synchrony was related to patient and physician affect and rapport in interactions with Black patients, but only patient affect in interactions with White patients, suggesting nonverbal synchrony is particularly important in interactions with Black patients. Next steps include investigating associations with patient outcomes (e.g., satisfaction). Findings could contribute to physician training.
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Background: Oncology nurses working across the cancer continuum need communication tools in order to navigate between oncology and palliative care for the benefit of patients and ...their families. An evidence-based communication training course funded by the National Cancer Institute and identified by the acronym COMFORT was provided to 187 oncology nurses across the nation. Launched in 2015, it is the first train-the-trainer communication training course for nurses and addresses communication across the cancer continuum. Methods: The curriculum, emphasizing team communication, teaches nurses how to provide life-altering news, assess patient/family health literacy needs, practice mindful communication, acknowledge family caregivers, and address communication openings and goals. The curriculum covers the continuum of cancer care (diagnosis, treatment, survivorship, recurrence, end of life). Two courses were held and participants were contacted at six months for follow-up evaluation. Results: Course participants reported teaching an additional 2,460 healthcare providers, primarily nurses (1,961) and physicians (264). On average, each participant trained 21 nurses and two physicians. The training manual, which was provided during the course, was used by 81% of course participants and was rated as effective (7.71 out of 10). The most commonly taught curriculum modules were Communication (25.5%), Mindful Communication (22.3%), Team Communication (18.5%), and Family Caregivers (11.4%). Course participants reported that their institution were most effective with communication during treatment (7.21 out of 10) and least effective communication occurred during bereavement (5.02), at time of death (5.97), through survivorship (5.63), and with patients facing end of life (6.09). Conclusions: The train-the-trainer model for communication training appears to be a viable and promising strategy for broadly teaching communication across the cancer continuum. Train-the-trainer is less costly than traditional on-site training methods and allows instruction to be tailored to address the institution’s least effective communication practices across the cancer continuum.
Financial toxicity affects 30–50% of people with cancer in the US. Although experts recommend patients and physicians discuss treatment cost, cost discussions occur infrequently. We pilot-tested the ...feasibility, acceptability and influence on outcomes of the DIScussions of COst (DISCO) App, a multi-level communication intervention designed to improve cost discussions and related outcomes.
While waiting to see their physician, patients (n = 32) used the DISCO App on a tablet. Physicians were given a cost discussion tip sheet. Clinic visits were video recorded and patients completed pre- and post-intervention measures of self-efficacy for managing costs, self-efficacy for interacting with physicians, cost-related distress, and perceptions of the DISCO App. Coders observed the recordings to determine the presence of cost discussions, initiators, and topics.
Most patients reported needing ≤15 min to use the DISCO App, and that it made it easier to ask cost-related questions. Findings showed increased self-efficacy for managing treatment costs (p = .02) and for interacting with physicians (p = .001). All visits included a cost discussion.
Prompting patients to discuss costs may improve cost treatment discussions and related outcomes.
An app-based and tailorable treatment-cost communication intervention is feasible, acceptable, and demonstrates promise in prompting cost discussions and improving outcomes.
Trial registration: Clinical Trials.gov registration number: NCT03676920 (September 19, 2018).
Background
Although communication quality is associated with patient outcomes, racial disparities in communication exist, disproportionately burdening Black patients. However, most communication ...research focuses on verbal behaviors in predominantly White patient populations. We used a newly developed and theory‐guided network analysis that examines the dynamic interplay and behavioral convergence and divergence between Black patients with cancer and their oncologists during cancer treatment discussions.
Methods
We applied a nonverbal behavioral coding system to thin slices of video recordings of Black patients and their oncologists discussing treatment. We then estimated 3 networks: 1) a temporal network to determine whether a nonverbal behavior predicts another nonverbal behavior at the next time point in an interaction, and how much each nonverbal behavior influences other nonverbal behaviors and is influenced by other nonverbal behaviors; 2) a contemporaneous network to determine whether a nonverbal behavior co‐occurs with other nonverbal behaviors at the same time point in an interaction; and 3) a between‐dyads network to examine the covariation between nonverbal behaviors across all dyads.
Results
Black patients (n = 74) and their non‐Black physicians (n = 15) showed a mix of convergence and divergence in their nonverbal behaviors at the same points in time, from one time point to the next, and across dyads. Across analyses, convergence was most likely to occur when physicians matched their behaviors to their patients; especially with smiling, gaze, leaning, and laughter behaviors.
Conclusion
Our findings reveal patterns of modifiable behaviors that can potentially inform interventions to reduce disparities in clinical communication and, in turn, treatment and mortality disparities.
A newly developed and theory‐guided network analysis effectively provides a way of describing and understanding the complex interplay between discrete nonverbal behaviors displayed by patients and oncologists and the patterns of mutual influence among them. Behavioral convergence or matching tends to occur most often when oncologists converge their behavior to their Black patients, which could have important implications for improving patient–oncologist communication.
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