Effectiveness of a Question Prompt List Intervention for Older Patients Considering Major Surgery A Multisite Randomized Clinical Trial
Effectiveness of a Question Prompt List Intervention for Older Patients Considering Major Surgery A Multisite Randomized Clinical Trial
复制标题
DOI：
10.1001/jamasurg.2019.3778
复制
发表时间：
2020-01-01
期刊：
影响因子：
16.9
通讯作者：
Brasel, Karen J.
中科院分区：
文献类型：
--
作者：
Schwarze, Margaret L.;Buffington, Anne;Brasel, Karen J.
重要性术前沟通不良可能导致严重后果，包括不想要的治疗和术后冲突。目的比较问题提示表(QPL)干预与常规护理对老年大手术患者敬业度和幸福感的影响。设计、设置和参与者这项随机临床试验采用阶梯楔形设计，根据患者在美国5个研究地点的40名外科医生中的1名就诊的时间，随机分配患者接受QPL干预(n=223)或常规护理(n=223)。患者年龄在60岁或以上，至少有1例合并症，并有肿瘤或血管(心脏、神经外科或外周血管)问题，可以通过大手术进行治疗。家庭成员也参加了研究(n=263)。研究日期为2016年6月至2018年11月。数据分析采用意向处理。干预一份由患者和家庭利益相关者编写的向外科医生提出的11个问题的小册子，以及外科医生的背书在患者门诊前被发送给他们。主要结果和测量主要患者参与结果包括在手术访问期间提出的问题的数量和类型，以及在手术访问后评估的患者报告的医患互动量表中的感知效果。主要的幸福感结果包括(1)患者术后报告的自我测量担忧和幸福感(MYCaW)评分与手术访问后报告的评分之间的差异，以及(2)术后6至8周与治疗相关的后悔。结果在1319名符合参与条件的患者中，223人被随机分为QPL干预组和223人接受常规护理。446例患者中，平均年龄71.8岁(7.1岁)，男性249例(55.8%)。在意向治疗分析中，对于所有患者报告的主要结果，QPL干预和常规护理之间没有显著差异。家庭成员在日常护理中的MYCAW评分差异更大(效果估计为1.51；95%CI为0.28-2.74；P=0.008)。当QPL干预组被限制为有明确证据他们审查QPL的患者时，关于选项(优势比，1.88；95%可信区间，0.81-4.35；P=.16)、期望(优势比，1.59；95%可信区间，0.67-3.80；P=.29)和风险(优势比，2.41；95%可信区间，1.04-5.59；P=0.04)(名义阿尔法=0.01)的问题，效果大小没有显著增加。结论和相关性：这项研究的结果与初级患者的参与度和幸福感结果无关。如果不直接解决临床医生的沟通问题，改变患者与医生的沟通可能是困难的。
Importance Poor preoperative communication can have serious consequences, including unwanted treatment and postoperative conflict. Objective To compare the effectiveness of a question prompt list (QPL) intervention vs usual care on patient engagement and well-being among older patients considering major surgery. Design, Setting, and Participants This randomized clinical trial used a stepped-wedge design to randomly assign patients to a QPL intervention (n = 223) or usual care (n = 223) based on the timing of their visit with 1 of 40 surgeons at 5 US study sites. Patients were 60 years or older with at least 1 comorbidity and an oncologic or vascular (cardiac, neurosurgical, or peripheral vascular) problem that could be treated with major surgery. Family members were also enrolled (n = 263). The study dates were June 2016 to November 2018. Data analysis was by intent-to-treat. Interventions A brochure of 11 questions to ask a surgeon developed by patient and family stakeholders plus an endorsement letter from the surgeon were sent to patients before their outpatient visit. Main Outcomes and Measures Primary patient engagement outcomes included the number and type of questions asked during the surgical visit and patient-reported Perceived Efficacy in Patient-Physician Interactions scale assessed after the surgical visit. Primary well-being outcomes included (1) the difference between patient's Measure Yourself Concerns and Well-being (MYCaW) scores reported after surgery and scores reported after the surgical visit and (2) treatment-associated regret at 6 to 8 weeks after surgery. Results Of 1319 patients eligible for participation, 223 were randomized to the QPL intervention and 223 to usual care. Among 446 patients, the mean (SD) age was 71.8 (7.1) years, and 249 (55.8%) were male. On intent-to-treat analysis, there was no significant difference between the QPL intervention and usual care for all patient-reported primary outcomes. The difference in MYCaW scores for family members was greater in usual care (effect estimate, 1.51; 95% CI, 0.28-2.74; P = .008). When the QPL intervention group was restricted to patients with clear evidence they reviewed the QPL, a nonsignificant increase in the effect size was observed for questions about options (odds ratio, 1.88; 95% CI, 0.81-4.35; P = .16), expectations (odds ratio, 1.59; 95% CI, 0.67-3.80; P = .29), and risks (odds ratio, 2.41; 95% CI, 1.04-5.59; P = .04) (nominal alpha = .01). Conclusions and Relevance The results of this study were null related to primary patient engagement and well-being outcomes. Changing patient-physician communication may be difficult without addressing clinician communication directly.