Evaluating an Intervention to Improve Communication Between Oncology Clinicians and Patients With Life-Limiting Cancer: A Cluster Randomized Clinical Trial of the Serious Illness Care Program
Evaluating an Intervention to Improve Communication Between Oncology Clinicians and Patients With Life-Limiting Cancer: A Cluster Randomized Clinical Trial of the Serious Illness Care Program
复制标题
DOI：
10.1001/jamaoncol.2019.0292
复制
发表时间：
2019-06-01
期刊：
影响因子：
28.4
通讯作者：
Block, Susan D.
中科院分区：
文献类型：
--
作者：
Paladino, Joanna;Bernacki, Rachelle;Block, Susan D.
重要性早期临床医生与患者就严重疾病中的价值观、目标和偏好进行对话（即严重疾病对话）与更好的结果相关，但在癌症护理中却不一致。目的评估沟通质量改善干预措施在改善肿瘤临床医生和晚期癌症患者之间记录的严重疾病对话的发生率、时间、质量和可及性方面的有效性。设计、设置、参与者这项针对门诊肿瘤学的集群随机临床试验在丹娜—法伯癌症研究所进行，参与者包括医生、高级临床医生和死亡风险高的癌症患者。主要成果和措施主要成果（目标一致的护理和临终时的平静）已在其他地方发表。本文报告了次要结局，包括 (1) 死亡前至少 1 次严重疾病对话的记录，(2) 死亡前首次对话的时间安排，(3) 对话的质量，以及 (4) 电子病历 (EMR) 中对话的可访问性。结果我们招募了 91 名临床医生（48 名干预组，43 名对照者）和 278 名患者（134 名干预组，144 名对照者）。在入组患者中，58% 的患者在研究期间死亡 (n=161)；平均年龄为 62.3 岁（95% CI，58.9-65.6 岁）； 55% 是女性 (n=88)。这些患者由 91 名登记临床医生中的 76 名提供护理（37 名干预，39 名对照）；实践年数，11.5（95% CI，9.2-13.8）； 57% 为女性 (n=43)。患者死亡后的病历审查表明，与对照组相比，干预患者中记录讨论的比例显着更高（96% vs 79%，P=0.005），并且干预对话发生时间中位数提前 2.4 个月（中位数为 143 天 vs 71 天，P
ImportanceEarlier clinician-patient conversations about patients' values, goals, and preferences in serious illness (ie, serious illness conversations) are associated with better outcomes but occur inconsistently in cancer care. ObjectiveTo evaluate the efficacy of a communication quality-improvement intervention in improving the occurrence, timing, quality, and accessibility of documented serious illness conversations between oncology clinicians and patients with advanced cancer. Design, Setting, ParticipantsThis cluster randomized clinical trial in outpatient oncology was conducted at the Dana-Farber Cancer Institute and included physicians, advanced-practice clinicians, and patients with cancer who were at high risk of death. Main Outcomes and MeasuresThe primary outcomes (goal-concordant care and peacefulness at the end of life) are published elsewhere. Secondary outcomes are reported herein, including (1) documentation of at least 1 serious illness conversation before death, (2) timing of the initial conversation before death, (3) quality of conversations, and (4) their accessibility in the electronic medical record (EMR). ResultsWe enrolled 91 clinicians (48 intervention, 43 control) and 278 patients (134 intervention, 144 control). Of enrolled patients, 58% died during the study (n=161); mean age was 62.3 years (95% CI, 58.9-65.6 years); 55% were women (n=88). These patients were cared for by 76 of the 91 enrolled clinicians (37 intervention, 39 control); years in practice, 11.5 (95% CI, 9.2-13.8); 57% female (n=43). Medical record review after patients' death demonstrated that a significantly higher proportion of intervention patients had a documented discussion compared with controls (96% vs 79%, P=.005) and intervention conversations occurred a median of 2.4 months earlier (median, 143 days vs 71 days, P