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Original Investigation
January 2017

Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced CancerThe VOICE Randomized Clinical Trial

Author Affiliations
  • 1Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
  • 2Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
  • 3Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
  • 4James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York
  • 5Center for Healthcare Policy and Research, University of California, Davis, Sacramento
  • 6UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento
  • 7Department of Family and Community Medicine, University of California, Davis, Sacramento
  • 8Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
  • 9Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester, New York
  • 10Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana
  • 11Tulane Cancer Center, Tulane University, New Orleans, Louisiana
  • 12Department of Pediatrics, University of California, Davis, Sacramento
  • 13School of Nursing, University of Rochester, Rochester, New York
  • 14Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York
  • 15Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
  • 16Department of Internal Medicine, University of California, Davis, Sacramento
  • 17Department of Communication, Texas A & M University, College Station
  • 18Houston Center for Healthcare Innovation, Quality, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
  • 19Department of Medicine, Baylor College of Medicine, Houston, Texas
  • 20Human Development and Family Studies Department, Purdue University, West Lafayette, Indiana
  • 21Purdue University Center for Cancer Research, Purdue University, West Lafayette, Indiana
  • 22Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana
  • 23Center on Poverty and Health Inequities, Purdue University, West Lafayette, Indiana
  • 24College of Health of Human Sciences, Purdue University, West Lafayette, Indiana
  • 25Fred Hutchinson Cancer Research Center, University of Washington, Seattle
  • 26Cambia Palliative Care Center of Excellence, University of Washington, Seattle
  • 27Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, Australia
  • 28Psycho-oncology Co-operative Research Group, University of Sydney, Sydney, Australia
  • 29School of Psychology, University of Sydney, Sydney, Australia
  • 30Sydney Medical School, University of Sydney, Sydney, Australia
  • 31Royal Prince Alfred Hospital, Sydney, Australia
  • 32University of California, Davis School of Medicine, University of California, Davis, Sacramento
  • 34Department of Social Work, Strong Memorial Hospital, Rochester, New York
  • 35Division of General Medicine, University of California, Davis, Sacramento
JAMA Oncol. 2017;3(1):92-100. doi:10.1001/jamaoncol.2016.4373
Key Points

Question  Can communication between patients with advanced cancer and their oncologists be improved?

Findings  This cluster randomized clinical trial of communication training for oncologists paired with previsit coaching for patients showed clinically and statistically significant improvement in patient-centered communication.

Meaning  Paired communication training for patients and oncologists helps achieve patient-centered care in advanced cancer: engaging patients in consultations (asking questions, expressing preferences), responding to emotions, and providing information about prognosis and treatment choices.

Abstract

Importance  Observational studies demonstrate links between patient-centered communication, quality of life (QOL), and aggressive treatments in advanced cancer, yet few randomized clinical trials (RCTs) of communication interventions have been reported.

Objective  To determine whether a combined intervention involving oncologists, patients with advanced cancer, and caregivers would promote patient-centered communication, and to estimate intervention effects on shared understanding, patient-physician relationships, QOL, and aggressive treatments in the last 30 days of life.

Design, Setting, and Participants  Cluster RCT at community- and hospital-based cancer clinics in Western New York and Northern California; 38 medical oncologists (mean age 44.6 years; 11 (29%) female) and 265 community-dwelling adult patients with advanced nonhematologic cancer participated (mean age, 64.4 years, 146 [55.0%] female, 235 [89%] white; enrolled August 2012 to June 2014; followed for 3 years); 194 patients had participating caregivers.

Interventions  Oncologists received individualized communication training using standardized patient instructors while patients received question prompt lists and individualized communication coaching to identify issues to address during an upcoming oncologist visit. Both interventions focused on engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information. Control participants received no training.

Main Outcomes and Measures  The prespecified primary outcome was a composite measure of patient-centered communication coded from audio recordings of the first oncologist visit following patient coaching (intervention group) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QOL, and aggressive treatments and hospice use in the last 30 days of life.

Results  Data from 38 oncologists (19 randomized to intervention) and 265 patients (130 intervention) were analyzed. In fully adjusted models, the intervention resulted in clinically and statistically significant improvements in the primary physician-patient communication end point (adjusted intervention effect, 0.34; 95% CI, 0.06-0.62; P = .02). Differences in secondary outcomes were not statistically significant.

Conclusions and Relevance  A combined intervention that included oncologist communication training and coaching for patients with advanced cancer was effective in improving patient-centered communication but did not affect secondary outcomes.

Trial Registration  clinicaltrials.gov Identifier: NCT01485627

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