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Original Investigation
March 14, 2019

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

Author Affiliations
  • 1Harvard Medical School, Boston, Massachusetts
  • 2Ariadne Labs, Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 3Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 4Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
  • 5Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia
  • 6Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
  • 7Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Oncol. 2019;5(6):801-809. doi:10.1001/jamaoncol.2019.0292
Key Points

Question  Does a communication quality-improvement intervention improve the occurrence, timing, quality, and electronic medical record accessibility of documented conversations about values, goals, and preferences (ie, serious illness conversations) between oncology clinicians and patients with advanced cancer?

Findings  In this cluster randomized clinical trial of 91 clinicians and 278 patients, the intervention resulted in more, earlier, and better serious illness conversations with clinicians for patients with advanced cancer, in addition to more accessible documentation of patient goals, in the face of life-limiting illness.

Meaning  A communication quality-improvement intervention that provides clinical tools, clinician training, and system changes can bring about meaningful improvement in timely, comprehensive serious illness conversations between patients and primary oncology clinicians.

Abstract

Importance  Earlier 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.

Objective  To 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, Participants  This 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 Measures  The 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).

Results  We 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 < .001). Conversation documentation for intervention patients was significantly more comprehensive and patient centered, with a greater focus on values or goals (89% vs 44%, P < .001), prognosis or illness understanding (91% vs 48%, P < .001), and life-sustaining treatment preferences (63% vs 32%, P = .004). Documentation about end-of-life care planning did not differ between arms (80% intervention vs 68% control, P = .08). Significantly more intervention patients had documentation that was accessible in the EMR (61% vs 11%, P < .001).

Conclusions and Relevance  This communication quality-improvement intervention resulted in more, earlier, better, and more accessible serious illness conversations documented in the EMR. To our knowledge, this is the first such study to demonstrate improvement in all 4 of these outcomes.

Trial Registration  ClinicalTrials.gov identifier: NCT01786811

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