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Original Investigation
October 30, 2019

Effectiveness of a Question Prompt List Intervention for Older Patients Considering Major Surgery: A Multisite Randomized Clinical Trial

Author Affiliations
  • 1Department of Surgery, University of Wisconsin–Madison, Madison
  • 2Department of Biostatistics & Medical Informatics, University of Wisconsin–Madison, Madison
  • 3Department of Population Health, The University of Texas at Austin, Austin
  • 4Division of Geriatrics, Department of Medicine, University of California, San Francisco
  • 5School of Medicine, Northwestern University, Evanston, Illinois
  • 6Department of Medicine, University of Wisconsin–Madison, Madison
  • 7Division of General Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
  • 8Adult Palliative Medicine Service, Division of Hematology/Oncology, Department of Medicine, Columbia University Medical Center, New York, New York
  • 9Department of Surgery, Rutgers New Jersey Medical School, Newark
  • 10Department of Surgery, University of California, San Francisco
  • 11Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
  • 12Department of Surgery, Oregon Health and Science University, Portland
JAMA Surg. 2020;155(1):6-13. doi:10.1001/jamasurg.2019.3778
Key Points

Question  Is a patient-mediated question prompt list intervention effective in improving patient engagement during preoperative visits and subsequent well-being?

Findings  In this randomized clinical trial of 40 surgeons and 446 patients, there was no difference in primary outcomes related to patient engagement or well-being. There was a significant difference in the change in rating of concerns reported by family members between 6 weeks after surgery and just after the surgical visit that was greater in usual care.

Meaning  This interventional study highlights the challenges of evaluating and changing patient-physician communication.


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 α = .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.

Trial Registration  ClinicalTrials.gov identifier: NCT02623335

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    1 Comment for this article
    Empowering patients to ask pre-operative questions
    Harald Aanning, MD | Retired general surgeon
    With the patient and family looking on as I wrote on a "Progress Sheet," I detailed the findings and reasons for the operation, then drew the operative stages, and finally listed the complications (with my own scores) - their detection and possible need for re-operation...

    The patient (and family) received copies as did both the hospital and clinic...

    The final result was that patients and their families were virtually always on the same page with me and the surgical environment and staff, especially when any complication arose...