Dataset Information

Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes.

ABSTRACT:

Background

Several clinician training interventions have been developed in the past decade to address serious illness communication. While numerous studies report on clinician attitudes and confidence, little is reported on individual education modalities and their impact on actual behavior change and patient outcomes.

Aim

To examine what is known about the education modalities used in serious illness communication training and their impact on clinician behaviors and patient outcomes.

Design

A scoping review using the Joanna Briggs Methods Manual for Scoping Reviews was conducted to examine studies measuring clinician behaviors or patient outcomes.

Data sources

Ovid MEDLINE and EMBASE databases were searched for English-language studies published between January 2011 and March 2023.

Results

The search identified 1317 articles: 76 met inclusion criteria describing 64 unique interventions. Common education modalities used were: single workshop (n = 29), multiple workshops (n = 11), single workshop with coaching (n = 7), and multiple workshops with coaching (n = 5); though they were inconsistently structured. Studies reporting improved clinician skills tended to be in simulation settings with neither clinical practice nor patient outcomes explored. While some studies reported behavior changes or improved patient outcomes, they did not necessarily confirm improvements in clinician skills. As multiple modalities were commonly used and often embedded within quality improvement initiatives, the impact of individual modalities could not be determined.

Conclusion

This scoping review of serious illness communication interventions found heterogeneity among education modalities used and limited evidence supporting their effectiveness in impacting patient-centered outcomes and long-term clinician skill acquisition. Well-defined educational modalities and consistent measures of behavior change and standard patient-centered outcomes are needed.

SUBMITTER: Lavecchia M

PROVIDER: S-EPMC10865772 | biostudies-literature | 2024 Feb

REPOSITORIES: biostudies-literature

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Publications

Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes.

Lavecchia Melissa M Myers Jeff J Bainbridge Daryl D Incardona Nadia N Levine Oren O Steinberg Leah L Schep Daniel D Vautour Joanna J Kumar Shilpa Jyothi SJ Seow Hsien H

Palliative medicine 20230709 2

<h4>Background</h4>Several clinician training interventions have been developed in the past decade to address serious illness communication. While numerous studies report on clinician attitudes and confidence, little is reported on individual education modalities and their impact on actual behavior change and patient outcomes.<h4>Aim</h4>To examine what is known about the education modalities used in serious illness communication training and their impact on clinician behaviors and patient outco ...[more]

PMID: 37424275

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Project description:ImportanceHigh-quality, person-centered patient-clinician communication is critical in health care and may be less effective for patients with serious illness. Little is understood about differences in patient-clinician communication experiences of adults with and without serious illness.ObjectivesTo determine whether perceptions of patient-clinician communication experiences differ between adults with and without serious illness.Design, setting, and participantsThis population-based cross-sectional survey was fielded from April 20 to May 31, 2021, and data were analyzed from January 27, 2023, to December 10, 2024. Participants included a nationally representative sample of US English- or Spanish-speaking adults, including people from historically marginalized groups (eg, Black and Hispanic or Latino individuals, people with low income), responding to an online or telephone survey.ExposureParticipants were categorized by serious illness status. Participants with serious illness replied yes to (1) having a diagnosis from a list of medical conditions and (2) reporting feeling sicker or having decreased functionality during the last year.Main outcomes and measuresThe survey asked about community partner-derived measures of patient-clinician communication experiences, including trusting clinicians, feeling afraid to speak up, and being unsure about next steps. Multivariable logistic regression models were used to estimate the association of serious illness with these communication experiences, adjusting for sociodemographic characteristics. Percentages were weighted according to the National Opinion Research Center's statistical weighting methods to account for differences in nonresponse.ResultsOf 6126 individuals invited, 1847 (30.2%) completed the survey and were included in analysis (mean [SD] age, 48.4 [17.5] years); 950 (51.8%) identified as female; 191 (11.9%) identified as Black and 287 (16.7%) as Hispanic; and 434 (17.8%) had an annual income less than $30 000 (here called low income). Among respondents, 363 participants (18.5%) had serious illness (mean [SD] age, 50.2 [18.1] years; 218 [64.5%] female; 34 [12.4%] Black; 54 [16.4%] Hispanic; 131 [27.3%] with low income), and 1484 (81.5%) had no serious illness (mean [SD] age, 48.0 [17.4] years; 732 [48.9%] female; 157 [11.8%] Black; 233 [16.7%] Hispanic; 303 [15.6%] with low income). Compared with adults without serious illness, adults with serious illness were more likely to report leaving a visit unsure about next steps (adjusted odds ratio [AOR], 2.30; 95% CI, 1.62-3.27); being afraid to ask questions or speak up (AOR, 2.18; 95% CI, 1.55-3.08); believing they were talked down to or made to feel inferior (AOR, 1.90; 95% CI, 1.24-2.91); and believing that they were treated unfairly by clinicians (AOR, 3.26; 95% CI, 2.43-4.38).Conclusions and relevanceIn this cross-sectional study, adults with serious illness more often had worse patient-clinician communication experiences. Further research is needed to better understand and develop interventions to improve perceptions of patient-clinician communication experiences for adults with serious illness.

Project description:ImportanceBlack patients with serious illness experience higher-intensity care at the end of life. Little research has used critical, race-conscious approaches to examine factors associated with these outcomes.ObjectiveTo investigate the lived experiences of Black patients with serious illness and how various factors may be associated with patient-clinician communication and medical decision-making.Design, setting, and participantsIn this qualitative study, one-on-one, semistructured interviews were conducted with 25 Black patients with serious illness hospitalized at an urban academic medical center in Washington State between January 2021 and February 2023. Patients were asked to discuss experiences with racism, how those experiences affected the way they communicated with clinicians, and how racism impacted medical decision-making. Public Health Critical Race Praxis was used as framework and process.Main outcomes and measuresThe experience and of racism and its association, as described by Black patients who had serious illness, with patient-clinician communication and medical decision-making within a racialized health care setting.ResultsA total of 25 Black patients (mean [SD] age, 62.0 [10.3] years; 20 males [80.0%]) with serious illness were interviewed. Participants had substantial socioeconomic disadvantage, with low levels of wealth (10 patients with 0 assets [40.0%]), income (annual income <$25 000 among 19 of 24 patients with income data [79.2%]), educational attainment (mean [SD] 13.4 [2.7] years of schooling), and health literacy (mean [SD] score in the Rapid Estimate of Adult Literacy in Medicine-Short Form, 5.8 [2.0]). Participants reported high levels of medical mistrust and high frequency of discrimination and microaggressions experienced in health care settings. Participants reported epistemic injustice as the most common manifestation of racism: silencing of their own knowledge and lived experiences about their bodies and illness by health care workers. Participants reported that these experiences made them feel isolated and devalued, especially if they had intersecting, marginalized identities, such as being underinsured or unhoused. These experiences were associated with exacerbation of existing medical mistrust and poor patient-clinician communication. Participants described various mechanisms of self-advocacy and medical decision-making based on prior experiences with mistreatment from health care workers and medical trauma.Conclusions and relevanceThis study found that Black patients' experiences with racism, specifically epistemic injustice, were associated with their perspectives on medical care and decision-making during serious illness and end of life. These findings suggest that race-conscious, intersectional approaches may be needed to improve patient-clinician communication and support Black patients with serious illness to alleviate the distress and trauma of racism as these patients near the end of life.

Project description:ImportanceClinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication.ObjectiveTo evaluate the efficacy of a patient-specific preconversation communication-priming intervention (Jumpstart-Tips) targeting both patients and clinicians and designed to increase goals-of-care conversations compared with usual care.Design, setting, and participantsMulticenter cluster-randomized trial in outpatient clinics with physicians or nurse practitioners and patients with serious illness. The study was conducted between 2012 and 2016.InterventionsClinicians were randomized to the bilateral, preconversation, communication-priming intervention (n = 65) or usual care (n = 67), with 249 patients assigned to the intervention and 288 to usual care.Main outcomes and measuresThe primary outcome was patient-reported occurrence of a goals-of-care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals-of-care conversation in the medical record and patient-reported quality of communication (Quality of Communication questionnaire [QOC]; 4-indicator latent construct) at 2 weeks, as well as patient assessments of goal-concordant care at 3 months and patient-reported symptoms of depression (8-item Patient Health Questionnaire; PHQ-8) and anxiety (7-item Generalized Anxiety Disorder survey; GAD-7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for confounders.ResultsWe enrolled 132 of 485 potentially eligible clinicians (27% participation; 71 women [53.8%]; mean [SD] age, 47.1 [9.6] years) and 537 of 917 eligible patients (59% participation; 256 women [47.7%]; mean [SD] age, 73.4 [12.7] years). The intervention was associated with a significant increase in a goals-of-care discussion at the target visit (74% vs 31%; P < .001) and increased medical record documentation (62% vs 17%; P < .001), as well as increased patient-rated quality of communication (4.6 vs 2.1; P = .01). Patient-assessed goal-concordant care did not increase significantly overall (70% vs 57%; P = .08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = .03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months.Conclusions and relevanceThis intervention increased the occurrence, documentation, and quality of goals-of-care communication during routine outpatient visits and increased goal-concordant care at 3 months among patients with stable goals, with no change in symptoms of anxiety or depression. Understanding the effect on subsequent health care delivery will require additional study.Trial registrationClinicalTrials.gov identifier: NCT01933789.

Project description:ImportanceCommunication about end-of-life care is a core clinical skill. Simulation-based training improves skill acquisition, but effects on patient-reported outcomes are unknown.ObjectiveTo assess the effects of a communication skills intervention for internal medicine and nurse practitioner trainees on patient- and family-reported outcomes.Design, setting, and participantsRandomized trial conducted with 391 internal medicine and 81 nurse practitioner trainees between 2007 and 2013 at the University of Washington and Medical University of South Carolina.InterventionParticipants were randomized to an 8-session, simulation-based, communication skills intervention (N = 232) or usual education (N = 240).Main outcomes and measuresPrimary outcome was patient-reported quality of communication (QOC; mean rating of 17 items rated from 0-10, with 0 = poor and 10 = perfect). Secondary outcomes were patient-reported quality of end-of-life care (QEOLC; mean rating of 26 items rated from 0-10) and depressive symptoms (assessed using the 8-item Personal Health Questionnaire [PHQ-8]; range, 0-24, higher scores worse) and family-reported QOC and QEOLC. Analyses were clustered by trainee.ResultsThere were 1866 patient ratings (44% response) and 936 family ratings (68% response). The intervention was not associated with significant changes in QOC or QEOLC. Mean values for postintervention patient QOC and QEOLC were 6.5 (95% CI, 6.2 to 6.8) and 8.3 (95% CI, 8.1 to 8.5) respectively, compared with 6.3 (95% CI, 6.2 to 6.5) and 8.3 (95% CI, 8.1 to 8.4) for control conditions. After adjustment, comparing intervention with control, there was no significant difference in the QOC score for patients (difference, 0.4 points [95% CI, -0.1 to 0.9]; P = .15) or families (difference, 0.1 [95% CI, -0.8 to 1.0]; P = .81). There was no significant difference in QEOLC score for patients (difference, 0.3 points [95% CI, -0.3 to 0.8]; P = .34) or families (difference, 0.1 [95% CI, -0.7 to 0.8]; P = .88). The intervention was associated with significantly increased depression scores among patients of postintervention trainees (mean score, 10.0 [95% CI, 9.1 to 10.8], compared with 8.8 [95% CI, 8.4 to 9.2]) for control conditions; adjusted model showed an intervention effect of 2.2 (95% CI, 0.6 to 3.8; P = .006).Conclusions and relevanceAmong internal medicine and nurse practitioner trainees, simulation-based communication training compared with usual education did not improve quality of communication about end-of-life care or quality of end-of-life care but was associated with a small increase in patients' depressive symptoms. These findings raise questions about skills transfer from simulation training to actual patient care and the adequacy of communication skills assessment.Trial registrationclinicaltrials.gov Identifier: NCT00687349.

Project description:ObjectiveCommunication about patients' values, goals, and prognosis in serious illness (serious illness communication) is a cornerstone of person-centered care yet difficult to implement in practice. As part of Serious Illness Care Program implementation in five health systems, we studied the clinical culture-related factors that supported or impeded improvement in serious illness conversations.MethodsQualitative analysis of semi-structured interviews of clinical leaders, implementation teams, and frontline champions.ResultsWe completed 30 interviews across palliative care, oncology, primary care, and hospital medicine. Participants identified four culture-related domains that influenced serious illness communication improvement: (1) clinical paradigms; (2) interprofessional empowerment; (3) perceived conversation impact; (4) practice norms. Changes in clinicians' beliefs, attitudes, and behaviors in these domains supported values and goals conversations, including: shifting paradigms about serious illness communication from 'end-of-life planning' to 'knowing and honoring what matters most to patients;' improvements in psychological safety that empowered advanced practice clinicians, nurses and social workers to take expanded roles; experiencing benefits of earlier values and goals conversations; shifting from avoidant norms to integration norms in which earlier serious illness discussions became part of routine processes. Culture-related inhibitors included: beliefs that conversations are about dying or withdrawing care; attitudes that serious illness communication is the physician's job; discomfort managing emotions; lack of reliable processes.ConclusionsAspects of clinical culture, such as paradigms about serious illness communication and inter-professional empowerment, are linked to successful adoption of serious illness communication. Further research is warranted to identify effective strategies to enhance clinical culture and drive clinician practice change.

Project description:Background: Natural language processing (NLP), a form of computer-assisted data abstraction, rapidly identifies serious illness communication domains such as code-status confirmation and goals of care (GOC) discussions within free-text notes, using a codebook of phrases. Differences in the phrases associated with palliative care for patients with different types of illness are unknown. Objective: To compare communication of code-status clarification and GOC discussions between patients with advanced pancreatic cancer undergoing palliative procedures and patients admitted with life-threatening trauma. Design: Retrospective cohort study. Setting/Subjects: Patients with in-hospital admissions within two academic medical centers. Measurements: Sensitivity and specificity of NLP-identified communication domains compared with manual review. Results: Among patients with advanced pancreatic cancer (n = 523), NLP identified code-status clarification in 54% of admissions and GOC discussions in 49% of admissions. The sensitivity and specificity for code-status clarification were 94% and 99% respectively, while the sensitivity and specificity for a GOC discussion were 93% and 100%, respectively. Using the same codebook in patients with life-threatening trauma (n = 2093), NLP identified code-status clarification in 25.9% of admissions and GOC discussions in 6.3% of admissions. While NLP identification had 100% specificity, the sensitivity for code-status clarification and GOC discussion was reduced to 86% and 50%, respectively. Adding dynamic phrases such as "ongoing discussions" and phrases related to "family meetings" increased the sensitivity of the NLP codebook for code status to 98% and for GOC discussions to 100%. Conclusions: Communication of code status and GOC differ between patients with advanced cancer and those with life-threatening trauma. Recognition of these differences can aid in identification in patterns of palliative care delivery.

Dataset Information

Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes.

Background

Aim

Design

Data sources

Results

Conclusion

Publications

Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes.

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