Evaluating Physician Emotion Regulation in Serious Illness Conversations Using Multimodal Assessment.

CONTEXT: Emotion regulation by the physician can influence the effectiveness of serious illness conversations. The feasibility of multimodal assessment of emotion regulation during these conversations is unknown. OBJECTIVES: To develop and assess an experimental framework for evaluating physician emotion regulation during serious illness conversations. METHODS: We developed and then assessed a multimodal assessment framework for physician emotion regulation using a cross-sectional, pilot study on physicians trained in the Serious Illness Conversation Guide (SICG) in a simulated, telehealth encounter. Development of the assessment framework included a literature review and subject matter expert consultations. Our predefined feasibility endpoints included: an enrollment rate of ≥60% of approached physicians, >90% completion rate of survey items, and <20% missing data from wearable heart rate sensors. To describe physician emotion regulation, we performed a thematic analysis of the conversation, its documentation, and physician interviews. RESULTS: Out of 12 physicians approached, 11 (92%) SICG-trained physicians enrolled in the study: five medical oncology and six palliative care physicians. All 11 completed the survey (100% completion rate). Two sensors (chest band, wrist sensor) had <20% missing data during study tasks. The forearm sensor had >20% missing data. The thematic analysis found that physicians': 1) overarching goal was to move beyond prognosis to reasonable hope; 2) tactically focused on establishing a trusting, supportive relationship; and 3) possessed incomplete awareness of their emotion regulation strategies. CONCLUSION: Our novel, multimodal assessment of physician emotion regulation was feasible in a simulated SICG encounter. Physicians exhibited an incomplete understanding of their emotion regulation strategies.

Structure and integration of specialty palliative care in three NCI-designated cancer centers: a mixed methods case study.

INTRODUCTION: Early access to specialty palliative care is associated with better quality of life, less intensive end-of-life treatment and improved outcomes for patients with advanced cancer. However, significant variation exists in implementation and integration of palliative care. This study compares the organizational, sociocultural, and clinical factors that support or hinder palliative care integration across three U.S. cancer centers using an in-depth mixed methods case study design and proposes a middle range theory to further characterize specialty palliative care integration. METHODS: Mixed methods data collection included document review, semi-structured interviews, direct clinical observation, and context data related to site characteristics and patient demographics. A mixed inductive and deductive approach and triangulation was used to analyze and compare sites' palliative care delivery models, organizational structures, social norms, and clinician beliefs and practices. RESULTS: Sites included an urban center in the Midwest and two in the Southeast. Data included 62 clinician and 27 leader interviews, observations of 410 inpatient and outpatient encounters and seven non-encounter-based meetings, and multiple documents. Two sites had high levels of "favorable" organizational influences for specialty palliative care integration, including screening, policies, and other structures facilitating integration of specialty palliative care into advanced cancer care. The third site lacked formal organizational policies and structures for specialty palliative care, had a small specialty palliative care team, espoused an organizational identity linked to treatment innovation, and demonstrated strong social norms for oncologist primacy in decision making. This combination led to low levels of specialty palliative care integration and greater reliance on individual clinicians to initiate palliative care. CONCLUSION: Integration of specialty palliative care services in advanced cancer care was associated with a complex interaction of organization-level factors, social norms, and individual clinician orientation. The resulting middle range theory suggests that formal structures and policies for specialty palliative care combined with supportive social norms are associated with greater palliative care integration in advanced cancer care, and less influence of individual clinician preferences or tendencies to continue treatment. These results suggest multi-faceted efforts at different levels, including social norms, may be needed to improve specialty palliative care integration for advanced cancer patients.

Harnessing the Collective Expertise of Patients, Care Partners, Clinical Teams, and Researchers Through a Coproduction Learning Health System: A Case Study of the Dartmouth Health Promise Partnership.

The coproduction learning health system (CLHS) model extends the definition of a learning health system to explicitly bring together patients and care partners, health care teams, administrators, and scientists to share the work of optimizing health outcomes, improving care value, and generating new knowledge. The CLHS model highlights a partnership for coproduction that is supported by data that can be used to support individual patient care, quality improvement, and research. We provide a case study that describes the application of this model to transform care within an oncology program at an academic medical center.

Interdisciplinary Approach and Patient/Family Partners to Improve Serious Illness Conversations in Outpatient Oncology.

PURPOSE: We aimed to increase Serious Illness Conversations (SIC) from a baseline of, at or near, zero to 25% of eligible patients by December 31, 2020. METHODS: We assembled an interdisciplinary team inclusive of a family partner and used the Model for Improvement as our quality improvement framework. The team developed a SMART Aim, key driver diagram, and SIC workflow. Standardized screening for SIC eligibility was implemented using the 2-year surprise question. Team members were trained in SIC communication skills by a trained facilitator and received ongoing coaching in quality improvement. We performed Plan-Do-Study-Act cycles and used audit-feedback data in weekly team meetings to inform iterative Plan-Do-Study-Act cycles. The primary outcome was the percent of eligible patients with documented SIC. RESULTS: Over 18 months, three clinics identified 63 eligible patients; of these, 32 (51%) were diagnosed with head and neck cancer and 31 (49%) with sarcoma. The SIC increased from a baseline near zero to 43 of 63 (70%) patients demonstrating three shifts in the median (95% CI). Conversations were interdisciplinary with 25 (57%) by oncology MD, six (14%) by advanced practice registered nurse, and 13 (30%) by specialty palliative care. We targeted four key drivers: (1) standardized work, (2) engaged interdisciplinary team, (3) engaged patients and families, and (4) system-level support. CONCLUSION: Our approach was successful in its documentation of end points and required resource investment (training and time) to embed into team workflows. Future work will evaluate scaling the approach across multiple clinics, the patient experience, and outcomes of care associated with oncology clinician-led SIC.

Systemic Therapy Decision Making in Advanced Cancer: A Qualitative Analysis of Patient-Oncologist Encounters.

PURPOSE: We sought to characterize patient-oncologist communication and decision making about continuing or limiting systemic therapy in encounters after an initial consultation, with a particular focus on whether and how oncologists foster shared decision making (SDM). METHODS: We performed content analysis of outpatient oncology encounters at two US National Cancer Institute-designated cancer centers audio recorded between November 2010 and September 2014. A multidisciplinary team used a hybrid approach of inductive and deductive coding and theme development. We used a combination of random and purposive sampling. We restricted quantitative frequency counts to the coded random sample but included all sampled encounters in qualitative thematic analysis. RESULTS: Among 31 randomly sampled dyads with three encounters each, systemic therapy decision making was discussed in 90% (84 of 93) encounters. Thirty-four (37%) broached limiting therapy, which 27 (79%) framed as temporary, nine (26%) as completion of a standard regimen, and five (15%) as permanent discontinuation. Thematic analysis of these 93 encounters, plus five encounters purposively sampled for permanent discontinuation, found that (1) patients and oncologists framed continuing therapy as the default, (2) deficiencies in the SDM process (facilitating choice awareness, discussing options, and incorporating patient preferences) contributed to this default, and (3) oncologists use persuasion rather than deliberation when broaching discontinuation. CONCLUSION: In this study of outpatient encounters between patients with advanced cancer and their oncologists, when discussing systemic therapy, there exists a default to continue systemic therapy, and deficiencies in SDM contribute to this default.

Implementation and Impact of a Serious Illness Communication Training for Hematology-Oncology Fellows.

Effective communication between providers and patients with serious illness is critical to ensure that treatment is aligned with patient goals. We developed and tested an implementation strategy for incorporating the previously developed Serious Illness Conversation Guide (SICG), a clinician script, into hematology-oncology fellowship training at a single US academic medical center. Between December 2017 and April 2018, we trained 8 oncology fellows to use and document the SICG. The training included associated communication skills-such as handling emotion and headlining-over 7 didactic sessions. Implementation strategies included training 4 oncology faculty as coaches to re-enforce fellows' skills and an electronic medical record template to document the SICG. We assessed effectiveness using 4 approaches: (1) SICG template use among fellows in the 12 months following training, (2) fellow confidence pre- and post-intervention via survey, (3) performance in 2 simulated patient encounters, and (4) semi-structured interviews after 12 months. Fellows successfully implemented the SICG in simulated patient encounters, though only 2 of 6 fellows documented any SICG in the clinical practice. Most fellows reported greater confidence in their communication after training. Thematic analysis of interviews revealed the following: (1) positive training experience, (2) improved patient preference elicitation, (3) selected SICG components used in a single encounter, (4) prioritize other clinical duties, (5) importance of emotion handling skills, (6) no faculty coaching receive outside training. Despite acquisition of communication skills, promoting new clinical behaviors remains challenging. More work is needed to identify which implementation strategies are required in this learner population.

Impact of neuroimaging in the pretreatment evaluation of early stage non-small cell lung cancer.

BACKGROUND: There are limited data and conflicting guideline recommendations regarding the role of neuroimaging in the pretreatment evaluation of non-small cell lung cancer (NSCLC). METHODS: We performed a retrospective, pragmatic cohort study of patients with NSCLC diagnosed between January 1 and December 31, 2015. Eligible patients were identified from an institutional tumor registry. We collected all records of pretreatment neuroimaging within 12 weeks of diagnosis, including CT head (CT) and MRI brain (MRI). We abstracted the indication for neuroimaging, presence of central neurologic symptoms and cancer stage (with and without neuroimaging findings) from the tumor registry and the electronic health record. RESULTS: We identified 216 evaluable patients with newly diagnosed NSCLC. 157 of 216 patients (72.7%) underwent neuroimaging as part of initial staging, and 41 (26%) were found to have brain metastases. Of 43 patients with central neurologic symptoms at the time of neuroimaging, 28 (67%) had brain metastasis. In patients without central neurologic symptoms, brain metastases were discovered in 0 of 33 patients with clinical stage I or II, 4 of 36 (11%) with clinical stage III and 9 of 45 (20%) with clinical stage IV disease. CONCLUSIONS: In patients with early stage NSCLC (i.e. clinical stage I and II) without central neurologic symptoms, brain metastases are unlikely. The continued use of neuroimaging in the pretreatment evaluation of clinical stage I patients without central neurologic symptoms is not needed.

End-of-life quality metrics among medicare decedents at minority-serving cancer centers: A retrospective study.

BACKGROUND: We calculated the performance of National Cancer Institute (NCI)/National Comprehensive Cancer Network (NCCN) cancer centers' end-of-life (EOL) quality metrics among minority and white decedents to explore center-attributable sources of EOL disparities. METHODS: We conducted a retrospective cohort study of Medicare beneficiaries with poor-prognosis cancers who died between April 1, 2016 and December 31, 2016 and had any inpatient services in the last 6 months of life. We attributed patients' EOL treatment to the center at which they received the preponderance of EOL inpatient services and calculated eight risk-adjusted metrics of EOL quality (hospice admission ≤3 days before death; chemotherapy last 14 days of life; ≥2 emergency department (ED) visits; intensive care unit (ICU) admission; or life-sustaining treatment last 30 days; hospice referral; palliative care; advance care planning last 6 months). We compared performance between patients across and within centers. RESULTS: Among 126,434 patients, 10,119 received treatment at one of 54 NCI/NCCN centers. In aggregate, performance was worse among minorities for ED visits (10.3% vs 7.4%, P < .01), ICU admissions (32.9% vs 30.4%, P = .03), no hospice referral (39.5% vs 37.0%, P = .03), and life-sustaining treatment (19.4% vs 16.2%, P < .01). Despite high within-center correlation for minority and white metrics (0.61-0.79; P < .01), five metrics demonstrated worse performance as the concentration of minorities increased: ED visits (P = .03), ICU admission (P < .01), no hospice referral (P < .01), and life-sustaining treatments (P < .01). CONCLUSION: EOL quality metrics vary across NCI/NCCN centers. Within center, care was similar for minority and white patients. Minority-serving centers had worse performance on many metrics.