Variation in question asking during cancer clinical interactions: a potential source of disparities in access to information

Reducing Health Disparities Among African American and Black Caribbean Patients by Improving the Communication Practices of Clinical Research Coordinators

This manuscript focuses on the communication factors that affect the willingness of African Americans and Black Caribbean patients to participate in clinical trials and research studies. Low rates of research participation by members of communities of color have long been linked to health disparities. While there are many factors that contribute to low rates of accrual of African American and Black patients to clinical trials, a lack of attention to communication factors that enhance or inhibit the recruitment process is central to the problem. In this study, we describe results from the analysis of six focus groups (N = 31) consisting of African American (k = 3) and Black Caribbean (k = 3) participants. Our analyses focus on verbal and nonverbal communication behaviors and how they affect participants' willingness to participate in clinical trials. Specifically, when clinical research coordinators (CRCs) had a professional appearance, made the effort to explain a study in detail, made eye contact, took the time to listen and answer questions patiently, and gave the sense that the CRC was being truthful and transparent, patients felt respected and valued. Additionally, participants emphasized the importance of the process of developing and maintaining a trusting relationship between study participants and CRCs. The results of this study will be used to develop a clinical trial communication training program designed to enhance the communication skills of clinical research coordinators who discuss research participation with African American and Caribbean Black patients.

Racial Disparities in Prostate Cancer Screening: The Role of Shared Decision Making

INTRODUCTION

The 2018 U.S. Preventive Services Task Force recommendations endorsed shared decision making for men aged 55-69 years, encouraging consideration of patient race/ethnicity for prostate-specific antigen screening. This study aimed to assess whether a proxy shared decision-making variable modified the impact of race/ethnicity on the likelihood of prostate-specific antigen screening.

METHODS

A cross-sectional analysis of men aged between 55 and 69 years, who responded to the prostate-specific antigen screening portions of the 2020 U.S.-based Behavioral Risk Factor Surveillance System survey, was performed between September and December 2022. Complex sample multivariable logistic regression models with an interaction term combining race and estimated shared decision making were used to test whether shared decision making modified the impact of race/ethnicity on screening.

RESULTS

Of a weighted sample of 26.8 million men eligible for prostate-specific antigen screening, 25.7% (6.9 million) reported for prostate-specific antigen screening. In adjusted analysis, estimated shared decision making was a significant predictor of prostate-specific antigen screening (AOR=2.65, 95% CI=2.36, 2.98, p<0.001). The interaction between race/ethnicity and estimated shared decision making on the receipt of prostate-specific antigen screening was significant (pint=0.001). Among those who did not report estimated shared decision making, both non-Hispanic Black (OR=0.77, 95% CI=0.61, 0.97, p=0.026) and Hispanic (OR=0.51, 95% CI=0.39, 0.68, p<0.001) men were significantly less likely to undergo prostate-specific antigen screening than non-Hispanic White men. On the contrary, among respondents who reported estimated shared decision making, no race-based differences in prostate-specific antigen screening were found.

CONCLUSIONS

Although much disparities research focuses on race-based differences in prostate-specific antigen screening, research on strategies to mitigate these disparities is needed. Shared decision making might attenuate the impact of race/ethnic disparities on the likelihood of prostate-specific antigen screening.

Patient and caregiver questions and clinician responses during initial outpatient neuropalliative care appointments

Objective

Open communication during appointments exemplifies person-centered care. The current study characterized questions asked by persons with neurologic illnesses and their caregivers-and clinicians' responses to those questions-during initial outpatient palliative care appointments.

Methods

We coded type (direct or indirect) and topic of questions stated by patients and their caregivers in audio recordings from 38 initial outpatient palliative care appointments. We also coded the completeness and quality features of clinicians' responses.

Results

Patients and caregivers stated 556 total questions; most were direct questions (79.7%) and primarily about symptoms, treatment, and lifestyle issues. Clinicians responded to more than 90% of all questions. Responses to both question types were similar in completeness and quality, but clinicians more frequently offered support in response to direct questions and gave recommendations in response to indirect questions.

Conclusion

Persons with neurologic illnesses and their caregivers use different question types to obtain information about symptoms and treatment during initial palliative care appointments. Results may guide clinician training and patient education for optimizing information exchange in palliative care.

Innovation

This study is the first to explore patient and caregiver use of indirect questions in neuropalliative care appointments and the quality of clinicians' responses to those questions.

Evaluation of a Novel Question Prompt List in Pediatric Surgical Oncology

INTRODUCTION

Parents of children with cancer describe interactions with clinicians as emotionally distressing. Patient engagement in treatment discussions decreases decisional conflict and improves decision quality which may limit such distress. We have shown that parents prefer to engage surgeons by asking questions, but parents may not know what to ask. Question Prompt Lists (QPLs), structured lists of questions designed to help patients ask important questions, have not been studied in pediatric surgery. We developed a QPL designed to empower parents to ask meaningful questions during pediatric surgical oncology discussions. We conducted a mixed methods analysis to assess the acceptability, appropriateness, and feasibility of using the QPL.

METHODS

Key stakeholders at an academic children's hospital participated in focus groups to discuss the QPL. Focus groups were recorded and transcribed. Participants were surveyed regarding QPL acceptability, appropriateness, and feasibility. Thematic content analysis of transcripts was performed.

RESULTS

Four parents, five nurses, five nurse practitioners, five oncologists, and four surgeons participated. Seven key themes were identified: (1) QPL as a tool of empowerment; (2) stick to the surgical details; (3) QPLs can impact discussion quality; (4) time consuming, but not overly disruptive; (5) parental emotion may impact QPL use; (6) provide QPLs prior to surgical consultation in both print and digital formats; and (7) expansion of QPLs to other disciplines. Over 70% of participants agreed that the QPL was acceptable, appropriate, and feasible.

CONCLUSIONS

Our novel QPL is acceptable, appropriate, and feasible to use with parents of pediatric surgical oncology patients.

Proactively tailoring implementation: the case of shared decision-making for lung cancer screening across the VA New England Healthcare Network

BACKGROUND

Shared Decision-Making to discuss how the benefits and harms of lung cancer screening align with patient values is required by the US Centers for Medicare and Medicaid and recommended by multiple organizations. Barriers at organizational, clinician, clinical encounter, and patient levels prevent SDM from meeting quality standards in routine practice. We developed an implementation plan, using the socio-ecological model, for Shared Decision-Making for lung cancer screening for the Department of Veterans Affairs (VA) New England Healthcare System. Because understanding the local context is critical to implementation success, we sought to proactively tailor our original implementation plan, to address barriers to achieving guideline-concordant lung cancer screening.

METHODS

We conducted a formative evaluation using an ethnographic approach to proactively identify barriers to Shared Decision-Making and tailor our implementation plan. Data consisted of qualitative interviews with leadership and clinicians from seven VA New England medical centers, regional meeting notes, and Shared Decision-Making scripts and documents used by providers. Tailoring was guided by the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS).

RESULTS

We tailored the original implementation plan to address barriers we identified at the organizational, clinician, clinical encounter, and patient levels. Overall, we removed two implementation strategies, added five strategies, and modified the content of two strategies. For example, at the clinician level, we learned that past personal and clinical experiences predisposed clinicians to focus on the benefits of lung cancer screening. To address this barrier, we modified the content of our original implementation strategy Make Training Dynamic to prompt providers to self-reflect about their screening beliefs and values, encouraging them to discuss both the benefits and potential harms of lung cancer screening.

CONCLUSIONS

Formative evaluations can be used to proactively tailor implementation strategies to fit local contexts. We tailored our implementation plan to address unique barriers we identified, with the goal of improving implementation success. The FRAME-IS aided our team in thoughtfully addressing and modifying our original implementation plan. Others seeking to maximize the effectiveness of complex interventions may consider using a similar approach.

Identifying, Understanding, and Addressing Disparities in Glaucoma Care in the United States

Glaucoma is the leading cause of irreversible blindness worldwide, currently affecting around 80 million people. Glaucoma prevalence is rapidly rising in the United States due to an aging population. Despite recent advances in the diagnosis and treatment of glaucoma, significant disparities persist in disease detection, management, and outcomes among the diverse patient populations of the United States. Research on disparities is critical to identifying, understanding, and addressing societal and healthcare inequalities. Disparities research is especially important and impactful in the context of irreversible diseases such as glaucoma, where earlier detection and intervention are the primary approach to improving patient outcomes. In this article, we first review recent studies identifying disparities in glaucoma care that affect patient populations based on race, age, and gender. We then review studies elucidating and furthering our understanding of modifiable factors that contribute to these inequities, including socioeconomic status (particularly age and education), insurance product, and geographic region. Finally, we present work proposing potential strategies addressing disparities in glaucoma care, including teleophthalmology and artificial intelligence. We also discuss the presence of non-modifiable factors that contribute to differences in glaucoma burden and can confound the detection of glaucoma disparities.

Translational Relevance

By recognizing underlying causes and proposing potential solutions, healthcare providers, policymakers, and other stakeholders can work collaboratively to reduce the burden of glaucoma and improve visual health and clinical outcomes in vulnerable patient populations.

Fertility Preservation Decisional Turning Points for Adolescents and Young Adults With Cancer: Exploring Alignment and Divergence by Race and Ethnicity

PURPOSE

For adolescents and young adults (AYAs) with cancer, fertility preservation (FP) decision making is complex and distressing. Racial/ethnic minority (REM) AYAs experience disparities in FP awareness, uptake, and outcomes. A turning point (TP) is a point of reflection, change, or decisive moment(s) resulting in changes in perspectives or trajectories. To enhance understanding of AYAs' diverse experiences, this study examined alignment and/or divergence of FP decisional TPs among non-Hispanic White (NHW) AYAs and REM AYAs.

METHODS

Qualitative semistructured interviews were conducted in person, by video, or phone with 36 AYAs (20 NHW and 16 REM [nine Hispanic and seven Black/multiracial Black). The constant comparative method was used to identify and analyze themes illustrating participants' conceptualization and/or experience of FP decisional TPs.

RESULTS

Seven thematic TPs emerged: (1) emotional reaction to discovering FP procedures exist; (2) encountering unclear or dismissive communication during initial fertility conversations with health care providers; (3) encountering direct and supportive communication during initial fertility conversations with health care providers; (4) participating in critical family conversations about pursuing FP; (5) weighing personal desire for a child against other priorities/circumstances; (6) realizing FP is not feasible, and (7) experiencing unanticipated changes in cancer diagnosis or treatment plans/procedures. TP variations include REM participants reported dismissive communication and suggested cost was prohibitive. NHW participants emphasized more forcefully that biological children may become a future priority.

CONCLUSION

Understanding how clinical communication and priorities/resources may vary for NHW and REM AYAs can inform future interventions aimed at reducing health disparities and enhancing patient-centered care.

Question prompt lists and caregiver question asking in pediatric specialty appointments: A randomized controlled trial

OBJECTIVE

Question prompt lists (QPLs) have been effective at increasing patient involvement and question asking in medical appointments, which is critical for shared decision making. We investigated whether pre-visit preparation (PVP), including a QPL, would increase question asking among caregivers of pediatric patients with undiagnosed, suspected genetic conditions.

METHODS

Caregivers were randomized to receive the PVP before their appointment (n = 59) or not (control, n = 53). Appointments were audio-recorded. Transcripts were analyzed to determine questions asked.

RESULTS

Caregivers in the PVP group asked more questions (MeanPVP = 4.36, SDPVP = 4.66 vs. Meancontrol = 2.83, SDcontrol = 3.03, p = 0.045), including QPL questions (MeanPVP = 1.05, SDPVP = 1.39 vs. Meancontrol = 0.36, SDcontrol = 0.81, p = 0.002). Caregivers whose child had insurance other than Medicaid in the PVP group asked more total and QPL questions than their counterparts in the control group (ps = 0.005 and 0.002); there was no intervention effect among caregivers of children with Medicaid or no insurance (ps = 0.775 and 0.166).

CONCLUSION

The PVP increased question asking but worked less effectively among traditionally underserved groups. Additional interventions, including provider-focused efforts, may be needed to promote engagement of underserved patients.

PRACTICE IMPLICATIONS

Patient/family-focused interventions may not be beneficial for all populations. Providers should be aware of potential implicit and explicit biases and encourage question asking to promote patient/family engagement.

Racial Disparities in Health Beliefs and Advance Care Planning Among Patients Receiving Maintenance Dialysis

CONTEXT

Among people receiving maintenance dialysis, little is known about racial disparities in the occurrence of prognostic discussions, beliefs about future health, and completion of advance care planning (ACP) documents.

OBJECTIVES

We examined whether Black patients receiving maintenance dialysis differ from White patients in prognostic discussions, beliefs about future health, and completion of ACP-related documents.

METHODS

We surveyed adult patients receiving maintenance dialysis from seven dialysis units in Cleveland, Ohio, and hospitalized patients at a tertiary care hospital in Cleveland. Of the 450 patients who were asked to participate in the study, 423 (94%) agreed. We restricted the current secondary analyses to include only Black (n=285) and White (n=114) patients. The survey assessed patients' knowledge of their kidney disease, attitudes toward chronic kidney disease (CKD) treatment, preferences for end-of-life (EoL) care, the patient-reported occurrence of prognostic discussions, experiences with kidney therapy decision making, sentiments of dialysis regret, beliefs about health over the next 12 months, and advance care planning. We used stepwise logistic regression to determine if race was associated with the occurrence of prognostic discussions, beliefs about future health, and completion of an ACP-related document, while controlling for potential confounders.

RESULTS

We found no significant difference in the frequency of prognostic discussions between Black (11.9%) versus White patients (7%) (P=0.15). However, Black patients (19%) had lower odds of believing that their health would worsen over the next 12 months (OR 0.22, CI 0.12, 0.44) and reporting completion of any ACP-related document (OR 0.5, CI 0.32, 0.81) compared to White patients CONCLUSION: Racial differences exist in beliefs about future health and completion of ACP-related documents. Systemic efforts to investigate differences in health beliefs and address racial disparities in the completion of ACP-related documents are needed.

Satisfaction With Information Predicts Satisfaction With Outcome and Surgeon in Black and Hispanic Patients Undergoing Breast Reconstruction

BACKGROUND

Racial disparities in American healthcare contribute to worse outcomes among minority patients. Minority patients undergoing breast reconstruction are more likely to report dissatisfaction with their reconstruction process as compared with White patients, yet there is limited research exploring contributory factors. This study investigates which process-of-care, clinical, and surgical variables are most strongly correlated with Black and Hispanic patients' reported satisfaction.

METHODS

A retrospective review of all patients who underwent postmastectomy breast reconstruction at a single academic center from 2015 to 2021 was performed. Patients were included for analysis if they identified as Black or Hispanic and completed preoperative, less than 1-year postoperative, and 1- to 3-year postoperative BREAST-Q surveys. At both postoperative time points, the association between satisfaction with outcome and surgeon and selected independent variables was determined using regression analysis.

RESULTS

One hundred eighteen Black and Hispanic patients were included for analysis, with average age 49.59 ± 9.51 years and body mass index 30.11 ± 5.00 kg/m2. In the multivariate model for predicting satisfaction with outcome, only satisfaction with preoperative information (P < 0.001) was a statistically significant predictor during early and late postoperative evaluations. For predicting satisfaction with surgeon, satisfaction with information (P < 0.001) remained a significant predictor in the early and late postoperative evaluations, with lower body mass index as an additionally significant predictor during the late postoperative period.

CONCLUSIONS

Patient satisfaction with preoperative information received is the single most significant factor associated with Black and Hispanic patient satisfaction with outcome and plastic surgeon. This finding encourages further research on effective and culturally inclusive information delivery so as to both improve patient satisfaction and reduce healthcare disparities.

A Direct Patient-Provider Relationship With the Medical Physicist Reduces Anxiety in Patients Receiving Radiation Therapy

PURPOSE

The complex technological processes involved in radiation therapy can be intimidating to patients, causing increased treatment-related anxiety and reduced satisfaction. An intervention was implemented to provide direct consultations between patients and medical physicists to reduce patient anxiety and improve patient satisfaction. A randomized clinical trial was conducted to test the intervention's effect on anxiety, distress, treatment adherence, technical understanding, and satisfaction in patients receiving radiation therapy.

METHODS AND MATERIALS

Eligible patients were recruited into "intervention" and "standard of care" arms within a phase 2 screening randomized trial. Intervention-arm patients met with a medical physicist who provided technical information and addressed patient questions or concerns at the time of treatment simulation and before the first treatment. In addition to baseline information collected before randomization, participants were surveyed (1) before simulation, (2) before the first treatment, and (3) before the completion of treatment to evaluate the study endpoints. Primary endpoints included patient anxiety and distress. Secondary endpoints included patient treatment adherence, overall satisfaction, and technical understanding of treatment. Patients in the intervention arm were surveyed before and after each physicist meeting.

RESULTS

Participant anxiety was significantly reduced in the intervention arm (difference, -0.29; 95% confidence interval, -0.57 to -0.02; P = .038). No differences in distress or treatment adherence were observed between groups. Although measures of technical understanding and satisfaction were evaluated as exploratory objectives, participants in the intervention group were more likely to feel that technical aspects of treatment were adequately explained (difference, 0.78; 95% confidence interval, 0.03-1.54), and all measures of technical understanding and satisfaction were considerably higher in the intervention group at the time of the first visit.

CONCLUSIONS

The establishment of a direct patient-provider relationship with the medical physicist reduced anxiety in patients receiving radiation therapy. In addition, increases in patient understanding of the technical aspects of care and in satisfaction were observed at the initiation of treatment.

What do patients want to know about surgery for low-risk thyroid cancer? A qualitative study

BACKGROUND

Shared decision-making about treatment for low-risk thyroid cancer requires patients and surgeons to work together to select treatment that best balances risks and expected outcomes with patient preferences and values. To participate, patients must be activated and ask questions. We aimed to characterize what topics patients prioritize during treatment decision-making.

METHODS

We identified substantive questions by patients with low-risk (cT1-2, N0) thyroid cancer during audio-recorded consultations with 9 surgeons at 2 unique health care systems. Logistics questions were excluded. Qualitative content analysis was used to identify major themes among patients' questions and surgeon responses.

RESULTS

Overall, 28 of 30 patients asked 253 substantive questions, with 2 patients not asking any substantive questions (median 8, range 0-25). Patients were 20 to 71 years old, mostly White (86.7%) and female (80.0%). The questions addressed extent of surgery, hormone supplementation, risk of cancer progression, radioactive iodine, and etiology of thyroid cancer. When patients probed for a recommendation regarding extent of surgery, surgeons often responded indirectly. When patients asked how surgery could impact quality of life, surgeons focused on oncologic benefits and surgical risk. Patients commonly asked about hormone supplementation and radioactive iodine.

CONCLUSION

Patient questions focused on the decision regarding extent of surgery, quality of life, and nonsurgical aspects of thyroid cancer care. Surgeon responses do not consistently directly answer patients' questions but focus on the risks, benefits, and conduct of surgery itself. These findings suggest an opportunity to help surgeons with resources to improve shared decision-making by providing information that patients prioritize.

Racial and Ethnic Disparities among Participants in Hepatocellular Carcinoma Clinical Studies Evaluating Transarterial Therapies

PURPOSE

To evaluate the racial and ethnic representation of transarterial therapy for hepatocellular carcinoma (HCC) clinical trials in the United States.

MATERIALS AND METHODS

The ClinicalTrials.gov database was examined to identify all completed studies with transarterial therapies for the management of HCC in the United States and extract information about the observed number of participants for each racial and ethnic group (based on the Office of Management and Budget definitions). The expected number of participants was calculated by multiplying the total number of participants in a trial with the U.S.-population HCC-based proportion for each group. The effects of the study phase, funding source, number of centers involved in the study, and the location of the participating center on racial and ethnic distribution were explored.

RESULTS

Seventy-nine relevant studies were identified, of which 27 (34.2%) and 18 (22.8%) reported ethnic and race characteristics, respectively. Most study participants were White (81%, 1,591/1,964) by ethnicity and not Hispanic or Latino (93%, 937/1,008) by race. In terms of the observed-to-expected ratios by race and ethnicity in all trials, White and not Hispanic or Latino participants were overrepresented with a ratio of 1.22 (1.10-1.37) and 1.33 (1.26-1.41), respectively, and all other racial and ethnic groups were underrepresented. The enrollment of African Americans and Asian Americans varied by the study phase, and a higher enrollment of African Americans was noted in the National Institutes of Health-funded and multicenter studies (P < .05).

CONCLUSIONS

This cross-sectional study demonstrates that in HCC transarterial therapy clinical trials, racial and ethnic minorities were underrepresented and the majority of the studies identified failed to report this demographic information.

Dónde Están? Latinx/Hispanic Representation in the Oncology Workforce: Present and Future

This manuscript reviews the status of Hispanic/Latinx physicians in oncology, the benefits and challenges to achieving equitable representation, and potential solutions and actions to increase diversity in the oncology workforce. Persons of Hispanic/Latinx origin comprise 18.7% of the population and 16.8% of the adult population in the United States but are only 4.7% of practicing oncologists. The reasons for the lack of representation of Hispanic/Latinx individuals in medicine are multifaceted and include discrimination and biases, exclusionary practices, financial barriers, and lack of role modeling. As a result, patients are deprived the benefits of a representative workforce, such as improved access, enhanced culturally and linguistically competent care, and minimization of health disparities. Solutions included in the manuscript include a description of efforts by ASCO to improve the representativeness of the oncology workforce through its awards programs and educational efforts, especially for Hispanic/Latinx clinicians. The manuscript also outlines individual actions that attending physicians, senior oncologists, oncology leaders, and hospital/cancer center leadership can take to improve the diversity of the oncology workforce and support our Latinx/Hispanic trainees and colleagues. Improving the representativeness of the oncology workforce will require collective action by institutions, medical societies, and individuals. Nevertheless, widespread commitment to creating an inclusive and supported workforce is necessary to ensure the quality of care for minority patients, reduce existing cancer care disparities, and advance innovation in oncology.

Perceptions of the impact of COVID-19 on healthcare communication in a nationally representative cross-sectional survey of family caregivers

OBJECTIVE

To understand the perceptions of the impact of the COVID-19 pandemic on healthcare communication with family caregivers.

DESIGN

Nationally representative survey.

SETTING

USA (national).

PARTICIPANTS

340 family caregivers, demographically representative of the US population by race/ethnicity.

PRIMARY OUTCOME MEASURES

Communication outcomes (feeling involved by the provider, feeling involved by the care recipient, feeling more encouraged to be involved in care, feeling contributory to discussions, feeling questions are being answered), behavioural/wellness outcomes (feeling anxious, feeling isolated, feeling it is easier to attend the clinic visit), and desire to continue using telemedicine.

RESULTS

Having less than a college degree was associated with decreased odds of feeling involved by the provider (OR 0.46; 95% CI 0.26 to 0.83; p=0.01), feeling involved by the care recipient (OR 0.44; 95% CI 0.24 to 0.79; p=0.01), feeling more encouraged to be involved in care (OR 0.49; 95% CI 0.27 to 0.86; p=0.01), feeling like they contribute to discussions (OR 0.45; 95% CI 0.25 to 0.82; p=0.01) and feeling like their questions are being answered (OR 0.33; 95% CI 0.18 to 0.60; p<0.001).

CONCLUSION

In our sample, the shift to telemedicine during COVID-19 was well received but caregivers of low educational attainment reported poorer health communication, and a greater proportion of black/African American and Hispanic caregivers reported a desire to return to in-person visits. There is an opportunity to improve health systems and increase equity as telemedicine becomes more widespread.

Web-based self-management intervention for patients with cancer: A meta-analysis and systematic review

AIM

This study is conducted to synthesize the effects of web-based self-management intervention on patients with cancer.

EVALUATION

We searched Web of Science, PubMed, Embase and Cochrane library databases for related randomized controlled trials from inception through 2021. Reference lists of included studies were also searched for additional qualified studies. For quantitative data synthesis, standardized mean differences were used to eliminate the influence caused by different scales. Narrative synthesis was also performed.

KEY ISSUES

Nine in 1149 studies were included for narrative and quantitative analysis. The pooled data suggested that patients in the intervention group had better quality of life (standardized mean difference = 1.091, 95% confidence interval: 0.155-2.028) and lower depression (standardized mean difference = -1.634, 95% confidence interval: -2.980 to -0.287) than those in the control group. The result of narrative synthesis is that patients receiving intervention had lower cancer or symptom distress and higher self-efficacy than those in the control group.

CONCLUSION

Web-based self-management intervention improved lives of cancer survivors.

How companions speak on patients' behalf without undermining their autonomy: Findings from a conversation analytic study of palliative care consultations

Companions are individuals who support patients and attend health-care appointments with them. Several studies characterised companions' participation in broad terms, glossing over the details of how they time and design their actions, and how patients and health-care practitioners (HCPs) respond to them. This article aims to examine these aspects in detail by using conversation analysis, focusing on actions whereby companions speak on patients' behalf-mentioning delicate aspects of patients' experience (specifically, by alluding to patients' thoughts or feelings about dying). Some studies suggested that these actions undermine patients' autonomy. By contrast, through examination of palliative care consultations in a UK hospice, we found that these interventions are warranted by contextual circumstances: they are either invited by patients or HCPs (through questions or gaze) or volunteered to help with the progression of an activity (e.g. when a patient does not answer an HCP's question). Additionally, all parties collaborate in constructing these companion interventions as temporary departures from an otherwise prevailing normative orientation to patients' right to speak for themselves. The study contributes to the sociology of health and illness by characterising how companions contribute to the ways in which participants coordinate their relative rights and responsibilities, and ultimately their relationships, within health-care interactions.

Nonverbal Synchrony: An Indicator of Clinical Communication Quality in Racially-Concordant and Racially-Discordant Oncology Interactions

Objectives

The aim of this cross-sectional study was to apply a novel software to measure and compare levels of nonverbal synchrony, as a potential indicator of communication quality, in video recordings of racially-concordant and racially-discordant oncology interactions. Predictions include that the levels of nonverbal synchrony will be greater during racially-concordant interactions than racially-discordant interactions, and that levels of nonverbal synchrony will be associated with traditional measures of communication quality in both racially-concordant and racially-discordant interactions.

Design

This is a secondary observational analysis of video-recorded oncology treatment discussions collected from 2 previous studies.

Setting

Two National Cancer Institute-designated Comprehensive Cancer Centers and another large urban cancer center.

Participants

Participants from Study 1 include 161 White patients with cancer and 11 White medical oncologists. Participants from Study 2 include 66 Black/African-American patients with cancer and 17 non-Black medical oncologists. In both studies inclusion criteria for patients was a recent cancer diagnosis; in Study 2 inclusion criteria was identifying as Black/African American.

Main outcome measures

Nonverbal synchrony and communication quality.

Results

Greater levels of nonverbal synchrony were observed in racially-discordant interactions than in racially-concordant interactions. Levels of nonverbal synchrony were associated with indicators of communication quality, and these associations were more consistently found in racially-discordant interactions.

Conclusion

This study advances clinical communication and disparities research by successfully applying a novel approach capturing the unconscious nature of communication, and revealing differences in communication in racially-discordant and racially-concordant oncology interactions. This study highlights the need for further exploration of nonverbal aspects relevant to patient-physician interactions.

Examining access to care in clinical genomic research and medicine: Experiences from the CSER Consortium

Introduction:

Ensuring equitable access to health care is a widely agreed-upon goal in medicine, yet access to care is a multidimensional concept that is difficult to measure. Although frameworks exist to evaluate access to care generally, the concept of “access to genomic medicine” is largely unexplored and a clear framework for studying and addressing major dimensions is lacking.

Methods:

Comprised of seven clinical genomic research projects, the Clinical Sequencing Evidence-Generating Research consortium (CSER) presented opportunities to examine access to genomic medicine across diverse contexts. CSER emphasized engaging historically underrepresented and/or underserved populations. We used descriptive analysis of CSER participant survey data and qualitative case studies to explore anticipated and encountered access barriers and interventions to address them.

Results:

CSER’s enrolled population was largely lower income and racially and ethnically diverse, with many Spanish-preferring individuals. In surveys, less than a fifth (18.7%) of participants reported experiencing barriers to care. However, CSER project case studies revealed a more nuanced picture that highlighted the blurred boundary between access to genomic research and clinical care. Drawing on insights from CSER, we build on an existing framework to characterize the concept and dimensions of access to genomic medicine along with associated measures and improvement strategies.

Conclusions:

Our findings support adopting a broad conceptualization of access to care encompassing multiple dimensions, using mixed methods to study access issues, and investing in innovative improvement strategies. This conceptualization may inform clinical translation of other cutting-edge technologies and contribute to the promotion of equitable, effective, and efficient access to genomic medicine.

Practitioners' Dilemmas and Strategies in Decision-Making Conversations Where Patients and Companions Take Divergent Positions on a Healthcare Measure: An Observational Study Using Conversation Analysis

The presence of companions adds complexity to healthcare interactions. Few studies have characterized challenges arising when interactions involve healthcare professionals (HCPs), patients, and companions, or how those challenges are managed. Using conversation analysis, we examined recorded episodes where patients and companions adopt divergent positions on healthcare measures (e.g., walking aids, homecare, medications). We found nine such episodes within a dataset of 37 palliative care consultations with 37 patients, their companions, and ten healthcare practitioners (HCPs) - doctors, physiotherapists and occupational therapists. Palliative care is one of several healthcare domains where companions substantially contribute to care, consultations, and decision making. We propose that, when patients and companions adopt divergent positions, HCPs face a 'dilemma of affiliation' wherein taking a position on the healthcare measure (e.g., recommending it) entails siding with one party, against the other. By examining what happens in the face of patient-companion divergence, we characterize HCPs' strategies and substantiate our proposal that these reflect an underlying dilemma. We show that: HCPs do not immediately take a position on the healthcare measure after patient-companion divergence emerges; and when HCPs take a position later in the consultation, they do so without ostensibly siding with the party who previously supported the healthcare measure. Further, once an HCP takes a position, the party who supports the measure can treat the HCP as an ally. We offer insights and propose implications for: palliative care; the interactional complexities of healthcare decision-making; and consultations in which companions participate.

Genetic Counseling and Testing in African American Patients With Breast Cancer: A Nationwide Survey of US Breast Oncologists

PURPOSE

To determine if physicians' self-reported knowledge, attitudes, and practices regarding genetic counseling and testing (GCT) vary by patients' race.

METHODS

We conducted a nationwide 49-item survey among breast oncology physicians in the United States. We queried respondents about their own demographics, clinical characteristics, knowledge, attitudes, practices, and perceived barriers in providing GCT to patients with breast cancer.

RESULTS

Our survey included responses from 277 physicians (females, 58.8%; medical oncologists, 75.1%; academic physicians, 61.7%; and Whites, 67.1%). Only 1.8% indicated that they were more likely to refer a White patient than refer an African American patient for GCT, and 66.9% believed that African American women with breast cancer have lower rates of GCT than White women. Regarding perceived barriers to GCT, 63.4% of respondents indicated that African American women face more barriers than White women do and 21% felt that African American women require more information and guidance during the GCT decision-making process than White women. Although 32% of respondents indicated that lack of trust was a barrier to GCT in all patients, 58.1% felt that this was a greater barrier for African American women (P < .0001). Only 13.9% believed that noncompliance with GCT is a barrier for all patients, whereas 30.6% believed that African American women are more likely than White women to be noncompliant (P < .0001).

CONCLUSION

We demonstrated that racial differences exist in oncology physicians' perceived barriers to GCT for patients with breast cancer. This nationwide survey will serve as a basis for understanding physicians' determinants of GCT for African American women and highlights the necessity of education and interventions to address bias among physicians. Awareness of such physician biases can enable further work to address inequities, ultimately leading to improved GCT equity for African American women with breast cancer.

DISCO App: study protocol for a randomized controlled trial to test the effectiveness of a patient intervention to reduce the financial burden of cancer in a diverse patient population

Background

Financial toxicity, the material and psychological burden of the cost of treatment, affects 30–50% of people with cancer, even those with health insurance. The burden of treatment cost can affect treatment adherence and, ultimately, mortality. Financial toxicity is a health equity issue, disproportionately affecting patients who are racial/ethnic minorities, have lower incomes, and are < 65 years old. Patient education about treatment cost and patient-oncologist cost discussions are recommended as ways to address financial toxicity; however, research shows cost discussions occur infrequently (Altice et al. J Natl Cancer Inst 109:djw205, 2017; Schnipper et al. J Clin Oncol 34:2925-34, 2016; Zafar et al. Oncologist 18:381-90, 2013; American Cancer Society Cancer Action Network 2010). Our overall goal is to address the burden of financial toxicity and work toward health equity through a tailorable education and communication intervention, the DISCO App. The aim of this longitudinal randomized controlled trial is to test the effectiveness of the DISCO App on the outcomes in a population of economically and racially/ethnically diverse cancer patients from all age groups.

Methods

Patients diagnosed with breast, lung, colorectal, or prostate cancer at a NCI-designated comprehensive cancer center in Detroit, MI, will be randomized to one of three study arms: one usual care arm (arm 1) and two intervention arms (arms 2 and 3). All intervention patients (arms 2 and 3) will receive the DISCO App before the second interaction with their oncologist, and patients in arm 3 will receive an intervention booster. The DISCO App, presented on an iPad, includes an educational video about treatment costs, ways to manage them, and the importance of discussing them with oncologists. Patients enter socio-demographic information (e.g., employment, insurance status) and indicate their financial concerns. They then receive a tailored list of questions to consider asking their oncologist. All patients will have up to two interactions with their oncologist video recorded and complete measures at baseline, after the recorded interactions and at 1, 3, 6, and 12 months after the second interaction. Outcome measures will assess discussions of cost, communication quality, knowledge of treatment costs, self-efficacy for treatment cost management, referrals for support, short- and longer-term financial toxicity, and treatment adherence.

Discussion

If effective, this intervention will improve awareness of and discussions of treatment cost and alleviate the burden of financial toxicity. It may be especially helpful to groups disproportionately affected by financial toxicity, helping to achieve health equity.

Trial registration

ClinicalTrials.gov NCT04766190. Registered on February 23, 2021

A Review of Research on Disparities in the Care of Black and White Patients With Cancer in Detroit

Racial disparities in cancer incidence and outcomes are well-documented in the US, with Black people having higher incidence rates and worse outcomes than White people. In this review, we present a summary of almost 30 years of research conducted by investigators at the Karmanos Cancer Institute's (KCI's) Population Studies and Disparities Research (PSDR) Program focusing on Black-White disparities in cancer incidence, care, and outcomes. The studies in the review focus on individuals diagnosed with cancer from the Detroit Metropolitan area, but also includes individuals included in national databases. Using an organizational framework of three generations of studies on racial disparities, this review describes racial disparities by primary cancer site, disparities associated with the presence or absence of comorbid medical conditions, disparities in treatment, and disparities in physician-patient communication, all of which contribute to poorer outcomes for Black cancer patients. While socio-demographic and clinical differences account for some of the noted disparities, further work is needed to unravel the influence of systemic effects of racism against Black people, which is argued to be the major contributor to disparate outcomes between Black and White patients with cancer. This review highlights evidence-based strategies that have the potential to help mitigate disparities, improve care for vulnerable populations, and build an equitable healthcare system. Lessons learned can also inform a more equitable response to other health conditions and crises.

Evaluating the clinical utility of early exome sequencing in diverse pediatric outpatient populations in the North Carolina Clinical Genomic Evaluation of Next-generation Exome Sequencing (NCGENES) 2 study: a randomized controlled trial

BACKGROUND

Exome sequencing (ES) has probable utility for shortening the diagnostic odyssey of children with suspected genetic disorders. This report describes the design and methods of a study evaluating the potential of ES as a routine clinical tool for pediatric patients who have suspected genetic conditions and who are in the early stages of the diagnostic odyssey.

METHODS

The North Carolina Clinical Genomic Evaluation by Next-generation Exome Sequencing (NCGENES) 2 study is an interdisciplinary, multi-site Phase III randomized controlled trial of two interventions: educational pre-visit preparation (PVP) and offer of first-line ES. In this full-factorial design, parent-child dyads are randomly assigned to one of four study arms (PVP + usual care, ES + usual care, PVP + ES + usual care, or usual care alone) in equal proportions. Participants are recruited from Pediatric Genetics or Neurology outpatient clinics in three North Carolina healthcare facilities. Eligible pediatric participants are < 16 years old and have a first visit to a participating clinic, a suspected genetic condition, and an eligible parent/guardian to attend the clinic visit and complete study measures. The study oversamples participants from underserved and under-represented populations. Participants assigned to the PVP arms receive an educational booklet and question prompt list before clinical interactions. Randomization to offer of first-line ES is revealed after a child's clinic visit. Parents complete measures at baseline, pre-clinic, post-clinic, and two follow-up timepoints. Study clinicians provide phenotypic data and complete measures after the clinic visit and after returning results. Reportable study-related research ES results are confirmed in a CLIA-certified clinical laboratory. Results are disclosed to the parent by the clinical team. A community consultation team contributed to the development of study materials and study implementation methods and remains engaged in the project.

DISCUSSION

NCGENES 2 will contribute valuable knowledge concerning technical, clinical, psychosocial, and health economic issues associated with using early diagnostic ES to shorten the diagnostic odyssey of pediatric patients with likely genetic conditions. Results will inform efforts to engage diverse populations in genomic medicine research and generate evidence that can inform policy, practice, and future research related to the utility of first-line diagnostic ES in health care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03548779 . Registered on June 07, 2018.

Being in Place: A Multimodal Analysis of the Contribution of the Patient's Companion to "First Time" Oncological Visits

Companions to medical visits have been alternatively viewed as members who “support” or “inhibit” and “interfere” with the doctor-patient interaction. One way of looking at the companions' contribution to medical visits is by coding roles or functions of their communicative behavior. Our paper aims at reconsidering these findings and analyzing how the companion participation is a local and sequential accomplishment, changing from time to time in the consultation. The paper relies upon an overall collection of 58 videorecordings of first oncological visits. Visits were conducted in two different hospitals, one of which a University hospital, and by different oncologists, including both senior professionals and (in the second setting) medical students in oncology. Visits were fully transcribed according to the Jeffersonian conventions and authors examined the transcripts and video according to the methodology of Conversation Analysis. The aim of the paper focused on how patient's companions orient and contribute to the accomplishment of the different aims and activities at different stages of the visit as an institutional speech event. The multimodal analysis of turns and actions (such as, gaze shifts, prosodic modulation, bodily arrangements), and the close examination of the sequential and temporal arrangements of companions' and their co-participants' turns revealed that companions finely attune to the multiparty framework of the encounter and the institutional constraints that govern the oncological first visit. Overall, results show two relevant features: that companions act as to preserve the doctor-patient interaction and to maintain the patient as the most responsible and legitimate agent in the interaction; that companions' contributions are relevant to the activities that sequentially unfold at different stages in the consultation (e.g., history taking, problem presentation, treatment recommendation etc.). The study complements earlier findings on the companion's roles, showing how these are highly mobile, multimodal and multiparty accomplishments, and they are tied to the specific contingencies of the visit. The results solicit to consider the value of multimodal analysis in understanding the complexity of multiparty communication in medical setting, and make it usable also in medical education.

Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (MI-SIGHT): Baseline Methodology for Implementing and Assessing a Community-based Program

PRECIS

The Michigan Screening and Intervention for Glaucoma and eye Health through Telemedicine (MI-SIGHT) program leverages community-engaged research, telemedicine, and health coaching to overcome key logistical and psychosocial barriers to improve glaucoma screening in underserved communities.

PURPOSE

To describe the methodology of the implementation and evaluation of the MI-SIGHT Program.

METHODS

The MI-SIGHT Program uses community engagement, telemedicine, and health coaching to overcome key logistical and psychosocial barriers to glaucoma identification and care among underserved populations. The MI-SIGHT Program will be evaluated in 2 community clinics: Hamilton Community Health Network, a federally qualified health center in Flint, Michigan, and the Hope Clinic, a free clinic in Ypsilanti, Michigan. A Community Advisory Board including the research team and health care providers, administrators, and patients from both clinics will guide program implementation. An ophthalmic technician at the community clinics will conduct screening tests for glaucoma and eye disease. The data will be transmitted through electronic health record to be reviewed by an ophthalmologist who will make recommendations for follow-up care. The ophthalmic technician will conduct a return visit to fit low-or no-cost glasses, help arrange follow-up with an ophthalmologist, and provide education. Those diagnosed with glaucoma or suspected glaucoma will be randomized to standard education or personalized glaucoma education and coaching. Costs will be assessed.

RESULTS

The authors hypothesize that the MI-SIGHT Program will detect a higher prevalence rate of glaucoma than that found in the general population, improve upon presenting visual acuity, enhance vision-related quality of life, and demonstrate that personalized glaucoma education and coaching improve adherence to follow-up care.

CONCLUSION

The MI-SIGHT Program may serve as a model for glaucoma screening and care in high-risk communities.

Mammography Screening Among Latinas: Does Gender and Ethnic Patient-Physician Concordance Matter?

Breast cancer is the most commonly diagnosed cancer among Latinas. Dominican women in particular have a higher lifetime risk of breast cancer than do other Latinas in the U.S. This study examines how gender, ethnic, and language concordance between providers and patients are associated with recent mammography screening for Latina immigrant women from the Dominican Republic. We conducted structured interviews, in Spanish, with 419 Dominican women aged 40 years or older living in New York City. Using bivariate analysis and logistic regressions, we tested whether patient-provider gender, ethnic, and language concordance was associated with recent mammography when controlling for demographic covariates, breast cancer screening knowledge, and self-rated health. Gender concordance predicted recent mammography after controlling for covariates (β = 0.13). Neither ethnic nor language concordance significantly predicted recent mammography. Our findings suggest that promotion of patient-provider gender concordance may help reduce health disparities among Latinos/as and other minority groups across the United States.

Impact of Patients' Companions on Clinical Encounters Between Black Patients and Their Non-Black Oncologists

PURPOSE

The presence of caregivers or companions during clinical encounters influences the dynamics and outcomes of the encounters. Most prior studies of companions in clinical encounters focus on non-Hispanic White patients. However, there is generally lower-quality patient-physician communication during encounters with Black patients; these communication differences may contribute to racial health disparities. The purpose of the present study was to examine effects of the presence and active participation of companions on encounters between Black patients with cancer and non-Black oncologists.

METHODS

This was a secondary analysis of data collected during a larger intervention study. Participants were Black patients with breast, colon, or lung cancer who had a treatment-discussion encounter with a participating non-Black medical oncologist. Video recordings of encounters were coded for patient, companion, and oncologist communication. After the encounter, patients reported perceptions of the recommended treatment; patients and oncologists reported perceptions of each other.

RESULTS

Data from 114 patients and 19 oncologists were included in analyses. Only 47% of patients brought a companion to the encounter. Oncologists spent more time with accompanied Black patients, used more patient-centered communication with them, and perceived them as having more social support compared with unaccompanied Black patients. Oncologists reported that accompanied patients asked more questions. When companions participated more actively in the encounter, oncologists used more patient-centered communication.

DISCUSSION

Bringing a companion to oncology appointments may be beneficial to Black patients because oncologists spend more time with patients, use more patient-centered communication, and perceive patients more positively, all of which may ultimately improve patient health and well-being outcomes.

Examining the dynamic nature of nonverbal communication between Black patients with cancer and their oncologists

BACKGROUND

Although communication quality is associated with patient outcomes, racial disparities in communication exist, disproportionately burdening Black patients. However, most communication research focuses on verbal behaviors in predominantly White patient populations. We used a newly developed and theory-guided network analysis that examines the dynamic interplay and behavioral convergence and divergence between Black patients with cancer and their oncologists during cancer treatment discussions.

METHODS

We applied a nonverbal behavioral coding system to thin slices of video recordings of Black patients and their oncologists discussing treatment. We then estimated 3 networks: 1) a temporal network to determine whether a nonverbal behavior predicts another nonverbal behavior at the next time point in an interaction, and how much each nonverbal behavior influences other nonverbal behaviors and is influenced by other nonverbal behaviors; 2) a contemporaneous network to determine whether a nonverbal behavior co-occurs with other nonverbal behaviors at the same time point in an interaction; and 3) a between-dyads network to examine the covariation between nonverbal behaviors across all dyads.

RESULTS

Black patients (n = 74) and their non-Black physicians (n = 15) showed a mix of convergence and divergence in their nonverbal behaviors at the same points in time, from one time point to the next, and across dyads. Across analyses, convergence was most likely to occur when physicians matched their behaviors to their patients; especially with smiling, gaze, leaning, and laughter behaviors.

CONCLUSION

Our findings reveal patterns of modifiable behaviors that can potentially inform interventions to reduce disparities in clinical communication and, in turn, treatment and mortality disparities.

Feasibility and Acceptability of an Interactive Cancer-Communication Video Program Using African American Breast Cancer Survivor Stories

To examine the feasibility and acceptability of an interactive video program of African American breast cancer survivor stories, we explored story reactions among African American women with newly diagnosed breast cancer and associations between patient factors and intervention use. During a randomized controlled trial, patients in the intervention arm completed a baseline/pre-intervention interview, received the video intervention, and completed a post-intervention 1-month follow-up interview. Additional video exposures and post-exposure interviews occurred at 6- and 12-month follow-ups. Multivariable linear mixed-effects models examined interview and clinical data in association with changes in minutes and actions using the program. After Exposure1, 104 of 108 patients allocated to the intervention reported moderate-to-high levels of positive emotional reactions to stories and identification with storytellers. Exposure1 mean usage was high (139 minutes) but declined over time (p <.0001). Patients receiving surgery plus radiation logged about 50 more minutes and actions over 12-month follow-up than patients receiving surgery only (p <.05); patients reporting greater trust in storytellers logged 18.6 fewer actions over time (p =.04). Patients' topical interests evolved, with patients watching more follow-up care and survivorship videos at Exposure3. The intervention was feasible and evaluated favorably. New videos might satisfy patients' changing interests.

Racial Differences in Do-Not-Resuscitate Orders among Pediatric Surgical Patients in the United States

Background: Very few studies have investigated the racial differences in do-not-resuscitate (DNR) orders in children, and these studies are limited to oncological cases. We aim to characterize the racial difference in DNR orders among U.S. pediatric surgical patients. Methods: We retrospectively evaluated the mortality of all children who underwent an inpatient surgery between 2012 and 2017 from the National Surgical Quality Improvement Program. We used log-binomial models to estimate the relative risk (RR) and 95% confidence interval (CI) of DNR use comparing white with African American (AA) children. To estimate the risk-adjusted difference in DNR orders, we controlled the analyses for age, prematurity status, emergent case status, American Society of Anesthesiologists class, year of operation, surgical specialty, and surgical complexity. Results: Between 2012 and 2017, a total of 276,917 children underwent inpatient surgery, of whom 0.8% (n = 1601) died within 30 days of operation. Of the 1601 mortality cases, we retained 1212 children who were of either AA (26.0%, n = 350) or white (63.9%, n = 862) race. Most children were neonates, had an American Society of Anesthesiologists class ≥4 (70.0%, n = 811), and developed one or more postoperative complications (68.7%, n = 833). Overall, AA children were more likely to be neonates at the time of surgery (42.0% vs. 40.3%, p < 0.001), to be premature (66.3% vs. 49.0%, p < 0.001), and develop one or more postoperative complications (73.7% vs. 66.7%, p = 0.017). White children were three times more likely to have a DNR order than their AA peers (adjusted RR: 3.01, 95% CI: 1.09-8.56, p = 0.044). Conclusion: Among pediatric surgical patients in the United States, children of white race were three times more likely to have a DNR order in place than their AA peers despite the latter being "sicker" and more likely to develop postoperative complications. The mechanisms underlying this racial difference deserve further elucidation to improve shared decision making and goal-concordant care.

Cultural Diversity and the Importance of Communication, Cultural Competence, and Uncertainty in Radiography

Cultural diversity has been well-recognized as a challenge for health care providers in many countries, thereby stressing the importance of effective and sufficient communications between patients and health care staff. Culturally competent care is a key to day-to-day practice, and we must strive to provide optimum care despite personal differences. If the health care service is to provide culturally competent care, our radiographers are vulnerable and prone to errors because effective communication requires both cultural competence and knowledge of the language. An understanding in effective communication, cultural competence, and uncertainty is important in the profession of radiographers.

Individuation and implicit racial bias in genetic counseling communication

OBJECTIVES

Genetic counselors (GCs) can frame information in either general terms (i.e., population risks) or individual terms (i.e., tailoring to specific client characteristics). We investigated whether informational framing might reflect GCs' implicit racial bias.

METHODS

We analyzed previously videotaped genetic counseling sessions with white and minority (Black and Latino) simulated clients (SCs) and modeled the relationship between sixty GCs' implicit racial bias, as measured by the Implicit Association Test (IAT), and informational framing (general or individual) as characterized by the Roter Interaction Analysis System.

RESULTS

Higher (more pro-white) IAT scores predicted less informational individuation for minority relative to white SCs. Similarly, higher IAT predicted fewer facilitation and activation statements to minority relative to white SCs. With higher IAT-scoring GCs, minority SCs disclosed less psychosocial and lifestyle information, and asked fewer medical questions (all p < 0.05).

CONCLUSION

GCs' racial implicit bias may be associated with less individualized communication style when counseling minority clients.

PRACTICE IMPLICATIONS

Future research should address whether increasing informational individuation can ameliorate negative consequences of implicit bias and help providers reframe perceptions of minority patients in individual rather than categorical terms.

Racial Differences in the Influence of Health Care System Factors on Informal Support for Cancer Care Among Black and White Breast and Lung Cancer Survivors

This retrospective, secondary qualitative analysis investigates whether health system factors influence social support among Black and white breast and lung cancer survivors and racial differences in support. These data come from race- and cancer-stratified focus groups (n = 6) and interviews (n = 2) to inform a randomized controlled trial utilizing antiracism and community-based participatory research approaches. Findings indicate social support was helpful for overcoming treatment-related challenges, including symptom management and patient-provider communication; racial differences in support needs and provision were noted. Resources within individual support networks reflect broader sociostructural factors. Reliance on family/friends to fill gaps in cancer care may exacerbate racial disparities.

Promise of Mobile Health Technology to Reduce Disparities in Patients With Cancer and Survivors

Despite recent advances in cancer control, numerous disparities exist in the areas of patient access to care, self-management, and quality of life. However, mobile health technology shows promise as a tool to reduce disparities among patients with cancer and cancer survivors by overcoming such barriers as limited access to providers, difficulty communicating with providers, and inadequate communication between patients and providers regarding symptoms. This narrative review draws on the literature in cancer and noncancer populations to identify factors that create or maintain disparities and to describe opportunities for mobile health technology to reduce disparities.

Racial and Ethnic Differences in Parental Decision-Making Roles in Pediatric Oncology

Background: Prior work in adult oncology suggests minority patients are less involved in decision making than preferred. However, few studies have explored decision-making experiences of minority parents in pediatric oncology. Objective: To determine whether parental decision-making preferences and experiences vary by race/ethnicity. Design: Questionnaire-based cohort study. Setting/Subjects: Three hundred sixty five parents of children with cancer and their oncologists at two academic centers. Measurements: Parents reported on preferred and actual decision-making roles. Associations between race/ethnicity and decision-making outcomes determined by chi-squared test. Results: Most parents preferred shared decision making (235/368, 64%), whereas 23% (84/368) preferred parent-led decision making and 13% (49/368) preferred oncologist-led decision making. Parental decision-making preferences did not differ by race/ethnicity (p = 0.38, chi-squared test). However, the actual role parents played in decision making differed by parental race/ethnicity, with 25% (71/290) of white parents reporting parent-led decision making, versus 37% (9/24) of black parents, 48% (13/27) of Hispanic parents, and 56% (15/27) of Asian/other parents (p = 0.005, chi-squared test). Oncologists accurately predicted parental preferences for decision making 49% of the time (n = 165/338), but accuracy also differed by race and ethnicity. Oncologists accurately predicted parental preferences for 53% of white parents (140/266), 23% of black parents (5/22), 37% of Hispanic parents (10/27), and 43% of Asian/other race parents (10/23) (p = 0.026, chi-squared test). Conclusions: Minority parents held more active roles than white parents, and oncologists had more difficulty predicting decisional preferences for minority parents relative to white parents. These findings suggest that minority parents are at risk of inferior decision-making experiences.

Psychosocial Determinants of Communication Satisfaction in Racially Concordant and Discordant Patient-Physician Interactions

INTRODUCTION

Although socioeconomic and race-related factors both influence the quality of medical encounters, it is not known how these effects differ between racially concordant and discordant medical visits. The current study investigated psychosocial determinants of physician visit satisfaction of Black adults based on a racial concordance of the medical encounter.

MATERIALS AND METHODS

Data came from the Detroit Area Study, a community survey of adults in Michigan, United States. The current analysis included 336 Black individuals who had visited a White (n = 191) or a Black (n = 145) physician in the last year. The outcome was satisfaction with the quality of communication with the doctor. Demographics (age and gender), socioeconomic status (education and income), psychosocial factors (control beliefs and social support), race-related factors (having a close White friend, negative attitudes about Blacks, discrimination), and health status (chronic disease count, self-rated health, and distress) of the patient as well as race of the doctor were measured. We used multi-group structural equation modeling for data analysis, where the two groups were racially concordant (those who met a Black physician) and racially discordant (those who met a White physician) visits.

RESULTS

Satisfaction with physician visit was lower in racially discordant than racially concordant encounters. In racially concordant visits, high education was associated with higher satisfaction; however, racial discrimination was associated with lower satisfaction. In racially discordant visits ((i.e., with a White doctor), having a White friend as well as high sense of control were associated with higher satisfaction, while negative attitudes about Blacks was associated with a lower level of satisfaction.

CONCLUSIONS

Racially concordant and discordant visits have different satisfaction levels. Racially concordant and discordant visits also have different predictors of communication satisfaction among Black patients. Socioeconomic status as well as racial attitudes and experiences impact the quality of communication of the Black patients with their doctors; however, these effects depend on the race of the doctor.

Information Needs Expressed During Patient-Oriented Oncology Consultations: Quantity, Variation, and Barriers

High-quality oncology consultation includes patient-oriented communication tailored to patients' individualized needs. Common methods used in studies to increase question-asking are prompt lists and coaching pre-consultations. However, our patients were encouraged to ask questions by the physician during their visit. We aimed to estimate the quantity, nature, and variation of their questions when they were invited to ask by their oncologist. During radiotherapy consultations from 2012 to 2016, patient's questions were deliberately elicited and physician-transcribed. We derived mean and median number of questions per patient, variance by patient factors, and a taxonomy of subjects using thematic analysis. Three hundred ninety-six patients asked 2386 questions, median asked per patient = 6 (interquartile range = 4). We found significant variance with age (mean = 6.9 questions for < 60 years, 5.4 for ≥ 70 years) p = 0.018, insurance type (mean = 4.7 for Medicaid, 7.2 for private insurance) p = 0.0004, and tumor site (mean number of questions: skin = 4.6, lymphoma = 5.2, lung = 5.8, breast = 6.1, prostate = 6.3, rectum = 6.7 head and neck = 6.9, brain = 7.0, bladder = 7.2, anus = 8.8, others = 5.8) p = 0.0440. Of the diverse set of 57 topics, the commonest were 1. logistics, 2. radiotherapy details, 3. side effects, 4. diagnosis, and 5. stage and prognosis. Only 17 topics were asked by more > 10% of patients and 40 topics were asked by < 10% of patients. With median of 6 questions, it is practicable to routinely elicit and address individualized information needs. Potential barriers may be older and underinsured patients. The wide variety of topics, often pertaining to individuals' case, suggests that cancer clinicians should take time-out during consultation to elicit patients' questions to accomplish best-practice communication.

Decoding the Role of Companions in Supporting the Health Communication of Older African-American Men With Cancer

The objective of this study was to systematically characterize the content and patterning of companion’s communicative behavior during oncology consultations for older African-American male patients. Companions and family members often play an important role in patient-centered communication for patients with cancer. Despite their disproportionate cancer burden, little is known about how companions facilitate patient-provider communication for older African-American men with cancer. This study represents a secondary qualitative analysis of 14 video-recorded doctor patient-companion medical visits for African-American male patients with cancer. Videos were captured with consent and institutional review board approval at a Midwest comprehensive cancer center between 2002 and 2006. These medical visits were transcribed, deidentified, and analyzed for the content, frequency, co-occurrence, and thematic clustering of companions’ active participation behaviors during the interaction. Results were well aligned with existing studies on accompanied oncology visits. Patients were on average, 60.14 years old and all but one of the 16 companions was a woman. A total 782 companion behaviors were coded across 14 medical interactions. While companions communicated directly with providers (eg, asking questions, providing medical history) and directly with patients (eg, clarifying information, giving advice), there was a lack of triadic communication. This study clarifies the role of mainly spousal companions as important intermediaries in the patient-provider communication dynamic for older African-American men with cancer.

Exome sequencing disclosures in pediatric cancer care: Patterns of communication among oncologists, genetic counselors, and parents

OBJECTIVE

To examine communication patterns and behaviors during disclosure of exome sequencing (ES) results to parents of pediatric cancer patients, and describe common themes in parental communication.

METHODS

Using mixed methods, we analyzed transcripts of sessions where parents of pediatric cancer patients received ES results from an oncologist and genetic counselor. Seventy-six transcripts were analyzed for frequency of clinician information-giving, partnering-supportive talk, and active parent participation. A subset of 40 transcripts were analyzed using thematic content analysis.

RESULTS

Disclosures consisted mostly of clinician talk (84% of total talk), which was focused on providing information (62% of clinicians' utterances) with occasional partnering-supportive talk (7% of clinicians' utterances). Most parents assumed a passive, listening role (16% of total talk). Themes in parental communication included expressing relief and the significance of an answer, concern about sharing results and responsibility for inheritance, and seeking clarification of health implications of results.

CONCLUSION

Our finding of low levels of active parent participation during ES disclosures highlights the need to improve patient/parent engagement and understanding in a genetic setting.

PRACTICE IMPLICATIONS

Clinician communication strategies that could encourage parent participation and understanding include checking for parent understanding, partnership-building, and tailoring ES discussions to address parent concerns and preferences.

Nonverbal synchrony as a behavioural marker of patient and physician race-related attitudes and a predictor of outcomes in oncology interactions: protocol for a secondary analysis of video-recorded cancer treatment discussions

INTRODUCTION

Racial disparities in cancer treatment contribute to racial disparities in mortality rates. The quality of patient-physician communication during clinical interactions with black patients and non-black physicians (racially discordant) is poorer than communication quality with white patients (racially concordant). Patient and physician race-related attitudes affect the quality of this communication. These attitudes are likely expressed through subtle non-verbal behaviours, but prior research has not examined these behaviours. Nonverbal synchrony, the coordination of physical movement, reflects the preinteraction attitudes of participants in interactions and predicts their postinteraction perceptions of and affect towards one another. In this study, peer reviewed and funded by the National Institute of Minority Health and Health Disparities (R21MD011766), we will investigate non-verbal synchrony in racially concordant and discordant interactions to better understand racial disparities in clinical communication.

METHODS AND ANALYSIS

This secondary analysis includes racially concordant (n=163) and racially discordant (n=68) video-recorded oncology interactions, patient and oncologist self-reported race-related attitudes, perceptions of the interaction and observer ratings of physician patient-centred communication and patient and physician affect and rapport. In aim 1, we will assess and compare non-verbal synchrony between physicians and patients in racially concordant and discordant interactions. In aim 2, we will determine the influence of non-verbal synchrony on patient and physician affect and communication. In aim 3, we will examine possible causes (ie, race-related attitudes) and consequences (ie, negative perceptions) of non-verbal synchrony in racially discordant interactions. In aim 4, we will develop and test a mediational model linking physician and patient race-related attitudes to non-verbal synchrony and, in turn, interaction outcomes.

ETHICS AND DISSEMINATION

The parent and current studies were approved by the Wayne State University Institutional Review Board. Since only archival data will be used, ethical or safety risks are low. We will disseminate our findings to relevant conferences and journals.

When Trust Is Not Enough: A Serial Mediation Model Explaining the Effect of Race Identity, eHealth Information Efficacy, and Information Behavior on Intention to Participate in Clinical Research

Black participants remain significantly underrepresented in clinical research. Mistrust in medical researchers has been named a key barrier to the successful enrollment of minority study participants. However, trust is a social-interactional construct, and its effects on behavior are complex. This study hypothesized that intention to participate in clinical research is mediated by trust in medical researchers, eHealth literacy, and information seeking behavior. The data were collected through an online survey ( N = 340) and analyzed to identify serial mediation. The model showed insignificant direct effect of race identity on behavioral intention, c' = -0.19, t(335) = -1.22, p = .22, but a significant total effect, c = -0.44, t(335) = -2.59, p < .01. The indirect effect of race identity on behavioral intention was also significant. The positive effect of trust in medical researchers on decisions to participate in clinical research can be amplified by stronger eHealth literacy and active information seeking, which can be supported through focused strategic health education and communication interventions. A focus on the development of information literacy that could provide prospective minority research volunteers with skills for informed decision making should be explored as an option for increasing mindful, informed participation in clinical research among currently underrepresented racial and ethnic groups.

The Why Behind the Questions: Question-asking in Parents of Children Newly Diagnosed With Cancer - A Report From the Children's Oncology Group

PURPOSE

For parents of children newly diagnosed with cancer, the exchange of information during initial educational processes is critical. This focused analysis was completed to describe parent question-asking during the new childhood cancer diagnosis timeframe.

DESIGN & METHODS

In previous research of new diagnosis education experiences, parents spoke extensively about asking questions. These data, captured in first level coding, were incorporated across higher level codes to describe how parents processed information after their child's cancer diagnosis. Using constant comparative analysis, we returned to our data to complete a focused analysis of our first level code, Asking Questions. Team members independently coded Asking Questions data from 20 parent interviews, followed by team discussions and consensus agreement for code assignment.

RESULTS

Parents asked questions to learn, fill an unmet need, or clarify information. Clinicians asked questions to assess parent learning.

CONCLUSION

Question-asking is a technique used by parents and clinicians to communicate new information, assess understanding of provided content, and/or to confirm previously provided information.

PRACTICE IMPLICATIONS

Clinicians can benefit from carefully listening to patients/parents and reflecting on the type of questions asked in an effort to understand the reason behind the question. This can be used to guide further education.

Partnering around cancer clinical trials (PACCT): study protocol for a randomized trial of a patient and physician communication intervention to increase minority accrual to prostate cancer clinical trials

BACKGROUND

Cancer clinical trials are essential for testing new treatments and represent state-of-the-art cancer treatment, but only a small percentage of patients ever enroll in a trial. Under-enrollment is an even greater problem among minorities, particularly African Americans, representing a racial/ethnic disparity in cancer care. One understudied cause is patient-physician communication, which is often of poor quality during clinical interactions between African-American patients and non-African-American physicians. Partnering Around Cancer Clinical Trials (PACCT) involves a transdisciplinary theoretical model proposing that patient and physician individual attitudes and beliefs and their interpersonal communication during racially discordant clinical interactions influence outcomes related to patients' decisions to participate in a trial. The overall goal of the study is to test a multilevel intervention designed to increase rates at which African-American and White men with prostate cancer make an informed decision to participate in a clinical trial.

METHODS/DESIGN

Data collection will occur at two NCI-designated comprehensive cancer centers. Participants include physicians who treat men with prostate cancer and their African-American and White patients who are potentially eligible for a clinical trial. The study uses two distinct research designs to evaluate the effects of two behavioral interventions, one focused on patients and the other on physicians. The primary goal is to increase the number of patients who decide to enroll in a trial; secondary goals include increasing rates of physician trial offers, improving the quality of patient-physician communication during video recorded clinical interactions in which trials may be discussed, improving patients' understanding of trials offered, and increasing the number of patients who actually enroll. Aims are to 1) determine the independent and combined effects of the two interventions on outcomes; 2) compare the effects of the interventions on African-American versus White men; and 3) examine the extent to which patient-physician communication mediates the effect of the interventions on the outcomes.

DISCUSSION

PACCT has the potential to identify ways to increase clinical trial rates in a diverse patient population. The research can also improve access to high quality clinical care for African American men bearing the disproportionate burden of disparities in prostate and other cancers.

TRIAL REGISTRATION

Clinical Trials.gov registration number: NCT02906241 (September 8, 2016).

Impact of Patient-Provider Race, Ethnicity, and Gender Concordance on Cancer Screening: Findings from Medical Expenditure Panel Survey

Background: Racial and ethnic minorities experience lower rates of cancer screening compared with non-Hispanic whites (NHWs). Previous studies evaluating the role of patient-provider race, ethnicity, or gender concordance in cancer screening have been inconclusive.Methods: In a cross-sectional analysis using the Medical Expenditure Panel Survey (MEPS), data from 2003 to 2010 were assessed for associations between patient-provider race, ethnicity, and/or gender concordance and, screening (American Cancer Society guidelines) for breast, cervical, and colorectal cancer. Multivariable logistic analyses were conducted to examine associations of interest.Results: Of the 32,041 patient-provider pairs in our analysis, more than 60% of the patients were NHW, 15% were non-Hispanic black (NHB), and 15% were Hispanic. Overall, patients adherent to cancer screening were more likely to be non-Hispanic, better educated, married, wealthier, and privately insured. Patient-provider gender discordance was associated with lower rates of breast [OR, 0.83; 95% confidence interval (CI), 0.76-0.90], cervical (OR, 0.83; 95% CI, 0.76-0.91), and colorectal cancer (OR, 0.84; 95% CI, 0.79-0.90) screening in all patients. This association was also significant after adjusting for racial and/or ethnic concordance. Conversely, among NHWs and NHBs, patient-provider racial and/or ethnic concordance was not associated with screening. Among Hispanics, patient-provider ethnic discordant pairs had higher breast (58% vs. 52%) and colorectal cancer (45% vs. 39%) screening rates compared with concordant pairs.Conclusions: Patient-provider gender concordance positively affected cancer screening. Patient-provider ethnic concordance was inversely associated with receipt of cancer screening among Hispanics. This counter-intuitive finding requires further study.Impact: Our findings highlight the importance of gender concordance in improving cancer screening rates. Cancer Epidemiol Biomarkers Prev; 26(12); 1804-11. ©2017 AACR.

Discussing prognosis and treatment goals with patients with advanced cancer: A qualitative analysis of oncologists' language

BACKGROUND

The National Academy of Medicine recommends that cancer patients be knowledgeable of their prognosis to enable them to make informed treatment decisions, but research suggests few patients receive this information.

OBJECTIVE

This qualitative study describes oncologists' language during discussions of prognosis and treatment goals in clinical interactions with African American patients diagnosed with cancer.

DESIGN

We analysed transcripts from video recordings of clinical interactions between patients with Stage III or IV cancer (n=26) and their oncologists (n=9). In-depth discourse analysis was conducted to describe and interpret oncologists' communication behaviours and common linguistic features in the interactions.

SETTING AND PARTICIPANTS

Data were from a larger study of patient-provider communication between African Americans and oncologists at two cancer hospitals in Detroit.

RESULTS

Prognosis was discussed in 73.1% (n=19) of the interactions; treatment goals were discussed in 92.3% (n=24). However, analysis revealed that oncologists' description of prognosis was vague (e.g. "prognosis is a bit worse in your case") and rarely included a survival estimate. Oncologists often used ambiguous terminology, including euphemisms and jargon, and emphasized uncertainty (e.g. "lesions are suspicious for the disease"). Conversation about prognosis was frequently brief, moving quickly to the urgency and details of treatment.

DISCUSSION

This study demonstrates how oncologists' language may obscure discussion of prognosis and treatment goals. The identified behaviours may lead to missed opportunities in eliciting and discussing patients' knowledge about and preferences for their care. Patient-, provider- and system-oriented interventions are needed to improve clinical communication, especially among minority patients with advanced cancer.