Impact of Patient Gender and Race and Physician Communication on Colorectal Cancer Diagnostic Visits in Primary Care

Automated Strategy Feedback Can Improve the Readability of Physicians' Electronic Communications to Simulated Patients

Modern communication between health care professionals and patients increasingly relies upon secure messages (SMs) exchanged through an electronic patient portal. Despite the convenience of secure messaging, challenges include gaps between physician and patient expertise along with the asynchronous nature of such communication. Importantly, less readable SMs from physicians (e.g., too complicated) may result in patient confusion, non-adherence, and ultimately poorer health outcomes. The current simulation trial synthesizes work on patient-physician electronic communication, message readability assessments, and feedback to explore the potential for automated strategy feedback to improve the readability of physicians' SMs to patients. Within a simulated secure messaging portal featuring multiple simulated patient scenarios, computational algorithms assessed the complexity of SMs written by 67 participating physicians to patients. The messaging portal provided strategy feedback for how physician responses might be improved (e.g., adding details and information to reduce complexity). Analyses of changes in SM complexity revealed that automated strategy feedback indeed helped physicians compose and refine more readable messages. Although the effects for any individual SM were slight, the cumulative effects within and across patient scenarios showed trends of decreasing complexity. Physicians appeared to learn how to craft more readable SMs via interactions with the feedback system. Implications for secure messaging systems and physician training are discussed, along with considerations for further investigation of broader physician populations and effects on patient experience.

Investigating potential disparities in clinical trial eligibility and enrollment at an NCI-designated comprehensive cancer center

BACKGROUND

Although barriers to trial accrual are well-reported, few studies have explored trial eligibility and trial offers as potential drivers of disparities in cancer clinical trial enrollment.

METHODS

We identified patients with gastrointestinal (GI) or head/neck (HN) malignancies who were seen as new patients at the University of Michigan Health Rogel Cancer Center in 2016. By exhaustive review of the electronic medical record, we assessed the primary outcomes: (1) eligibility for, (2) documented offer of, and (3) enrollment in a clinical trial. All 41 of the clinical trials available to these patients were considered. Independent variables included clinical and non-clinical patient-related factors. We assessed associations between these variables and the primary outcomes using multivariable regression.

RESULTS

Of 1446 patients, 43% were female, 15% were over age 75, 6% were Black. 305 (21%) patients were eligible for a clinical trial. Among eligible patients, 154 (50%) had documentation of a trial offer and 90 (30%) enrolled. Among the GI cohort, bivariate analyses demonstrated that older age was associated with decreased trial eligibility. Bivariate analyses also demonstrated that Black race was associated with increased trial offer. After adjustment, patients 75 or older were less likely to be eligible for a clinical trial in the GI cohort; however, we found no significant associations between race and any of the outcomes after adjustment. Among eligible GI patients, we found no significant associations between non-clinical factors and enrollment. Among the HN cohort, bivariate analyses demonstrated that female sex, older age, Black race, and unpartnered marital status were associated with decreased likelihood of trial offer; however, we found no significant associations between race, age, and marital status and any of the outcomes after adjustment. We found no significant associations between non-clinical factors and eligibility after adjustment; however, women were less likely to be offered and to enroll in a clinical trial in the HN cohort.

CONCLUSION

Factors associated with eligibility, documented offer, and enrollment differed between disease site cohorts at our institution. Future work is needed to ensure the equitable inclusion of women and elderly patients in clinical trials.

Age-related experiences of colorectal cancer diagnosis: a secondary analysis of the English National Cancer Patient Experience Survey

OBJECTIVE

The incidence of colorectal cancer (CRC) in people aged <50 years has been increasing dramatically in the past three decades and such patients are known to face difficulties in diagnosis. The objective of this study was to better understand the diagnostic experiences of patients with CRC and explore age-related differences in the proportion with positive experiences.

METHOD

A secondary analysis of the English National Cancer Patient Experience Survey (CPES) 2017 was conducted on the responses of patients with CRC, restricted to those likely to have been diagnosed in the preceding 12 months via pathways other than routine screening. Ten diagnosis-related experience questions were identified, with responses to them categorised as positive, negative or uninformative. Age group-related difference in positive experiences were described and ORs estimated, both raw and adjusted for selected characteristics. Sensitivity analysis was performed by weighting survey responses to 2017 cancer registrations by strata defined by age group, sex and cancer site, to assess whether differential response patterns by these characteristics affected the estimated proportion of positive experiences.

RESULTS

The reported experiences of 3889 patients with CRC were analysed. There was a significant linear trend (p<0.0001) for 9 of 10 experience items, with older patients consistently displaying higher rates of positive experiences and patients aged 55-64 showing rates of positive experience intermediate between younger and older age groups. This was unaffected by differences in patient characteristics or CPES response rates.

CONCLUSION

The highest rates of positive diagnosis-related experiences were reported by patients aged 65-74 or 75 years and older, and this is robust.

People with early-onset colorectal cancer describe primary care barriers to timely diagnosis: a mixed-methods study of web-based patient reports in the United Kingdom, Australia and New Zealand

BACKGROUND

People with early-onset colorectal cancer, under the age of 50, are more likely to experience diagnostic delay and to be diagnosed at later stages of the disease than older people. Advanced stage diagnosis potentially requires invasive therapeutic management at a time of life when these patients are establishing intimate relationships, raising families, building careers and laying foundations for financial stability. Barriers to timely diagnosis at primary care level have been identified but the patient perspective has not been investigated.

METHODS

Personal accounts of cancer care are increasingly accessed as rich sources of patient experience data. This study uses mixed methods, incorporating quantitative content analysis and qualitative thematic analysis, to investigate patients' accounts of early-onset colorectal cancer diagnosis published on prominent bowel cancer support websites in the United Kingdom, Australia and New Zealand.

RESULTS

Patients' perceptions (n = 273) of diagnostic barriers at primary care level were thematically similar across the three countries. Patients perceived that GPs' low suspicion of cancer due to age under 50 contributed to delays. Patients reported that their GPs seemed unaware of early-onset colorectal cancer and that they were not offered screening for colorectal cancer even when 'red flag' symptoms were present. Patients described experiences of inadequate information continuity within GP practices and across primary, specialist and tertiary levels of care, which they perceived contributed to diagnostic delay. Patients also reported tensions with GPs over the patient-centredness of care, describing discord related to symptom seriousness and lack of shared decision-making.

CONCLUSIONS

Wider dissemination of information about early-onset colorectal cancer at primary care level is imperative given the increasing incidence of the disease, the frequency of diagnostic delay, the rates of late-stage diagnosis and the dissatisfaction with patient experience reported by patients whose diagnosis is delayed. Patient education about diagnostic protocols may help to pre-empt or resolve tensions between GPs' enactment of value-based care and patients' concerns about cancer. The challenges of diagnosing early-onset colorectal cancer are significant and will become more pressing for GPs, who will usually be the first point of access to a health system for this growing patient population.

"I was never one of those people who just jumped right in for me": patient perspectives on self-advocacy training for women with advanced cancer

PURPOSE

Patients with advanced cancer experience many complicated situations that can make self-advocacy (defined as the ability speak up for yourself in the face of a challenge) difficult. Few self-advocacy interventions exist, and most are atheoretical with minimal patient engagement. The purpose of this study is to describe participant perspectives of a novel, self-advocacy serious game intervention called Strong Together.

METHODS

This was a qualitative cross-sectional descriptive study among women receiving cancer care at an academic cancer center within 3 months of an advanced gynecologic or breast cancer diagnosis. Participants randomized to receive the intervention completed one-on-one semi-structured interviews 3-months post Strong Together and had the option to share voice journals about their experiences. Inductive qualitative approaches were used to descriptively analyze transcripts and voice journals. Descriptive content analysis approaches were used to group similar codes together into themes summarizing participants' experiences engaging with the Strong Together intervention.

RESULTS

Participants (N = 40) reported that the Strong Together intervention was acceptable, noting that it was realistic and reflective of their personal experiences. Overarching themes included seeing myself in most scenarios and wanting more content; giving me the go ahead to expect more; offering ideas for how to stand up for myself; reinforcing what I am already doing; and reminding me of what I have. Participants suggested adding additional content including diverse characters.

CONCLUSION

This study demonstrated that women with advanced cancer were receptive to a self-advocacy skills-building intervention. Future research should explore the mechanisms linking serious games to learning and health outcomes.

The impact of gender patient-physician concordance on interpersonal processes of care and patients' outcomes in the diabetes care setting

OBJECTIVE

To investigate whether patient-physician gender concordance influences the patient's perceptions of interpersonal processes of care and patient outcomes in Muslim patients with diabetes.

METHODS

We conducted a cross-sectional telephone survey involving 4152 randomly selected patients using electronic diabetes records. Outcome measures included perceptions of interpersonal processes of care, adherence to medications, and HbA1c. Linear mixed regression models were used to explore the associations between the outcome variables and patient gender and gender concordance.

RESULTS

The best processes of care were observed consistently for female concordant dyads. In adjusted mixed models, lower Hurried Communication was associated with female concordant (-0.91, p < 0.001) and female physician-male patient dyads (-0.82, p = 0.007). Higher Elicited Concerns was associated with female concordant (0.65, p = 0.003) and female physician-male patient dyads (0.59, p = 0.013). Higher Explained Results and Compassionate/Respectful were associated with female concordant dyads (0.83, p < 0.001, and 0.55, p = 0.010 respectively). Lower HbA1c was independently linked with female concordant dyads (-0.84, p < 0.001).

CONCLUSION

This study highlights the importance of female gender concordance on perceptions of interpersonal processes of diabetes care and glycemic control.

PRACTICE IMPLICATIONS

Strengthening physicians' communication skills with female patients should be taken into consideration.

"I pretty much followed the law, and there weren't any decisions to make": A qualitative study of self-advocacy experiences of men with cancer

Current conceptualizations of patient self-advocacy focus on women with cancer, leaving knowledge of male self-advocacy deficient. The purpose of this study is to describe the key components of self-advocacy among men with cancer. Adult (≥18 years old) men with a history of invasive cancer were recruited from cancer clinics and registries. Trained researchers led individual semi-structured interviews regarding participants' challenges, how they overcame those challenges, and barriers and facilitators to their self-advocacy. All interviews were analyzed using descriptive content analysis methods and synthesized into major themes. These themes were refined after receiving feedback from key stakeholders. Participants (N = 28) reported three major self-advocacy themes: (i) managing through information and planning; (ii) finding the best team and falling in line; and (iii) strategic social connections. These themes are richly described with representative quotations for each theme and subtheme. Based on these findings, existing models of patient self-advocacy should be adjusted to encompass how men self-advocate. Clinicians should consider how gender may impact how and why patients with cancer self-advocate so that they can best support their patients in achieving patient-centered care.

Role of primary care physician factors on diagnostic testing and referral decisions for symptoms of possible cancer: a systematic review

BACKGROUND

Missed opportunities for diagnosing cancer cause patients harm and have been attributed to suboptimal use of tests and referral pathways in primary care. Primary care physician (PCP) factors have been suggested to affect decisions to investigate cancer, but their influence is poorly understood.

OBJECTIVE

To synthesise evidence evaluating the influence of PCP factors on decisions to investigate symptoms of possible cancer.

METHODS

We searched MEDLINE, Embase, Scopus, CINAHL and PsycINFO between January 1990 and March 2021 for relevant citations. Studies examining the effect or perceptions and experiences of PCP factors on use of tests and referrals for symptomatic patients with any cancer were included. PCP factors comprised personal characteristics and attributes of physicians in clinical practice.

DATA EXTRACTION AND SYNTHESIS

Critical appraisal and data extraction were undertaken independently by two authors. Due to study heterogeneity, data could not be statistically pooled. We, therefore, performed a narrative synthesis.

RESULTS

29 studies were included. Most studies were conducted in European countries. A total of 11 PCP factors were identified comprising modifiable and non-modifiable factors. Clinical judgement of symptoms as suspicious or 'alarm' prompted more investigations than non-alarm symptoms. 'Gut feeling' predicted a subsequent cancer diagnosis and was perceived to facilitate decisions to investigate non-specific symptoms as PCP experience increased. Female PCPs investigated cancer more than male PCPs. The effect of PCP age and years of experience on testing and referral decisions was inconclusive.

CONCLUSIONS

PCP interpretation of symptoms as higher risk facilitated testing and referral decisions for possible cancer. However, in the absence of 'alarm' symptoms or 'gut feeling', PCPs may not investigate cancer. PCPs require strategies for identifying patients with non-alarm and non-specific symptoms who need testing or referral.

PROSPERO REGISTRATION NUMBER

CRD420191560515.

How do colorectal cancer patients rate their GP: a mixed methods study

BACKGROUND

New Zealand (NZ) has a high incidence of colorectal cancer (CRC) and low rates of early diagnosis. With screening not yet nationwide, the majority of CRC is diagnosed through general practice. A good patient-general practitioner (GP) relationship can facilitate prompt diagnosis, but when there is a breakdown in this relationship, delays can occur. Delayed diagnosis of CRC in NZ receives a disproportionally high number of complaints directed against GPs, suggesting deficits in the patient-GP connection. We aimed to investigate patient-reported confidence and ratings of their GP following the diagnostic process.

METHODS

This study is a mixed methods analysis of responses to a structured questionnaire and free text comments from patients newly diagnosed with CRC in the Midland region of NZ. A total of 195 patients responded to the structured questionnaire, and 113 patients provided additional free text comments. Descriptive statistics were used to describe the study population and chi square analysis determined the statistical significance of factors possibly linked to delay. Free text comments were analysed using a thematic framework.

RESULTS

Most participants rated their GP as 'Very good/Good' at communication with patients about their health conditions and involving them in decisions about their care, and 6.7% of participants rated their overall level of confidence and trust in their GP as 'Not at all'. Age, gender, ethnicity and a longer diagnostic interval were associated with lower confidence and trust. Free text comments were grouped in to three themes: 1. GP Interpersonal skills; (communication, listening, taking patient symptoms seriously), 2. Technical competence; (speed of referral, misdiagnoses, lack of physical examination), and 3. Organisation of general practice care; (appointment length, getting an appointment, continuity of care).

CONCLUSIONS

Māori, females, and younger participants were more likely to report low confidence and trust in their GP. Participants associate a poor diagnostic experience with deficits in the interpersonal and technical skills of their GP, and health system factors within general practice. Short appointment times, access to appointments and poor GP continuity are important components of how patients assess their experience and are particularly important to ensure equal access for Māori patients.

Physician-patient racial concordance and disparities in birthing mortality for newborns

Recent work has emphasized the benefits of patient-physician concordance on clinical care outcomes for underrepresented minorities, arguing it can ameliorate outgroup biases, boost communication, and increase trust. We explore concordance in a setting where racial disparities are particularly severe: childbirth. In the United States, Black newborns die at three times the rate of White newborns. Results examining 1.8 million hospital births in the state of Florida between 1992 and 2015 suggest that newborn-physician racial concordance is associated with a significant improvement in mortality for Black infants. Results further suggest that these benefits manifest during more challenging births and in hospitals that deliver more Black babies. We find no significant improvement in maternal mortality when birthing mothers share race with their physician.

Negotiating bodily sensations between patients and GPs in the context of standardized cancer patient pathways - an observational study in primary care

BACKGROUND

How interactions during patient-provider encounters in Swedish primary care construct access to further care is rarely explored. This is especially relevant nowadays since Standardized Cancer Patient Pathways have been implemented as an organizational tool for standardizing the diagnostic process and increase equity in access. Most patients with symptoms indicating serious illness as cancer initially start their diagnostic trajectory in primary care. Furthermore, cancer symptoms are diverse and puts high demands on general practitioners (GPs). Hence, we aim to explore how presentation of bodily sensations were constructed and legitimized in primary care encounters within the context of Standardized Cancer Patient Pathways (CPPs).

METHODS

Participant observations of patient-provider encounters (n = 18, on 18 unique patients and 13 GPs) were carried out at primary healthcare centres in one county in northern Sweden. Participants were consecutively sampled and inclusion criteria were i) patients (≥18 years) seeking care for sensations/symptoms that could indicate cancer, or had worries about cancer, Swedish speaking and with no cognitive disabilities, and ii) GPs who met with these patients during the encounter. A constructivist approach of grounded theory method guided the data collection and was used as a method for analysis, and the COREQ-checklist for qualitative studies (Equator guidelines) were employed.

RESULTS

One conceptual model emerged from the analysis, consisting of one core category Negotiating bodily sensations to legitimize access, and four categories i) Justifying care-seeking, ii) Transmitting credibility, iii) Seeking and giving recognition, and iv) Balancing expectations with needs. We interpret the four categories as social processes that the patient and GP constructed interactively using different strategies to negotiate. Combined, these four processes illuminate how access was legitimized by negotiating bodily sensations.

CONCLUSIONS

Patients and GPs seem to be mutually dependent on each other and both patients' expertise and GPs' medical expertise need to be reconciled during the encounter. The four social processes reported in this study acknowledge the challenging task which both patients and primary healthcare face. Namely, negotiating sensations signaling possible cancer and further identifying and matching them with the best pathway for investigations corresponding as well to patients' needs as to standardized routines as CPPs.