Guibo Xing

Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer: The VOICE Randomized Clinical Trial.

Importance Observational studies demonstrate links between patient-centered communication, quality of life (QOL), and aggressive treatments in advanced cancer, yet few randomized clinical trials (RCTs) of communication interventions have been reported. Objective To determine whether a combined intervention involving oncologists, patients with advanced cancer, and caregivers would promote patient-centered communication, and to estimate intervention effects on shared understanding, patient-physician relationships, QOL, and aggressive treatments in the last 30 days of life. Design, Setting, and Participants Cluster RCT at community- and hospital-based cancer clinics in Western New York and Northern California; 38 medical oncologists (mean age 44.6 years; 11 (29%) female) and 265 community-dwelling adult patients with advanced nonhematologic cancer participated (mean age, 64.4 years, 146 [55.0%] female, 235 [89%] white; enrolled August 2012 to June 2014; followed for 3 years); 194 patients had participating caregivers. Interventions Oncologists received individualized communication training using standardized patient instructors while patients received question prompt lists and individualized communication coaching to identify issues to address during an upcoming oncologist visit. Both interventions focused on engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information. Control participants received no training. Main Outcomes and Measures The prespecified primary outcome was a composite measure of patient-centered communication coded from audio recordings of the first oncologist visit following patient coaching (intervention group) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QOL, and aggressive treatments and hospice use in the last 30 days of life. Results Data from 38 oncologists (19 randomized to intervention) and 265 patients (130 intervention) were analyzed. In fully adjusted models, the intervention resulted in clinically and statistically significant improvements in the primary physician-patient communication end point (adjusted intervention effect, 0.34; 95% CI, 0.06-0.62; Pu2009=u2009.02). Differences in secondary outcomes were not statistically significant. Conclusions and Relevance A combined intervention that included oncologist communication training and coaching for patients with advanced cancer was effective in improving patient-centered communication but did not affect secondary outcomes. Trial Registration clinicaltrials.gov Identifier: NCT01485627

Short-term outcomes of screening mammography using computer-aided detection a population-based study of medicare enrollees

BACKGROUNDnComputer-aided detection (CAD) has rapidly diffused into screening mammography practice despite limited and conflicting data on its clinical effect.nnnOBJECTIVEnTo determine associations between CAD use during screening mammography and the incidence of ductal carcinoma in situ (DCIS) and invasive breast cancer, invasive cancer stage, and diagnostic testing.nnnDESIGNnRetrospective cohort study.nnnSETTINGnMedicare program.nnnPARTICIPANTSnWomen aged 67 to 89 years having screening mammography between 2001 and 2006 in U.S. SEER (Surveillance, Epidemiology and End Results) regions (409 459 mammograms from 163 099 women).nnnMEASUREMENTSnIncident DCIS and invasive breast cancer within 1 year after mammography, invasive cancer stage, and diagnostic testing within 90 days after screening among women without breast cancer.nnnRESULTSnFrom 2001 to 2006, CAD prevalence increased from 3.6% to 60.5%. Use of CAD was associated with greater DCIS incidence (adjusted odds ratio [OR], 1.17 [95% CI, 1.11 to 1.23]) but no difference in invasive breast cancer incidence (adjusted OR, 1.00 [CI, 0.97 to 1.03]). Among women with invasive cancer, CAD was associated with greater likelihood of stage I to II versus III to IV cancer (adjusted OR, 1.27 [CI, 1.14 to 1.41]). In women without breast cancer, CAD was associated with increased odds of diagnostic mammography (adjusted OR, 1.28 [CI, 1.27 to 1.29]), breast ultrasonography (adjusted OR, 1.07 [CI, 1.06 to 1.09]), and breast biopsy (adjusted OR, 1.10 [CI, 1.08 to 1.12]).nnnLIMITATIONnShort follow-up for cancer stage, potential unmeasured confounding, and uncertain generalizability to younger women.nnnCONCLUSIONnUse of CAD during screening mammography among Medicare enrollees is associated with increased DCIS incidence, the diagnosis of invasive breast cancer at earlier stages, and increased diagnostic testing among women without breast cancer.nnnPRIMARY FUNDING SOURCEnCenter for Healthcare Policy and Research, University of California, Davis.

Costs of needlestick injuries and subsequent hepatitis and HIV infection

ABSTRACT Background: Physicians, nurses and other healthcare workers (HCWs) are at risk of bloodborne pathogens infection from needlestick injuries, but costs of needlesticks are little studied. Methods: We used the cost-of-illness and incidence approaches. We used the perspective of the medical provider (medical costs) and the individual (lost productivity). Data on needlesticks, infections from hepatitis B and C (HBV, HCV) and human immune-deficiency (HIV) among HCWs, as well as data on per-unit costs were culled from research literature, Centers for Disease Control and Prevention reports, and Bureau of Labor Statistics reports. We also generated estimates based upon industry employment and scenarios for source-patients. These data and estimates were combined with assumptions to produce a model that generated base-case estimates as well as one-way and multi-way probabilistic sensitivity analyses. Future costs were discounted by 3%. Results: We estimated 644u2009963 needlesticks in the healthcare industry for 2004 of which 49% generated costs. Medical costs were

Determinants of Patient-Oncologist Prognostic Discordance in Advanced Cancer

107.3 million of which 96% resulted from testing and prophylaxis and 4% from treating long-term infections (34 persons with chronic HBV, 143 with chronic HCV, and 1 with HIV). Lost-work productivity generated

Underuse and Overuse of Osteoporosis Screening in a Regional Health System: a Retrospective Cohort Study

81.2 million, for which 59% involved testing and prophylaxis and 41% involved long-term infections. Combined medical and work productivity costs summed to

Promoting end-of-life discussions in advanced cancer: Effects of patient coaching and question prompt lists

188.5 million. Multi-way sensitivity analysis suggested a range on combined costs from

Computer-aided detection in mammography: downstream effect on diagnostic testing, ductal carcinoma in situ treatment, and costs.

100.7 million to

Impact of Prognostic Discussions on the Patient-Physician Relationship: Prospective Cohort Study

405.9 million. Conclusion: Detailed methodology was developed to estimate costs of needlesticks and subsequent infections for hospital-based and non-hospital-based health care workers. The combined medical and lost productivity costs comprised roughly 0.1% of all occupational injury and illness costs for all jobs in the economy. We did not account for lost home production or pain and suffering costs, however, nor did we estimate benefit/cost ratios of specific interventions to reduce needlesticks.

A cluster randomized trial of a patient-centered communication intervention in advanced cancer: The Values and Options In Cancer Care (VOICE) study.

ImportancenPatients with advanced cancer often report expectations for survival that differ from their oncologists expectations. Whether patients know that their survival expectations differ from those of their oncologists remains unknown. This distinction is important because knowingly expressing differences of opinion is important for shared decision making, whereas patients not knowing that their understanding differs from that of their treating physician is a potential marker of inadequate communication.nnnObjectivenTo describe the prevalence, distribution, and proportion of prognostic discordance that is due to patients knowingly vs unknowingly expressing an opinion that differs from that of their oncologist.nnnDesign, Setting, and ParticipantsnCross-sectional study conducted at academic and community oncology practices in Rochester, New York, and Sacramento, California. The sample comprises 236 patients with advanced cancer and their 38 oncologists who participated in a randomized trial of an intervention to improve clinical communication. Participants were enrolled from August 2012 to June 2014 and followed up until October 2015.nnnMain Outcomes and MeasuresnWe ascertained discordance by comparing patient and oncologist ratings of 2-year survival probability. For discordant pairs, we determined whether patients knew that their opinions differed from those of their oncologists by asking the patients to report how they believed their oncologists rated their 2-year survival.nnnResultsnAmong the 236 patients (mean [SD] age, 64.5 [11.4] years; 54% female), 161 patient-oncologist survival prognosis ratings (68%; 95% CI, 62%-75%) were discordant. Discordance was substantially more common among nonwhite patients compared with white patients (95% [95% CI, 86%-100%] vs 65% [95% CI, 58%-73%], respectively; Pu2009=u2009.03). Among 161 discordant patients, 144 (89%) did not know that their opinions differed from that of their oncologists and nearly all of them (155 of 161 [96%]) were more optimistic than their oncologists.nnnConclusions and RelevancenIn this study, patient-oncologist discordance about survival prognosis was common and patients rarely knew that their opinions differed from those of their oncologists.

The ecology of patient and caregiver participation in consultations involving advanced cancer

ABSTRACTBACKGROUNDThe United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis with dual-energy x-ray absorptiometry (DXA) for women aged ≥ 65xa0years and younger women with increased risk. “Choosing Wisely” initiatives advise avoiding DXA screening in women younger than 65xa0years without osteoporosis risk factors.OBJECTIVEWe aimed to determine the extent to which DXA screening is used in accordance with USPSTF recommendations within a regional health system.DESIGNThis was a retrospective longitudinal cohort study within 13 primary care clinics in the Sacramento, CA region.PATIENTSThe study included 50,995 women aged 40–85xa0years without prior osteoporosis screening, diagnosis, or treatment attending primary carexa0visits from 2006 to 2012, observed for a mean of 4.4xa0years.MAIN MEASURESWe examined incidence of DXA screening. Covariates included age, race/ethnicity, and osteoporosis risk factors (body mass indexu2009<u200920, glucocorticoid use, secondary osteoporosis, prior high-risk facture, rheumatoid arthritis, alcohol abuse, and current smoking).KEY RESULTSAmong previously unscreened women for whom the USPSTF recommends screening, 7-year cumulative incidence of DXA screening was 58.8xa0% among women aged 60–64xa0years with ≥ 1 risk factor (95xa0% CI: 51.9–65.8xa0%), 57.8xa0% for women aged 65–74xa0years (95xa0% CI: 55.6–60.0xa0%), and 42.7xa0% for women aged ≥ 75xa0years (95xa0% CI: 38.7–46.7xa0%). Among women for whom the USPSTF does not recommend screening, 7-year cumulative incidence was 45.5xa0% among women aged 50–59xa0years (95xa0% CI 44.1–46.9xa0%) and 58.6xa0% among women aged 60–64xa0years without risk factors (95xa0% CI 55.9–61.4xa0%).CONCLUSIONSDXA screening was underused in women at increased fracture risk, including women aged ≥ 65xa0years. Meanwhile, DXA screening was common among women at low fracture risk, such as younger women without osteoporosis risk factors. Interventions may be needed to augment the value of population screening for osteoporosis.