clinical problem

CONSULTATION RECORDING USE IN CONSULTATION RECORDING USE IN ONCOLOGY: WHY DOESN’T EVIDENCE ONCOLOGY: WHY DOESN’T EVIDENCE ALONE LEAD TO PRACTICE CHANGE?ALONE LEAD TO PRACTICE CHANGE?

PROFESSOR TOM HACKFACULTY OF NURSING, UNIVERSITY OF MANITOBAUNIVERSITY OF CENTRAL LANCASHIRE, ENGLAND

HEALTH RESEARCH WITH REAL IMPACT CONFERENCE, MAY 2013

Clinical ProblemClinical ProblemInformation needs are many, varied and persistent for newly diagnosed cancer patients

Patient information needs are highest at the time of diagnosis and treatment planning

The initial consultation is one during which fundamental, critical disease, prognosis and treatment information is provided to patients

Clinical ProblemClinical ProblemPatient anxiety is high during the initial treatment consultation, making it difficult to focus attention on information being communicated

Patient recall of salient facts from this consultation is poor

Involvement in treatment decision making is compromised if recall is poor

Treatment Consultation

http://www.youtube.com/watch?feature=player_detailpage&v=uyyGu5OUD-o#t=26s




Solution to Clinical ProblemSolution to Clinical Problem

Consultation recordings:◦ reduce anxiety, improve recall of information, and enhance patient satisfaction (Cochrane Collaboration Systematic Reviews)

Pitkethly M, MacGillivray S, Ryan R. Recording or summaries of consultations for people with cancer (Review). The Cochrane Collaboration 2008; Issue 3.

Scott JT, Harmsen M, Prictor MJ, Entwistle VA, Sowden AJ, Watt I. Recording or summaries of consultations for people with cancer (Review). The Cochrane Collaboration 2007; Issue 2.

Challenge with the SolutionChallenge with the Solution Recordings yield benefits to patients, are

rated as beneficial by patients, and are supported by oncologists, BUT no widespread uptake! Why?

Can theory help us understand why? Can a knowledge management theory help

us understand why consulting recording uptake into clinical practice is weak?

Theory– PARIHS Knowledge Theory– PARIHS Knowledge Translation Framework (UK)Translation Framework (UK)

The EvidenceThe Evidence Consultation recordings:

enhance learning and recall of disease and treatment information

improve communication with family members help patients assume an active role in decision

making produce better outcomes than standardized

recordings produce better outcomes than summary letters have very high patient satisfaction ratings

The EvidenceThe Evidence Hack TF, Ruether JD, Weir LM, Grenier D, Degner, LF (2012). Promoting consultation recording

practice in oncology: Identification of critical implementation factors and determination of patient benefit. Psycho-Oncol. Published online July 20, 2012. doi: 10.1002/pon.3135.

Hack TF, Whelan TJ, Olivotto IA, Bultz BD, Weir L, Magwood BD, Ashbury F, Brady J. Standardized audiotape versus recorded consultation to enhance informed consent to a clinical trial in breast oncology: A feasibility study. Psycho-Oncol 2006;16:371-6.

Hack TF, Pickles T, Bultz BD. Ruether JD, Degner LF. Impact of providing audiotapes of primary treatment consultations to men with prostate cancer: A multi-site, randomized, controlled trial. Psycho-Oncol 2007;16:543-52.

Hack TF, Pickles T, Bultz BD, Ruether JD, Weir LM, Degner LF, et al. Impact of providing audiotapes of primary adjuvant treatment consultations to women with breast cancer: A multi-site, randomized, controlled trial. J Clin Oncol 2003;21:4138-44.

McClement SE, Hack TF. Audio-taping the oncology treatment consultation: a literature review. Patient Educ Couns 1999;36:229-38.

Tattersall MH, Butow PN. Consultation audio tapes: an underused cancer patient information aid and clinical research tool. Lancet Oncol 2002;3:431-7.

Tattersall MHN, Butow PN, Griffin AM, Dunn SM. The take-home message: patients prefer consultation audiotapes to summary letters. J Clin Oncol 1994;12:1305-11.

PARIHS Knowledge Translation PARIHS Knowledge Translation Framework (UK)Framework (UK)

ContextContextUnderstand and address the contextual factors and barriers that influence consultation recording use in oncology

Implementation StudyImplementation StudyIdentify the factors and processes associated with increased uptake and maintenance of consultation recording use

MethodMethod Pre-Implementation Contextual

Readiness Assessment Interviews with oncologists Interviews with nurses and administrators Identify all the barriers to, and facilitators of,

successful implementation

MethodMethod Implementation

Initial treatment consultations recorded for 228 cancer patients in 3 Canadian cities

Patients given recording on USB key Patients interviewed on Day 2 post-

consultation and at Day 7 post-consultation

Oncologists provided with summary patient feedback letter

ResultsResults

Results – Results – Reduction in anxiety

I found the recording very helpful. I was told originally would not need radiation but when I met with Dr. _______ he told me I needed it…Once he told me that my mind went blank…very thankful I had the recording.

You listen at the consultation and afterwards I had so much running through my head. The first night I had trouble going to sleep, so I got up and listened to the recording. It really helped me settle down.

A very upsetting experience…found it very helpful to have it [the recording]. I had to play it back so I could remember. There was a lot of information that I was not aware of.

Results – Results – Enhanced retention of information

Hearing it again helps so much. Every time I listen to it I get something else out of it. I think the recording is a super idea. You take everything in but then find you cannot remember anything. I will probably listen to it a few times in the next few weeks.

So happy to have the recording; was applying information to the wrong thing. Things I forgot, my mind is whirling so the recording is very beneficial. I missed the measurements in the appointment but was able to get it from the recording.

Results – Results – Better informed decision making

Listening to Dr. _____ about the clinical trial in the appointment, I wasn`t sure what treatment I wanted, but once I listened to the recording I knew it was not for me. I decided to go the other way. The recording has been wonderful and excellent.

Helped with the treatment decision as I thought I remembered the doctor saying something but not sure, so able to go back and listen again. The doctor tells numbers and hard to remember but able to hear again…. I was unsure whether to have oral chemotherapy and this definitely helped with that.

Results - Results - Improved communication with

family I found it very useful to be able to play for my family. My

daughters thought it was a wonderful idea, seeing as how they do not live here and could not attend the consultation.

My children found the information on the recording presented in a very orderly fashion. They also stated it was helpful to hear the same information their parents had heard.

My wife was unable to attend the consultation. Listening to the recording at home with her generated the most open conversation we’ve had about this diagnosis.

PARIHS Knowledge Translation PARIHS Knowledge Translation Framework (UK)Framework (UK)

Consultation Recording Service

As of May 27, 2013, CancerCare Manitoba will offer a Consultation Recording Service to all cancer patients attending a “pivotal” appointment. Pivotal appointment – appointment when a

significant change in treatment is indicated, e.g., initial treatment consultation, recurrence consultation, palliative care consultation

Rolling out this service via disease site Starting in Winnipeg and rolling out across

province of Manitoba

Critical Factors for Critical Factors for Successful ImplementationSuccessful Implementation

Evidence Provide oncology staff with evidence fact sheet

Make key research papers available


ContextIdentify implementation “champions”Meet with disease site leaders, chief nursing officers, and chief executive officer to secure administrative support

Critical Factors for Critical Factors for Successful Successful

ImplementationImplementationContext

Secure commitment of financial and staff resources to pay for digital recorders and USB keys to notify the patient of the option of receiving a

consultation recording to place the digital recorder properly in the

consultation room to transfer the recording to a computer and then to

a USB key


Context Technology issues

USB key – storage size (Gb) Digital recorders – make and model USB or website or app

Medico-legal concerns Retain a copy at the cancer centre What if the patient loses the USB key? “What if the patient sues me?”


Facilitation Disease site team meetings Launch meetings Media campaign Monitor and support Evaluation audit Oncologist feedback summary letter (Research)

Thank You

“To him who devotes his life to science, nothing can give

more happiness than increasing the

number of discoveries, but his cup of joy is full when the results of his studies

immediately find practical applications.”

~Louis Pasteur