Association of Communication Quality With Patient-Centered Outcomes Among Patients With Incidental Pulmonary Nodules.

Millions of patients are diagnosed with pulmonary nodules annually; this number is expected to increase with the growth of lung cancer screening programs.1Gould M.K. Tang T. Liu I.L. et al.Recent trends in the identification of incidental pulmonary nodules.Am J Respir Crit Care Med. 2015; 192: 1208-1214Crossref PubMed Scopus (349) Google Scholar, 2Ost D. Fein A.M. Feinsilver S.H. Clinical practice. The solitary pulmonary nodule.N Engl J Med. 2003; 348: 2535-2542Crossref PubMed Scopus (481) Google Scholar, 3Slatore C.G. Wiener R.S. Golden S.E. et al.Longitudinal assessment of distress among veterans with incidental pulmonary nodules.Ann Amer Thorac Soc. 2016; 13: 1983-1991Crossref PubMed Scopus (31) Google Scholar, 4Krist A.H. Davidson K.W. Mangione C.M. et al.Screening for lung cancer: US Preventive Services Task Force recommendation statement.JAMA. 2021; 325: 962-970Crossref PubMed Scopus (483) Google Scholar Prior evidence has shown that, among patients with incidental pulmonary nodules who participate in active surveillance programs, distress and anxiety are common,5Gareen I.F. Duan F. Greco E.M. et al.Impact of lung cancer screening results on participant health-related quality of life and state anxiety in the National Lung Screening Trial.Cancer. 2014; 120: 3401-3409Crossref PubMed Scopus (113) Google Scholar perhaps because many overestimate their risk of lung cancer.6Slatore C.G. Wiener R.S. Pulmonary nodules: a small problem for many, severe distress for some, and how to communicate about it.CHEST. 2018; 153: 1004-1015Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar High-quality communication between patients and physicians at the time of nodule notification has been associated with decreased patient distress,7Slatore C.G. Golden S.E. Ganzini L. et al.Distress and patient-centered communication among veterans with incidental (not screen-detected) pulmonary nodules. A cohort study.Ann Amer Thorac Soc. 2015; 12: 184-192Crossref PubMed Scopus (47) Google Scholar suggesting a possible mechanism by which to improve other patient-centered outcomes. However, its influence on outcomes (eg, depression, anxiety, worry) is unclear.8de Haes H. Bensing J. Endpoints in medical communication research, proposing a framework of functions and outcomes.Patient Educ Couns. 2009; 74: 287-294Crossref PubMed Scopus (266) Google Scholar Therefore, we evaluated the association of quality of communication at the time of nodule notification with symptoms of depression, anxiety, and lung cancer worry, hypothesizing that high-quality communication would be associated with better outcomes over time. We conducted a prospective, repeated-measures, cross-sectional cohort study of patients with incidentally detected pulmonary nodule(s) treated within the VA Portland Health Care System from June 2011 to November 2015 as previously described.9Moseson E.M. Wiener R.S. Golden S.E. et al.Patient and clinician characteristics associated with adherence. A cohort study of veterans with incidental pulmonary nodules.Ann Am Thorac Soc. 2016; 13: 651-659Crossref PubMed Google Scholar We included patients with newly reported, incidental nodules < 3 cm in diameter with plans for nonurgent follow-up CT scan. We excluded patients whose primary residence included skilled nursing facilities, and those with previous diagnoses of lung cancer, psychotic or cognitive disorder, or terminal illness. Patients were contacted after notification of their imaging results, and after the study team received approval from the managing physician.3Slatore C.G. Wiener R.S. Golden S.E. et al.Longitudinal assessment of distress among veterans with incidental pulmonary nodules.Ann Amer Thorac Soc. 2016; 13: 1983-1991Crossref PubMed Scopus (31) Google Scholar We surveyed participants after their first incidental nodule was detected, and again shortly after each follow-up CT scan if applicable or every 6 months (whichever came first) for up to 2 years. We then abstracted medical records for the duration of nodule surveillance or 2 years after the nodule was first detected, whichever occurred first. The primary exposure was quality of communication at the time of notification of patients’ abnormal thoracic imaging results measured using the Consultation Care Measure.3Slatore C.G. Wiener R.S. Golden S.E. et al.Longitudinal assessment of distress among veterans with incidental pulmonary nodules.Ann Amer Thorac Soc. 2016; 13: 1983-1991Crossref PubMed Scopus (31) Google Scholar,10Little P. Everitt H. Williamson I. et al.Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations.BMJ. 2001; 323: 908-911Crossref PubMed Google Scholar This measure is based on the patient-centered communication model and has been previously recommended for use in an analysis of multiple communication instruments.10Little P. Everitt H. Williamson I. et al.Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations.BMJ. 2001; 323: 908-911Crossref PubMed Google Scholar,11Hudon C. Fortin M. Haggerty J.L. Lambert M. Poitras M.E. Measuring patients’ perceptions of patient-centered care: a systematic review of tools for family medicine.Ann Fam Med. 2011; 9: 155-164Crossref PubMed Scopus (218) Google Scholar For the primary analysis, quality of communication was dichotomized as high quality if participants indicated they agreed, strongly agreed, or very strongly agreed with the following question: the overall quality of communication with your provider (who is caring for your nodule) is excellent as rated on a seven-point Likert scale from very strongly agree to very strongly disagree. Communication was considered low quality for all other responses. Missing responses were excluded. Primary outcomes included symptoms of depression and anxiety, and lung cancer worry. We used the Hospital Anxiety and Depression Scale (HADS)12Singer S. Kuhnt S. Götze H. et al.Hospital anxiety and depression scale cutoff scores for cancer patients in acute care.Br J Cancer. 2009; 100: 908-912Crossref PubMed Scopus (207) Google Scholar to measure symptoms of depression and anxiety at the time of each follow-up survey. We categorized HADS scores 0 through 7 as low and scores ≥ 8 as high depression and/or anxiety.12Singer S. Kuhnt S. Götze H. et al.Hospital anxiety and depression scale cutoff scores for cancer patients in acute care.Br J Cancer. 2009; 100: 908-912Crossref PubMed Scopus (207) Google Scholar We used the Lerman Breast Cancer Worry Scale13Lerman C. Trock B. Rimer B.K. et al.Psychological side effects of breast cancer screening.Health Psychol. 1991; 10: 259-267Crossref PubMed Google Scholar adapted for lung cancer, which included a one-item Likert scale question with responses from not at all worried to extremely worried (range, 1-5). We categorized individuals who responded that they were not at all worried, slightly worried, or moderately worried as less worried, and those who responded very or extremely worried as more worried. Results are presented as predicted mean outcome score (95% CI). We used linear regression models to evaluate the association of high-quality communication with symptoms of depression, anxiety, and lung cancer worry at the time of each follow-up survey. Based on previous work,3Slatore C.G. Wiener R.S. Golden S.E. et al.Longitudinal assessment of distress among veterans with incidental pulmonary nodules.Ann Amer Thorac Soc. 2016; 13: 1983-1991Crossref PubMed Scopus (31) Google Scholar we adjusted for age, smoking status, income, and self-reported history of depression. We used logistic regression to perform sensitivity analyses with each outcome as a dichotomized variable, with results presented as predicted probabilities. All tests were two-tailed using robust SEs; we used Stata version 16 software (StataCorp) and considered P < .05 to be statistically significant. After excluding patients with missing data, among the 121 initially included, 104 patients (with 276 unique encounters) remained. The average age was 65 ± 9 years; 95% identified as men and 86% as White; 49% self-reported a history of depression. Among the participants, 20 (19.2%) completed one research visit, 30 (28.9%) completed two research visits, 28 (26.9%) completed three research visits, and 26 (25%) completed four or five visits. Overall, 26.8% of patients met criteria for high depression, 27.9% met criteria for high anxiety, and 17.0% met criteria for more lung cancer worry over all visits. Figure 1 shows the distribution of depression, anxiety, and lung cancer worry scores over time. In adjusted analyses, we found that high-quality communication between physicians and patients was associated with significantly lower mean depression scores (5.03; 95% CI, 4.50-5.55) compared with low-quality communication (6.44; 95% CI, 6.44-7.52; difference, −1.42; 95% CI, −2.63 to −0.20; P = .02) (Table 1). However, the measured difference between the mean depression scores did not meet the threshold14Wynne S.C. Patel S. Barker R.E. et al.Anxiety and depression in bronchiectasis: response to pulmonary rehabilitation and minimal clinically important difference of the Hospital Anxiety and Depression Scale.Chron Respir Dis. 2020; 171479973120933292Crossref PubMed Scopus (25) Google Scholar,15Lemay K.R. Tulloch H.E. Pipe A.L. et al.Establishing the minimal clinically important difference for the Hospital Anxiety and Depression Scale in patients with cardiovascular disease.J Cardiopulm Rehabil Prev. 2019; 39: E6-E11Crossref PubMed Scopus (116) Google Scholar to indicate a clinically meaningful difference in depression symptoms. In addition, high-quality communication was not associated with predicted anxiety (P = .82) or worry (P = .46) scores. In sensitivity analyses, there was no association between high-quality communication and any of the three primary outcomes (predicted probability difference: depression: −0.09; 95% CI, −0.20 to 0.03; P = .13; anxiety: 0.01; 95% CI, −0.11 to 0.13; P = .88; lung cancer worry: −0.05; 95% CI, −0.15 to 0.05; P = .31).Table 1Association Between Communication Quality With Provider With Primary Outcomes of Depression, Anxiety, and Lung Cancer WorryaModels are adjusted for age, income, smoking status, and self-reported depression at baseline.Quality of CommunictionPredicted Mean Depression Score (95% CI)Predicted Mean Anxiety Score (95% CI)Predicted Mean Worry Score (95% CI)Less than excellent communication6.44 (5.36 to 7.52)6.00 (4.89 to 7.11)2.27 (1.95 to 2.58)Excellent communication5.03 (4.50 to 5.55)5.85 (5.31 to 6.39)2.13 (1.98 to 2.29)Difference−1.42 (−2.63 to −0.20)−0.15 (−1.40 to 1.10)−0.13 (−0.49 to 0.22)a Models are adjusted for age, income, smoking status, and self-reported depression at baseline. Open table in a new tab In this prospective cohort study of veterans with a high rate of self-reported depression, most did not have elevated depression and anxiety scores after the incidental detection of pulmonary nodule(s). We found that high-quality communication between physicians and patients was not associated with self-reported symptoms of anxiety or lung cancer worry over time. High-quality communication was associated with statistically significantly lower mean depression scores. However, the effect size was small—likely below the minimally clinically important difference14Wynne S.C. Patel S. Barker R.E. et al.Anxiety and depression in bronchiectasis: response to pulmonary rehabilitation and minimal clinically important difference of the Hospital Anxiety and Depression Scale.Chron Respir Dis. 2020; 171479973120933292Crossref PubMed Scopus (25) Google Scholar, 15Lemay K.R. Tulloch H.E. Pipe A.L. et al.Establishing the minimal clinically important difference for the Hospital Anxiety and Depression Scale in patients with cardiovascular disease.J Cardiopulm Rehabil Prev. 2019; 39: E6-E11Crossref PubMed Scopus (116) Google Scholar, 16Smid D.E. Franssen F.M. Houben-Wilke S. et al.Responsiveness and MCID estimates for CAT, CCQ, and HADS in patients with COPD undergoing pulmonary rehabilitation: a prospective analysis.J Am Med Dir Assoc. 2017; 18: 53-58Abstract Full Text Full Text PDF PubMed Google Scholar—and the association was not found in sensitivity analyses when the outcome was dichotomized. Our findings support previous research. In a systematic review of patient-centered outcomes among patients with nodules detected during lung cancer screening, those with benign nodules had short-term increases in distress and state anxiety but did not suffer other adverse psychosocial consequences (eg, worse depression, worse quality of life).17Slatore C.G. Sullivan D.R. Pappas M. et al.Patient-centered outcomes among lung cancer screening recipients with computed tomography: a systematic review.J Thorac Oncol. 2014; 9: 927-934Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar Similarly, the Pan-Canadian Early Detection of Lung Cancer Study investigators18Taghizadeh N. Tremblay A. Cressman S. et al.Health-related quality of life and anxiety in the PAN-CAN lung cancer screening cohort.BMJ Open. 2019; 9e024719Crossref PubMed Scopus (28) Google Scholar reported a nodule diagnosis was not associated with health-related quality of life but was associated with short-term and to a lesser extent longer-term anxiety. This study has several strengths. It is the largest longitudinal cohort study of patients with pulmonary nodules in a routine care setting that uses validated instruments to measure patient-centered outcomes and communication. Limitations include its small sample size, missing data, and limited generalizability because of the predominately male, White, and veteran population. We found that among veterans with incidental pulmonary nodule(s), communication strategies may not meaningfully influence depression, anxiety, or lung cancer worry, and that other interventions may be required to affect these important patient-centered outcomes. This study was sponsored by VA HSR&D Career Development Awards (Awards CDA 09-025, CDP 11-227) to C. G. S. It was also supported by resources from the VA Portland Health Care System, Portland, Oregon.