- Email: [email protected]
Educational intervention to improve code status discussion skills and confidence for obstetrics and gynecology residents
206
Abstracts / Gynecologic Oncology 145 (2017) 2–220
Results: Of the original 213 patients who answered the GCLQ survey, 10 patients (4.72%) had a diagnosis of LLL in the medical record. The respondents had a mean age of 67.8 years (SD ± 49.7) and BMI of 33.5 kg/m² (SD ± 23.5). The majority of patients underwent surgery (98.5%) and did not receive chemotherapy (70.6%) or radiation (60.1%). Seventy-eight patients (36.6% response rate) completed a follow-up survey 5 years later. The most common symptoms in the initial survey were tenderness (35.7%), stiffness (51.2%), and aching (55.1%). Five years later, stiffness (48.7%) and aching (53.9%) were still the most common symptoms reported along with limited movement in the knee (44.2%). There was a significant decrease in the swelling domain symptoms from 38.5% initially to 34.6% 5 years later (P b 0.001). There was a significant increase in infection domain symptoms from 35.9% to 44.9% (P = 0.008). By GCLQ criteria, 14.1% (n = 11) of patients who answered both surveys met the diagnosis of LLL. Five years later, 12.8% (n = 10) of patients met the diagnosis. Two patients had persistent LLL, while 8 patients developed LLL. Conclusions: Patient-reported outcomes by GCLQ define a greater symptom burden of LLL, which is underreported in the medical record. Almost 3 times as many uterine cancer patients are diagnosed with LLL by the GCLQ survey. These patients continue to develop symptoms even 5 years later. Improving capture of LLL with earlier identification and referral to lymphedema programs could decrease the symptom burden for uterine cancer survivors over an extended period of time.
doi:10.1016/j.ygyno.2017.03.473
446 - Poster Session Perceptions of risk and reward in BRCA1 and BRCA2 mutation carriers choosing salpingectomy for ovarian cancer prevention T. Ghezelayagha, L. Stewarta, V. Yub, K.J. Agnewc, B.M. Norquistd, K. Penningtonc, E.M. Swishera. aUniversity of Washington Medical Center, Seattle, WA, USA, bGeorgetown/Washington Hospital Center, Washington, DC, USA, cUniversity of Washington School of Medicine, Seattle, WA, USA, d University of Washington, Seattle, WA, USA Objective: Salpingectomy with delayed oophorectomy has gained traction as an ovarian cancer prevention strategy but is not currently recommended for high-risk women. Nevertheless, some women choose this procedure. We aimed to better understand BRCA1 or BRCA2 (BRCA) mutation carriers who chose bilateral salpingectomy for ovarian cancer prevention. Method: This was a longitudinal survey study of BRCA mutation carriers who had previous bilateral salpingectomy to reduce ovarian cancer risk. An initial written questionnaire and telephone interview were followed by annual follow-up phone interviews. Patients were divided into 2 groups, those pursuing salpingectomy before and those pursuing salpingectomy after the recommended age of oophorectomy (age 40 years for BRCA1 and 45 years for BRCA2 carriers). Results: Twenty-one women were enrolled, 11 with BRCA1 and 11 with BRCA2 (1 patient had both) with median follow-up of 1 year (range 0–2 years). Fourteen (66.7%) women had salpingectomy before and 7 (33.3%) after the recommended age of oophorectomy. The median age at salpingectomy was 40 years (range 27–49). The majority of patients were white (100%), had completed graduate education (66%), and were married/partnered (76%). Nearly half (42.9%) were nulliparous. Most (80%) expressed
decreased worry about developing ovarian cancer after salpingectomy. Seventy percent were getting regular pelvic ultrasounds and CA-125 for screening. There was no difference in levels of worry about ovarian cancer or in risk perception between women who had salpingectomy before or those who had it after the recommended age. Patients who had pursued salpingectomy after the recommended age of oophorectomy were less likely to plan for future oophorectomy (13% vs 87%, P = 0.006). All were satisfied with their decision to delay oophorectomy throughout the study time, with the most cited reasons including the low risk and repercussions of salpingectomy and the feeling that they reduced their risk while delaying menopause. There were no diagnoses of ovarian cancer during our limited study period. Conclusion: This exploratory study of BRCA mutation carriers demonstrates that most are satisfied with their decision, have decreased worry, and have lower risk perception after salpingectomy. Surprisingly, most older women undergoing salpingectomy did not plan on future oophorectomy, suggesting an important educational need.
doi:10.1016/j.ygyno.2017.03.474
447 - Poster Session Educational intervention to improve code status discussion skills and confidence for obstetrics and gynecology residents B.A. Margolisa, A. Buckley de Meritensb, C. Blindermana, S. Chatterjeec, A.I. Tergasa, W.M. Burked, J.Y. Houa, J.D. Wrightd. aNYP/ Columbia University Medical Center, New York, NY, USA, bUMDNJ-The Cancer Institute of New Jersey, New Brunswick, NJ, USA, cNYPH, Columbia University Medical Center and Weill Cornell Medical College, New York, NY, USA, dColumbia University College of Physicians and Surgeons, New York, NY, USA Objective: Obstetrics and gynecology (OBGYN) residents frequently care for patients with advanced gynecologic malignancy yet receive little formal training in conducting code status discussions (CSDs). We piloted an educational intervention to improve resident confidence and skills at conducting CSDs. Method: OBGYN residents at a single institution underwent consent and participated in an institutional review board-approved 3-part educational program: a journal article reading, an online module, and CSD simulations. The CSD simulations included an observed resident-to-resident mock patient encounter and a videotaped CSD with a standardized patient (SP). Pre- and postintervention surveys and performance evaluations were analyzed with descriptive methods. Results: Our cohort of 24 residents was 85% female, and the average age was 29 years. Postgraduate years 1–4 were represented. Half of the participants previously reported having received 1–3 hours of end-of-life care training and 15% received none. On average, 23% of respondents had never conducted a CSD, given bad news, or discussed prognosis or hospice. Residents initially felt most prepared to discuss treatment options (3.3/5 on Likert scale) and less prepared to discuss hospice, end-of-life care, and code status (2.2–2.3/5). Most (78%) disagreed that it is solely the attending’s responsibility to discuss goals of care with inpatients. Performance during the resident-to-resident CSD was variable with scores (percentage of skills achieved) from 27% to 93% (average 64%). Performance at the SP encounter was similar with scores from 40% to 73% (average 56%). Skills that few residents were proficient at included making a clear
Abstracts / Gynecologic Oncology 145 (2017) 2–220
recommendation regarding CPR (22%), suggesting a follow-up plan (28%), and summarizing the discussion (6%). Post-intervention, residents felt more prepared for CSDs (3.7/5) and end-of-life care (3.9/5). Overall, 72% of respondents felt that the educational intervention changed the way they communicate with patients. Conclusion: The majority of participants believe they have a role in counseling patients at the end of life, yet many residents had never done so and lacked explicit direction. Participants felt more prepared to lead a CSD after the intervention. Future attempts at improving CSD skills should include more intensive mentoring and ongoing practice.
doi:10.1016/j.ygyno.2017.03.475
448 - Poster Session Critical conversations in gynecologic oncology: Pilot study of communication skills training for fellows and advanced practice providers C. Lefkowitsa, K.S. Bevisb, E. Careyc, J. Sheederd, R. Arnolde, L. Podgurskif. aUniversity of Colorado Denver, Denver, CO, USA, b University of Alabama at Birmingham, Birmingham, AL, USA, cMayo Clinic, Rochester, MN, USA, dUniversity of Colorado Denver, Aurora, CO, USA, eUniversity of Pittsburgh Medical Center, Pittsburgh, PA, USA, f University of Pittsburgh/Magee-Women's Hosiptal, Pittsburgh, PA, USA Objective: Effective communication improves patient outcomes and satisfaction and is crucial to good patient care. Challenging communication scenarios abound in oncology, including giving serious news and discussing goals of care. Communication skills training (CST) has been shown to improve skill acquisition in nongynecologic oncology providers; we sought to test CST with gynecologic oncology providers. Method: We conducted a 2-day CST workshop based on the VitalTalk model with 4 faculty (2 gynecologic oncologists, 2 palliative care physicians) and 10 gynecologic oncology provider participants (5 fellows, 5 advanced practice providers). Acceptability, preparedness to address challenging communication scenarios, and impact on clinical practice were assessed by self-report. Using Fisher’s exact test, we compared prevalence of score of 4 or 5/5 on a Likert scale of preparedness to handle 13 challenging communication scenarios preworkshop, immediately postworkshop, and 1 month postworkshop. Results: Participants showed a statistically significant increase in preparedness for 10 out of 13 challenging communication scenarios immediately postworkshop (all P b 0.05). Improvements were sustained or increased at 1 month (Table 1). One month postworkshop, 89% of participants reported using skills learned in the course at least weekly. All participants rated the educational quality as very good or excellent, and all rated the training as important or very important to the development of their clinical skills. All strongly agreed they would recommend the course to others and that this training should be required of all gynecologic oncology clinicians. Conclusion: Participants felt strongly that the workshop provided high-quality education that changed their clinical practice. As a result of the workshop, participants reported statistically significant, sustained improvement in preparedness to handle challenging communication scenarios. CST for gynecologic oncology providers is feasible, with high rates of perceived effectiveness and impact on clinical practice. Formal CST should be integrated into gynecologic oncology training.
207
Table 1 How prepared do you feel to…
Convey serious news about a patient’s illness to the patient or family Convey prognosis to a patient or family member Express empathy Discuss code status with a patient or family member Respond to patients who deny the seriousness of their illness Respond to patients or family members who want treatments you believe are not indicated Discuss religious or spiritual issues with a patient or family member Elicit a patient or family member’s concerns about death & dying Manage conflict that arises during a family meeting Describe comfort-focused care Explore patient values to develop a treatment plan in a seriously ill patient Conduct a family conference Counsel a patient or family member in what to expect in the dying process How prepared do you feel to…
Convey serious news about a patient’s illness to the patient or family Convey prognosis to a patient or family member Express empathy Discuss code status with a patient or family member Respond to patients who deny the seriousness of their illness Respond to patients or family members who want treatments you believe are not indicated Discuss religious or spiritual issues with a patient or family member Elicit a patient or family member’s concerns about death & dying Manage conflict that arises during a family meeting Describe comfort-focused care Explore patient values to develop a treatment plan in a seriously ill patient Conduct a family conference Counsel a patient or family member in what to expect in the dying process
Percent of Participants Rating 4 or 5 on 5 Point Likert Scale (5=Very prepared) Preworkshop (n =10)
Immediate Postworkshop (n =10)
1 month Post workshop (n = 9)
0%
100%
100%
10%
100%
100%
60% 0%
100% 50%
100% 89%
10%
80%
78%
10%
80%
100%
10%
70%
78%
0%
90%
100%
0%
60%
78%
0% 0%
40% 100%
89% 100%
0% 0%
50% 30%
78% 56%
Percent of Participants Rating 4 or 5 on 5 Point Likert Scale (5=Very prepared) p-value Pre vs Immediate Post
p-value Pre vs 1 month Post
b 0.001
b 0.001
b 0.001
b 0.001
0.09 0.03
0.09 b 0.001
0.005
0.005
0.005
b 0.001
0.02
0.005
b 0.001
b 0.001
0.01
0.001
0.09 b 0.001
b 0.001 b 0.001
0.03 0.21
0.001 0.01
doi:10.1016/j.ygyno.2017.03.476
449 - Poster Session Comparison of longitudinal patient reported outcomes on an enhanced recovery pathway in patients with ovarian cancer undergoing primary vs interval cytoreductive surgery L.A. Meyera, A.M. Nickb, Q. Shia, M.D. Iniestaa, J.D. Lasalaa, M. Harrisa, C.C.L. Suna, K.H. Lua, P.T. Ramireza. aThe University of Texas MD Anderson Cancer Center, Houston, TX, USA, bSt. Thomas Medical
Abstracts / Gynecologic Oncology 145 (2017) 2–220
Results: Of the original 213 patients who answered the GCLQ survey, 10 patients (4.72%) had a diagnosis of LLL in the medical record. The respondents had a mean age of 67.8 years (SD ± 49.7) and BMI of 33.5 kg/m² (SD ± 23.5). The majority of patients underwent surgery (98.5%) and did not receive chemotherapy (70.6%) or radiation (60.1%). Seventy-eight patients (36.6% response rate) completed a follow-up survey 5 years later. The most common symptoms in the initial survey were tenderness (35.7%), stiffness (51.2%), and aching (55.1%). Five years later, stiffness (48.7%) and aching (53.9%) were still the most common symptoms reported along with limited movement in the knee (44.2%). There was a significant decrease in the swelling domain symptoms from 38.5% initially to 34.6% 5 years later (P b 0.001). There was a significant increase in infection domain symptoms from 35.9% to 44.9% (P = 0.008). By GCLQ criteria, 14.1% (n = 11) of patients who answered both surveys met the diagnosis of LLL. Five years later, 12.8% (n = 10) of patients met the diagnosis. Two patients had persistent LLL, while 8 patients developed LLL. Conclusions: Patient-reported outcomes by GCLQ define a greater symptom burden of LLL, which is underreported in the medical record. Almost 3 times as many uterine cancer patients are diagnosed with LLL by the GCLQ survey. These patients continue to develop symptoms even 5 years later. Improving capture of LLL with earlier identification and referral to lymphedema programs could decrease the symptom burden for uterine cancer survivors over an extended period of time.
doi:10.1016/j.ygyno.2017.03.473
446 - Poster Session Perceptions of risk and reward in BRCA1 and BRCA2 mutation carriers choosing salpingectomy for ovarian cancer prevention T. Ghezelayagha, L. Stewarta, V. Yub, K.J. Agnewc, B.M. Norquistd, K. Penningtonc, E.M. Swishera. aUniversity of Washington Medical Center, Seattle, WA, USA, bGeorgetown/Washington Hospital Center, Washington, DC, USA, cUniversity of Washington School of Medicine, Seattle, WA, USA, d University of Washington, Seattle, WA, USA Objective: Salpingectomy with delayed oophorectomy has gained traction as an ovarian cancer prevention strategy but is not currently recommended for high-risk women. Nevertheless, some women choose this procedure. We aimed to better understand BRCA1 or BRCA2 (BRCA) mutation carriers who chose bilateral salpingectomy for ovarian cancer prevention. Method: This was a longitudinal survey study of BRCA mutation carriers who had previous bilateral salpingectomy to reduce ovarian cancer risk. An initial written questionnaire and telephone interview were followed by annual follow-up phone interviews. Patients were divided into 2 groups, those pursuing salpingectomy before and those pursuing salpingectomy after the recommended age of oophorectomy (age 40 years for BRCA1 and 45 years for BRCA2 carriers). Results: Twenty-one women were enrolled, 11 with BRCA1 and 11 with BRCA2 (1 patient had both) with median follow-up of 1 year (range 0–2 years). Fourteen (66.7%) women had salpingectomy before and 7 (33.3%) after the recommended age of oophorectomy. The median age at salpingectomy was 40 years (range 27–49). The majority of patients were white (100%), had completed graduate education (66%), and were married/partnered (76%). Nearly half (42.9%) were nulliparous. Most (80%) expressed
decreased worry about developing ovarian cancer after salpingectomy. Seventy percent were getting regular pelvic ultrasounds and CA-125 for screening. There was no difference in levels of worry about ovarian cancer or in risk perception between women who had salpingectomy before or those who had it after the recommended age. Patients who had pursued salpingectomy after the recommended age of oophorectomy were less likely to plan for future oophorectomy (13% vs 87%, P = 0.006). All were satisfied with their decision to delay oophorectomy throughout the study time, with the most cited reasons including the low risk and repercussions of salpingectomy and the feeling that they reduced their risk while delaying menopause. There were no diagnoses of ovarian cancer during our limited study period. Conclusion: This exploratory study of BRCA mutation carriers demonstrates that most are satisfied with their decision, have decreased worry, and have lower risk perception after salpingectomy. Surprisingly, most older women undergoing salpingectomy did not plan on future oophorectomy, suggesting an important educational need.
doi:10.1016/j.ygyno.2017.03.474
447 - Poster Session Educational intervention to improve code status discussion skills and confidence for obstetrics and gynecology residents B.A. Margolisa, A. Buckley de Meritensb, C. Blindermana, S. Chatterjeec, A.I. Tergasa, W.M. Burked, J.Y. Houa, J.D. Wrightd. aNYP/ Columbia University Medical Center, New York, NY, USA, bUMDNJ-The Cancer Institute of New Jersey, New Brunswick, NJ, USA, cNYPH, Columbia University Medical Center and Weill Cornell Medical College, New York, NY, USA, dColumbia University College of Physicians and Surgeons, New York, NY, USA Objective: Obstetrics and gynecology (OBGYN) residents frequently care for patients with advanced gynecologic malignancy yet receive little formal training in conducting code status discussions (CSDs). We piloted an educational intervention to improve resident confidence and skills at conducting CSDs. Method: OBGYN residents at a single institution underwent consent and participated in an institutional review board-approved 3-part educational program: a journal article reading, an online module, and CSD simulations. The CSD simulations included an observed resident-to-resident mock patient encounter and a videotaped CSD with a standardized patient (SP). Pre- and postintervention surveys and performance evaluations were analyzed with descriptive methods. Results: Our cohort of 24 residents was 85% female, and the average age was 29 years. Postgraduate years 1–4 were represented. Half of the participants previously reported having received 1–3 hours of end-of-life care training and 15% received none. On average, 23% of respondents had never conducted a CSD, given bad news, or discussed prognosis or hospice. Residents initially felt most prepared to discuss treatment options (3.3/5 on Likert scale) and less prepared to discuss hospice, end-of-life care, and code status (2.2–2.3/5). Most (78%) disagreed that it is solely the attending’s responsibility to discuss goals of care with inpatients. Performance during the resident-to-resident CSD was variable with scores (percentage of skills achieved) from 27% to 93% (average 64%). Performance at the SP encounter was similar with scores from 40% to 73% (average 56%). Skills that few residents were proficient at included making a clear
Abstracts / Gynecologic Oncology 145 (2017) 2–220
recommendation regarding CPR (22%), suggesting a follow-up plan (28%), and summarizing the discussion (6%). Post-intervention, residents felt more prepared for CSDs (3.7/5) and end-of-life care (3.9/5). Overall, 72% of respondents felt that the educational intervention changed the way they communicate with patients. Conclusion: The majority of participants believe they have a role in counseling patients at the end of life, yet many residents had never done so and lacked explicit direction. Participants felt more prepared to lead a CSD after the intervention. Future attempts at improving CSD skills should include more intensive mentoring and ongoing practice.
doi:10.1016/j.ygyno.2017.03.475
448 - Poster Session Critical conversations in gynecologic oncology: Pilot study of communication skills training for fellows and advanced practice providers C. Lefkowitsa, K.S. Bevisb, E. Careyc, J. Sheederd, R. Arnolde, L. Podgurskif. aUniversity of Colorado Denver, Denver, CO, USA, b University of Alabama at Birmingham, Birmingham, AL, USA, cMayo Clinic, Rochester, MN, USA, dUniversity of Colorado Denver, Aurora, CO, USA, eUniversity of Pittsburgh Medical Center, Pittsburgh, PA, USA, f University of Pittsburgh/Magee-Women's Hosiptal, Pittsburgh, PA, USA Objective: Effective communication improves patient outcomes and satisfaction and is crucial to good patient care. Challenging communication scenarios abound in oncology, including giving serious news and discussing goals of care. Communication skills training (CST) has been shown to improve skill acquisition in nongynecologic oncology providers; we sought to test CST with gynecologic oncology providers. Method: We conducted a 2-day CST workshop based on the VitalTalk model with 4 faculty (2 gynecologic oncologists, 2 palliative care physicians) and 10 gynecologic oncology provider participants (5 fellows, 5 advanced practice providers). Acceptability, preparedness to address challenging communication scenarios, and impact on clinical practice were assessed by self-report. Using Fisher’s exact test, we compared prevalence of score of 4 or 5/5 on a Likert scale of preparedness to handle 13 challenging communication scenarios preworkshop, immediately postworkshop, and 1 month postworkshop. Results: Participants showed a statistically significant increase in preparedness for 10 out of 13 challenging communication scenarios immediately postworkshop (all P b 0.05). Improvements were sustained or increased at 1 month (Table 1). One month postworkshop, 89% of participants reported using skills learned in the course at least weekly. All participants rated the educational quality as very good or excellent, and all rated the training as important or very important to the development of their clinical skills. All strongly agreed they would recommend the course to others and that this training should be required of all gynecologic oncology clinicians. Conclusion: Participants felt strongly that the workshop provided high-quality education that changed their clinical practice. As a result of the workshop, participants reported statistically significant, sustained improvement in preparedness to handle challenging communication scenarios. CST for gynecologic oncology providers is feasible, with high rates of perceived effectiveness and impact on clinical practice. Formal CST should be integrated into gynecologic oncology training.
207
Table 1 How prepared do you feel to…
Convey serious news about a patient’s illness to the patient or family Convey prognosis to a patient or family member Express empathy Discuss code status with a patient or family member Respond to patients who deny the seriousness of their illness Respond to patients or family members who want treatments you believe are not indicated Discuss religious or spiritual issues with a patient or family member Elicit a patient or family member’s concerns about death & dying Manage conflict that arises during a family meeting Describe comfort-focused care Explore patient values to develop a treatment plan in a seriously ill patient Conduct a family conference Counsel a patient or family member in what to expect in the dying process How prepared do you feel to…
Convey serious news about a patient’s illness to the patient or family Convey prognosis to a patient or family member Express empathy Discuss code status with a patient or family member Respond to patients who deny the seriousness of their illness Respond to patients or family members who want treatments you believe are not indicated Discuss religious or spiritual issues with a patient or family member Elicit a patient or family member’s concerns about death & dying Manage conflict that arises during a family meeting Describe comfort-focused care Explore patient values to develop a treatment plan in a seriously ill patient Conduct a family conference Counsel a patient or family member in what to expect in the dying process
Percent of Participants Rating 4 or 5 on 5 Point Likert Scale (5=Very prepared) Preworkshop (n =10)
Immediate Postworkshop (n =10)
1 month Post workshop (n = 9)
0%
100%
100%
10%
100%
100%
60% 0%
100% 50%
100% 89%
10%
80%
78%
10%
80%
100%
10%
70%
78%
0%
90%
100%
0%
60%
78%
0% 0%
40% 100%
89% 100%
0% 0%
50% 30%
78% 56%
Percent of Participants Rating 4 or 5 on 5 Point Likert Scale (5=Very prepared) p-value Pre vs Immediate Post
p-value Pre vs 1 month Post
b 0.001
b 0.001
b 0.001
b 0.001
0.09 0.03
0.09 b 0.001
0.005
0.005
0.005
b 0.001
0.02
0.005
b 0.001
b 0.001
0.01
0.001
0.09 b 0.001
b 0.001 b 0.001
0.03 0.21
0.001 0.01
doi:10.1016/j.ygyno.2017.03.476
449 - Poster Session Comparison of longitudinal patient reported outcomes on an enhanced recovery pathway in patients with ovarian cancer undergoing primary vs interval cytoreductive surgery L.A. Meyera, A.M. Nickb, Q. Shia, M.D. Iniestaa, J.D. Lasalaa, M. Harrisa, C.C.L. Suna, K.H. Lua, P.T. Ramireza. aThe University of Texas MD Anderson Cancer Center, Houston, TX, USA, bSt. Thomas Medical