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High levels of socioeconomic deprivation do not inhibit patients’ communication of concerns in head and neck cancer review clinics
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High levels of socioeconomic deprivation do not inhibit patients’ communication of concerns in head and neck cancer review clinics S. Allen a,∗ , R. Harris b , S.L. Brown c , G. Humphris d , Y. Zhou d , S.N. Rogers e,f a
Department of Health Services Research, Institute of Psychology Health and Society, University of Liverpool, Room 111, 1st floor, Block B, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK b Department of Health Services Research, Institute of Psychology Health and Society, Block B, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK c Department of Psychological Sciences, University of Liverpool, Liverpool, L69 3BX, UK d School of Medicine, University of St Andrews, St Andrews, Fife, KY16 9TF St Andrews, Scotland, UK e Evidence-Based Practice Research Centre (EPRC), Faculty of Health and Social Care, Edge Hill University, St Helens Road, Ormskirk, L39 4QP f Consultant Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, L9 1AE, UK
Abstract To examine associations between socioeconomic status and the extent to which patients with cancer of the head and neck expressed concerns to surgeons during routine follow-up clinics, we analysed audio recordings of 110 consultations with one consultant. We used the Verona Coding Definitions of Emotional Sequences (VRCoDES) to measure communication between the doctor and the patient, and grouped the English indices of multiple deprivation (IMD) 2015 scores into deciles to compare the VRCoDES with socioeconomic status. There were no significant correlations between IMD decile and the number and type of cues and concerns, or the type of response by the consultant, but there was a positive correlation between IMD decile and duration of appointment (r = 0.288, p < 0.01). When the duration of appointment was controlled for, there was a negative correlation between IMD decile and number of cues and concerns (r = −0.221, p < 0.05). These findings question the assumption that socioeconomic status is associated with a patient’s willingness to express concerns. Shorter consultations suggest that less time is spent responding to their concerns or building a rapport. Clinicians might find it advantageous to adopt strategies that will improve their understanding of these patients and help them to communicate more effectively. © 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Doctor-patient Communication; Head and Neck Cancer; Deprivation; VRCoDES; Indices of Multiple Deprivation
Introduction Cancer of the head and neck can cause a range of long-term problems that include pain, xerostomia, fear of recurrence,
∗
Corresponding author. Tel.: +44 151 795 5317. E-mail addresses: [email protected] (S. Allen), [email protected] (R. Harris), [email protected] (S.L. Brown), [email protected] (G. Humphris), [email protected] (Y. Zhou), [email protected] (S.N. Rogers).
disfigurement, and problems with feeding and speech.1 Research has suggested that patients of a low socioeconomic status are more likely to develop the disease. They also have a poorer quality of life, and lower survival rates than those of higher status.2–4 Patient-centred communication, in which patients are encouraged to raise and discuss their concerns, and to participate in the decisions made about their treatment,5 is linked to positive outcomes. These include a better quality of life, a reduction in anxiety and depression, greater satisfaction, a
https://doi.org/10.1016/j.bjoms.2018.05.015 0266-4356/© 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Allen S, et al. High levels of socioeconomic deprivation do not inhibit patients’ communication of concerns in head and neck cancer review clinics. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.05.015
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willingness to share information, and improved compliance with treatment.6–9 Studies, however, have found that communication between the doctor and patient can differ according to the patient’s socioeconomic status.10 Low-status patients tend to participate less actively in consultations, for example, they ask fewer questions, and are not as likely to express emotion and volunteer information spontaneously. Healthcare professionals tend to give them less information, spend a shorter time building a rapport, and do not listen to them as attentively.9,11,12 The level of deprivation is an indicator of socioeconomic status in the UK that is based on seven variables that include quality of housing, employment and crime, and living environment.13 It is the primary indicator of area-based socioeconomic deprivation because it reflects inequalities over a broad range of social indicators. High levels of deprivation are associated with greater morbidity and mortality,14 and with a prevalence of mental disorders,15 obesity and smoking,16 and poorer self-reported health.16 To our knowledge, few authors have explored the effect that socioeconomic status has on communication between clinicians and patients with cancer of the head and neck, and none has used the level of deprivation as a measure of socioeconomic status. The UK National Health Service theoretically provides equal access to health services across all levels of society, which allows systematic comparison between different groups. We aimed to explore the association between low socioeconomic status and communication between the doctor and patient in head and neck oncology review clinics. This will improve our understanding of the effect of deprivation on such interactions. Material and methods We examined associations between the level of deprivation and the incidence and timing of patients’ expressions of concern in 110 audio recordings of head and neck oncology review consultations with a single consultant head and neck surgeon. We split Index of Multiple Deprivation (IMD) scores into deciles to measure socioeconomic status.17 IMD scores comprise aggregated summaries of income, employment, education, health, crime, access to housing and services, and living environment, which pertain to areas of around 1500 people in England. They are available on the website of the Department for Communities and Local Government, and can be accessed using postcodes.18 The audiotapes were analysed using the Verona Coding Definitions of Emotional Sequences (VRCoDES), which quantify patients’ expressions of worry or concern in a medical consultation, together with the responses of the healthcare provider.19–21 Patients’ utterances are coded as cues (verbal or non-verbal hints about negative emotions) or concerns (explicit expressions of emotion that are clearly stated), and
Table 1 Distribution of Index of Multiple Deprivation (IMD) deciles in sample. IMD decile
Percentage of sample
1 2 3 4 5 6 7 8 9 10
30.9 9.1 4.5 1.8 10 9.1 10 10 8.2 6.4
Table 2 Clinical characteristics of sample. Percentage of sample Treatment: Operation only Operation and radiotherapy Radio/chemoradiotherapy without operation Stage at diagnosis: Early Late Missing Primary site: Oral Pharyngeal Other
40.9 52.7 6.4 50 31.8 18.2 51.8 25.5 22.7
each is coded in terms of whether it was elicited by the patient or the healthcare professional.20 Responses by the healthcare provider are coded in terms of explicitness and whether they provided or reduced the opportunity for further disclosure; in other words, whether the healthcare provider encouraged or discouraged the patient from voicing their emotional concerns, and whether they did so directly or indirectly.19 VRCoDES have been used to study communication between doctors and patients in a variety of healthcare settings and in many different groups.22,23 Pearson’s correlation was used to examine associations between the IMD decile and number of cues and concerns, elicitation, and type of response by the consultant. Pearson’s partial correlation was used to control for duration of appointment.
Results The mean (range) age of the patients was 62.9 (29–93) years and most of them were male (n = 70, 64%). The mean (range) duration of appointment was 9 minutes 17 seconds (3 minutes 52 seconds–21 minutes 55 seconds), and the mean (SD) time since diagnosis was 56.85 (51.74) range 6–240 months. Table 1 shows the distribution of IMD deciles and Table 2 the clinical characteristics of the sample. Table 3 shows the mean number of cues and concerns. As shown in Table 4, there were no significant correlations
Please cite this article in press as: Allen S, et al. High levels of socioeconomic deprivation do not inhibit patients’ communication of concerns in head and neck cancer review clinics. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.05.015
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S. Allen et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx Table 3 Mean number of cues and concerns/consultation. There were no instances of cues “e” and “f”. Mean Median SD Total number of cues and concerns Total number of cues Number of concerns Number of cues: “a” “b” “c” “d” “g”
Range IQR
1.81 1.08 0.73
1.00 0 0
2.4 0–13 1.69 0–8 1.2 0–8
3 2 1
0.23 0.65 0.03 0.15 0.02
0 0 0 0 0
0.55 1.08 0.16 0.41 0.19
0 1 0 0 0
0–3 0–5 0–1 0–2 0–2
Table 4 Correlation coefficients and p values for Index of Multiple Deprivation (IMD) deciles. Number of cues and concerns Number of patient-elicited cues and concerns Number of consultant-elicited cues and concerns Time to first cue or concern Number of explicit responses to reduce space Number of explicit responses to provide space Number of non-explicit responses to reduce space Number of non-explicit responses to provide space Duration of appointment Number of cue “a” Number of cue “b” Number of cue “c” Number of cue “d” Number of cue “g” Proportion of concerns to cues
R
p value
−0.004 0.072 −0.059 0.218 0.03 −0.083 0.004 0.055 0.288 −0.091 0.02 −0.05 −0.074 0.072 0.009
0.97 0.456 0.543 0.077 0.756 0.389 0.97 0.566 <0.01 0.346 0.836 0.603 0.445 0.456 0.943
between IMD decile and number of cues and concerns, elicitation of cues and concerns, responses by the clinician, type of cues, and proportion of concerns to cues. There was, however, a significant positive correlation between IMD decile and duration of appointment (r = 0.288, p < 0.01). Also, when the duration of appointment was controlled using Pearson’s partial correlation, there was a significant and negative association between the number of cues and concerns and IMD decile (r = −0.221, p < 0.05). There was a positive correlation between IMD decile and time to first cue or concern, which approached significance (r = 0.218, p = 0.077).
Discussion We found no significant correlations between IMD decile and number of cues and concerns, elicitation, or responses by the consultant. This contrasts with previous findings such as those by Siminoff et al,11 who found that patients with higher levels of education and income asked more questions, were given more information, and had a better rapport with the clinician. We used the level of deprivation to indicate the socioeconomic status of an area, rather than education and income, which apply to individuals, and it suggests that the
3
influence of socioeconomic status on doctor-patient communication in this group may be limited. Previously reported effects of education and income on communication may reflect the specific influence of verbal or other academic skills, rather than socioeconomic status. When the duration of the consultation was controlled, however, there was a significant negative association between IMD decile and number of cues and concerns. This does not show that lower-status patients expressed more cues and concerns, but that more time was spent on general discussion and building a rapport. This is supported by our finding that lower-status patients took less (but not significantly less) time to broach their first cue or concern. It may be that this group of patients were quick to express their concerns and there was relatively little small talk. Such an interpretation agrees with previous findings that healthcare professionals spend more time building a rapport with patients from a higher socioeconomic level,11 and shows that it may be the patient, and not the doctor, who curtails it by moving directly towards the problem in hand. Nonetheless, building a rapport, which is an important aspect of communication, has several benefits for patients,5,7–9 and those in low-status groups may be disadvantaged if less time is taken to do it. However, clinicians may have responded in more detail to the cues and concerns of patients in higher socioeconomic groups, but we found that the clinician did not favour a particular group when eliciting concerns. This confirms the results of Aelbrecht et al24 who found that patients with a low level of education attached most importance to “affective” elements of a consultation, whereas those with middle and high levels of education felt that problem-solving was more important. In our study, patients of high socioeconomic status may have preferred the consultant to answer their questions and to find ways to solve their problems. Our study has a number of limitations. First, as only 110 audiotapes were analysed, the sample may have been too small to detect significant differences. Future studies will need to be larger. Secondly, only one consultant participated in our present study, which meant that we could not generalise the findings. On the other hand, the use of only one consultant allowed us to control for variation and it isolated the effect of the level of deprivation. The use of IMD scores to measure socioeconomic status is also limited because they rely on postcodes, and not everyone who lives in an area has the same level of education or occupation. In conclusion, the absence of significant correlations between the IMD decile and number of cues and concerns (as well as the consultant’s responses) suggest that socioeconomic status, when assessed by geographical location, may be a weaker indicator of association with the quality of communication than individual-level variables such as education.11 However, our finding that there seems to be less discussion between patients from lower-status groups and their clinician is possibly because the patients broached their concerns more quickly. While we acknowledge that more
Please cite this article in press as: Allen S, et al. High levels of socioeconomic deprivation do not inhibit patients’ communication of concerns in head and neck cancer review clinics. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.05.015
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communication is not necessarily better communication,25 it may be advantageous for clinicians to adopt active strategies that help them to build a rapport with the patients in this group who would like an opportunity to voice their concerns. Conflict of interest We have no conflicts of interest. Ethics statement/confirmation of patients’ permission All procedures in this study were approved by and in accordance with the ethical standards of the Clinical Audit Department, University Hospital Aintree, the University of St Andrews School of Medicine, and the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The article does not contain any studies with animals done by any of the authors. Informed consent was obtained from all participants. Acknowledgements Sarah Allen is funded by The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North West Coast (NIHR CLAHRC NWC). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. References 1. Rogers SN. Quality of life perspectives in patients with oral cancer. Oral Oncol 2010;46:445–7. 2. Auluck A, Walker BB, Hislop G, et al. Population-based incidence trends of oropharyngeal and oral cavity cancers by sex among the poorest and underprivileged populations. BMC Cancer 2014;14:316. 3. Allen S, Lowe D, Harris RV, et al. Is social inequality related to different patient concerns in routine oral cancer follow-up clinics? Eur Arch Otorhinolaryngol 2017;274:451–9. 4. Rylands J, Lowe D, Rogers SN. Outcomes by area of residence deprivation in a cohort of oral cancer patients: survival, health-related quality of life, and place of death. Oral Oncol 2016;52:30–6. 5. Epstein RM, Fiscella K, Lesser CS, et al. Why the nation needs a policy push on patient-centered health care. Health Aff (Millwood) 2010;29:1489–95. 6. Morris J, Royle GT. Offering patients a choice of surgery for early breastcancer - a reduction in anxiety and depression in patients and their husbands. Soc Sci Med 1988;26:583–5.
7. Arora NK. Interacting with cancer patients: the significance of physicians’ communication behavior. Soc Sci Med 2003;57:791–806. 8. Street Jr RL, Voigt B. Patient participation in deciding breast cancer treatment and subsequent quality of life. Med Decis Making 1997;17:298–306. 9. Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care 1988;26:657–75. 10. Verlinde E, De Laender N, De Maesschalck S, et al. The social gradient in doctor-patient communication. Int J Equity Health 2012;11:12. 11. Siminoff LA, Graham GC, Gordon NH. Cancer communication patterns and the influence of patient characteristics: disparities in informationgiving and affective behaviors. Patient Educ Couns 2006;62:355–60. 12. Martin E, Russell D, Goodwin S, et al. Why patients consult and what happens when they do. BMJ 1991;303:289–92. 13. Macintyre S, Maciver S, Sooman A. Area, class and health: should we be focusing on places or people? J Soc Policy 1993;22:213–34. 14. Reijneveld SA, Verheij RA, de Bakker DH. Relative importance of urbanicity, ethnicity and socioeconomic factors regarding area mortality differences. J Epidemiol Community Health 1999;53:444–5. 15. Reijneveld SA, Schene AH. Higher prevalence of mental disorders in socioeconomically deprived urban areas in the Netherlands:community or personal disadvantage? J Epidemiol Community Health 1998;52:2–7. 16. Reijneveld SA. The impact of individual and area characteristics on urban socioeconomic differences in health and smoking. Int J Epidemiol 1998;27:33–40. 17. Ministry of Housing, Communities & Local Government. The English indices of deprivation 2015. Available from URL: https://www.gov.uk/ government/statistics/english-indices-of-deprivation-2015 (last accessed 5 May 2018). 18. Ministry of Housing, Communities & Local Government. The English indices of deprivation 2010. Available from URL: https://www.gov.uk/ government/statistics/english-indices-of-deprivation-2010 (last accessed 5 May 2018). 19. Del Piccolo L, de Haes H, Heaven C, et al. Development of the Verona coding definitions of emotional sequences to code health providers’ responses (VR-CoDES-P) to patient cues and concerns. Patient Educ Couns 2011;82:149–55. 20. Zimmermann C, Del Piccolo L, Bensing J, et al. Coding patient emotional cues and concerns in medical consultations: the Verona coding definitions of emotional sequences (VR-CoDES). Patient Educ Couns 2011;82:141–8. 21. Piccolo LD, Finset A, Mellblom AV, et al. Verona coding definitions of emotional sequences (VR-CoDES): conceptual framework and future directions. Patient Educ Couns 2017;100:2303–11. 22. Del Piccolo L, Pietrolongo E, Radice D, et al. Patient expression of emotions and neurologist responses in first multiple sclerosis consultations. PLoS One 2015;10:e0127734. 23. Finset A, Heyn L, Ruland C. Patterns in clinicians’ responses to patient emotion in cancer care. Patient Educ Couns 2013;93:80–5. 24. Aelbrecht K, Rimondini M, Bensing J, et al. Quality of doctor-patient communication through the eyes of the patient: variation according to the patient’s educational level. Adv Health Sci Educ 2015;20:873–84. 25. Elmore N, Burt J, Abel G, et al. Investigating the relationship between consultation length and patient experience: a cross-sectional study in primary care. Br J Gen Pract 2016;66:e896–903.
Please cite this article in press as: Allen S, et al. High levels of socioeconomic deprivation do not inhibit patients’ communication of concerns in head and neck cancer review clinics. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.05.015
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High levels of socioeconomic deprivation do not inhibit patients’ communication of concerns in head and neck cancer review clinics S. Allen a,∗ , R. Harris b , S.L. Brown c , G. Humphris d , Y. Zhou d , S.N. Rogers e,f a
Department of Health Services Research, Institute of Psychology Health and Society, University of Liverpool, Room 111, 1st floor, Block B, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK b Department of Health Services Research, Institute of Psychology Health and Society, Block B, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK c Department of Psychological Sciences, University of Liverpool, Liverpool, L69 3BX, UK d School of Medicine, University of St Andrews, St Andrews, Fife, KY16 9TF St Andrews, Scotland, UK e Evidence-Based Practice Research Centre (EPRC), Faculty of Health and Social Care, Edge Hill University, St Helens Road, Ormskirk, L39 4QP f Consultant Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, L9 1AE, UK
Abstract To examine associations between socioeconomic status and the extent to which patients with cancer of the head and neck expressed concerns to surgeons during routine follow-up clinics, we analysed audio recordings of 110 consultations with one consultant. We used the Verona Coding Definitions of Emotional Sequences (VRCoDES) to measure communication between the doctor and the patient, and grouped the English indices of multiple deprivation (IMD) 2015 scores into deciles to compare the VRCoDES with socioeconomic status. There were no significant correlations between IMD decile and the number and type of cues and concerns, or the type of response by the consultant, but there was a positive correlation between IMD decile and duration of appointment (r = 0.288, p < 0.01). When the duration of appointment was controlled for, there was a negative correlation between IMD decile and number of cues and concerns (r = −0.221, p < 0.05). These findings question the assumption that socioeconomic status is associated with a patient’s willingness to express concerns. Shorter consultations suggest that less time is spent responding to their concerns or building a rapport. Clinicians might find it advantageous to adopt strategies that will improve their understanding of these patients and help them to communicate more effectively. © 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Doctor-patient Communication; Head and Neck Cancer; Deprivation; VRCoDES; Indices of Multiple Deprivation
Introduction Cancer of the head and neck can cause a range of long-term problems that include pain, xerostomia, fear of recurrence,
∗
Corresponding author. Tel.: +44 151 795 5317. E-mail addresses: [email protected] (S. Allen), [email protected] (R. Harris), [email protected] (S.L. Brown), [email protected] (G. Humphris), [email protected] (Y. Zhou), [email protected] (S.N. Rogers).
disfigurement, and problems with feeding and speech.1 Research has suggested that patients of a low socioeconomic status are more likely to develop the disease. They also have a poorer quality of life, and lower survival rates than those of higher status.2–4 Patient-centred communication, in which patients are encouraged to raise and discuss their concerns, and to participate in the decisions made about their treatment,5 is linked to positive outcomes. These include a better quality of life, a reduction in anxiety and depression, greater satisfaction, a
https://doi.org/10.1016/j.bjoms.2018.05.015 0266-4356/© 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Allen S, et al. High levels of socioeconomic deprivation do not inhibit patients’ communication of concerns in head and neck cancer review clinics. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.05.015
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willingness to share information, and improved compliance with treatment.6–9 Studies, however, have found that communication between the doctor and patient can differ according to the patient’s socioeconomic status.10 Low-status patients tend to participate less actively in consultations, for example, they ask fewer questions, and are not as likely to express emotion and volunteer information spontaneously. Healthcare professionals tend to give them less information, spend a shorter time building a rapport, and do not listen to them as attentively.9,11,12 The level of deprivation is an indicator of socioeconomic status in the UK that is based on seven variables that include quality of housing, employment and crime, and living environment.13 It is the primary indicator of area-based socioeconomic deprivation because it reflects inequalities over a broad range of social indicators. High levels of deprivation are associated with greater morbidity and mortality,14 and with a prevalence of mental disorders,15 obesity and smoking,16 and poorer self-reported health.16 To our knowledge, few authors have explored the effect that socioeconomic status has on communication between clinicians and patients with cancer of the head and neck, and none has used the level of deprivation as a measure of socioeconomic status. The UK National Health Service theoretically provides equal access to health services across all levels of society, which allows systematic comparison between different groups. We aimed to explore the association between low socioeconomic status and communication between the doctor and patient in head and neck oncology review clinics. This will improve our understanding of the effect of deprivation on such interactions. Material and methods We examined associations between the level of deprivation and the incidence and timing of patients’ expressions of concern in 110 audio recordings of head and neck oncology review consultations with a single consultant head and neck surgeon. We split Index of Multiple Deprivation (IMD) scores into deciles to measure socioeconomic status.17 IMD scores comprise aggregated summaries of income, employment, education, health, crime, access to housing and services, and living environment, which pertain to areas of around 1500 people in England. They are available on the website of the Department for Communities and Local Government, and can be accessed using postcodes.18 The audiotapes were analysed using the Verona Coding Definitions of Emotional Sequences (VRCoDES), which quantify patients’ expressions of worry or concern in a medical consultation, together with the responses of the healthcare provider.19–21 Patients’ utterances are coded as cues (verbal or non-verbal hints about negative emotions) or concerns (explicit expressions of emotion that are clearly stated), and
Table 1 Distribution of Index of Multiple Deprivation (IMD) deciles in sample. IMD decile
Percentage of sample
1 2 3 4 5 6 7 8 9 10
30.9 9.1 4.5 1.8 10 9.1 10 10 8.2 6.4
Table 2 Clinical characteristics of sample. Percentage of sample Treatment: Operation only Operation and radiotherapy Radio/chemoradiotherapy without operation Stage at diagnosis: Early Late Missing Primary site: Oral Pharyngeal Other
40.9 52.7 6.4 50 31.8 18.2 51.8 25.5 22.7
each is coded in terms of whether it was elicited by the patient or the healthcare professional.20 Responses by the healthcare provider are coded in terms of explicitness and whether they provided or reduced the opportunity for further disclosure; in other words, whether the healthcare provider encouraged or discouraged the patient from voicing their emotional concerns, and whether they did so directly or indirectly.19 VRCoDES have been used to study communication between doctors and patients in a variety of healthcare settings and in many different groups.22,23 Pearson’s correlation was used to examine associations between the IMD decile and number of cues and concerns, elicitation, and type of response by the consultant. Pearson’s partial correlation was used to control for duration of appointment.
Results The mean (range) age of the patients was 62.9 (29–93) years and most of them were male (n = 70, 64%). The mean (range) duration of appointment was 9 minutes 17 seconds (3 minutes 52 seconds–21 minutes 55 seconds), and the mean (SD) time since diagnosis was 56.85 (51.74) range 6–240 months. Table 1 shows the distribution of IMD deciles and Table 2 the clinical characteristics of the sample. Table 3 shows the mean number of cues and concerns. As shown in Table 4, there were no significant correlations
Please cite this article in press as: Allen S, et al. High levels of socioeconomic deprivation do not inhibit patients’ communication of concerns in head and neck cancer review clinics. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.05.015
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S. Allen et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx Table 3 Mean number of cues and concerns/consultation. There were no instances of cues “e” and “f”. Mean Median SD Total number of cues and concerns Total number of cues Number of concerns Number of cues: “a” “b” “c” “d” “g”
Range IQR
1.81 1.08 0.73
1.00 0 0
2.4 0–13 1.69 0–8 1.2 0–8
3 2 1
0.23 0.65 0.03 0.15 0.02
0 0 0 0 0
0.55 1.08 0.16 0.41 0.19
0 1 0 0 0
0–3 0–5 0–1 0–2 0–2
Table 4 Correlation coefficients and p values for Index of Multiple Deprivation (IMD) deciles. Number of cues and concerns Number of patient-elicited cues and concerns Number of consultant-elicited cues and concerns Time to first cue or concern Number of explicit responses to reduce space Number of explicit responses to provide space Number of non-explicit responses to reduce space Number of non-explicit responses to provide space Duration of appointment Number of cue “a” Number of cue “b” Number of cue “c” Number of cue “d” Number of cue “g” Proportion of concerns to cues
R
p value
−0.004 0.072 −0.059 0.218 0.03 −0.083 0.004 0.055 0.288 −0.091 0.02 −0.05 −0.074 0.072 0.009
0.97 0.456 0.543 0.077 0.756 0.389 0.97 0.566 <0.01 0.346 0.836 0.603 0.445 0.456 0.943
between IMD decile and number of cues and concerns, elicitation of cues and concerns, responses by the clinician, type of cues, and proportion of concerns to cues. There was, however, a significant positive correlation between IMD decile and duration of appointment (r = 0.288, p < 0.01). Also, when the duration of appointment was controlled using Pearson’s partial correlation, there was a significant and negative association between the number of cues and concerns and IMD decile (r = −0.221, p < 0.05). There was a positive correlation between IMD decile and time to first cue or concern, which approached significance (r = 0.218, p = 0.077).
Discussion We found no significant correlations between IMD decile and number of cues and concerns, elicitation, or responses by the consultant. This contrasts with previous findings such as those by Siminoff et al,11 who found that patients with higher levels of education and income asked more questions, were given more information, and had a better rapport with the clinician. We used the level of deprivation to indicate the socioeconomic status of an area, rather than education and income, which apply to individuals, and it suggests that the
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influence of socioeconomic status on doctor-patient communication in this group may be limited. Previously reported effects of education and income on communication may reflect the specific influence of verbal or other academic skills, rather than socioeconomic status. When the duration of the consultation was controlled, however, there was a significant negative association between IMD decile and number of cues and concerns. This does not show that lower-status patients expressed more cues and concerns, but that more time was spent on general discussion and building a rapport. This is supported by our finding that lower-status patients took less (but not significantly less) time to broach their first cue or concern. It may be that this group of patients were quick to express their concerns and there was relatively little small talk. Such an interpretation agrees with previous findings that healthcare professionals spend more time building a rapport with patients from a higher socioeconomic level,11 and shows that it may be the patient, and not the doctor, who curtails it by moving directly towards the problem in hand. Nonetheless, building a rapport, which is an important aspect of communication, has several benefits for patients,5,7–9 and those in low-status groups may be disadvantaged if less time is taken to do it. However, clinicians may have responded in more detail to the cues and concerns of patients in higher socioeconomic groups, but we found that the clinician did not favour a particular group when eliciting concerns. This confirms the results of Aelbrecht et al24 who found that patients with a low level of education attached most importance to “affective” elements of a consultation, whereas those with middle and high levels of education felt that problem-solving was more important. In our study, patients of high socioeconomic status may have preferred the consultant to answer their questions and to find ways to solve their problems. Our study has a number of limitations. First, as only 110 audiotapes were analysed, the sample may have been too small to detect significant differences. Future studies will need to be larger. Secondly, only one consultant participated in our present study, which meant that we could not generalise the findings. On the other hand, the use of only one consultant allowed us to control for variation and it isolated the effect of the level of deprivation. The use of IMD scores to measure socioeconomic status is also limited because they rely on postcodes, and not everyone who lives in an area has the same level of education or occupation. In conclusion, the absence of significant correlations between the IMD decile and number of cues and concerns (as well as the consultant’s responses) suggest that socioeconomic status, when assessed by geographical location, may be a weaker indicator of association with the quality of communication than individual-level variables such as education.11 However, our finding that there seems to be less discussion between patients from lower-status groups and their clinician is possibly because the patients broached their concerns more quickly. While we acknowledge that more
Please cite this article in press as: Allen S, et al. High levels of socioeconomic deprivation do not inhibit patients’ communication of concerns in head and neck cancer review clinics. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.05.015
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communication is not necessarily better communication,25 it may be advantageous for clinicians to adopt active strategies that help them to build a rapport with the patients in this group who would like an opportunity to voice their concerns. Conflict of interest We have no conflicts of interest. Ethics statement/confirmation of patients’ permission All procedures in this study were approved by and in accordance with the ethical standards of the Clinical Audit Department, University Hospital Aintree, the University of St Andrews School of Medicine, and the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The article does not contain any studies with animals done by any of the authors. Informed consent was obtained from all participants. Acknowledgements Sarah Allen is funded by The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North West Coast (NIHR CLAHRC NWC). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. References 1. Rogers SN. Quality of life perspectives in patients with oral cancer. Oral Oncol 2010;46:445–7. 2. Auluck A, Walker BB, Hislop G, et al. Population-based incidence trends of oropharyngeal and oral cavity cancers by sex among the poorest and underprivileged populations. BMC Cancer 2014;14:316. 3. Allen S, Lowe D, Harris RV, et al. Is social inequality related to different patient concerns in routine oral cancer follow-up clinics? Eur Arch Otorhinolaryngol 2017;274:451–9. 4. Rylands J, Lowe D, Rogers SN. Outcomes by area of residence deprivation in a cohort of oral cancer patients: survival, health-related quality of life, and place of death. Oral Oncol 2016;52:30–6. 5. Epstein RM, Fiscella K, Lesser CS, et al. Why the nation needs a policy push on patient-centered health care. Health Aff (Millwood) 2010;29:1489–95. 6. Morris J, Royle GT. Offering patients a choice of surgery for early breastcancer - a reduction in anxiety and depression in patients and their husbands. Soc Sci Med 1988;26:583–5.
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Please cite this article in press as: Allen S, et al. High levels of socioeconomic deprivation do not inhibit patients’ communication of concerns in head and neck cancer review clinics. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.05.015