IMPORTANCE Clinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication. OBJECTIVE To evaluate the efficacy of a patient-specific preconversation communicationpriming intervention (Jumpstart-Tips) targeting both patients and clinicians and designed to increase goals-of-care conversations compared with usual care. DESIGN, SETTING, AND PARTICIPANTS Multicenter cluster-randomized trial in outpatient clinics with physicians or nurse practitioners and patients with serious illness. The study was conducted between 2012 and 2016. INTERVENTIONS Clinicians were randomized to the bilateral, preconversation, communication-priming intervention (n = 65) or usual care (n = 67), with 249 patients assigned to the intervention and 288 to usual care. MAIN OUTCOMES AND MEASURES The primary outcome was patient-reported occurrence of a goals-of-care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals-of-care conversation in the medical record and patient-reported quality of communication (Quality of Communication questionnaire [QOC]; 4-indicator latent construct) at 2 weeks, as well as patient assessments of goal-concordant care at 3 months and patient-reported symptoms of depression (8-item Patient Health Questionnaire; PHQ-8) and anxiety (7-item Generalized Anxiety Disorder survey; GAD-7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for confounders. RESULTS We enrolled 132 of 485 potentially eligible clinicians (27% participation; 71 women [53.8%]; mean [SD] age, 47.1 [9.6] years) and 537 of 917 eligible patients (59% participation; 256 women [47.7%]; mean [SD] age, 73.4 [12.7] years). The intervention was associated with a significant increase in a goals-of-care discussion at the target visit (74% vs 31%; P < .001) and increased medical record documentation (62% vs 17%; P < .001), as well as increased patient-rated quality of communication (4.6 vs 2.1; P = .01). Patient-assessed goal-concordant care did not increase significantly overall (70% vs 57%; P = .08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = .03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months. CONCLUSIONS AND RELEVANCE This intervention increased the occurrence, documentation, and quality of goals-of-care communication during routine outpatient visits and increased goal-concordant care at 3 months among patients with stable goals, with no change in symptoms of anxiety or depression. Understanding the effect on subsequent health care delivery will require additional study. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01933789

The importance of good clinician-patient communication to quality end-of-life care has been well documented yet there are no validated measures that allow patients to assess the quality of this communication. Using a sample of hospice patients (n = 83) and patients with chronic obstructive pulmonary disease (COPD) (n = 113), we evaluated the psychometric characteristics of a 13-item patient-centered, patient-report questionnaire about the quality of end-of-life communication (QOC). Our purpose was to explore the measurement structure of the QOC items to ascertain if the items represent unitary or multidimensional constructs and to describe the construct validity of the QOC score(s). Analyses included: principal component analyses to identify scales, internal consistency analyses to demonstrate reliability, and correlational and group comparisons to support construct validity. Findings support the construction of two scales: a six-item "general communication skills" scale and a seven-item, "communication about end-of-life care" scale. The two scales meet standards of scale measurement, including good factor convergence (values >or= 0.63) and discrimination (values different >or= 0.25), percent of variance explained (69.3%), and good internal consistency (alpha >or= 0.79). The scales' construct validity is supported by significant associations (p

We used exploratory factor analysis within the confirmatory analysis framework, and data provided by family members and friends of 205 decedents in Missoula, Montana, to construct a model of latent variable domains underlying the Quality of Dying and Death (QODD) questionnaire. We then used data from 182 surrogate respondents, representing Seattle decedents, to verify the latent variable structure. Results from the two samples suggested that survivors’ retrospective ratings of 13 specific aspects of decedents’ end-of-life experience served as indicators of four correlated, but distinct, latent variable domains: symptom control, preparation, connectedness, and transcendence. A model testing a unidimensional domain structure exhibited unsatisfactory fit to the data, implying that a single global quality measure of dying and death may provide insufficient evidence for guiding clinical practice, evaluating interventions to improve quality of care, or assessing the status or trajectory of individual patients. In anticipation of possible future research tying the quality of dying and death to theoretical constructs, we linked the inferred domains to concepts from Identity Theory and Existential Psychology. We conclude that research based on the current version of the QODD questionnaire might benefit from use of composite measures representing the four identified domains, but that future expansion and modification of the QODD are in order.

This study compared characteristics of patients who had herpes simplex virus (HSV) type 1 with characteristics of patients who had HSV-2, by use of data from a cross-sectional analysis. Data were collected in an urban sexually transmitted diseases clinic from patients who had positive genital HSV cultures. Overall, 17.1% (95% confidence interval [CI], 14.9%-19.3%) of 1145 genital HSV isolates obtained during 1993-1997 were HSV-1. The proportion of HSV-1 among initial genital herpes infections was higher among men who had sex with men (46.9%) than among women (21.4%) and was lowest among heterosexual men (14.6%). White race (odds ratio [OR], 3.7; 95% CI, 2.3-5.9) and receptive oral sex in the preceding 2 months (OR, 2.8; 95% CI, 1.9-4.3) significantly increased the odds that initial infections were HSV-1 rather than HSV-2. Genital HSV-1 may often be acquired through contact with a partner's mouth. These data suggest that seroprevalence studies based solely on HSV-2 type-specific assays underestimate overall prevalence of genital HSV infection.