Use of the Patient-generated Index in systemic sclerosis to assess patient-centered outcomes

OBJECTIVE

To evaluate the content and construct validity of an individualized patient-reported instrument, the Patient-generated Index (PGI), in patients with systemic sclerosis (SSc), and to compare its performance to that of other instruments and to the Patient-reported Outcomes Measurement Information System (PROMIS) framework.

METHODS

Patients identified the 5 most important life areas affected by SSc, which we categorized into domains of the PROMIS framework (mental, physical, and social). Correlations were obtained between PGI and the Health Assessment Questionnaire (HAQ), the Medical Outcomes Study Short Form-36 (SF-36), and the Symptom Burden Index (SBI) scores.

RESULTS

Sixty-two patients with SSc completed the PGI: 87% women, 69% white, mean age 53 years, mean disease duration 8 years, and 63% with diffuse disease. A total of 258 individual life area responses were recorded: 54% in social health (social function and relationship subcomponents); 28% in physical health (physical function, symptoms, general physical health); and 19% in mental health (consisting largely of the affect subcomponent). Patient PGI responses were categorized into 6 of the 7 subcomponents of the PROMIS framework; substance use/alcohol was not identified. Statistically significant correlations ranging in absolute value from 0.26 to 0.50 were observed between the PGI and the HAQ, SF-36 summary component scores, and the large majority of SF-36 subscales and SBI components.

CONCLUSION

The PGI is a personalized instrument that adequately assessed a wide range of health-related quality of life outcomes within the PROMIS framework. The PGI captured additional constructs not yet defined within the framework that are important for patients with SSc.

Olfactory assessment using the NIH Toolbox

The human olfactory system provides us with information about our environment that is critical to our physical and psychological well-being. Individuals can vary widely in their ability to detect, recognize, and identify odors, but still be within the range of normal function. Although several standardized tests of odor identification are available, few specifically address the issues in testing very young children, most of whom are likely to be unfamiliar with many of the odor stimuli used in adult tests and have limited ability to read and identify labels to select among choices. Based on the format of the San Diego Odor Identification Test and the delivery system of the University of Pennsylvania Smell Identification Test, we developed 2 versions of an odor identification test using standardized odor stimuli in a scratch-and-sniff format in which participants match 5 (children) or 9 (adults) odors to pictures representing the odor source. Results from normative testing and validation showed that for most participants, the test could be completed in 5 minutes or less and that the poorer performance among the youngest children and the elderly was consistent with data from tests with larger numbers of items. Expanding on the pediatric version of the test with adult-specific and public health-relevant odors increased the ecological validity of the test and facilitated comparisons of intraindividual performance across developmental stages.

Primary care physicians' use of an informed decision-making process for prostate cancer screening

PURPOSE

Leading professional organizations acknowledge the importance of an informed decision-making process for prostate cancer screening. We describe primary care physicians' reports of their prescreening discussions about the potential harms and benefits of prostate cancer screening.

METHODS

Members of the American Academy of Family Physicians National Research Network responded to a survey that included (1) an indicator of practice styles related to discussing harms and benefits of prostate-specific antigen testing and providing a screening recommendation or letting patients decide, and (2) indicators reflecting physicians' beliefs about prostate cancer screening. The survey was conducted between July 2007 and January 2008.

RESULTS

Of 426 physicians 246 (57.7%) completed the survey questionnaire. Compared with physicians who ordered screening without discussion (24.3%), physicians who discussed harms and benefits with patients and then let them decide (47.7%) were more likely to endorse beliefs that scientific evidence does not support screening, that patients should be told about the lack of evidence, and that patients have a right to know the limitations of screening; they were also less likely to endorse the belief that there was no need to educate patients because they wanted to be screened. Concerns about medicolegal risk associated with not screening were more common among physicians who discussed the harms and benefits and recommended screening than among physicians who discussed screening and let their patients decide.

CONCLUSIONS

Much of the variability in physicians' use of an informed decision-making process can be attributed to beliefs about screening. Concerns about medicolegal risk remain an important barrier for shared decision making.

Effect of a clinic-wide social marketing campaign to improve adherence to antiretroviral therapy for HIV infection

This demonstration study tested the impact of a 5-month clinic-wide social marketing campaign at improving adherence to antiretroviral therapy (ART). The intervention included a video, posters, pens, mugs, and lapel buttons with the campaign slogan "Live the Solution: Take Your Pills Every Day." Participants self-reported adherence over a 4-week interval, the primary outcome, with a visual analogue scale. Pre- and post-intervention surveys were completed by 141 participants. Adherence did not change over time (absolute mean change -2.02 %, paired t test P = 0.39). Among the 39.7 % of participants who correctly identified the campaign slogan on the post-intervention survey, adherence increased by 3.3 %, while it decreased in the other participants by 5.5 % (paired t test P = 0.07). The well-received campaign did not increase short-term adherence to ART, but adherence tended to increase in participants who were more engaged with the intervention. Future interventions should engage patients more completely and have a more potent effect on adherence.

Exploring communication pathways to better health: clinician communication of expectations for acupuncture effectiveness

OBJECTIVE

This study tested a pathway whereby acupuncturists' communication of optimism for treatment effectiveness would enhance patients' satisfaction during treatment, which in turn would contribute to better pain and function outcomes for patients with osteoarthritis of the knee.

METHODS

Secondary analysis from a 2 arm (real vs. sham acupuncture, high vs. neutral expectations) RCT. 311 patients with knee osteoarthritis received acupuncture over 10-12 sessions. Coders rated the degree to which acupuncturists communicated optimism for the treatment's effectiveness. Satisfaction with acupuncture was assessed 4 weeks into treatment. Pain and function were assessed 6 weeks following treatment.

RESULTS

Patients experiencing better outcomes were more satisfied with acupuncture during treatment, were younger, and had better baseline pain and function scores. Satisfaction during treatment was greater when patients interacted with more optimistic clinicians and had higher pretreatment expectations for acupuncture efficacy.

CONCLUSION

Acupuncturists' communication of optimism about treatment effectiveness contributed to pain and function outcomes indirectly through its effect on satisfaction during treatment. Future research should model pathways through which clinician-patient communication affects mediating variables that in turn lead to improved health outcomes.

PRACTICAL IMPLICATIONS

While clinicians should not mislead patients, communicating hope and optimism for treatment effectiveness has therapeutic value for patients.

Impact of antiretroviral dosing frequency and pill burden on adherence among newly diagnosed, antiretroviral-naive HIV patients

There are few data on the impact of antiretroviral therapy (ART) regimen factors on adherence in ART-naïve HIV patients on contemporary once- or twice-daily regimens. Ninety-nine newly diagnosed patients in a prospective observational cohort study completed a visual analogue scale to assess their ART adherence. Adherence by type of ART and dosing frequency were compared by Brown-Mood median tests. Participants taking once-daily regimens had higher adherence (n = 70, 99.5%) compared with participants taking twice-daily regimens (n = 29, 94%; P = 0.01). Adherence of participants taking the fixed dose combination efavirenz-emtricitabine-tenofovir (n = 34, 100%) compared with those taking once-daily regimens of two or more pills was no different (n = 36, 99.3%; P = 0.34). Among a cohort of newly diagnosed ART-naïve patients, once-daily dosing of ART resulted in higher adherence than twice-daily dosing. Pill burden among once-daily regimens did not predict adherence, suggesting that factors other than pill burden should drive regimen selection.

Improving wait time for chemotherapy in an outpatient clinic at a comprehensive cancer center

PURPOSE

We conducted our study at the Ambulatory Treatment Center (ATC) of the MD Anderson Cancer Center, a network of six outpatient treatment units for patients receiving infusion therapies. Excessive patient wait time for chemotherapy was a primary source of ATC patient dissatisfaction. ATC employees expressed frustration, because often, patients arrived physically on time but were not treatment ready. Additionally, ATC staff emphasized challenges associated with obtaining finalized treatment orders for prescheduled appointments (ie, placeholder appointments without associated physician treatment orders). We aimed to decrease mean patient wait time from check-in to treatment in one ATC unit by 25%.

METHODS

We studied appointment cycle time in the ATC Green Unit, stratifying appointments by type (ie, prescheduled [no finalized treatment orders] and scheduled [finalized treatment orders]). We obtained mean wait times at baseline (control) and again after our intervention period. We conducted interviews and observations in ATC Green, from which we developed a three-part plan to reduce wait time: increase process efficiency within ATC Green, enhance communications with MD Anderson clinics and centers, and incorporate information technology applications.

RESULTS

After our intervention, we observed a 15% decrease in wait time for patients with prescheduled appointments and a 29% decrease for those with scheduled appointments. Overall, there was a 26.8% reduction in mean patient wait time relative to baseline (control).

CONCLUSION

We observed a significantly decreased mean patient wait time after implementing our intervention. This decrease may improve patient satisfaction, relieve employee frustration with appointment scheduling, and create opportunities for increasing institutional revenue.

Low rates of hepatitis B virus screening at the onset of chemotherapy

PURPOSE

Patients with hepatitis B virus (HBV) infection are at risk for reactivation after chemotherapy. Effective prophylaxis is available but depends on detection of prior infection. Previous studies have shown low screening rates, but no large-scale US studies have been conducted. We sought to determine predictors of screening and positive HBV test results in patients receiving chemotherapy.

METHODS

We conducted a retrospective cohort study of patients with newly diagnosed cancer who received chemotherapy between January 2004 and September 2007 at a comprehensive cancer center. We determined rates and predictors of screening for HBV infection with HB surface antigen (HBsAg) and antibody to hepatitis B core antigen (anti-HBc) tests as well as the prevalence and predictors of positive results. We explored rates of acutely elevated liver function tests and liver decompensation after chemotherapy.

RESULTS

Of 10,729 new patients who received chemotherapy, 1,787 (16.7%) underwent HBsAg or anti-HBc screening. Less than 20% of patients with HBV risk factors were screened, even though their odds of HBV infection were increased four-fold compared with those without risk factors. The prevalence of chronic HBV infection was 1.5%. whereas 7.4% had positive anti-HBc only. The strongest predictors of HBV screening were having a history of HBV infection, hematologic malignancy, and rituximab treatment (P < .001). Asian ethnicity was not a significant predictor of screening, despite being a strong and highly significant predictor of positive test results (P < .001).

CONCLUSION

HBV screening among patients with cancer is low, especially among those known to be at high risk for HBV infection. Future research directed toward identifying best screening methods and HBV risk tools will be necessary to reduce the risk of reactivation of HBV infection after chemotherapy.

Validity of self-report measures in assessing antiretroviral adherence of newly diagnosed, HAART-naïve, HIV patients

PURPOSE

To compare the performance of self-report instruments assessing adherence to antiretroviral therapy (ART) in patients starting ART for the first time and in a predominately Hispanic population.

METHODS

Of 184 patients in a prospective observational cohort study of newly diagnosed, minority patients of low socioeconomic status, 54 were given Medication Event Monitoring System (MEMS) caps for their boosted protease inhibitor (PI) or non-nucleoside reverse transcriptase inhibitor (NNRTI). They completed a 4-week recall visual analogue scale (VAS), the Adult AIDS Clinical Trial Group (AACTG) 4-day recall instrument, and a 1-month recall qualitative single-item measure every 3 months for up to 18 months in English or Spanish. Electronic pharmacy records recorded refill dates. Spearman correlation coefficients were calculated to compare self-report measures with MEMS data and pharmacy data.

RESULTS

Of 46 patients with MEMS data, mean adherence was 84.7% (SD 35.6) by MEMS, 84.5% (SD 15.1) by pharmacy, 95.4% (SD 11.9) by VAS, 95.8% (SD 17.2) by AACTG, and 87.6% (SD 28.2) by qualitative single item. The correlation coefficient (CC) of VAS with MEMS was 0.37 (P < .01), and with pharmacy it was 0.34 (P < .01). The CC of the AACTG with MEMS was 0.32 (P < .01), and with pharmacy it was 0.28 (P < .01). The qualitative single item had a CC with MEMS of 0.24 (P < .01) and with pharmacy of 0.32 (P < .01). Spanish-speaking patients' VAS adherence had a CC of 0.40 (P < .01) with MEMS.

CONCLUSIONS

The VAS, AACTG, and qualitative single-item measures correlated significantly with MEMS and pharmacy data. Our data support self-administration of the VAS, even in Span-ish speakers.

Psychosocial determinants of outcomes in knee replacement

OBJECTIVE

To identify potential psychosocial and educational barriers to clinical success following knee replacement.

PATIENTS AND METHODS

The authors evaluated 241 patients undergoing total knee replacement, preoperatively and 6 months after surgery. Outcomes included the Western Ontario McMaster (WOMAC) scale and the Knee Society rating system (KSRS). Independent variables included: the medical outcome study-social support scale; depression, anxiety and stress scale; brief COPE inventory; health locus of control; arthritis self-efficacy scale and the life orientation test-revised. Multiple regression models evaluated associations of baseline demographic and psychosocial variables with outcomes at 6 months, controlling for body mass index, comorbidities and baseline outcome scores.

RESULTS

Patients' mean age was 65 ± 9 years; 65% were women. Most patients improved outcomes after surgery. Several psychosocial variables were associated with outcomes. Regression analyses indicated lower education, less tangible support, depression, less problem-solving coping, more dysfunctional coping, lower internal locus of control were associated with worse WOMAC scores (R(2) contribution of psychosocial variables for pain 0.07; for function, 0.14). Older age, lower education, depression and less problem-solving coping were associated with poorer total KSRS scores (R(2) contribution of psychosocial variables to total KSRS model 0.09). Psychosocial variables as a set contributed from 25% to 74% of total explained variance across the models tested.

CONCLUSION

Patients' level of education, tangible support, depression, problem-solving coping, dysfunctional coping and internal locus of control were associated with pain and functional outcomes after knee replacement. The findings suggest that, in addition to medical management, perioperative psychosocial evaluation and intervention are crucial in enhancing knee replacement outcomes.

The symptom burden index: development and initial findings from use with patients with systemic sclerosis

OBJECTIVE

Our study had 3 aims: (1) to evaluate the functioning of the Symptom Burden Index (SBI) in patients with systemic sclerosis (SSc); (2) to determine the amount of burden per problem experienced by patients as well as the number of patients experiencing each measured problem area, and the number of SSc problems per patient; and (3) to characterize the burden profiles of problem area-specific subgroups of patients.

METHODS

We developed the SBI to determine the effect of problems in 8 major symptomatic areas of importance to patients (skin, hand mobility, calcinosis, shortness of breath, eating, bowel, sleep, and pain).

RESULTS

Sixty-two patients with SSc completed questionnaires on current disease-related problems, physical functioning, and health status. On average, patients were 53.4 years old and had had SSc for 8 years. Patients were mainly women (87%), English-speaking (87%), with diffuse SSc (63%), white (69%), married (61%), and lived with 1 or more additional household members (84%). Only 26% were employed full-time. The 3 most widely reported problem areas were pain, hand, and skin, experienced by 92%, 89%, and 88%, respectively. About one-third reported experiencing 0-5 problems and one-third 7-8 problems; individual patients experienced, on average, 5.7 problems.

CONCLUSION

Psychometric evaluation determined that (1) summarizing SBI problem area item sets to report burden scores per problem measured is justified; (2) the 8 proposed problem areas are independent and deserve separate evaluation; and (3) burden scores correlate as expected with the Health Assessment Questionnaire-Disability Index and the Medical Outcomes Study Short-Form 36 questionnaire. The number of problems experienced and the degree of problem-associated burden that patients with SSc bear are substantial. Use of the SBI's patient-focused measurements may aid physicians in resolving problems most directly affecting patients' quality of life. This approach to measuring symptomatic burden in patients with chronic disease could be extended to other conditions.

Outcomes of a cancer-related fatigue clinic in a comprehensive cancer center

Cancer-related fatigue (CRF) is a significant issue for cancer patients and frequently precipitates increased stress and anxiety for patients and caregivers alike. CRF may present well after the initial phase of cancer diagnosis and treatment, regardless of whether the cancer is in remission, widely metastatic, or somewhere in between. Determining whether the etiology of fatigue is potentially reversible and whether it is an effect of treatment or another unrelated cause is often perplexing. Because of the significant impact of CRF on patients at our institution, we organized a CRF clinic and began evaluating patients for fatigue in 1998. Our goal has been to initiate a more focused and, at the same time, more comprehensive effort in educating, evaluating, and treating CRF. The purpose of this report was to present a retrospective review of patients treated in our CRF clinic between 1998 and 2005, to examine the outcomes of our patients, and to briefly describe some of the challenges encountered in treating these patients. This information may help reassess and improve approaches in addressing CRF and subsequently improve fatigue in these patients.

Improving benchmarking by using an explicit framework for the development of composite indicators: an example using pediatric quality of care

BACKGROUND

The measurement of healthcare provider performance is becoming more widespread. Physicians have been guarded about performance measurement, in part because the methodology for comparative measurement of care quality is underdeveloped. Comprehensive quality improvement will require comprehensive measurement, implying the aggregation of multiple quality metrics into composite indicators.

OBJECTIVE

To present a conceptual framework to develop comprehensive, robust, and transparent composite indicators of pediatric care quality, and to highlight aspects specific to quality measurement in children.

METHODS

We reviewed the scientific literature on composite indicator development, health systems, and quality measurement in the pediatric healthcare setting. Frameworks were selected for explicitness and applicability to a hospital-based measurement system.

RESULTS

We synthesized various frameworks into a comprehensive model for the development of composite indicators of quality of care. Among its key premises, the model proposes identifying structural, process, and outcome metrics for each of the Institute of Medicine's six domains of quality (safety, effectiveness, efficiency, patient-centeredness, timeliness, and equity) and presents a step-by-step framework for embedding the quality of care measurement model into composite indicator development.

CONCLUSIONS

The framework presented offers researchers an explicit path to composite indicator development. Without a scientifically robust and comprehensive approach to measurement of the quality of healthcare, performance measurement will ultimately fail to achieve its quality improvement goals.

Accuracy of reporting current medications by cancer patients presenting to an emergency center

BACKGROUND

Due to high coexistence of comorbidity, cancer patients take many medications and are susceptible to negative consequences of polypharmacy. To avoid adverse events during care transitions, patients need to correctly communicate their medications. The emergency center (EC) presents opportunities to assess patients' knowledge of medications and reconcile medication profiles.

OBJECTIVE

The purpose was to evaluate the medication knowledge of cancer patients presenting to the EC and to identify factors associated with higher knowledge.

DESIGN AND MEASUREMENTS

For the cross-sectional self-administered survey, 254 patients were enrolled and gave name, dose, frequency, route, and indication for medications. Responses were checked for accuracy against outpatient pharmacy dispensing records within or outside M. D. Anderson Cancer Center. Demographic data was obtained from medical records. For each patient, we calculated a patient medication knowledge (PMK-overall) score indicating percentage of correct responses.

RESULTS

Median PMK-overall score was 80%. Patients who used a medication aid to fill out the survey were 6.5 times more likely to have a high level of medication knowledge, or PMK-overall score > or = 80%. Predictors of using a medication aid included lower education level, solid tumor, more than five medications, married, and using a medication list at home.

CONCLUSIONS

Though our findings may not be generalizable to settings outside the EC, we found cancer patients to have high levels of medication knowledge. Future studies should validate the use of PMK scores to predict medication adherence and other outcomes. Patients should be encouraged to use a medication aid when presenting information to the health care system.

Having a fit: impact of number of items and distribution of data on traditional criteria for assessing IRT's unidimensionality assumption

PURPOSE

Confirmatory factor analysis fit criteria typically are used to evaluate the unidimensionality of item banks. This study explored the degree to which the values of these statistics are affected by two characteristics of item banks developed to measure health outcomes: large numbers of items and nonnormal data.

METHODS

Analyses were conducted on simulated and observed data. Observed data were responses to the Patient-Reported Outcome Measurement Information System (PROMIS) Pain Impact Item Bank. Simulated data fit the graded response model and conformed to a normal distribution or mirrored the distribution of the observed data. Confirmatory factor analyses (CFA), parallel analysis, and bifactor analysis were conducted.

RESULTS

CFA fit values were found to be sensitive to data distribution and number of items. In some instances impact of distribution and item number was quite large.

CONCLUSIONS

We concluded that using traditional cutoffs and standards for CFA fit statistics is not recommended for establishing unidimensionality of item banks. An investigative approach is favored over reliance on published criteria. We found bifactor analysis to be appealing in this regard because it allows evaluation of the relative impact of secondary dimensions. In addition to these methodological conclusions, we judged the items of the PROMIS Pain Impact bank to be sufficiently unidimensional for item response theory (IRT) modeling.

Poor reporting of search strategy and conflict of interest in over 250 narrative and systematic reviews of two biologic agents in arthritis: a systematic review

OBJECTIVE

To evaluate the quality of reviews about etanercept (ETN) and infliximab (IFX), two biologic treatments for rheumatoid arthritis (RA).

STUDY DESIGN

A comprehensive, systematic review, including searches of MEDLINE, EMBASE, and other electronic databases and hand-searches for published and unpublished literature. Two raters independently examined each article and identified systematic reviews as those including either a description of: (1) sources for identification and data retrieval; or (2) search strategy. They applied the quality of reporting of meta-analyses (QUOROM) instrument to systematic reviews.

RESULTS

Of 3,620 total citations, 281 were identified as reviews. Of these, 26 (9%) qualified as systematic rather than narrative. Overall, few reviews described selection of sources, critical appraisal, or quantitative summary or synthesis. Systematic reviews most often failed to explain validity assessment. Several articles did not disclose authors' participation in industry-funded clinical trials. Most reviews published in high impact factor and rheumatology journals did not meet many quality standards. Significant associations existed between review type (narrative vs. systematic) and reported funding (P=0.05), conflicts of interest (P=0.005), and country of publication (P<0.0001).

CONCLUSION

More than 90% of the published reviews were narrative and did not report methods and conflicts of interest in sufficient detail, raising concerns about selection and reporting bias.

Conspiracy beliefs about HIV infection are common but not associated with delayed diagnosis or adherence to care

We sought to determine the prevalence of HIV conspiracy beliefs in patients with HIV and how those beliefs correlate with access and adherence to HIV care and health outcomes. From March to December 2005, 113 patients at four public facilities in Houston, Texas, diagnosed with HIV for 3 years or less, participated in a cross-sectional survey. Conspiracy beliefs were assessed with five items that dealt with HIV origin, cure, and vaccine. Medical records were reviewed for CD4 cell counts, HAART use, and appointment dates. Statistical analyses (including analysis of variance [ANOVA], chi(2) testing, and regression) determined the predictors of conspiracy beliefs and correlated them with outcomes. Sixty-three percent of the participants endorsed 1 or more conspiracy beliefs. African American patients more often held HIV conspiracy beliefs than white and other/mixed race patients (73%, 52%, 47%; p = 0.045). Persons holding 1 or more conspiracy beliefs had higher CD4 cell counts at diagnosis (254 cells/mm(3) versus 92, p = 0.03); and similar rates of highly active antiretroviral therapy (HAART) use (73% versus 71%), 100% adherence to HAART by self-report (53% versus 45%,), mean adherence by pharmacy refill (83% versus 87%), and gaps in care greater than 120 days (49% versus 53%), compared to subjects who did not hold any conspiracy beliefs (all p > 0.40). Since recruitment focused on patients in care, patients with extreme conspiracy beliefs may be underrepresented. Despite this, more than 50% of the study population endorsed 1 or more conspiracy belief. However, these beliefs did not negatively impact access or adherence to HIV care. Efforts to improve adherence to HIV care may not need to focus on eliminating conspiracy beliefs.

Improving hypertension control in diabetes mellitus: the effects of collaborative and proactive health communication

BACKGROUND

Communication between patients and clinicians using collaborative goals and treatment plans may overcome barriers to achieving hypertension control in routine diabetes mellitus care. We assessed the interrelation of patient-clinician communication factors to determine their independent associations with hypertension control in diabetes care.

METHODS AND RESULTS

We identified 566 older adults with diabetes mellitus and hypertension at the DeBakey VA Medical Center in Houston, Tex. Clinical and pharmacy data were collected, and a patient questionnaire was sent to all participants. A total of 212 individuals returned surveys. Logistic regression analyses were performed to assess the effect of patient characteristics, self-management behaviors, and communication factors on hypertension control. Three communication factors had significant associations with hypertension control. Two factors, patients' endorsement of a shared decision-making style (odds ratio 1.61, 95% confidence interval 1.01 to 2.57) and proactive communication with one's clinician about abnormal results of blood pressure self-monitoring (odds ratio 1.89, 95% confidence interval 1.10 to 3.26), had direct, independent associations in multivariate regression. Path analysis was used to investigate the direct and indirect effects of communication factors and hypertension control. Decision-making style (beta=0.20, P<0.01) and proactive communication (beta=0.50, P<0.0001) again demonstrated direct effects on hypertension control. A third factor, clinicians' use of collaborative communication when setting treatment goals, had a total effect on hypertension control of 0.16 (P<0.05) through its direct effects on decision-making style (beta=0.28, P<0.001) and proactive communication (beta=0.22, P<0.01).

CONCLUSIONS

Three communication factors were found to have significant associations with hypertension control. Patient-clinician communication that facilitates collaborative blood pressure goals and patients' input related to the progress of treatment may improve rates of hypertension control in diabetes care independent of medication adherence.

Disease and symptom burden in systemic sclerosis: a patient perspective

OBJECTIVE

Studies of systemic sclerosis (SSc) have enlisted measures of physical function and generic health-related quality of life in order to determine health status. However, the measurements obtained may not discriminate other essential quality of life (QOL) domains important to patients with SSc. Our study used qualitative methods to evaluate patients' assessment of disease and symptom burden in SSc.

METHODS

We conducted 3 focus groups and 5 in-depth interviews of patients with SSc. Guiding questions were based on 5 themes: patient awareness, SSc-related problems, disease activity and progression, symptoms, and expectations. Thematic analysis was conducted using qualitative, grounded theory methodologies.

RESULTS

Symptoms such as pain (localized or generalized), fatigue, and malaise were reported to have major influence on daily activities and QOL. Gastrointestinal symptoms were among the worst prevalent and disruptive physical problems. All participants reported significant disruptions in their social lives, a burden considered by many as the worst consequence of their disease. All expressed major effects on their overall well-being because of emotional distress, including depression, low self-esteem, concerns with physical appearance, and uncertainty about future outcomes.

CONCLUSION

Patients with SSc report significant symptomatic and emotional burdens, which, in turn, affect their QOL and psychological well-being. Additional research and fuller awareness of the disease and symptom-related burdens experienced by patients with SSc may lead to additional relevant outcome measures and more effective overall treatment programs.

A combined-method psychometric analysis recommended modification of the multidimensional health locus of control scales

OBJECTIVE

The Multidimensional Health Locus of Control (MHLC) scales are widely used to measure beliefs about determinants of persons' health. We evaluated the scales over the largest-ever disease-specific sample of subjects using a combined-method psychometric approach.

STUDY DESIGN AND SETTING

We performed a secondary analysis of data from 1,206 subjects from three osteoarthritis studies, using Rasch analysis and confirmatory factor analysis simultaneously. Differential item functioning (DIF) by gender and data source, scale dimensionality, and item fit were examined. The Rasch model fit the data if Rasch residual principal components analysis (PCA) corroborated three distinct dimensions and item fit statistics fell between 0.80 and 1.20. The confirmatory factor (CFA) model fit the data if factor loadings exceeded 0.50 for all items.

RESULTS

DIF by gender or data source was not materially evident for any items. PCA supported existence of three dimensions in the data. Both Rasch and CFA models fit the data for 16 items; two items were detected as misperforming. When these items were removed, fit of both models improved.

CONCLUSION

Results of this large-sample evaluation of the MHLC scales corroborated earlier findings that removal of certain items improves the scales. The combined Rasch-CFA approach provided better insight to scale performance problems than either method alone provided.

Predictors of delayed HIV diagnosis in a recently diagnosed cohort

Delayed diagnosis of HIV is associated with a worse prognosis despite highly active antiretroviral therapy. Many persons with HIV infection are diagnosed late in the disease process. We conducted a study of 119 persons recently diagnosed with HIV infection to determine the association of health literacy and other factors with delayed diagnosis. Patients were recruited from four publicly funded facilities in Houston, Texas. Health literacy was measured with the Test of Functional Health Literacy in Adults (TOFHLA). Delayed diagnosis was assessed by CD4 cell count at diagnosis. Sixty-five percent of patients had CD4 cell counts 350 cells/mm(3) or less. Twenty-eight percent had inadequate health literacy, but literacy was not associated with CD4 cell count. Thirty-eight percent were tested because they "felt sick." In multivariable analysis, female gender (p = 0.005), reason tested other than "felt sick" (p < 0.001), and marijuana use (p = 0.004) and other illicit drug use (p = 0.01) were predictors of having a higher CD4 cell count at diagnosis. These results confirm that late diagnosis of HIV is common among users of public health care facilities. Expanded routine testing for HIV infection is needed with attention directed to men and persons who may not recognize that they are at risk for contracting HIV infection.