151
|
Cunningham BA, Marsteller JA, Romano MJ, Carson KA, Noronha GJ, McGuire MJ, Yu A, Cooper LA. Perceptions of health system orientation: quality, patient centeredness, and cultural competency. Med Care Res Rev 2014; 71:559-79. [PMID: 25389301 DOI: 10.1177/1077558714557891] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
As part of a pragmatic trial to reduce hypertension disparities, we conducted a baseline organizational assessment to identify aspects of organizational functioning that could affect the success of our interventions. Through qualitative interviewing and the administration of two surveys, we gathered data about health care personnel's perceptions of their organization's orientations toward quality, patient centeredness, and cultural competency. We found that personnel perceived strong orientations toward quality and patient centeredness. The prevalence of these attitudes was significantly higher for these areas than for cultural competency and varied by occupational role and race. Larger percentages of survey respondents perceived barriers to addressing disparities than barriers to improving safety and quality. Health care managers and policy makers should consider how we have built strong quality orientations and apply those lessons to cultural competency.
Collapse
|
152
|
Golden SH, Purnell T, Halbert JP, Matens R, Miller ERP, Levine DM, Nguyen TH, Gudzune KA, Crews DC, Mahlangu-Ngcobo M, Cooper LA. A community-engaged cardiovascular health disparities research training curriculum: implementation and preliminary outcomes. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2014; 89:1348-56. [PMID: 25054421 PMCID: PMC4175191 DOI: 10.1097/acm.0000000000000426] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
To overcome cardiovascular disease (CVD) disparities impacting high-risk populations, it is critical to train researchers and leaders in conducting community-engaged CVD disparities research. The authors summarize the key elements, implementation, and preliminary outcomes of the CVD Disparities Fellowship and Summer Internship Programs at the Johns Hopkins University Schools of Medicine, Nursing, and Bloomberg School of Public Health. In 2010, program faculty and coordinators established a transdisciplinary CVD disparities training and career development fellowship program for scientific investigators who desire to conduct community-engaged clinical and translational disparities research. The program was developed to enhance mentorship support and research training for faculty, postdoctoral fellows, and predoctoral students interested in conducting CVD disparities research. A CVD Disparities Summer Internship Program for undergraduate and preprofessional students was also created to provide a broad experience in public health and health disparities in Baltimore, Maryland, with a focus on CVD. Since 2010, 39 predoctoral, postdoctoral, and faculty fellows have completed the program. Participating fellows have published disparities-related research and given presentations both nationally and internationally. Five research grant awards have been received by faculty fellows. Eight undergraduates, one postbaccalaureate, and two medical professional students representing seven universities have participated in the summer undergraduate internship. Over half of the undergraduate students are applying to or have been accepted into medical or graduate school. The tailored CVD health disparities training curriculum has been successful at equipping varying levels of trainees (from undergraduate students to faculty) with clinical research and public health expertise to conducting community-engaged CVD disparities research.
Collapse
|
153
|
Gudzune KA, Bennett WL, Cooper LA, Bleich SN. Patients who feel judged about their weight have lower trust in their primary care providers. PATIENT EDUCATION AND COUNSELING 2014; 97:128-31. [PMID: 25049164 PMCID: PMC4162829 DOI: 10.1016/j.pec.2014.06.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 05/28/2014] [Accepted: 06/28/2014] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To evaluate whether overweight and obese patients have less trust in their primary care providers (PCPs) if they feel judged about their weight by these PCPs. METHODS We conducted a national internet-based survey of 600 adults engaged in primary care with a BMI ≥ 25 kg/m(2) in 2012. Our dependent variable was high patient trust in their PCP (score ≥ 8/10). Our independent variable was "feeling judged about my weight by my PCP" dichotomized as "often/sometimes" versus "never." We conducted a multivariate logistic regression model adjusted for patient and PCP factors using survey weights. RESULTS Overall, 21% felt that their PCP judged them about their weight. Respondents who perceived judgment were significantly less likely to report high trust in their PCP [OR 0.55, 95% CI 0.31-0.98]. CONCLUSION While only a fifth of overweight and obese patients perceived weight-related judgment from their PCPs, these patients were significantly less likely to report high trust in these providers. Given patients' decreased trust in providers who convey weight-related judgment, our results raise concerns about potential effects on the doctor-patient relationship and patient outcomes. PRACTICE IMPLICATIONS Addressing provider stigma toward patients with obesity could help build trust in these patient-provider relationships and improve quality of care.
Collapse
|
154
|
Gudzune KA, Bennett WL, Cooper LA, Clark JM, Bleich SN. Prior doctor shopping resulting from differential treatment correlates with differences in current patient-provider relationships. Obesity (Silver Spring) 2014; 22:1952-5. [PMID: 24942593 PMCID: PMC4149586 DOI: 10.1002/oby.20808] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 05/27/2014] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To determine the prevalence of doctor shopping resulting from differential treatment and to examine associations between this shopping and current primary care relationships. METHODS In 2012, a national internet-based survey of 600 adults receiving primary care in the past year with a BMI ≥ 25 kg/m(2) was conducted. Our independent variable was "switching doctors because I felt treated differently because of my weight." Logistic regression models to examine the association of prior doctor shopping with characteristics of current primary care relationships: duration, trust in primary care provider (PCP), and perceived PCP weight-related judgment, adjusted for patient factors were used. RESULTS Overall, 13% of adults with overweight/obesity reported previously doctor shopping resulting from differential treatment. Prior shoppers were more likely to report shorter durations of their current relationships [73% vs. 52%; p = 0.01] or perceive that their current PCP judged them because of their weight [74% vs. 11%; p < 0.01] than nonshoppers. No significant differences in reporting high trust in current PCPs were found. CONCLUSIONS A subset of patients with overweight/obesity doctor shop resulting from perceived differential treatment. These prior negative experiences have no association with trust in current relationships, but our results suggest that patients may remain sensitive to provider weight bias.
Collapse
|
155
|
Price-Haywood EG, Harden-Barrios J, Cooper LA. Comparative effectiveness of audit-feedback versus additional physician communication training to improve cancer screening for patients with limited health literacy. J Gen Intern Med 2014; 29:1113-21. [PMID: 24590734 PMCID: PMC4099465 DOI: 10.1007/s11606-014-2782-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 12/05/2013] [Accepted: 12/27/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND We designed a continuing medical education (CME) program to teach primary care physicians (PCP) how to engage in cancer risk communication and shared decision making with patients who have limited health literacy (HL). OBJECTIVE We evaluated whether training PCPs, in addition to audit-feedback, improves their communication behaviors and increases cancer screening among patients with limited HL to a greater extent than only providing clinical performance feedback. DESIGN Four-year cluster randomized controlled trial. PARTICIPANTS Eighteen PCPs and 168 patients with limited HL who were overdue for colorectal/breast/cervical cancer screening. INTERVENTIONS Communication intervention PCPs received skills training that included standardized patient (SP) feedback on counseling behaviors. All PCPs underwent chart audits of patients' screening status semiannually up to 24 months and received two annual performance feedback reports. MAIN MEASURES PCPs experienced three unannounced SP encounters during which SPs rated PCP communication behaviors. We examined between-group differences in changes in SP ratings and patient knowledge of cancer screening guidelines over 12 months; and changes in patient cancer screening rates over 24 months. KEY RESULTS There were no group differences in SP ratings of physician communication at baseline. At follow-up, communication intervention PCPs were rated higher in general communication about cancer risks and shared decision making related to colorectal cancer screening compared to PCPs who only received performance feedback. Screening rates increased among patients of PCPs in both groups; however, there were no between-group differences in screening rates except for mammography. The communication intervention did not improve patient cancer screening knowledge. CONCLUSION Compared to audit and feedback alone, including PCP communication training increases PCP patient-centered counseling behaviors, but not cancer screening among patients with limited HL. Larger studies must be conducted to determine whether lack of changes in cancer screening were due to clinic/patient sample size versus ineffectiveness of communication training to change outcomes.
Collapse
|
156
|
Cunningham BA, Bonham VL, Sellers SL, Yeh HC, Cooper LA. Physicians' anxiety due to uncertainty and use of race in medical decision making. Med Care 2014; 52:728-33. [PMID: 25025871 PMCID: PMC4214364 DOI: 10.1097/mlr.0000000000000157] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The explicit use of race in medical decision making is contested. Researchers have hypothesized that physicians use race in care when they are uncertain. OBJECTIVES The aim of this study was to investigate whether physician anxiety due to uncertainty (ADU) is associated with a higher propensity to use race in medical decision making. RESEARCH DESIGN This study included a national cross-sectional survey of general internists. SUBJECTS A national sample of 1738 clinically active general internists drawn from the SK&A physician database were included in the study. MEASURES ADU is a 5-item measure of emotional reactions to clinical uncertainty. Bonham and Sellers Racial Attributes in Clinical Evaluation (RACE) scale includes 7 items that measure self-reported use of race in medical decision making. We used bivariate regression to test for associations between physician characteristics, ADU, and RACE. Multivariate linear regression was performed to test for associations between ADU and RACE while adjusting for potential confounders. RESULTS The mean score on ADU was 19.9 (SD=5.6). Mean score on RACE was 13.5 (SD=5.6). After adjusting for physician demographics, physicians with higher levels of ADU scored higher on RACE (+β=0.08 in RACE, P=0.04, for each 1-point increase in ADU), as did physicians who understood "race" to mean biological or genetic ancestral, rather than sociocultural, group. Physicians who graduated from a US medical school, completed fellowship, and had more white patients scored lower on RACE. CONCLUSIONS This study demonstrates positive associations between physicians' ADU, meanings attributed to race, and self-reported use of race in medical decision making. Future research should examine the potential impact of these associations on patient outcomes and health care disparities.
Collapse
|
157
|
Ephraim PL, Hill-Briggs F, Roter DL, Bone LR, Wolff JL, Lewis-Boyer L, Levine DM, Aboumatar HJ, Cooper LA, Fitzpatrick SJ, Gudzune KA, Albert MC, Monroe D, Simmons M, Hickman D, Purnell L, Fisher A, Matens R, Noronha GJ, Fagan PJ, Ramamurthi HC, Ameling JM, Charlston J, Sam TS, Carson KA, Wang NY, Crews DC, Greer RC, Sneed V, Flynn SJ, DePasquale N, Boulware LE. Improving urban African Americans' blood pressure control through multi-level interventions in the Achieving Blood Pressure Control Together (ACT) study: a randomized clinical trial. Contemp Clin Trials 2014; 38:370-82. [PMID: 24956323 PMCID: PMC4169070 DOI: 10.1016/j.cct.2014.06.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/10/2014] [Accepted: 06/13/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given their high rates of uncontrolled blood pressure, urban African Americans comprise a particularly vulnerable subgroup of persons with hypertension. Substantial evidence has demonstrated the important role of family and community support in improving patients' management of a variety of chronic illnesses. However, studies of multi-level interventions designed specifically to improve urban African American patients' blood pressure self-management by simultaneously leveraging patient, family, and community strengths are lacking. METHODS/DESIGN We report the protocol of the Achieving Blood Pressure Control Together (ACT) study, a randomized controlled trial designed to study the effectiveness of interventions that engage patient, family, and community-level resources to facilitate urban African American hypertensive patients' improved hypertension self-management and subsequent hypertension control. African American patients with uncontrolled hypertension receiving health care in an urban primary care clinic will be randomly assigned to receive 1) an educational intervention led by a community health worker alone, 2) the community health worker intervention plus a patient and family communication activation intervention, or 3) the community health worker intervention plus a problem-solving intervention. All participants enrolled in the study will receive and be trained to use a digital home blood pressure machine. The primary outcome of the randomized controlled trial will be patients' blood pressure control at 12months. DISCUSSION Results from the ACT study will provide needed evidence on the effectiveness of comprehensive multi-level interventions to improve urban African American patients' hypertension control.
Collapse
|
158
|
Mobula LM, Okoye MT, Boulware LE, Carson KA, Marsteller JA, Cooper LA. Cultural competence and perceptions of community health workers' effectiveness for reducing health care disparities. J Prim Care Community Health 2014; 6:10-5. [PMID: 24986493 DOI: 10.1177/2150131914540917] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Community health worker (CHW) interventions improve health outcomes of patients from underserved communities, but health professionals' perceptions of their effectiveness may impede integration of CHWs into health care delivery systems. Whether health professionals' attitudes and skills, such as those related to cultural competence, influence perceptions of CHWs, is unknown. METHODS A questionnaire was administered to providers and clinical staff from 6 primary care practices in Maryland from April to December 2011. We quantified the associations of self-reported cultural competence and preparedness with attitudes toward the effectiveness of CHWs using logistic regression adjusting for respondent age, race, gender, provider/staff status, and years at the practice. RESULTS We contacted 200 providers and staff, and 119 (60%) participated. Those reporting more cultural motivation had higher odds of perceiving CHWs as helpful for reducing health care disparities (odds ratio [OR] = 9.66, 95% confidence interval [CI] = 3.48-28.80). Those reporting more frequent culturally competent behaviors also had higher odds of believing CHWs would help reduce health disparities (OR = 3.58, 95% CI = 1.61-7.92). Attitudes toward power and assimilation were not associated with perceptions of CHWs. Cultural preparedness was associated with perceived utility of CHWs in reducing health care disparities (OR = 2.33, 95% CI = 1.21-4.51). CONCLUSIONS Providers and staff with greater cultural competence and preparedness have more positive expectations of CHW interventions to reduce healthcare disparities. Cultural competency training may complement the use of CHWs and support their effective integration into primary care clinics that are seeking to reduce disparities.
Collapse
|
159
|
Peek ME, Drum M, Cooper LA. The Association of Patient Chronic Disease Burden and Self-Management Requirements With Shared Decision Making in Primary Care Visits. Health Serv Res Manag Epidemiol 2014; 1. [PMID: 26640812 PMCID: PMC4670035 DOI: 10.1177/2333392814538775] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Shared decision making (SDM) is associated with positive health outcomes and may be particularly relevant for patients with chronic disease. OBJECTIVES To investigate whether (1) patients with chronic diseases, particularly those requiring self-management, are more likely to engage in SDM behaviors than patients without chronic diseases and (2) patients with chronic diseases are more likely to have their physicians engage them in SDM. DESIGN A cross-sectional study of patients who were enrolled in a randomized controlled trial to improve patient-physician communication. PARTICIPANTS Adult patients with hypertension at community health clinics in Baltimore, Maryland. APPROACH We used multivariable regression models to examine the associations of the following predictor variables: (1) chronic disease burden and (2) diseases requiring self-management with the following outcome variables measuring SDM components: (1) patient information sharing, (2) patient decision making, and (3) physician SDM facilitation. KEY RESULTS Patients with greater chronic disease burden and more diseases requiring self-management reported more information sharing (β = .07, P = .03 and β = .12, P = .046, respectively) and decision making (β = .06, P = .02 and β = .21, P < .001) as did patients who reported poor general health. Physician facilitation of SDM was not associated with chronic disease burden or with diseases requiring self-management but was associated with higher patient income. CONCLUSIONS Patients with chronic diseases, particularly those requiring self-management, may be more likely to engage in SDM behaviors, but physicians may not be more likely to engage such patients in SDM. Targeting patients with chronic disease for SDM may improve health outcomes among the chronically ill, particularly among vulnerable patients (eg, minorities, low-income patients) who suffer disproportionately from such conditions.
Collapse
|
160
|
Brewer LC, Cooper LA. Race, discrimination, and cardiovascular disease. THE VIRTUAL MENTOR : VM 2014; 16:455-460. [PMID: 25090666 PMCID: PMC5955868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
|
161
|
|
162
|
Ameling JM, Ephraim PL, Bone LR, Levine DM, Roter DL, Wolff JL, Hill-Briggs F, Fitzpatrick SL, Noronha GJ, Fagan PJ, Lewis-Boyer L, Hickman D, Simmons M, Purnell L, Fisher A, Cooper LA, Aboumatar HJ, Albert MC, Flynn SJ, Boulware LE. Adapting hypertension self-management interventions to enhance their sustained effectiveness among urban African Americans. FAMILY & COMMUNITY HEALTH 2014; 37:119-33. [PMID: 24569158 PMCID: PMC4002996 DOI: 10.1097/fch.0000000000000020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
African Americans suffer disproportionately poor hypertension control despite the availability of efficacious interventions. Using principles of community-based participatory research and implementation science, we adapted established hypertension self-management interventions to enhance interventions' cultural relevance and potential for sustained effectiveness among urban African Americans. We obtained input from patients and their family members, their health care providers, and community members. The process required substantial time and resources, and the adapted interventions will be tested in a randomized controlled trial.
Collapse
|
163
|
Cooper LA, Boulware LE, Miller ER, Golden SH, Carson KA, Noronha G, Huizinga MM, Roter DL, Yeh HC, Bone LR, Levine DM, Hill-Briggs F, Charleston J, Kim M, Wang NY, Aboumatar H, Halbert JP, Ephraim PL, Brancati FL. Creating a transdisciplinary research center to reduce cardiovascular health disparities in Baltimore, Maryland: lessons learned. Am J Public Health 2013; 103:e26-38. [PMID: 24028238 PMCID: PMC3828697 DOI: 10.2105/ajph.2013.301297] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2013] [Indexed: 01/08/2023]
Abstract
Cardiovascular disease (CVD) disparities continue to have a negative impact on African Americans in the United States, largely because of uncontrolled hypertension. Despite the availability of evidence-based interventions, their use has not been translated into clinical and public health practice. The Johns Hopkins Center to Eliminate Cardiovascular Health Disparities is a new transdisciplinary research program with a stated goal to lower the impact of CVD disparities on vulnerable populations in Baltimore, Maryland. By targeting multiple levels of influence on the core problem of disparities in Baltimore, the center leverages academic, community, and national partnerships and a novel structure to support 3 research studies and to train the next generation of CVD researchers. We also share the early lessons learned in the center's design.
Collapse
|
164
|
Brewer LC, Carson KA, Williams DR, Allen A, Jones CP, Cooper LA. Association of race consciousness with the patient-physician relationship, medication adherence, and blood pressure in urban primary care patients. Am J Hypertens 2013; 26:1346-52. [PMID: 23864583 DOI: 10.1093/ajh/hpt116] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Race consciousness (the frequency with which one thinks about his or her own race) is a measure that may be useful in assessing whether racial discrimination negatively impacts blood pressure (BP). However, the relation between race consciousness and BP has yet to be empirically tested, especially within the context of the patient-physician relationship and medication adherence. METHODS Race-stratified generalized estimating equations were used to assess the relationship of race consciousness on BP, measures of the patient-physician relationship, and self-reported medication adherence, controlling for patients being nested within physicians and for patient age and sex. RESULTS The mean age of the patients was 61.3 years, 62% were black, and 65% were women. Black patients were more likely to ever think about race than were white patients (49% vs. 21%; P < 0.001). Race-conscious blacks had significantly higher diastolic BP (79.4 vs. 74.5 mm Hg; P = 0.004) and somewhat higher systolic BP (138.8 vs. 134.7 mm Hg; P = 0.13) than blacks who were not race conscious. Race-conscious whites were more likely to perceive respect from their physician (57.1% vs. 25.8%; P = 0.01) but had lower medication adherence (62.4% vs. 82.9%; P = 0.05) than whites who were not race-conscious. CONCLUSIONS Among blacks, race consciousness was associated with higher diastolic BP. In contrast, among whites, there was no association between race consciousness and BP, but race consciousness was associated with poor ratings of adherence, despite more favorable ratings of the patient-physician relationship. Future work should explore disparities in race consciousness and its impact on health and health-care disparities.
Collapse
|
165
|
Gudzune KA, Beach MC, Roter DL, Cooper LA. Physicians build less rapport with obese patients. Obesity (Silver Spring) 2013; 21:2146-52. [PMID: 23512862 PMCID: PMC3694993 DOI: 10.1002/oby.20384] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 01/09/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Physicians' negative attitudes toward patients with obesity are well documented. Whether or how these beliefs may affect patient-physician communication is unknown. To describe the relationship between patient body mass index (BMI) and physician communication behaviors (biomedical, psychosocial/lifestyle, and rapport building) during typical outpatient primary care visits was aimed. DESIGN AND METHODS Using audio-recorded outpatient encounters from 39 urban primary care physicians (PCPs) and 208 of their patients, the frequency of communication behaviors using the Roter Interaction Analysis System was examined. The independent variable was measured; patient BMI and dependent variables were communication behaviors by the PCP within the biomedical, psychosocial/lifestyle, and rapport building domains. A cross-sectional analysis using multilevel Poisson regression models to evaluate the association between BMI and physician communication was performed. RESULTS PCPs demonstrated less emotional rapport with overweight and obese patients (incidence rate ratio, IRR, 0.65, 95%CI 0.48-0.88, P = 0.01; IRR 0.69, 95%CI 0.58-0.82, P < 0.01, respectively) than for normal weight patients. No differences in PCPs' biomedical or psychosocial/lifestyle communication by patient BMI were found. CONCLUSIONS Our findings raise the concern that low levels of emotional rapport in primary care visits with overweight and obese patients may weaken the patient-physician relationship, diminish patients' adherence to recommendations, and decrease the effectiveness of behavior change counseling.
Collapse
|
166
|
Martin KD, Cooper LA. Maximizing the benefits of "we" in race-discordant patient-physician relationships: novel insights raise intriguing questions. J Gen Intern Med 2013. [PMID: 23588671 DOI: 10.1007/s1160601324487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
|
167
|
Cruz M, Roter DL, Cruz RF, Wieland M, Larson S, Cooper LA, Pincus HA. Appointment length, psychiatrists' communication behaviors, and medication management appointment adherence. Psychiatr Serv 2013; 64:886-92. [PMID: 23771555 DOI: 10.1176/appi.ps.201200416] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors explored the relationship between critical elements of medication management appointments (appointment length, patient-centered talk, and positive nonverbal affect among providers) and patient appointment adherence. METHODS The authors used an exploratory, cross-sectional design employing quantitative analysis of 83 unique audio recordings of split treatment medication management appointments for 46 African-American and 37 white patients with 24 psychiatrists at four ambulatory mental health clinics. All patients had a diagnosis of depression. Data collected included demographic information; Patient Health Questionnaire-9 scores for depression severity; psychiatrist verbal and nonverbal communication behaviors during medication management appointments, identified by the Roter Interaction Analysis System during analysis of audio recordings; and appointment adherence. Bivariate analyses were employed to identify covariates that might influence appointment adherence. Generalized estimating equations (GEEs) were employed to assess the relationship between appointment length, psychiatrist patient-centered talk, and positive voice tone ratings and patient appointment adherence, while adjusting for covariates and the clustering of observations within psychiatrists. Wald chi square analyses were used to test whether all or some variables significantly influenced appointment adherence. RESULTS GEE revealed a significant relationship between positive voice tone ratings and appointment adherence (p=.03). Chi square analyses confirmed the hypothesis of a positive and significant relationship between appointment adherence and positive voice tone ratings (p=.03) but not longer visit length and more patient-centered communication. CONCLUSIONS The nonverbal conveyance of positive affect was associated with greater adherence to medication management appointments by depressed patients. These findings potentially have important implications for communication skills training and adherence research.
Collapse
|
168
|
Schacter DL, Cooper LA, Tharan M, Rubens AB. Preserved priming of novel objects in patients with memory disorders. J Cogn Neurosci 2013; 3:117-30. [PMID: 23972088 DOI: 10.1162/jocn.1991.3.2.117] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Amnesic patients perform poorly on explicit memory tests that require conscious recollection of recent experiences, but frequently show preserved facilitations of performance or priming effects on implicit memory tasks that do not require conscious recollection. We examined implicit memory for novel visual objects on an object decision test in which subjects decide whether structurally possible and impossible objects could exist in three-dimensional form. Patients with organic memory disorders showed robust priming effects on this task---object decision accuracy was higher for previously studied objects than for nonstudied objects---and the magnitude of priming did not differ from matched control subjects or college students. However, patients showed impaired explicit memory for novel visual objects on a recognition test. We argue that priming is mediated by the structural description system, a subsystem of the perceptual representation system, that operates at a presemantic level and is preserved in amnesic patients.
Collapse
|
169
|
Flynn SJ, Ameling JM, Hill-Briggs F, Wolff JL, Bone LR, Levine DM, Roter DL, Lewis-Boyer L, Fisher AR, Purnell L, Ephraim PL, Barbers J, Fitzpatrick SL, Albert MC, Cooper LA, Fagan PJ, Martin D, Ramamurthi HC, Boulware LE. Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members. Patient Prefer Adherence 2013; 7:741-9. [PMID: 23966772 PMCID: PMC3743518 DOI: 10.2147/ppa.s46517] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION We aimed to inform the design of behavioral interventions by identifying patients' and their family members' perceived facilitators and barriers to hypertension self-management. MATERIALS AND METHODS We conducted focus groups of African American patients with hypertension and their family members to elicit their views about factors influencing patients' hypertension self-management. We recruited African American patients with hypertension (n = 18) and their family members (n = 12) from an urban, community-based clinical practice in Baltimore, Maryland. We conducted four separate 90-minute focus groups among patients with controlled (one group) and uncontrolled (one group) hypertension, as well as their family members (two groups). Trained moderators used open-ended questions to assess participants' perceptions regarding patient, family, clinic, and community-level factors influencing patients' effective hypertension self-management. RESULTS Patient participants identified several facilitators (including family members' support and positive relationships with doctors) and barriers (including competing health priorities, lack of knowledge about hypertension, and poor access to community resources) that influence their hypertension self-management. Family members also identified several facilitators (including their participation in patients' doctor's visits and discussions with patients' doctors outside of visits) and barriers (including their own limited health knowledge and patients' lack of motivation to sustain hypertension self-management behaviors) that affect their efforts to support patients' hypertension self-management. CONCLUSION African American patients with hypertension and their family members reported numerous patient, family, clinic, and community-level facilitators and barriers to patients' hypertension self-management. Patients' and their family members' views may help guide efforts to tailor behavioral interventions designed to improve hypertension self-management behaviors and hypertension control in minority populations.
Collapse
|
170
|
Bleich SN, Gudzune KA, Bennett WL, Jarlenski MP, Cooper LA. How does physician BMI impact patient trust and perceived stigma? Prev Med 2013; 57:120-4. [PMID: 23743418 PMCID: PMC3745018 DOI: 10.1016/j.ypmed.2013.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 04/29/2013] [Accepted: 05/12/2013] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The objective is to evaluate whether physician body mass index (BMI) impacts their patients' trust or perceptions of weight-related stigma. METHODS We used a national cross-sectional survey of 600 non-pregnant overweight and obese patients conducted between April 5 and April 13, 2012. The outcome variables were patient trust (overall and by type of advice) and patient perceptions of weight-related stigma. The independent variable of interest was primary care physician (PCP) BMI. We conducted multivariate regression analyses to determine whether trust or perceived stigma differed by physician BMI, adjusting for covariates. RESULTS Patients reported high levels of trust in their PCPs, regardless of the PCPs body weight (normal BMI=8.6; overweight=8.3; obese=8.2; where 10 is the highest). Trust in diet advice was significantly higher among patients seeing overweight PCPs as compared to normal BMI PCPs (87% vs. 77%, p=0.04). Reports of feeling judged by their PCP were significantly higher among patients seeing obese PCPs (32%; 95% confidence interval (CI): 23-41) as compared to patients seeing normal BMI PCPs (14%; 95% CI: 7-20). CONCLUSION Overweight and obese patients generally trust their PCP, but they more strongly trust diet advice from overweight PCPs as compared to normal BMI PCPs.
Collapse
|
171
|
Cooper LA, Marsteller JA, Noronha GJ, Flynn SJ, Carson KA, Boonyasai RT, Anderson CA, Aboumatar HJ, Roter DL, Dietz KB, Miller ER, Prokopowicz GP, Dalcin AT, Charleston JB, Simmons M, Huizinga MM. A multi-level system quality improvement intervention to reduce racial disparities in hypertension care and control: study protocol. Implement Sci 2013; 8:60. [PMID: 23734703 PMCID: PMC3680084 DOI: 10.1186/1748-5908-8-60] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 05/24/2013] [Indexed: 12/20/2022] Open
Abstract
Background Racial disparities in blood pressure control have been well documented in the United States. Research suggests that many factors contribute to this disparity, including barriers to care at patient, clinician, healthcare system, and community levels. To date, few interventions aimed at reducing hypertension disparities have addressed factors at all of these levels. This paper describes the design of Project ReD CHiP (Reducing Disparities and Controlling Hypertension in Primary Care), a multi-level system quality improvement project. By intervening on multiple levels, this project aims to reduce disparities in blood pressure control and improve guideline concordant hypertension care. Methods Using a pragmatic trial design, we are implementing three complementary multi-level interventions designed to improve blood pressure measurement, provide patient care management services and offer expanded provider education resources in six primary care clinics in Baltimore, Maryland. We are staggering the introduction of the interventions and will use Statistical Process Control (SPC) charting to determine if there are changes in outcomes at each clinic after implementation of each intervention. The main hypothesis is that each intervention will have an additive effect on improvements in guideline concordant care and reductions in hypertension disparities, but the combination of all three interventions will result in the greatest impact, followed by blood pressure measurement with care management support, blood pressure measurement with provider education, and blood pressure measurement only. This study also examines how organizational functioning and cultural competence affect the success of the interventions. Discussion As a quality improvement project, Project ReD CHiP employs a novel study design that specifically targets multi-level factors known to contribute to hypertension disparities. To facilitate its implementation and improve its sustainability, we have incorporated stakeholder input and tailored components of the interventions to meet the specific needs of the involved clinics and communities. Results from this study will provide knowledge about how integrated multi-level interventions can improve hypertension care and reduce disparities. Trial Registration ClinicalTrials.gov NCT01566864
Collapse
|
172
|
Scott VK, Hashmi ZG, Schneider EB, Hui X, Efron DT, Cornwell EE, Cooper LA, Haider AH. Counting the lives lost: how many black trauma deaths are attributable to disparities? J Surg Res 2013; 184:480-7. [PMID: 23827793 DOI: 10.1016/j.jss.2013.04.080] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 04/23/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The number of black trauma deaths attributable to racial disparities is unknown. The objective of this study was to quantify the excess mortality experienced by black patients given disparities in the risk of mortality. MATERIALS AND METHODS We performed a retrospective analysis of patients aged 16-65 y with blunt and penetrating injuries, who were included in the National Trauma Data Bank from 2007-2010. Generalized linear modeling estimated the relative risk of death for black patients versus white patients, adjusting for known confounders. This analysis determined the difference in the observed number of black trauma deaths at Level I and II centers and the expected number of deaths if the risk of mortality for black patients had been equivalent to that of white patients. RESULTS A total of 1.06 million patients were included. Among patients with blunt and penetrating injuries at Level I trauma centers, white males and females had a relative risk of death of 0.82 (95% confidence interval [CI], 0.80-0.85) and 0.78 (95% CI, 0.74-0.83), respectively, compared with black patients. Similarly, at Level II trauma centers, white males and females had a relative risk of death of 0.84 (95% CI, 0.80-0.88) and 0.82 (95% CI, 0.73-0.91). Overall, of the estimated 41,613 deaths that occurred at Level I and II centers, 2206 (5.3%) were excess deaths among black patients. CONCLUSIONS Over a 4-y period, approximately 5% of trauma center deaths could be attributed to racial disparities in trauma outcomes. These data underscore the need to better understand and intervene against the mechanisms that lead to trauma outcomes disparities.
Collapse
|
173
|
Bleich SN, Gudzune KA, Bennett WL, Cooper LA. Do physician beliefs about causes of obesity translate into actionable issues on which physicians counsel their patients? Prev Med 2013; 56:326-8. [PMID: 23399006 PMCID: PMC3745015 DOI: 10.1016/j.ypmed.2013.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 01/14/2013] [Accepted: 01/20/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the relationship between primary care physicians' (PCPs') beliefs about the causes of obesity with the frequency of nutritional counseling. METHODS We analyzed a national cross-sectional internet-based survey of 500 US PCPs collected between February and March 2011. RESULTS PCPs that identified overconsumption of food as a very important cause of obesity had significantly greater odds of counseling patients to reduce portion sizes (OR 3.40; 95%CI: 1.73-6.68) and to avoid high calorie ingredients when cooking (OR 2.16; 95%CI: 1.07-4.33). Physicians who believed that restaurant/fast food eating was a very important cause of obesity had significantly greater odds of counseling patients to avoid high calorie menu items outside the home (OR 1.93; 95%CI: 1.20-3.11). Physicians who reported that sugar-sweetened beverages were a very important cause of obesity had significantly greater odds of counseling their obese patients to reduce consumption (OR 5.99; 95%CI: 3.53-10.17). CONCLUSIONS PCP beliefs about the diet-related causes of obesity may translate into actionable nutritional counseling topics for physicians to use with their patients.
Collapse
|
174
|
Jarlenski MP, Gudzune KA, Bennett WL, Cooper LA, Bleich SN. Insurance coverage for weight loss: overweight adults' views. Am J Prev Med 2013; 44:453-8. [PMID: 23597807 PMCID: PMC3671931 DOI: 10.1016/j.amepre.2013.01.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 10/19/2012] [Accepted: 01/08/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Given the prevalence of obesity and associated chronic conditions among U.S. adults, wellness benefits are an increasingly popular approach to promoting weight loss. PURPOSE The goal of the study was to assess overweight and obese adults' beliefs about the helpfulness of insurance coverage of weight loss-related benefits, their willingness to pay for such benefits, and whether these opinions differ by individuals' weight or health insurance type. METHODS A national survey was fielded in 2012 among non-pregnant, overweight, and obese adults who had seen a primary care provider in the past year (n=600). Descriptive statistics summarized beliefs about which weight loss-related benefits would be helpful, willingness to pay for such benefits, and agreement about whether health insurers should be able to charge more to obese individuals. Multivariable logistic regression was employed to determine whether beliefs differed by weight category or health insurance type. Analyses were conducted in July 2012. RESULTS The majority (83%) of respondents cited a specific benefit as helpful. Those with private health insurance had a higher probability (89%, 95% CI=86%, 93%) of endorsing any benefit as helpful relative to those with other types of health insurance. Being obese relative to overweight was associated with greater support (57% vs 39%, p<0.05) for preventing health insurers from charging higher premiums to obese individuals. CONCLUSIONS In this sample of overweight adults, a large proportion endorsed the value of weight loss-related benefits offered by health plans. However, only about one third were willing to pay extra for them, and half disagreed with the notion that health plans should charge more to obese individuals. Given evidence of their effectiveness, wellness benefits should be offered to all individuals.
Collapse
|
175
|
Aboumatar HJ, Cooper LA. Contextualizing patient-centered care to fulfill its promise of better health outcomes: beyond who, what, and why. Ann Intern Med 2013; 158:628-9. [PMID: 23588750 PMCID: PMC4077271 DOI: 10.7326/0003-4819-158-8-201304160-00008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|