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Ding A, Patel JP, Auyeung V. Understanding the Traditional Chinese Medicine (TCM) consultation: Why do patients adhere to treatment? Complement Ther Clin Pract 2020; 39:101139. [PMID: 32379674 DOI: 10.1016/j.ctcp.2020.101139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 02/26/2020] [Accepted: 03/06/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND and purpose: Adherence is an issue that affects Complementary and Alternative Medicine (CAM) and conventional medicine practitioners, whereby approximately half of the patients do not take their medicines or remedies as prescribed. The consultation is an opportune area where practitioners can have an impact on patient adherence to treatment. As such, research was undertaken to explore this in depth within one CAM. The aim of the study was to understand the Traditional Chinese Medicine (TCM) consultation process that occurs in relation to adherence and develop a consultation model health professionals can use. MATERIALS AND METHODS A classical grounded theory approach was employed to semi-structured interviews of TCM practitioners and patients along with observations of their consultations. Sampling was theoretical and by snowball in the United Kingdom. NVivo 11 was used to assist with analysis of the transcribed interviews and observations. RESULTS Seven TCM practitioners and twenty-eight patients were recruited. TCM practitioners built a therapeutic relationship through the consultation by enabling patients to feel comfortable, valued as individuals which incorporated feeling understood and known, as well as supported in the management of their health. Fundamentally, patients needed to feel cared for and have trust in their TCM practitioner for the therapeutic relationship to be established. This motivated patients to continue with treatment. CONCLUSION The TCM Consultation Model for Adherence was developed to conceptualise the consultation process that occurs in relation to adherence. It can be used to encourage patient persistence with treatment by TCM practitioners and potentially other health professionals.
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Affiliation(s)
- Amally Ding
- Institute of Pharmaceutical Science, King's College London, 150 Stamford Street, London, SE1 9NH, United Kingdom.
| | - Jignesh P Patel
- Institute of Pharmaceutical Science, King's College London, 150 Stamford Street, London, SE1 9NH, United Kingdom; Department of Haematological Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
| | - Vivian Auyeung
- Institute of Pharmaceutical Science, King's College London, 150 Stamford Street, London, SE1 9NH, United Kingdom
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Milky G, Thomas J. Shared decision making, satisfaction with care and medication adherence among patients with diabetes. PATIENT EDUCATION AND COUNSELING 2020; 103:661-669. [PMID: 31676101 DOI: 10.1016/j.pec.2019.10.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 10/10/2019] [Accepted: 10/12/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES We examined factors associated with shared decision making and whether shared decision-making (SDM) was associated with satisfaction with care or with adherence to anti-diabetic medication. METHODS A retrospective study was conducted using 2011-2014 Medical Expenditure Panel Survey (MEPS) data. Inclusion criteria were 18 years or older and visit to a usual source of care during the prior 12 months. Exclusion criteria were reported cognitive limitation, proxy response, less than two prescription fills, or missing data on study variables. SDM was assessed using seven MEPS items. Satisfaction with care was assessed using a single MEPS item 12 months after SDM measurement. Adherence was assessed using Medication Possession Ratio in 12 months after SDM measurement. RESULTS The weighted sample of 797 respondents represented 15.6 million with diabetes. Being older, male, or uninsured were associated with low SDM. High SDM was associated with higher satisfaction (p < 0.0001). SDM was not associated with adherence. CONCLUSIONS Patients with higher SDM were more satisfied with their healthcare. We did not find association between SDM and adherence to antidiabetic medication. PRACTICE IMPLICATIONS Involvement in SDM is encouraged to improve patient satisfaction. Providers may consider age, sex and insurance status in facilitating communications to improve SDM.
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Affiliation(s)
- Gediwon Milky
- Department of Pharmacy Practice, Purdue University, West Lafayette, IN, USA
| | - Joseph Thomas
- Department of Pharmacy Practice, Purdue University, West Lafayette, IN, USA.
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Tate A, Rimel BJ. The duality of option-listing in cancer care. PATIENT EDUCATION AND COUNSELING 2020; 103:71-76. [PMID: 31383562 PMCID: PMC7034307 DOI: 10.1016/j.pec.2019.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 06/29/2019] [Accepted: 07/23/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Listing more than one option for treatment, termed "option-listing" (OL) is one way to facilitate shared decision-making. We seek to evaluate how oncologists do option-listing in clinical encounters across disease contexts. METHOD We coded and transcribed 90 video-recorded interactions between 5 oncologist participants and a convenience sample of 82 patients at 2 large clinics in the western U.S. We used conversation analytic (CA) methods to examine patterns of behavior when oncologists provided more than one treatment option to patients. RESULTS In early-stage disease, OL provides patients with options while at the same time constraining those options through expression of physician bias. This effect disappears when cancer is at an advanced stage. In this context, OL is presented without physician preference and demonstrates recission of medical authority. CONCLUSION In early-stage contexts, OL functions as a way for physicians to array available options to patients while also communicating their expertise. In advanced-stage contexts, OL functions as a way to minimize treatment options and highlight dwindling possibilities. PRACTICE IMPLICATIONS OL is one way to implement shared decision-making, but it can also be used to facilitate a realization that treatment choices are diminishing and disease is progressing beyond a cure.
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Affiliation(s)
- Alexandra Tate
- Department of Medicine, The University of Chicago, United States.
| | - B J Rimel
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, United States
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Moin T, Duru OK, Turk N, Chon JS, Frosch DL, Martin JM, Jeffers KS, Castellon-Lopez Y, Tseng CH, Norris K, Mangione CM. Effectiveness of Shared Decision-making for Diabetes Prevention: 12-Month Results from the Prediabetes Informed Decision and Education (PRIDE) Trial. J Gen Intern Med 2019; 34:2652-2659. [PMID: 31471729 PMCID: PMC6848409 DOI: 10.1007/s11606-019-05238-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/06/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
IMPORTANCE Intensive lifestyle change (e.g., the Diabetes Prevention Program) and metformin reduce type 2 diabetes risk among patients with prediabetes. However, real-world uptake remains low. Shared decision-making (SDM) may increase awareness and help patients select and follow through with informed options for diabetes prevention that are aligned with their preferences. OBJECTIVE To test the effectiveness of a prediabetes SDM intervention. DESIGN Cluster randomized controlled trial. SETTING Twenty primary care clinics within a large regional health system. PARTICIPANTS Overweight/obese adults with prediabetes (BMI ≥ 24 kg/m2 and HbA1c 5.7-6.4%) were enrolled from 10 SDM intervention clinics. Propensity score matching was used to identify control patients from 10 usual care clinics. INTERVENTION Intervention clinic patients were invited to participate in a face-to-face SDM visit with a pharmacist who used a decision aid (DA) to describe prediabetes and four possible options for diabetes prevention: DPP, DPP ± metformin, metformin only, or usual care. MAIN OUTCOMES AND MEASURES Primary endpoint was uptake of DPP (≥ 9 sessions), metformin, or both strategies at 4 months. Secondary endpoint was weight change (lbs.) at 12 months. RESULTS Uptake of DPP and/or metformin was higher among SDM participants (n = 351) than controls receiving usual care (n = 1028; 38% vs. 2%, p < .001). At 12-month follow-up, adjusted weight loss (lbs.) was greater among SDM participants than controls (- 5.3 vs. - 0.2, p < .001). LIMITATIONS Absence of DPP supplier participation data for matched patients in usual care clinics. CONCLUSIONS AND RELEVANCE A prediabetes SDM intervention led by pharmacists increased patient engagement in evidence-based options for diabetes prevention and was associated with significantly greater uptake of DPP and/or metformin at 4 months and weight loss at 12 months. Prediabetes SDM may be a promising approach to enhance prevention efforts among patients at increased risk. TRIAL REGISTRATION This study was registered at clinicaltrails.gov (NCT02384109)).
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Affiliation(s)
- Tannaz Moin
- David Geffen School of Medicine, University of California, Glendon Ave Suite, Los Angeles, CA, USA.
- VA Greater Los Angeles Health System and HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA, USA.
| | - O Kenrik Duru
- David Geffen School of Medicine, University of California, Glendon Ave Suite, Los Angeles, CA, USA
| | - Norman Turk
- David Geffen School of Medicine, University of California, Glendon Ave Suite, Los Angeles, CA, USA
| | - Janet S Chon
- David Geffen School of Medicine, University of California, Glendon Ave Suite, Los Angeles, CA, USA
| | | | - Jacqueline M Martin
- David Geffen School of Medicine, University of California, Glendon Ave Suite, Los Angeles, CA, USA
| | - Kia Skrine Jeffers
- David Geffen School of Medicine, University of California, Glendon Ave Suite, Los Angeles, CA, USA
| | - Yelba Castellon-Lopez
- David Geffen School of Medicine, University of California, Glendon Ave Suite, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- David Geffen School of Medicine, University of California, Glendon Ave Suite, Los Angeles, CA, USA
| | - Keith Norris
- David Geffen School of Medicine, University of California, Glendon Ave Suite, Los Angeles, CA, USA
| | - Carol M Mangione
- David Geffen School of Medicine, University of California, Glendon Ave Suite, Los Angeles, CA, USA
- Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA, USA
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Shoemaker K, Smith CP. The impact of patient-physician alliance on trust following an adverse event. PATIENT EDUCATION AND COUNSELING 2019; 102:1342-1349. [PMID: 30827569 DOI: 10.1016/j.pec.2019.02.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 02/07/2019] [Accepted: 02/09/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Adverse events in maternity care have a negative impact on the patient-physician relationship. This study assesses the effects of healthcare institutions, communication, and patient involvement on patient trust following adverse events. METHODS Surveys were distributed online to women across the US who had given birth. Women were asked to recount their experiences during their most recent pregnancy including unexpected procedures, adverse events, support from healthcare institutions, and perceived betrayals by healthcare institutions. RESULTS Adverse events were negatively correlated with patient trust in their physician. This study's results illustrated that patient involvement and institutional betrayal mediated patient trust following adverse events. Patients who were more involved in decision-making with their physician were found to have more trust in them following adverse events than those who did not. CONCLUSIONS Patient-physician trust is negatively affected by adverse events, but patient-physician alliance in decision-making can decrease this impact. Therefore, physicians can work proactively to lessen the detrimental effects of adverse events on patient trust, but the patient-physician relationship is still impacted by healthcare institutions. PRACTICE IMPLICATIONS This study demonstrates the benefits of encouraging patient alliance with their physician and supports a need for education on the use of these strategies in healthcare.
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Chevalier B, Watson BM, Barras MA, Cottrell WN. Developing Preliminary Steps in a Pharmacist Communication - Patient Outcome Pathway. Can J Hosp Pharm 2019; 72:271-281. [PMID: 31452538 PMCID: PMC6699868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Nonadherence to medication therapy has been associated with poor health outcomes and increased health care costs. The literature describes pharmacists as key health care professionals in identifying and addressing nonadherence issues but does not explain how and why effective pharmacist-patient communication affects patients' medication adherence. Previously published pathways used in linking effective physician-patient communication to patient outcomes are proposed for the context of pharmacist-patient communication. OBJECTIVES To develop preliminary steps in a pharmacist communication - patient outcome pathway, adapted from a physician-patient communication pathway. METHODS This longitudinal descriptive study, which took place in a large quaternary hospital, involved hospital pharmacists and patients. Patients' assessment of pharmacist communication behaviours and reporting of patient satisfaction occurred after the pharmacist-patient consultation. Medication-taking behaviour questionnaires were administered before the consultation and again 4 weeks after discharge. Developing the preliminary pathway (based on previously established physician communication pathways) involved 2 steps, with investigation of the following associations: (1) between patient-reported effective communication by pharmacists, as per the Communication Accommodation Theory (CAT), and patient satisfaction; and (2) between patient-reported pharmacist communication and satisfaction and patients' medication-taking behaviour. RESULTS Twelve pharmacists and 48 patients participated. For step 1, almost all patient-reported pharmacist communication behaviours were positively correlated with patient satisfaction statements. Strong associations between CAT-related pharmacist communication behaviours and patient satisfaction highlighted the pharmacists' behaviours that are important to patients and necessary for effective conversations to take place. In step 2, there were fewer correlations of medication-taking behaviour indices with pharmacist communication behaviours and patient satisfaction. CONCLUSIONS This study showed how a preliminary pharmacist communication - patient outcome pathway could be successfully adapted from existing physician communication pathways. Such pathways provide an initial platform upon which future pharmacist communication - patient outcome research can be built.
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Affiliation(s)
- Bernadette Chevalier
- , PhD, is an Honorary Fellow, School of Pharmacy, The University of Queensland, Queensland, Australia
| | - Bernadette M Watson
- , PhD, is a Professor in the Department of English, and Director, International Research Centre for the Advancement of Health Communication, The Hong Kong Polytechnic University, Hong Kong, SAR
| | - Michael A Barras
- , PhD, is an Associate Professor in the School of Pharmacy, The University of Queensland, and Deputy-Director in the Pharmacy Department, Princess Alexandra Hospital, Queensland, Australia
| | - William N Cottrell
- , PhD, is an Associate Professor and Director, Interprofessional Education, Faculty of Health and Behavioural Sciences, The University of Queensland, Queensland, Australia
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Abstract
The National Academy of Medicine's (NAM) vision for 21st-century health care underscored the need for increased patient engagement and charged health-care researchers to develop tools to evaluate patient experience. The most widely studied patient experience tools are the Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. The Clinician and Group (CG)-CAHPS survey is the preferred patient experience survey for primary care, and thus a systematic review of patient reports from the CG-CAHPS empirical literature is ideal to appreciate the voice of health-care consumers. This systematic review revealed patient subjective reports regarding the acceptability of health-care delivery models, the effectiveness of interventions, the timeliness of care in different practice climates, and their responses to quality improvement initiatives. The synthesized results inform clinicians, organizations, and the health-care system where to prioritize and how to adapt services to efficiently provide equitable care, achieving the NAM's vision for a patient-centered US health-care system.
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Affiliation(s)
- Jeana M Holt
- University of Wisconsin-Milwaukee College of Nursing, Milwaukee, WI, USA
- Department of Family & Community Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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58
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Cheen MHH, Tan YZ, Oh LF, Wee HL, Thumboo J. Prevalence of and factors associated with primary medication non-adherence in chronic disease: A systematic review and meta-analysis. Int J Clin Pract 2019; 73:e13350. [PMID: 30941854 DOI: 10.1111/ijcp.13350] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 03/20/2019] [Accepted: 03/30/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Primary medication non-adherence (PMN), defined as failure to obtain newly prescribed medications, results in adverse clinical and economic outcomes. We aimed to (a) assess the prevalence of PMN in six common chronic diseases: asthma and/ or chronic obstructive pulmonary disease, depression, diabetes mellitus, hyperlipidaemia, hypertension and osteoporosis; (b) identify and categorise factors associated with PMN; (c) explore characteristics that contributed to heterogeneity between studies. METHODS We performed a systematic search in MEDLINE, Embase, Cochrane Library, CINAHL and PsycINFO. Studies published in English between January 2008 and August 2018 assessing PMN in subjects aged ≥18 years were included. We used the Cochrane risk of bias tool, Newcastle-Ottawa Scale and National Heart, Lung and Blood Institute Quality Assessment Tool to assess the quality of randomised controlled trials, cohort and cross-sectional studies, respectively. Findings were reported using the PRISMA checklist. PMN rates were pooled using a random effects model. We summarised factors associated with PMN descriptively. Subgroup analysis was performed to explore sources of heterogeneity. RESULTS We screened 3083 articles and included 33 (5 randomised controlled trials, 26 cohort and 2 cross-sectional studies, n = 539 156), of which 31 (n = 519 971) were used in meta-analysis. The pooled PMN rate was 17% (95% CI: 15%-20%). Pooled PMN rates were highest in osteoporosis (25%, 95% CI: 7%-44%) and hyperlipidaemia (25%, 95% CI: 18%-32%) and lowest in diabetes mellitus (10%, 95% CI: 7%-12%). Factors commonly associated with PMN include younger age, number of concurrent medications, practitioner specialty and higher co-payment. Type of chronic disease, age, study setting and PMN definition contributed to heterogeneity between studies (all P < 0.001). CONCLUSION Primary medication non-adherence is common among patients with chronic diseases and more needs to be done to address this issue in order to improve patient outcomes. Future PMN studies could benefit from greater standardisation to enhance comparability.
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Affiliation(s)
- McVin Hua Heng Cheen
- Department of Pharmacy, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Yan Zhi Tan
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Ling Fen Oh
- Department of Pharmacy, National University of Singapore, Singapore
| | - Hwee Lin Wee
- Saw Swee Hock School of Public Health, Department of Pharmacy, National University of Singapore, Singapore
| | - Julian Thumboo
- Duke-NUS Medical School, Singapore
- Rheumatology and Immunology, Singapore General Hospital, Singapore
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Ramachandran S, Rosenthal M, Young J, Holmes E, Bentley JP. Subtle scales: An avenue for identification of prescription drug abuse. Res Social Adm Pharm 2019; 15:936-942. [PMID: 30954396 DOI: 10.1016/j.sapharm.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/26/2022]
Abstract
Prescription drug abuse and diversion behavior is sustained by overprescribing of abuse-liable substances. Individuals who intend to abuse or divert prescriptions can feign symptoms easily and effectively. Efforts to identify such faking behavior have been lacking because most drug abuse screening tools and self-reported symptom inventories are known to have poor sensitivities to faking. This paper makes the case for the potential of subtle scales in the identification of faking behavior. Subtlety in scale development is the degree to which the psychopathological meaning of an item can be determined in an a priori fashion. Scales containing subtle items, such as the Minnesota Multiphasic Personality Inventory and the Substance Abuse Subtle Screening Inventory, have traditionally shown only moderate sensitivity to faking due to the lack of a tailored and focused approach. This paper provides a guide for the development of a subtle scale that is tailored to a specific condition and using sound measurement theory, a theoretical framework, and knowledge derived from literature. The Accuracy of Knowledge framework proposed by Lanyon is presented along with its application to the development of a subtle scale. Further, specific recommendations have been provided for the various steps involved in the development of a subtle scale including item development, sample selection, item refinement, and scale scoring. Use of well-developed subtle scales can present opportunities to reduce overprescribing, over-diagnosis, and help in the early identification of abuse behavior for targeted interventions. We conclude by presenting opportunities, scope, and possible avenues for research within the cultural context of the United States.
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Affiliation(s)
- Sujith Ramachandran
- Department of Pharmacy Administration, University of Mississippi, University, MS, USA.
| | - Meagen Rosenthal
- Department of Pharmacy Administration, University of Mississippi, University, MS, USA
| | - John Young
- Department of Psychology, University of Mississippi, University, MS, USA
| | - Erin Holmes
- Department of Pharmacy Administration, University of Mississippi, University, MS, USA
| | - John P Bentley
- Department of Pharmacy Administration, University of Mississippi, University, MS, USA
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Dannenberg MD, Bienvenida JCM, Bruce ML, Nguyen T, Hinn M, Matthews J, Bartels SJ, Elwyn G, Barr PJ. End-user views of an electronic encounter decision aid linked to routine depression screening. PATIENT EDUCATION AND COUNSELING 2019; 102:555-563. [PMID: 30497800 DOI: 10.1016/j.pec.2018.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/10/2018] [Accepted: 10/01/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Our aim was to gather community stakeholder input to inform the development of a digital system linking depression screening to decision support. METHODS Views and feature requirements were identified through (1) focus groups with patients and consumers with depression, and interviews with primary care clinicians and (2) usability sessions where patients and consumers used the current version of encounter decision aid (eDA) in a primary care waiting room. Qualitative data were analyzed using the framework method. RESULTS We conducted six focus groups with 15 participants, seven clinician interviews and 10 usability sessions. Patients were comfortable completing the Patient Health Questionnaire (PHQ-9) and receiving the electronic eDA in clinic. They felt this would allow patients to prepare for their visit and instill a sense of agency. Participants were comfortable receiving the PHQ-9 results and a subsequent eDA on a tablet in the waiting room. CONCLUSION Patients with and without depression, as well as clinicians, viewed linking the PHQ-9, results, and eDA positively. Patients were comfortable doing this in the clinic waiting room. PRACTICE IMPLICATIONS Linking depression decision support to screening was viewed positively by patients and clinicians, and could help overcome barriers to shared decision-making implementation in this population.
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Affiliation(s)
- Michelle D Dannenberg
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth Lebanon, New Hampshire, USA
| | - John Carlo M Bienvenida
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth Lebanon, New Hampshire, USA
| | - Martha L Bruce
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth Lebanon, New Hampshire, USA; Departments of Psychiatry and Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | | | | | | | - Stephen J Bartels
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth Lebanon, New Hampshire, USA; Departments of Psychiatry and Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth Lebanon, New Hampshire, USA
| | - Paul J Barr
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth Lebanon, New Hampshire, USA.
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Differences in Experiences With Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities With Tailored and Nontailored Primary Care Teams. Med Care 2019; 56:610-618. [PMID: 29762272 DOI: 10.1097/mlr.0000000000000926] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients. OBJECTIVE To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities). RESEARCH DESIGN We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities. SUBJECTS Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). MEASURES Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. RESULTS In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0). CONCLUSIONS VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.
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Rowe CA, Sirois FM, Toussaint L, Kohls N, Nöfer E, Offenbächer M, Hirsch JK. Health beliefs, attitudes, and health-related quality of life in persons with fibromyalgia: mediating role of treatment adherence. PSYCHOL HEALTH MED 2019; 24:962-977. [PMID: 30724586 DOI: 10.1080/13548506.2019.1576913] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Fibromyalgia is a chronic illness characterized by pain and fatigue. Persons with fibromyalgia experience increased the risk for poor mental and physical health-related quality of life, which may be dependent on multiple factors, including health beliefs, such as confidence in physicians and the health-care system, and health behaviors, such as treatment adherence. Respondents with fibromyalgia (n = 409) were recruited nationally, via support organizations, and completed self-report measures: Multidimensional Health Profile - Health Functioning Index (MHP-H), Short-Form-36 Health Survey (SF-36v2), and Medical Outcomes Study (MOS) Measure of Patient Adherence - General Adherence Items. In mediation models, belief in the healthcare system and health-care personnel, and health efficacy exerted an indirect effect through treatment adherence on mental and physical quality of life. Adaptive health beliefs and attitudes were related to greater treatment adherence and, in turn, to a better quality of life. Maladaptive health beliefs and mistrusting attitudes about physician-level and systemic-level healthcare provision are negatively related to both treatment adherence and consequent physical and mental health-related quality of life in persons with fibromyalgia. Future randomized controlled trials are needed to determine if therapeutic strategies to alter health values might improve adherence and self-rated health.
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Affiliation(s)
| | - Fuschia M Sirois
- b Department of Psychology , University of Sheffield , Sheffield , UK
| | - Loren Toussaint
- c Department of Psychology , Luther University , IA , Decorah , US
| | - Niko Kohls
- d Department of Integrative Health Promotion , Coburg University of Applied Sciences and Arts , Coburg , Germany
| | - Eberhard Nöfer
- d Department of Integrative Health Promotion , Coburg University of Applied Sciences and Arts , Coburg , Germany
| | | | - Jameson K Hirsch
- f Department of Psychology , East Tennessee State University , Johnson City , TN , USA
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Drenkard C, Bao G, Lewis TT, Pobiner B, Priest J, Lim SS. Physician-patient interactions in African American patients with systemic lupus erythematosus: Demographic characteristics and relationship with disease activity and depression. Semin Arthritis Rheum 2019; 48:669-677. [PMID: 30075991 PMCID: PMC6509352 DOI: 10.1016/j.semarthrit.2018.05.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 05/18/2018] [Accepted: 05/29/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE African American patients with systemic lupus erythematosus (SLE) are at high risk for poor outcomes. Both patient characteristics and the severity of the disease may influence physician-patient interactions, which in turn can impact disease outcomes. We aimed to examine whether patient perceptions of interpersonal processes of care (i.e. physician-patient interactions) varied by demographic characteristics, disease activity, and/or depression in African American patients with SLE. METHODS The Georgians Organized Against Lupus (GOAL) is a cohort drawn from a population-based registry of people with SLE. We conducted a cross-sectional analysis of patient-reported data collected in 2016-17 among 698 African American participants (out of 863 GOAL participants). We assessed physician-patient interactions (communication, patient-centered decision making, and physician interpersonal style) through the Interpersonal Processes of Care survey (IPC-29), disease activity through the Systemic Lupus Activity Questionnaire, and depression through the Patient Health Questionnaire-9. Mean scores of the IPC-29 scales were compared by gender, age and educational attainment with Wilcoxon rank-sum 2-sample test or Kruskal Wallis test. We conducted linear trend test to examine demographic-adjusted scores of IPC across severity of disease activity and depression, and multivariate logistic regression analyses to examine the association of disease activity and depression with suboptimal IPC scores. RESULTS Overall, the lowest mean scores were observed for the patient-centered decision making domain, and specifically about how often doctors assessed patients' problems to follow recommendations and treatment among females compared with males (mean scores 3.13 ± 1.42 and 3.64 ± 1.38, respectively; p = 0.015). Mean scores for the assumed socioeconomic level subdomain (how often doctors make assumptions about a patient's socioeconomic level) were worse in individuals aged 18-34 (mean score 1.59 ± 0.94), compared to those aged 35-55 (mean score 1.47 ± 0.94; p = 0.033). Patients with some college or higher educational attainment reported poorer mean scores for most communication and interpersonal style scales than those who reported high-school or less. We found significant linear trends of poorer scores for all communication scales across more severe disease activity and depression symptoms, and poorer scores for all interpersonal style scales across more severe disease activity. Multivariate models revealed that while depression was associated with suboptimal quality of both communication (OR 1.20; 95% CI 1.04-1.39) and interpersonal style (OR 1.12; 95% CI 1.01-1.25), disease activity only increased the odds of suboptimal interpersonal style (OR 1.13; 95% CI 1.03-1.25). CONCLUSION In the African American population with SLE, suboptimal interactions with providers may be explained in part by the mental and physical symptoms of the patient, regardless of age, gender and education. In addition to standard of care treatment, SLE patients with more severe disease activity and depression might need provider-based interventions focused on communication and interpersonal style.
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Affiliation(s)
- Cristina Drenkard
- Emory University, Department of Medicine, Division of Rheumatology, 49 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, USA.
| | - Gaobin Bao
- Emory University, Department of Medicine, Division of Rheumatology, 49 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, USA
| | - Tené T Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Julie Priest
- GlaxoSmithKline, Research Triangle Park, NC, USA
| | - S Sam Lim
- Emory University, Department of Medicine, Division of Rheumatology, 49 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, USA
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Corso KA, Dorrance KA, LaRochelle J. The Physician Shortage: A Red Herring in American Health Care Reform. Mil Med 2018; 183:220-224. [PMID: 30462337 DOI: 10.1093/milmed/usy211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 08/09/2018] [Indexed: 11/12/2022] Open
Abstract
Although the USA spends more on health care than any other comparable nation, Americans are less healthy than citizens of high-income countries that spend far less. Over the past 12 years, the number of physicians per capita in the USA has been a concerning problem that may contribute to the disparity between health care costs and health status. Some have argued that remediating the shortage of primary care physicians will improve patient health. Others assert that the relationship between health care costs and health outcomes is more complex, influenced by a broad range of variables intrinsic to health care (i.e., provider availability, continuity, coordination); patient factors (ethnicity, socioeconomic status, health behaviors, health literacy, and other social factors); and systems factors (health information management, health information technology and health care measurement itself). This article contends that increasing the physician supply will not improve the health of Americans. Rather, solutions which lower health care costs while concomitantly improving health status will. Aside from community-level actions, health can improve at lower costs by increasing the prevalence of and proficiency in team-based care models, that address individual patient determinants of health, and poorly coordinated care. Future directions for this research and policy development are discussed.
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Affiliation(s)
- Kent A Corso
- NCR Behavioral Health, LLC 6241 Woodfair Drive Fairfax Station, VA
| | | | - Jeffrey LaRochelle
- Uniformed Service University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
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Hagiwara N, Mezuk B, Elston Lafata J, Vrana SR, Fetters MD. Study protocol for investigating physician communication behaviours that link physician implicit racial bias and patient outcomes in Black patients with type 2 diabetes using an exploratory sequential mixed methods design. BMJ Open 2018; 8:e022623. [PMID: 30341127 PMCID: PMC6196822 DOI: 10.1136/bmjopen-2018-022623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/12/2018] [Accepted: 08/17/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Patient-physician racial discordance is associated with Black patient reports of dissatisfaction and mistrust, which in turn are associated with poor adherence to treatment recommendations and underutilisation of healthcare. Research further has shown that patient dissatisfaction and mistrust are magnified particularly when physicians hold high levels of implicit racial bias. This suggests that physician implicit racial bias manifests in their communication behaviours during medical interactions. The overall goal of this research is to identify physician communication behaviours that link physician implicit racial bias and Black patient immediate (patient-reported satisfaction and trust) and long-term outcomes (eg, medication adherence, self-management and healthcare utilisation) as well as clinical indicators of diabetes control (eg, blood pressure, HbA1c and history of diabetes complication). METHODS AND ANALYSIS Using an exploratory sequential mixed methods research design, we will collect data from approximately 30 family medicine physicians and 300 Black patients with type 2 diabetes mellitus. The data sources will include one physician survey, three patient surveys, medical interaction videos, video elicitation interviews and medical chart reviews. Physician implicit racial bias will be assessed with the physician survey, and patient outcomes will be assessed with the patient surveys and medical chart reviews. In video elicitation interviews, a subset of patients (approximately 20-40) will watch their own interactions while being monitored physiologically to identify evocative physician behaviours. Information from the interview will determine which physician communication behaviours will be coded from medical interactions videos. Coding will be done independently by two trained coders. A series of statistical analyses (zero-order correlations, partial correlations, regressions) will be conducted to identify physician behaviours that are associated significantly with both physician implicit racial bias and patient outcomes. ETHICS AND DISSEMINATION Ethics approval was obtained from the Virginia Commonwealth University IRB. Study results will be disseminated through publications in peer-reviewed journals and presentations at conferences. A novel Medical Interaction involving Black Patients Coding System from this project will be made publicly available.
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Affiliation(s)
- Nao Hagiwara
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Briana Mezuk
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Elston Lafata
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Scott R Vrana
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael D Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Holt JM. An evolutionary view of patient experience in primary care: A concept analysis. Nurs Forum 2018; 53:555-566. [PMID: 30196531 DOI: 10.1111/nuf.12286] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 06/10/2018] [Accepted: 06/28/2018] [Indexed: 06/08/2023]
Abstract
AIM This concept analysis explores "patient experience" in the context of primary care. BACKGROUND In the 21st century, person-centered care became the manner to address the healthcare quality needs of the United States. This study led to using measures of patient experience as an evaluation of patient-centered care. DESIGN Concept analysis. DATA SOURCES CINAHL, Cochrane Review, PUBMED Central, PsycINFO, Web of Science, and Scopus were queried using "patient experience" and "primary care." All peer-reviewed US-based articles were included from January 2000 to October 2017 (n = 59). REVIEW METHODS Rodgers' evolutionary view of concept analysis guided this inquiry. RESULTS Patient experience is any process discernible by patients, including subjective experiences, objective experiences, and observations of provider or staff behavior. Patient experience reports are mediated and moderated by many variables and reflect care experiences that directly measure patient-centeredness from the patient's viewpoint. Consequences of patient experience may lead to adherence to shared plans of care, patient engagement, and appropriate use of healthcare services. CONCLUSION Conceptual clarity of patient experience adds to the understanding of how patients experience healthcare quality. If healthcare aspires to deliver patient-centered care, understanding quality from the viewpoint of the patient is essential.
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Affiliation(s)
- Jeana M Holt
- University of Wisconsin-Milwaukee, College of Nursing, Milwaukee, Wisconsin
- Department of Family & Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Romanelli RJ, Huang Q, LaMori J, Doshi D, Chung S. Patients' Medication-Related Experience of Care Is Associated with Adherence to Cardiometabolic Disease Therapy in Real-World Clinical Practice. Popul Health Manag 2018; 21:409-414. [DOI: 10.1089/pop.2017.0163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Robert J. Romanelli
- Sutter Health, Palo Alto Medical Foundation Research Institute, Palo Alto, California
| | - Qiwen Huang
- Sutter Health, Palo Alto Medical Foundation Research Institute, Palo Alto, California
| | - Joyce LaMori
- Janssen Scientific Affairs, Titusville, New Jersey
| | - Dilesh Doshi
- Janssen Scientific Affairs, Titusville, New Jersey
| | - Sukyung Chung
- Sutter Health, Palo Alto Medical Foundation Research Institute, Palo Alto, California
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Physician–patient shared decision making in the treatment of primary immunodeficiency: an interview-based survey of immunologists. LYMPHOSIGN JOURNAL 2018. [DOI: 10.14785/lymphosign-2018-0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Patient–physician shared decision making (SDM) can result in better care as well as reduced treatment costs. A better understanding of the factors predicting when physicians implement SDM during the treatment of primary immunodeficiency (PID) could provide insight for making recommendations to improve outcomes and reduce healthcare costs in PID and other long-term chronic conditions. Method: This study made use of grounded theory and was based on the interview responses of 15 immunologists in the United States. It focused on their decision making in the diagnosis and treatment of PID, how they interact with patients, and the circumstances under which they encourage SDM with patients. Results: All invited immunologists took part in the interviews and were included in the study. All but one had 10 or more years of experience in treating PID. The study found that SDM is bounded/limited by “nudging” bias, power balance considerations, and consideration of patient health literacy alignment. Immunologists also reported that they were mainly responsible for coordinating care and for allowing sufficient time for consultations. Conclusion: SDM occurs between the physician and patient throughout the treatment of PID. The study also shows the ways physicians influence SDM by guiding patients through the process. Statement of novelty: Little is known about the factors that influence SDM in the long-term management of chronic diseases. The present study investigated the extent to which immunologists experienced in the treatment of patients with PID include SDM in clinical practice. Findings such of these may be of use when formulating treatment guidelines and improving the effectiveness of long-term management of PID.
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Gonzalez CM, Deno ML, Kintzer E, Marantz PR, Lypson ML, McKee MD. Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development. PATIENT EDUCATION AND COUNSELING 2018; 101:1669-1675. [PMID: 29843933 PMCID: PMC7065496 DOI: 10.1016/j.pec.2018.05.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 05/06/2018] [Accepted: 05/19/2018] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Patients describe feelings of bias and prejudice in clinical encounters; however, their perspectives on restoring the encounter once bias is perceived are not known. Implicit bias has emerged as a target for curricular interventions. In order to inform the design of novel patient-centered curricular interventions, this study explores patients' perceptions of bias, and suggestions for restoring relationships if bias is perceived. METHODS The authors conducted bilingual focus groups with purposive sampling of self-identified Black and Latino community members in the US. Data were analyzed using grounded theory. RESULTS Ten focus groups (in English (6) and Spanish (4)) with N = 74 participants occurred. Data analysis revealed multiple influences patients' perception of bias in their physician encounters. The theory emerging from the analysis suggests if bias is perceived, the outcome of the encounter can still be positive. A positive or negative outcome depends on whether the physician acknowledges this perceived bias or not, and his or her subsequent actions. CONCLUSIONS Participant lived experience and physician behaviors influence perceptions of bias, however clinical relationships can be restored following perceived bias. PRACTICE IMPLICATIONS Providers might benefit from skill development in the recognition and acknowledgement of perceived bias in order to restore patient-provider relationships.
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Affiliation(s)
- Cristina M Gonzalez
- Albert Einstein College of Medicine & Montefiore Medical Center, Montefiore Medical Center- Weiler Division, Bronx, 10461, USA.
| | - Maria L Deno
- Albert Einstein College of Medicine & Universidad Iberoamericana, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, 10461, USA.
| | | | - Paul R Marantz
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, 10461, USA.
| | - Monica L Lypson
- George Washington University School of Medicine and Health Sciences, University of Michigan Medical School & Office of Academic Affiliations, Department of Veterans Affairs, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - M Diane McKee
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, 10461, USA.
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Petrillo LA, McMahan RD, Tang V, Dohan D, Sudore RL. Older Adult and Surrogate Perspectives on Serious, Difficult, and Important Medical Decisions. J Am Geriatr Soc 2018; 66:1515-1523. [PMID: 29972594 PMCID: PMC6167167 DOI: 10.1111/jgs.15426] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 03/09/2018] [Accepted: 04/06/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To elicit decisions that diverse older adults and surrogates perceive as serious, difficult, or important and explore what helped them make those decisions. DESIGN Focus groups (N=13) in which participants were asked to recall serious, difficult, or important medical decisions and what helped them make those decisions. SETTING Clinics, support groups and senior centers. PARTICIPANTS Diverse English- and Spanish-speaking older adults (age: mean 78, range 64-89) and surrogates (age: mean 57, range 33-76) (29% African American, 26% white, 26% Asian or Pacific Islander, 19% Hispanic) (N=69). MEASUREMENTS We used thematic analysis to analyze transcripts. RESULTS We identified 168 decisions. Older adults from all racial and ethnic groups frequently recalled cancer treatment decisions and decisions about chronic illness management. Surrogates described decisions about transitions in care and medical crises. Older adults valued self-sufficiency and maximizing survival and relied on personal experiences as often as medical advice. In all racial and ethnic groups, surrogates valued avoiding suffering for loved ones. CONCLUSION Diverse older adults and surrogates perceive life-threatening illness and day-to-day decisions about chronic disease to be serious, difficult, and important. The surrogates' goal of avoiding suffering of older adults may differ from older adults' priorities of self-sufficiency and maximizing survival. Clinicians should support older adults and surrogates in identifying important and difficult decisions and learn about the values and information sources they bring to decision-making. With this knowledge, clinicians can customize decision support and achieve person-centered care.
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Affiliation(s)
- Laura A Petrillo
- Division of Palliative Care and Geriatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Ryan D McMahan
- School of Medicine, University of California, San Francisco, San Francisco, California
| | - Victoria Tang
- Division of Geriatrics, Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Daniel Dohan
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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Jones AL, Mor MK, Haas GL, Gordon AJ, Cashy JP, Schaefer JH, Hausmann LRM. The Role of Primary Care Experiences in Obtaining Treatment for Depression. J Gen Intern Med 2018; 33:1366-1373. [PMID: 29948804 PMCID: PMC6082202 DOI: 10.1007/s11606-018-4522-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 04/03/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Managing depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown. OBJECTIVE In a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression. DESIGN AND PARTICIPANTS We conducted a lagged cross-sectional study of depression treatment among Veterans with depression diagnoses (n = 27,362) in the years before (Y1) and after (Y2) they completed the Veterans Health Administration's national 2013 PCMH Survey of Healthcare Experiences of Patients. MAIN MEASURES We assessed patient experiences in four domains, each categorized as positive/moderate/negative. Depression treatment, determined from administrative records, was defined annually as 90 days of antidepressant medications or six psychotherapy visits. Multivariable logistic regressions measured associations between PCMH experiences and receipt of depression treatment in Y2, accounting for treatment in Y1. KEY RESULTS Among those who did not receive depression treatment in Y1 (n = 4613), positive experiences in three domains (comprehensiveness, shared decision-making, self-management support) predicted greater initiation of treatment in Y2. Among those who received depression treatment in Y1 (n = 22,749), positive or moderate experiences in four domains (comprehensiveness, care coordination, medication decision-making, self-management support) predicted greater continuation of treatment in Y2. CONCLUSIONS In a national PCMH setting, patient experiences with integrated care, including care coordination, comprehensiveness, involvement in shared decision-making, and self-management support predicted patients' subsequent initiation and continuation of depression treatment over time-a relationship that could affect physical and mental health outcomes.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation (IDEAS 2.0), Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Maria K Mor
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Gretchen L Haas
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- VISN4 Mental Illness Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation (IDEAS 2.0), Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - John P Cashy
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - James H Schaefer
- Department of Veterans Affairs Office of Reporting, Analytics, Performance, Improvement and Deployment, Durham, NC, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Lau Y, Chan KS. Psychometric evaluation of the Chinese version of the fear of intimacy with helping professionals scale. PLoS One 2018; 13:e0196774. [PMID: 29795563 PMCID: PMC5967800 DOI: 10.1371/journal.pone.0196774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/19/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES This study aimed to evaluate the internal consistency, reliability, convergent validity, known-group comparisons, and structural validity of the Chinese version of Fear of Intimacy with Helping Professionals (C-FIS-HP) scale in Macau. METHODS A cross-sectional design was used on a sample of 593 older people in 6 health centers. We used Chinese version of Exercise of Self-Care Agency Scale (C-ESCAS) and Morisky 4-item medication adherence scale to evaluate self-care actions and medication adherence. The internal consistency and reliability of C-FIS-HP were analyzed using the Spearman-Brown split-half reliability, Cronbach's alpha, and test-retest reliability. Convergent validity was tested the construct of C-FIS-HP and self-care actions. Known-group comparisons differentiated predefined groups in an expected direction. Two separated samples were used to test the structural validity. An exploratory factor analysis (EFA) tested the factor structure of C-FISHP using the principal axis factoring. A confirmatory factor analysis (CFA) was further conducted to confirm the factor structure constructed in the prior EFA. RESULTS The C-FIS-HP had a Spearman-Brown split-half coefficient, Cronbach's alpha, and intraclass correlation coefficient of 0.96, 0.93, and 0.96, respectively. Convergent validity was satisfactory with significantly correlations between the C-FIS-HP and C-ESCAS. C-FIS-HP to differentiate the differences between high-, moderate-, and low- medication adherence groups. EFA demonstrated a two-factor structure among 297 older people. A first-order CFA was performed to confirm the construct dimensionality of C-FIS-HP with satisfactory fit indices (NFI = 0.92; IFI = 0.95; TLI = 0.94; CFI = 0.95 and RMSEA = 0.07) among 296 older people. CONCLUSIONS C-FIS-HP is a reliable and valid test for assessing helping relationships in older Chinese people. Health professionals can use C-FIS-HP as a clinical tool to assess the comfort level of patients in a helping relationship, and use this information to develop culturally sensitive therapeutic interventions and treatment plans. Further studies need to be conducted concerning the different psychometric properties, as well as the application of C-FIS-HP in various regions.
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Affiliation(s)
- Ying Lau
- Department of Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kin Sun Chan
- Faculty of Social Sciences and Humanities, the University of Macau, Macau Special Administration Region, China
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Gerard M, Chimowitz H, Fossa A, Bourgeois F, Fernandez L, Bell SK. The Importance of Visit Notes on Patient Portals for Engaging Less Educated or Nonwhite Patients: Survey Study. J Med Internet Res 2018; 20:e191. [PMID: 29793900 PMCID: PMC5992450 DOI: 10.2196/jmir.9196] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/25/2018] [Accepted: 03/11/2018] [Indexed: 02/06/2023] Open
Abstract
Background OpenNotes, a national initiative to share clinicians’ visit notes with patients, can improve patient engagement, but effects on vulnerable populations are not known very well. Objective Our aim is to examine the importance of visit notes to nonwhite and less educated patients. Methods Patients at an urban academic medical center with an active patient portal account and ≥1 available ambulatory visit note over the prior year were surveyed during June 2016 until September 2016. The survey was designed with patients and families and assessed importance of reading notes (scale 0-10) for (1) understanding health conditions, (2) feeling informed about care, (3) understanding the provider’s thought process, (4) remembering the plan of care, and (5) making decisions about care. We compared the proportion of patients reporting 9-10 (extremely important) for each item stratified by education level, race/ethnicity, and self-reported health. Principal component analysis and correlation measures supported a summary score for the 5 items (Cronbach alpha=.93). We examined factors associated with rating notes as extremely important to engage in care using logistic regression. Results Of 24,722 patients, 6913 (27.96%) completed the survey. The majority (6736/6913, 97.44%) read at least one note. Among note readers, 74.0% (727/982) of patients with ≤high school education, 70.7% (130/184) of black patients, and 69.9% (153/219) of Hispanic/Latino patients reported that notes are extremely important to feel informed about their care. The majority of less educated and nonwhite patients reported notes as extremely important to remember the care plan (62.4%, 613/982 ≤high school education; 62.0%, 114/184 black patients; and 61.6%, 135/219 Hispanic/Latino patients) and to make care decisions (62.3%, 612/982; 59.8%, 110/184; and 58.5%, 128/219, respectively, and P<.003 for all comparisons to more educated and white patients, respectively). Among patients with the poorest self-reported health, 65.9% (499/757) found notes extremely important to be informed and to understand the provider. On multivariable modeling, less educated patients were nearly three times as likely to report notes were extremely important to engage in care compared with the most educated patients (odds ratio [OR] 2.9, 95% CI 2.4-3.3). Nonwhite patients were twice as likely to report the same compared with white patients (OR 2.0, 95% CI 1.5-2.7 [black] and OR 2.2, 95% CI 1.6-2.9 [Hispanic/Latino and Asian], P<.001 for each comparison). Healthier patients, women, older patients, and those who read more notes were more likely to find notes extremely important to engage in care. Conclusions Less educated and nonwhite patients using the portal each assigned higher importance to reading notes for several health behaviors than highly educated and white patients, and may find transparent notes especially valuable for understanding their health and engaging in their care. Facilitating access to notes may improve engagement in health care for some vulnerable populations who have historically been more challenging to reach.
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Affiliation(s)
- Macda Gerard
- Wayne State University School of Medicine, Detroit, MI, United States
| | - Hannah Chimowitz
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Alan Fossa
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Fabienne Bourgeois
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Leonor Fernandez
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Sigall K Bell
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
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Jones AL, Hausmann LRM, Haas GL, Mor MK, Cashy JP, Schaefer JH, Gordon AJ. A national evaluation of homeless and nonhomeless veterans' experiences with primary care. Psychol Serv 2018; 14:174-183. [PMID: 28481602 DOI: 10.1037/ser0000116] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons' avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration's medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth "homeless") were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record
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Affiliation(s)
- Audrey L Jones
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - Leslie R M Hausmann
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - Gretchen L Haas
- VISN 4 Mental Illness Research, Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - John P Cashy
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - James H Schaefer
- Department of Veterans Affairs Office of Analytics and Business Intelligence
| | - Adam J Gordon
- VA Center for Health Equity Research and Promotion, VISN4 Mental Illness Research, Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System
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75
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Veilleux S, Noiseux I, Lachapelle N, Kohen R, Vachon L, Guay BW, Bitton A, Rioux JD. Patients' perception of their involvement in shared treatment decision making: Key factors in the treatment of inflammatory bowel disease. PATIENT EDUCATION AND COUNSELING 2018; 101:331-339. [PMID: 28760459 DOI: 10.1016/j.pec.2017.07.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 07/21/2017] [Accepted: 07/24/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES This study aims to characterize the relationships between the quality of the information given by the physician, the involvement of the patient in shared decision making (SDM), and outcomes in terms of satisfaction and anxiety pertaining to the treatment of inflammatory bowel disease (IBD). METHODS A Web survey was conducted among 200 Canadian patients affected with IBD. The theoretical model of SDM was adjusted using path analysis. SAS software was used for all statistical analyses. RESULTS The quality of the knowledge transfer between the physician and the patient is significantly associated with the components of SDM: information comprehension, patient involvement and decision certainty about the chosen treatment. In return, patient involvement in SDM is significantly associated with higher satisfaction and, as a result, lower anxiety as regards treatment selection. CONCLUSIONS This study demonstrates the importance of involving patients in shared treatment decision making in the context of IBD. PRACTICE IMPLICATIONS Understanding shared decision making may motivate patients to be more active in understanding the relevant information for treatment selection, as it is related to their level of satisfaction, anxiety and adherence to treatment. This relationship should encourage physicians to promote shared decision making.
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Affiliation(s)
| | | | | | - Rita Kohen
- Division of Gastroenterology, McGill University Health Centre, Montreal, Canada
| | | | | | - Alain Bitton
- Division of Gastroenterology, McGill University Health Centre, Montreal, Canada
| | - John D Rioux
- Department of Medicine, Université de Montréal & Montreal Heart Institute, Montreal, Canada
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76
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Lemstra M, Nwankwo C, Bird Y, Moraros J. Primary nonadherence to chronic disease medications: a meta-analysis. Patient Prefer Adherence 2018; 12:721-731. [PMID: 29765208 PMCID: PMC5944464 DOI: 10.2147/ppa.s161151] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Medication nonadherence is a global problem that requires urgent attention. Primary nonadherence occurs when a patient consults with a medical doctor, receives a referral for medical therapy but never fills the first dispensation for the prescription medication. Nonadherence to chronic disease medications costs the USA ~$290 billion (USD) every year in avoidable health care costs. In Canada, it is estimated that 5.4% of all hospitalizations are due to medication nonadherence. OBJECTIVES The objective of this study was to quantify the extent of primary nonadherence for four of the most common chronic disease medications. The second objective was to identify factors associated with primary nonadherence to chronic disease medications. MATERIALS AND METHODS We conducted an extensive systematic literature review of eight databases with a wide range of keywords. We identified relevant articles for primary nonadherence to antihypertensives, lipid-lowering agents, hypoglycemics, and antidepressants. After further screening and assessment of methodologic quality, relevant data were extracted and analyzed using a random-effects model. RESULTS Twenty-four articles were included for our meta-analysis after full review and assessment for risk of bias. The pooled primary nonadherence rate for the four chronic disease medications was 14.6% (95% CI: 13.1%-16.2%). Primary medication nonadherence was higher for lipid-lowering medications among the four chronic disease medications assessed (20.8%; 95% CI: 16.0%-25.6%). The rates in North America (17.0%; 95% CI: 14.4%-19.5%) were twice those from Europe (8.5%; 95% CI: 7.1%-9.9%). The absence of social support (20%; 95% CI: 14.4%-26.6%) was the most common sociodemographic variable associated with chronic disease medication primary nonadherence. CONCLUSION Evidence suggests that a considerable percentage of patients do not initially fill their medications for treatable chronic diseases or conditions. This represents a major health care problem that can be successfully addressed. Efforts should be directed toward proper medication counseling, patient social support, and clinical follow-up, especially when the indications for the prescribed medication aim to provide primary prevention.
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Affiliation(s)
- Mark Lemstra
- Alliance Health Medical Clinics, Moose Jaw, Regina and Saskatoon, Saskatchewan, Canada
- Correspondence: Mark Lemstra, Alliance Health Medical Clinics, B70 500 – 1st Avenue NW, Moose Jaw, SK S6H 3M5, Canada, Email
| | - Chijioke Nwankwo
- School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Yelena Bird
- School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - John Moraros
- School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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77
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Simon GE, Johnson E, Stewart C, Rossom RC, Beck A, Coleman KJ, Waitzfelder B, Penfold R, Operskalski BH, Shortreed SM. Does Patient Adherence to Antidepressant Medication Actually Vary Between Physicians? J Clin Psychiatry 2018; 79:16m11324. [PMID: 29068611 PMCID: PMC7518124 DOI: 10.4088/jcp.16m11324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/08/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Previous research and improvement efforts have presumed that patients' nonadherence to antidepressant medication reflects physicians' quality of care. We used population-based health records to examine whether adherence to antidepressant medication actually varies between prescribing physicians. METHODS Electronic health records and insurance claims data from 5 integrated health systems in Washington, Idaho, Minnesota, Colorado, Hawaii, and California were used to identify 150,318 adults starting new episodes of antidepressant treatment for depression between January 1, 2010, and December 31, 2012. Early adherence was defined as any refill or dispensing of antidepressant medication in the 180 days following an initial antidepressant prescription. Patient-level demographic and clinical characteristics potentially associated with adherence were identified from health system records. RESULTS Average probability of early adherence was 82% for psychiatrists and 74% for primary care physicians. Among individual physicians, the range of raw or unadjusted early adherence rates (5th to 95th percentiles) was from 33% to 100% for psychiatrists and from 0% to 100% for primary care physicians. After accounting for sampling variation and case mix differences, the range of adjusted early adherence rates (5th to 95th percentiles) was from 72% to 78% for psychiatrists and from 64% to 69% for primary care physicians. CONCLUSIONS After accounting for sampling variation and case mix differences, early adherence to antidepressant medication varies minimally among prescribing physicians. Early discontinuation of antidepressant treatment is not an appropriate measure of individual physician performance, and efforts to improve adherence should emphasize system-level interventions rather than the performance of individual physicians.
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Affiliation(s)
- Gregory E Simon
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101. .,Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Eric Johnson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Christine Stewart
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Rebecca C Rossom
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota, USA
| | - Arne Beck
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado, USA
| | - Karen J Coleman
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena, California, USA
| | - Beth Waitzfelder
- Kaiser Permanente Hawaii Center for Health Research, Honolulu, Hawaii, USA
| | - Robert Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | | | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
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78
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Darwish L, Beroncal E, Sison MV, Swardfager W. Depression in people with type 2 diabetes: current perspectives. Diabetes Metab Syndr Obes 2018; 11:333-343. [PMID: 30022843 PMCID: PMC6044353 DOI: 10.2147/dmso.s106797] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is associated with depressive symptoms, and comorbid depression in those with T2DM has been associated with adverse clinical profiles. Recognizing and addressing psychological symptoms remain significant clinical challenges in T2DM. Possible mediators of the reciprocal relationship between T2DM and depression may include physical activity levels, effectiveness of self-management, distress associated with a new T2DM diagnosis, and frailty associated with advanced diabetes duration. The latter considerations contribute to a "J-shaped" trajectory from the time of diagnosis. There remain significant challenges to screening for clinical risks associated with psychological symptoms in T2DM; poorer outcomes may be associated with major depressive episodes, isolated (eg, anhedonic), or subsyndromal depressive symptoms, depressive-like symptoms more specific to T2DM (eg, diabetes-related distress), apathy or fatigue. In this review, we discuss current perspectives on depression in the context of T2DM with implications for screening and management of these highly comorbid conditions.
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Affiliation(s)
- Lina Darwish
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada,
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada,
- Cardiac Rehabilitation Program, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada,
- Canadian Partnership for Stroke Recovery, Toronto, ON, Canada,
| | - Erika Beroncal
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada,
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada,
- Cardiac Rehabilitation Program, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada,
| | - Ma Veronica Sison
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada,
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada,
- Cardiac Rehabilitation Program, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada,
| | - Walter Swardfager
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada,
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada,
- Cardiac Rehabilitation Program, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada,
- Canadian Partnership for Stroke Recovery, Toronto, ON, Canada,
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79
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Saini V, Garcia-Armesto S, Klemperer D, Paris V, Elshaug AG, Brownlee S, Ioannidis JPA, Fisher ES. Drivers of poor medical care. Lancet 2017; 390:178-190. [PMID: 28077235 DOI: 10.1016/s0140-6736(16)30947-3] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain.
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Affiliation(s)
| | - Sandra Garcia-Armesto
- Aragon Agency for Research and Development, Zaragoza, Spain; Aragon Health Sciences Institute, Aragon, Spain
| | - David Klemperer
- Ostbayerische Technische Hochschule Regensburg, Fakultät Angewandte Sozial-und Gesundheitswissenschaften, Regensburg, Germany
| | - Valerie Paris
- Health Division, Organisation for Economic Co-operation and Development, Paris, France
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, University of Sydney, NSW, Australia
| | - Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Havard T.H. Chan School of Public Health, Cambridge, MA, USA
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, CA, USA; Department of Health Research and Policy, Stanford University School of Medicine, Stanford University, Stanford, CA, USA; Department of Statistics, Stanford University School of Humanities and Sciences and Meta-Research Innovation Center at Stanford, Stanford University, Stanford, CA, USA
| | - Elliott S Fisher
- The Dartmouth Institute for Health Policy and Clinical Practice, Stanford University, Stanford, CA, USA; Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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80
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Pinto MD, Greenblatt AM, Williams BL, Kaplin AI. Exploring the Mechanism of the Clinical Encounter on Depressive Symptoms in Young Adults: A Path Analysis. Issues Ment Health Nurs 2017; 38:533-539. [PMID: 28521547 DOI: 10.1080/01612840.2017.1305023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Elucidating mechanisms of how high quality clinical encounters with providers may alleviate depressive symptoms in young adults are critical to reduce psychological morbidity and disability. Guided by Street's Model of Health Communication (SMHC), this study explores the predictive relationships of the clinical encounter, which includes communication functions (patient-provider communication and patient self-appraisal of communication skills with provider) and proximal outcomes (patient activation; PA) to improve health outcomes (depressive symptoms) in young adults. This study of young adults (n = 60) employed path analysis to examine the overall model fit and direct and indirect effects of each variable on depressive symptoms. The final SMHC had excellent model fit (X2 = 2.26, p =.32, TLI =.99, CFI = 1.00, RMSEA =.05). Patient-provider communication and self-appraised communication skills with providers had indirect effects on depressive symptoms and a direct effect on PA; PA had a direct effect on depressive symptoms (R2 =.30, p <.01). Findings elucidate potential novel targets, amenable to behavioral intervention, to improve depressive symptoms within the clinical encounter, and provide a foundation for hypothesis-driven model testing among young adults with depressive symptoms.
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Affiliation(s)
- Melissa D Pinto
- a Nell Hodgson Woodruff School of Nursing , Emory University , Atlanta , Georgia , USA
| | - Amy M Greenblatt
- a Nell Hodgson Woodruff School of Nursing , Emory University , Atlanta , Georgia , USA
| | - Bryan L Williams
- a Nell Hodgson Woodruff School of Nursing , Emory University , Atlanta , Georgia , USA
| | - Adam I Kaplin
- b Chief Psychiatric Consultant Johns Hopkins Multiple Sclerosis & Transverse Myelitis Centers of Excellence; School of Medicine, Johns Hopkins Hospital , Johns Hopkins University , Baltimore , Maryland , USA
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81
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Hallgren KA, Bauer AM, Atkins DC. Digital technology and clinical decision making in depression treatment: Current findings and future opportunities. Depress Anxiety 2017; 34:494-501. [PMID: 28453916 PMCID: PMC6138456 DOI: 10.1002/da.22640] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/07/2017] [Accepted: 04/11/2017] [Indexed: 12/21/2022] Open
Abstract
Clinical decision making encompasses a broad set of processes that contribute to the effectiveness of depression treatments. There is emerging interest in using digital technologies to support effective and efficient clinical decision making. In this paper, we provide "snapshots" of research and current directions on ways that digital technologies can support clinical decision making in depression treatment. Practical facets of clinical decision making are reviewed, then research, design, and implementation opportunities where technology can potentially enhance clinical decision making are outlined. Discussions of these opportunities are organized around three established movements designed to enhance clinical decision making for depression treatment, including measurement-based care, integrated care, and personalized medicine. Research, design, and implementation efforts may support clinical decision making for depression by (1) improving tools to incorporate depression symptom data into existing electronic health record systems, (2) enhancing measurement of treatment fidelity and treatment processes, (3) harnessing smartphone and biosensor data to inform clinical decision making, (4) enhancing tools that support communication and care coordination between patients and providers and within provider teams, and (5) leveraging treatment and outcome data from electronic health record systems to support personalized depression treatment. The current climate of rapid changes in both healthcare and digital technologies facilitates an urgent need for research, design, and implementation of digital technologies that explicitly support clinical decision making. Ensuring that such tools are efficient, effective, and usable in frontline treatment settings will be essential for their success and will require engagement of stakeholders from multiple domains.
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Affiliation(s)
- Kevin A. Hallgren
- Department of Psychiatry and Behavioral Sciences, Behavioral Research in Technology and Engineering (BRiTE) Center; University of Washington; WA USA
| | - Amy M. Bauer
- Department of Psychiatry and Behavioral Sciences, Behavioral Research in Technology and Engineering (BRiTE) Center; University of Washington; WA USA
| | - David C. Atkins
- Department of Psychiatry and Behavioral Sciences, Behavioral Research in Technology and Engineering (BRiTE) Center; University of Washington; WA USA
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82
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Pollard S, Bansback N, FitzGerld JM, Bryan S. The burden of nonadherence among adults with asthma: a role for shared decision-making. Allergy 2017; 72:705-712. [PMID: 27873330 DOI: 10.1111/all.13090] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 01/29/2023]
Abstract
A shared approach to decision-making framework has been suggested for chronic disease management especially where multiple treatment options exist. Shared decision-making (SDM) requires that both physician and patients are actively engaged in the decision-making process, including information exchange; expressing treatment preferences; as well as agreement over the final treatment decision. Although SDM appears well supported by patients, practitioners and policymakers alike, the current challenge is to determine how best to make SDM a reality in everyday clinical practice. Within the context of asthma, adherence rates are poor and are linked to outcomes such as reduced asthma control, increased symptoms, healthcare expenditures, and lower patient quality of life. It has been suggested that SDM can improve treatment adherence and that ignoring patients' personal goals and preferences may result in reduced rates of adherence. Furthermore, understanding predictors of poor treatment adherence is a necessary step toward developing effective strategies to improve the patient-reported and clinically important outcomes. Here, we describe why a shared approach to treatment decision-making for asthma has the potential to be an effective tool for improving adherence, with associated clinical and patient-related outcomes. In addition, we explore insights into the reasons why SDM has not been implemented into routine clinical practice.
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Affiliation(s)
- S. Pollard
- School of Population and Public Health; University of British Columbia; Vancouver BC Canada
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
| | - N. Bansback
- School of Population and Public Health; University of British Columbia; Vancouver BC Canada
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
- Centre for Health Evaluation and Outcome Sciences; St Paul's Hospital; Vancouver BC Canada
| | - J. M. FitzGerld
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
- Institute for Heart and Lung Health; Faculty of Medicine; University of British Columbia; Vancouver BC Canada
| | - S. Bryan
- School of Population and Public Health; University of British Columbia; Vancouver BC Canada
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
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83
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Klein NS, van Rijsbergen GD, Ten Doesschate MC, Hollon SD, Burger H, Bockting CLH. Beliefs about the causes of depression and recovery and their impact on adherence, dosage, and successful tapering of antidepressants. Depress Anxiety 2017; 34:227-235. [PMID: 28102582 DOI: 10.1002/da.22598] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 12/07/2016] [Accepted: 12/12/2016] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Continuation of antidepressant medication (ADM) after remission is widely used to prevent depressive relapse/recurrence. Little is known about predictors of ADM use in terms of adherence, dosage, and successful tapering. The current study aimed to explore beliefs about the causes of depression and recovery (i.e., causal beliefs) and to examine whether they predict ADM use. METHODS The data were drawn from a controlled trial and an extension of this trial with additional experience sampling. In total, 289 remitted patients with recurrent depression (ADM ≥ 6 months) were randomly assigned to Preventive Cognitive Therapy (PCT) with ADM tapering, PCT with maintenance ADM, or maintenance ADM alone. Adherence, ADM dosage, and causal beliefs regarding the first and last depressive episodes were explored via questionnaires. RESULTS Most patients mentioned stressful life events as cause of depression, although more patients tended to endorse external causes for the first episode and internal causes for the last episode. ADM was most often mentioned as helpful during recovery from both episodes. Over half of all patients were adherent and under half of the patients in the tapering condition were able to complete the taper. Causal beliefs did not predict ADM use. CONCLUSIONS The results suggest that causal beliefs play little role in the use of maintenance ADM. More information is needed on factors contributing to successful tapering. The results must be interpreted with caution as this is not a naturalistic study and the results might be biased toward a more favorable view regarding ADM.
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Affiliation(s)
- Nicola S Klein
- Department of Clinical Psychology, University of Groningen, Groningen, the Netherlands
| | - Gerard D van Rijsbergen
- Department of Clinical Psychology, University of Groningen, Groningen, the Netherlands.,Department of early detection and intervention in psychosis, GGZ Drenthe, the Netherlands
| | | | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Huibert Burger
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Claudi L H Bockting
- Department of Clinical Psychology, University of Groningen, Groningen, the Netherlands.,Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands
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84
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Aznar-Lou I, Fernández A, Gil-Girbau M, Fajó-Pascual M, Moreno-Peral P, Peñarrubia-María MT, Serrano-Blanco A, Sánchez-Niubó A, March-Pujol MA, Jové AM, Rubio-Valera M. Initial medication non-adherence: prevalence and predictive factors in a cohort of 1.6 million primary care patients. Br J Clin Pharmacol 2017; 83:1328-1340. [PMID: 28229476 DOI: 10.1111/bcp.13215] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 11/30/2016] [Accepted: 12/13/2016] [Indexed: 11/28/2022] Open
Abstract
AIMS Adherence to medicines is vital in treating diseases. Initial medication non-adherence (IMNA) - defined as not obtaining a medication the first time it is prescribed - has been poorly explored. Previous studies show IMNA rates between 6 and 28% in primary care (PC). The aims of this study were to determine prevalence and predictive factors of IMNA in the most prescribed and expensive pharmacotherapeutic groups in the Catalan health system. METHODS This is a retrospective, register-based cohort study which linked the Catalan PC System (Spain) prescription and invoicing databases. Medication was considered non-initiated when it was not collected from the pharmacy by the end of the month following the one in which it was prescribed. IMNA prevalence was calculated using July 2013-June 2014 prescription data. Predictive factors related to patients, general practitioners and PC centres were identified through multilevel logistic regression analyses. Missing data were attributed using simple imputation. RESULTS Some 1.6 million patients with 2.9 million prescriptions were included in the study sample. Total IMNA prevalence was 17.6% of prescriptions. The highest IMNA rate was observed in anilides (22.6%) and the lowest in angiotensin-converting-enzyme (ACE) inhibitors (7.4%). Predictors of IMNA are younger age, American nationality, having a pain-related or mental disorder and being treated by a substitute/resident general practitioner in a resident-training centre. CONCLUSIONS The rate of IMNA is high when all medications are taken into account. Attempts to strengthen trust in resident general practitioners and improve motivation to initiate a needed medication in the general young and older immigrant population should be addressed in Catalan PC.
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Affiliation(s)
- Ignacio Aznar-Lou
- Teaching, Research & Innovation Unit, Fundació Sant Joan de Déu, Esplugues de Llobregat, Spain.,Primary Care Prevention and Health Promotion Research Network (redIAPP), Barcelona, Spain.,School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Ana Fernández
- Mental Health Policy Unit, The Brain and Mind Research Institute; and Centre for Disability Research and Policy, Faculty of Health Sciences, University of Sydney, Sydney, Australia
| | - Montserrat Gil-Girbau
- Teaching, Research & Innovation Unit, Fundació Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Marta Fajó-Pascual
- Faculty of Health and Sport Sciences, University of Zaragoza, Huesca, Spain
| | - Patricia Moreno-Peral
- Primary Care Prevention and Health Promotion Research Network (redIAPP), Barcelona, Spain.,Unidad de Investigación del Distrito Sanitario de Atención Primaria Málaga-Guadalhorce, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | | | - Antoni Serrano-Blanco
- Primary Care Prevention and Health Promotion Research Network (redIAPP), Barcelona, Spain.,Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
| | - Albert Sánchez-Niubó
- Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Spain
| | | | | | - Maria Rubio-Valera
- Teaching, Research & Innovation Unit, Fundació Sant Joan de Déu, Esplugues de Llobregat, Spain.,Primary Care Prevention and Health Promotion Research Network (redIAPP), Barcelona, Spain.,School of Pharmacy, University of Barcelona, Barcelona, Spain
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85
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Abstract
Medication non-adherence is a significant clinical challenge that adversely affects psychosocial factors, costs, and outcomes that are shared by patients, family members, providers, healthcare systems, payers, and society. Patient-centered care (i.e., involving patients and their families in planning their health care) is increasingly emphasized as a promising approach for improving medication adherence, but clinician education around what this might look like in a busy primary care environment is lacking. We use a case study to demonstrate key skills such as motivational interviewing, counseling, and shared decision-making for clinicians interested in providing patient-centered care in efforts to improve medication adherence. Such patient-centered approaches hold considerable promise for addressing the high rates of non-adherence to medications for chronic conditions.
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86
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Orom H, Underwood W, Cheng Z, Homish DL, Scott I. Relationships as Medicine: Quality of the Physician-Patient Relationship Determines Physician Influence on Treatment Recommendation Adherence. Health Serv Res 2016; 53:580-596. [PMID: 27981559 DOI: 10.1111/1475-6773.12629] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine whether quality of physician-patient relationships influences uptake of physician treatment recommendations in men with clinically localized prostate cancer (PCa). STUDY SETTING Data were collected July 2010 to August 2014 at two cancer centers and three community facilities. STUDY DESIGN Analyses were prospective and cross-sectional. We modeled associations between quality of the patient-physician relationship and influence of physician recommendations on treatment choice using generalized estimating equations (GEE). DATA COLLECTION Data were collected via survey and medical record abstraction. PRINCIPAL FINDINGS Participants (N = 1166) were 14.7 percent minority; 37.1 percent had low-, 47.5 percent had intermediate-, and 15.4 percent had high-risk PCa. Those reporting a better physician-patient relationship perceived that their physician's treatment recommendation was more influential (RR = 1.05, 95 percent CI = 1.04-1.05, p < .001) and were more likely to choose the recommended treatment (OR = 2.92, 95 percent CI = 2.39, 3.58, p < .001). A pattern of interactions emerged indicating that quality of the physician-patient relationship was more strongly associated with influence of recommendations for more, versus less aggressive treatment in those with low-risk, but not intermediate-risk disease. CONCLUSIONS Prioritizing quality of the physician-patient relationship through training, practice change, and patient feedback may increase adherence. However, strategies need to align with efforts to reduce physician recommendations for inefficacious treatments to prevent overtreatment.
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Affiliation(s)
- Heather Orom
- Department of Community Health and Health Behavior, University at Buffalo, Buffalo, NY
| | - Willie Underwood
- Department of Urology, Roswell Park Cancer Institute, Buffalo, NY
| | - Zinan Cheng
- Touro College of Osteopathic Medicine, Middletown, NY
| | - D Lynn Homish
- Department of Community Health and Health Behavior, University at Buffalo, Buffalo, NY
| | - I'Yanna Scott
- Department of Community Health and Health Behavior, University at Buffalo, Buffalo, NY
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87
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Tran DQ, Barry V, Antun A, Ribeiro M, Stein S, Kempton CL. Physician trust and depression influence adherence to factor replacement: a single-centre cross-sectional study. Haemophilia 2016; 23:98-104. [PMID: 27686244 DOI: 10.1111/hae.13078] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Poor adherence to factor replacement therapy among patients with haemophilia can lead to joint bleeding and eventual disability. AIM The aim of this study was to determine patient-related characteristics associated with adherence to factor replacement in adults with haemophilia. METHODS Adults with haemophilia were recruited to participate in this cross-sectional study. Adherence was measured using either the Validated Hemophilia Regimen Treatment Adherence Scale (VERITAS)-Pro or the VERITAS-PRN questionnaire. Simple and multiple regression analyses that controlled for confounding were performed to determine the association between patient-related characteristics and adherence to factor replacement therapy. RESULTS Of the 99 subjects enrolled, all were men; 91% had haemophilia A and 78% had severe disease. Age ranged from 18 to 62 years. Most (95%) had functional health literacy; but only 23% were numerate. Mean adherence scores were 45.6 (SD 18) and 51.0 (SD 15) for those on a prophylactic and those on an episodic regimen, respectively, with a lower score indicating better adherence. On multivariable analysis, being on any chronic medication, longer duration followed at our haemophilia treatment centre, higher physician trust and better quality of life were associated with higher adherence. A history of depression was associated with lower adherence. CONCLUSION Two potentially modifiable characteristics, physician trust and depression, were identified as motivator and barrier to adherence to factor replacement therapy. Promoting a high level of trust between the patient and the healthcare team as well as identifying and treating depression may impact adherence to factor replacement therapy and accordingly reduce joint destruction.
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Affiliation(s)
- D Q Tran
- Department of Hematology and Oncology, Emory University, School of Medicine, Atlanta, GA, USA.,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - V Barry
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - A Antun
- Department of Hematology and Oncology, Emory University, School of Medicine, Atlanta, GA, USA
| | - M Ribeiro
- Department of Hematology and Oncology, Emory University, School of Medicine, Atlanta, GA, USA
| | - S Stein
- Department of Hematology and Oncology, Emory University, School of Medicine, Atlanta, GA, USA
| | - C L Kempton
- Department of Hematology and Oncology, Emory University, School of Medicine, Atlanta, GA, USA.,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
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88
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Curtis LM, Mullen RJ, Russell A, Fata A, Bailey SC, Makoul G, Wolf MS. An efficacy trial of an electronic health record-based strategy to inform patients on safe medication use: The role of written and spoken communication. PATIENT EDUCATION AND COUNSELING 2016; 99:1489-1495. [PMID: 27444235 PMCID: PMC5300020 DOI: 10.1016/j.pec.2016.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/27/2016] [Accepted: 07/02/2016] [Indexed: 05/29/2023]
Abstract
OBJECTIVE We tested the feasibility and efficacy of an electronic health record (EHR) strategy that automated the delivery of print medication information at the time of prescribing. METHODS Patients (N=141) receiving a new prescription at one internal medicine clinic were recruited into a 2-arm physician-randomized study. We leveraged an EHR platform to automatically deliver 1-page educational 'MedSheets' to patients after medical encounters. We also assessed if physicians counseled patients via patient self-report immediately following visits. Patients' understanding was objectively measured via phone interview. RESULTS 122 patients completed the trial. Most intervention patients (70%) reported receiving MedSheets. Patients reported physicians frequently counseled on indication and directions for use, but less often for risks. In multivariable analysis, written information (OR 2.78, 95% CI 1.10-7.04) and physician counseling (OR 2.95, 95% CI 1.26-6.91) were independently associated with patient understanding of risk information. Receiving both was most beneficial; 87% of those receiving counseling and MedSheets correctly recalled medication risks compared to 40% receiving neither. CONCLUSION An EHR can be a reliable means to deliver tangible, print medication education to patients, but cannot replace the salience of physician-patient communication. PRACTICE IMPLICATIONS Offering both written and spoken modalities produced a synergistic effect for informing patients.
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Affiliation(s)
- Laura M Curtis
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, USA.
| | - Rebecca J Mullen
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, USA
| | - Allison Russell
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, USA
| | - Aimee Fata
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, USA
| | - Stacy C Bailey
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina, Chapel Hill, USA
| | - Gregory Makoul
- PatientWisdom, New Haven, USA and Connecticut Institute for Primary Care Innovation, Hartford, USA
| | - Michael S Wolf
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, USA
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89
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Exploring the role of physician communication about adjuvant endocrine therapy among breast cancer patients on active treatment: a qualitative analysis. Support Care Cancer 2016; 25:75-83. [PMID: 27557832 DOI: 10.1007/s00520-016-3389-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/17/2016] [Indexed: 01/13/2023]
Abstract
PURPOSE To better understand how physicians communicate with breast cancer patients about adjuvant endocrine therapy (AET), we explored, from the breast cancer patient's perspective, dimensions of the patient-provider communication among women who were on active AET treatment. METHODS Qualitative methods using semi-structured in-depth interviews were conducted with breast cancer patients (n = 22) who filled a prescription for AET in the previous 12 months. Interview questions aimed to elicit experiences with AET. We reviewed and coded interview transcripts using qualitative principles of inductive reasoning to identify concepts and themes from interview data. RESULTS We grouped emergent themes into four major functions of physician-patient communication: (1) information exchange, (2) decision-making to take and continue AET, (3) enabling patient self-management and monitoring potential side effects, and (4) emotional support. Physicians exchanged information with patients in a way that they understood and enhanced patient's health literacy regarding the benefits and knowledge of AET. Physicians empowered patients to make decisions about their care. Patients expressed trust and confidence in their physician which helped them seek care when needed. Patients reported a high degree of self-efficacy to self-manage AET and were continuing treatment despite potential side effects. CONCLUSIONS The results from our study suggest that women's interactions and communication with their physician may be an important factor that contributes to the continued use of AET. Physicians who can communicate information about AET treatment benefits, purpose, and expectations in a way that patients can understand is a critical aspect of care that needs to be further studied.
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90
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Hofer R, Choi H, Mase R, Fagerlin A, Spencer M, Heisler M. Mediators and Moderators of Improvements in Medication Adherence. HEALTH EDUCATION & BEHAVIOR 2016; 44:285-296. [PMID: 27417502 DOI: 10.1177/1090198116656331] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In a randomized controlled trial we compared two models of community health worker-led diabetes medication decision support for low-income Latino and African American adults with diabetes. Most outcomes were improved when community health workers used either an interactive e-Health tool or print materials. This article investigates mediators and moderators of improved medication adherence in these two models. METHOD Because both programs significantly improved satisfaction with medication information, medication knowledge, and decisional conflict, we examined whether improvements in each of these outcomes in turn were associated with improvements in self-reported medication adherence, and if so, whether these improvements were mediated by improvements in diabetes self-efficacy or diabetes distress. Potential moderators of improvement included gender, race/ethnicity, age, education, insulin use, health literacy, and baseline self-efficacy, diabetes distress, and A1c. RESULTS A total of 176 participants (94%) completed all assessments. After adjusting for potential confounders, only increased satisfaction with medication information was correlated with improved medication adherence ( p = .024). Improved self-efficacy, but not diabetes distress, was associated with improvements in both satisfaction with medication information and medication adherence. However, the Sobel-Goodman Mediation test did not support improvements in self-efficacy as a mechanism by which improved satisfaction led to better adherence. None of the examined variables achieved statistical significance as moderators. CONCLUSIONS Improvements in satisfaction with medication information but not in medication knowledge or decision conflict were associated with improvements in medication adherence. Interventions that target low-income ethnic and racial minorities may need to focus on increasing participants' satisfaction with information provided on diabetes medications and not just improving their knowledge about medications. Future research should explore in more depth other possible mediators and moderators of improvements in medication adherence in low-income minority populations.
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Affiliation(s)
| | | | - Rebecca Mase
- 1 University of Michigan, Ann Arbor, MI, USA.,2 Ann Arbor Veterans' Affairs Healthcare System, Ann Arbor, MI, USA
| | - Angela Fagerlin
- 1 University of Michigan, Ann Arbor, MI, USA.,2 Ann Arbor Veterans' Affairs Healthcare System, Ann Arbor, MI, USA.,3 Center for Bioethics and Social Sciences in Medicine, Ann Arbor, MI, USA
| | | | - Michele Heisler
- 1 University of Michigan, Ann Arbor, MI, USA.,2 Ann Arbor Veterans' Affairs Healthcare System, Ann Arbor, MI, USA
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91
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Adams AS, Parker MM, Moffet HH, Jaffe M, Schillinger D, Callaghan B, Piette J, Adler NE, Bauer A, Karter AJ. Communication Barriers and the Clinical Recognition of Diabetic Peripheral Neuropathy in a Diverse Cohort of Adults: The DISTANCE Study. JOURNAL OF HEALTH COMMUNICATION 2016; 21:544-553. [PMID: 27116591 PMCID: PMC4920056 DOI: 10.1080/10810730.2015.1103335] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The purpose of this study was to explore communication barriers as independent predictors and potential mediators of variation in clinical recognition of diabetic peripheral neuropathy (DPN). In this cross-sectional analysis, we estimated the likelihood of having a DPN diagnosis among 4,436 patients with DPN symptoms. We controlled for symptom frequency, demographic and clinical characteristics, and visit frequency using a modified Poisson regression model. We then evaluated 4 communication barriers as independent predictors of clinical documentation and as possible mediators of racial/ethnic differences: difficulty speaking English, not talking to one's doctor about pain, limited health literacy, and reports of suboptimal patient-provider communication. Difficulty speaking English and not talking with one's doctor about pain were independently associated with not having a diagnosis, though limited health literacy and suboptimal patient-provider communication were not. Limited English proficiency partially attenuated, but did not fully explain, racial/ethnic differences in clinical documentation among Chinese, Latino, and Filipino patients. Providers should be encouraged to talk with their patients about DPN symptoms, and health systems should consider enhancing strategies to improve timely clinical recognition of DPN among patients who have difficult speaking English. More work is needed to understand persistent racial/ethnic differences in diagnosis.
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Affiliation(s)
| | | | | | - Marc Jaffe
- Department of Medicine and Endocrinology, The Permanente Medical Group
| | - Dean Schillinger
- University of California San Francisco Center for Vulnerable Populations, San Francisco General Hospital and Trauma Center
- University of California San Francisco Division of General Internal Medicine, San Francisco General Hospital and Trauma Center
| | | | - John Piette
- University of Michigan School of Medicine, Ann Arbor
| | - Nancy E. Adler
- University of San Francisco Department of Pediatrics and Center for Health and Community
| | - Amy Bauer
- University of Washington Department of Psychiatry and Behavioral Sciences
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92
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Hickman RL, Clochesy JM, Alaamri M. Validation of an Interaction Model of Health Behavior Among Adults With Hypertension. West J Nurs Res 2016; 38:874-92. [DOI: 10.1177/0193945916628864] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The purpose of this study was to test the Interaction Model of Client Health Behavior among adults with hypertension. The predictive associations among health literacy, quality of the provider interaction, perceived communication skills, and behavioral activation on blood pressure control were examined. Participants were 109 adults with hypertension recruited from community settings. A path analysis using maximum likelihood estimation was conducted in Analysis of Moment Structures for Windows (AMOS). The model fit to these data was excellent (χ2 = 1.1, p = .76, Tucker–Lewis index [TLI] = 1.1, comparative fit index [CFI] = 1.0, root mean square error of approximation [RMSEA] = .00, standardized root mean residual [SRMR] = .03). As hypothesized, health literacy, quality of the provider interaction, and perceived communication skills directly affected behavioral action. The quality of the provider interaction, perceived communication skills, and behavioral activation had direct effects on systolic blood pressure control. The study results support health literacy screening and communication skill building, and improving the quality of provider interactions to enhance blood pressure control among adults with hypertension.
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93
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Polonsky WH, Henry RR. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient Prefer Adherence 2016; 10:1299-307. [PMID: 27524885 PMCID: PMC4966497 DOI: 10.2147/ppa.s106821] [Citation(s) in RCA: 415] [Impact Index Per Article: 51.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
At least 45% of patients with type 2 diabetes (T2D) fail to achieve adequate glycemic control (HbA1c <7%). One of the major contributing factors is poor medication adherence. Poor medication adherence in T2D is well documented to be very common and is associated with inadequate glycemic control; increased morbidity and mortality; and increased costs of outpatient care, emergency room visits, hospitalization, and managing complications of diabetes. Poor medication adherence is linked to key nonpatient factors (eg, lack of integrated care in many health care systems and clinical inertia among health care professionals), patient demographic factors (eg, young age, low education level, and low income level), critical patient beliefs about their medications (eg, perceived treatment inefficacy), and perceived patient burden regarding obtaining and taking their medications (eg, treatment complexity, out-of-pocket costs, and hypoglycemia). Specific barriers to medication adherence in T2D, especially those that are potentially modifiable, need to be more clearly identified; strategies that target poor adherence should focus on reducing medication burden and addressing negative medication beliefs of patients. Solutions to these problems would require behavioral innovations as well as new methods and modes of drug delivery.
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Affiliation(s)
- William H Polonsky
- Behavioral Diabetes Institute, San Diego
- University of California, San Diego
- Correspondence: William H Polonsky, Behavioral Diabetes Institute, PO Box 2148, Del Mar, CA 92014, USA, Tel +1 760 525 5256, Email
| | - Robert R Henry
- University of California, San Diego
- Center for Metabolic Research, VA San Diego Healthcare System, San Diego, CA, USA
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94
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White RO, Chakkalakal RJ, Presley CA, Bian A, Schildcrout JS, Wallston KA, Barto S, Kripalani S, Rothman R. Perceptions of Provider Communication Among Vulnerable Patients With Diabetes: Influences of Medical Mistrust and Health Literacy. JOURNAL OF HEALTH COMMUNICATION 2016; 21:127-134. [PMID: 27662442 PMCID: PMC5540358 DOI: 10.1080/10810730.2016.1207116] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Patient-provider communication is modifiable and is linked to diabetes outcomes. The association of communication quality with medical mistrust is unknown. We examined these factors within the context of a low-literacy/numeracy-focused intervention to improve diabetes care, using baseline data from diverse patients enrolled in a randomized trial of a health communication intervention. Demographics, measures of health communication (Communication Assessment Tool [CAT], Interpersonal Processes of Care survey [IPC-18]), health literacy (Short Test of Functional Health Literacy in Adults), depression, medical mistrust, and glycemic control were ascertained. Adjusted proportional odds models were used to test the association of mistrust with patient-reported communication quality. The interaction effect of health literacy on mistrust and communication quality was also assessed. A total of 410 patients were analyzed. High levels of mistrust were observed. In multivariable modeling, patients with higher mistrust had lower adjusted odds of reporting a higher CAT score (adjusted odds ratio [AOR] = 0.67, 95% confidence interval [CI] [0.52, 0.86], p = .003) and higher scores on the Communication (AOR = 0.69, 95% CI [0.55, 0.88], p = .008), Decided Together (AOR = 0.74, 95% CI [0.59, 0.93], p = .02), and Interpersonal Style (AOR = 0.69, 95% CI [0.53, 0.90], p = .015) subscales of the IPC-18. We observed evidence of an interaction effect of health literacy for the association between mistrust and the Decided Together subscale of the IPC-18 such that patients with higher mistrust and lower literacy perceived worse communication relative to mistrustful patients with higher literacy. In conclusion, medical mistrust was associated with poorer communication with providers in this public health setting. Patients' health literacy level may vary the effect of mistrust on interactional aspects of communication. Providers should consider the impact of mistrust on communication with vulnerable diabetes populations and focus efforts on mitigating its influence.
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Affiliation(s)
- Richard O. White
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Rosette J. Chakkalakal
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Caroline A. Presley
- School of Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan S. Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Shari Barto
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sunil Kripalani
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Russell Rothman
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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95
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Lyles CR, Seligman HK, Parker MM, Moffet HH, Adler N, Schillinger D, Piette JD, Karter AJ. Financial Strain and Medication Adherence among Diabetes Patients in an Integrated Health Care Delivery System: The Diabetes Study of Northern California (DISTANCE). Health Serv Res 2015; 51:610-24. [PMID: 26256117 DOI: 10.1111/1475-6773.12346] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To examine self-reported financial strain in relation to pharmacy utilization adherence data. DATA SOURCES/STUDY SETTING Survey, administrative, and electronic medical data from Kaiser Permanente Northern California. STUDY DESIGN Retrospective cohort design (2006, n = 7,773). DATA COLLECTION/EXTRACTION METHODS We compared survey self-reports of general and medication-specific financial strain to three adherence outcomes from pharmacy records, specifying adjusted generalized linear regression models. PRINCIPAL FINDINGS Eight percent and 9 percent reported general and medication-specific financial strain. In adjusted models, general strain was significantly associated with primary nonadherence (RR = 1.37; 95 percent CI: 1.04-1.81) and refilling late (RR = 1.34; 95 percent CI: 1.07-1.66); and medication-specific strain was associated with primary nonadherence (RR = 1.42, 95 percent CI: 1.09-1.84). CONCLUSIONS Simple, minimally intrusive questions could be used to identify patients at risk of poor adherence due to financial barriers.
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Affiliation(s)
- Courtney R Lyles
- University of California San Francisco, 1001 Potrero Ave, San Francisco, CA.,Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Hilary K Seligman
- Division of General Internal Medicine at SFGH, UCSF Center for Vulnerable Populations, San Francisco, CA
| | - Melissa M Parker
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Howard H Moffet
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Nancy Adler
- UCSF Departments of Psychiatry and Pediatrics, San Francisco, CA
| | - Dean Schillinger
- Division of General Internal Medicine at SFGH, UCSF Center for Vulnerable Populations, San Francisco, CA.,Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - John D Piette
- Schools of Public Health and Medicine, VA Ann Arbor Center for Clinical Management Research, University of Michigan, Ann Arbor, MI
| | - Andrew J Karter
- Kaiser Permanente Northern California Division of Research, Oakland, CA
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96
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Ratanawongsa N, Karter AJ, Quan J, Parker MM, Handley M, Sarkar U, Schmittdiel JA, Schillinger D. Reach and Validity of an Objective Medication Adherence Measure Among Safety Net Health Plan Members with Diabetes: A Cross-Sectional Study. J Manag Care Spec Pharm 2015; 21:688-98. [PMID: 26233541 PMCID: PMC4553246 DOI: 10.18553/jmcp.2015.21.8.688] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND With the expansion of Medicaid and low-cost health insurance plans among diverse patient populations, objective measures of medication adherence using pharmacy claims could advance clinical care and translational research for safety net care. However, safety net patients may experience fluctuating prescription drug coverage, affecting the performance of adherence measures. OBJECTIVE To evaluate the performance of continuous medication gap (CMG) for diverse, low-income managed care members with diabetes. METHODS We conducted this cross-sectional analysis using administrative and clinical data for 680 members eligible for a self-management support trial at a nonprofit, government-sponsored managed care plan. We applied CMG methodology to cardiometabolic medication claims for English- , Cantonese- , or Spanish-speaking members with diabetes. We examined inclusiveness (the proportion with calculable CMG) and selectivity (sociodemographic and medical differences from members without CMG). For validity, we examined unadjusted associations of suboptimal adherence (CMG > 20%) with suboptimal cardiometabolic control. RESULTS 429 members (63%) had calculable CMG. Compared with members without CMG, members with CMG were younger, more likely employed, and had poorer glycemic control but had better blood pressure and lipid control. Suboptimal adherence occurred more frequently among members with poor cardiometabolic control than among members with optimal control (28% vs. 12%, P = 0.02). CONCLUSIONS CMG demonstrated acceptable inclusiveness and validity in a diverse, low-income safety net population, comparable with its performance in studies among other insured populations. CMG may provide a useful tool to measure adherence among increasingly diverse Medicaid populations, complemented by other strategies to reach those not captured by CMG.
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Affiliation(s)
- Neda Ratanawongsa
- UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, 1001 Potrero Ave., Box 1364, San Francisco CA 94110.
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97
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Lahijani S, Rosenthal LJ. Insights from Collaborative Care: A Review of the Evidence for Depression and Diabetes. Psychiatr Ann 2015. [DOI: 10.3928/00485713-20150803-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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98
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Koster ES, van Meeteren MM, van Dijk M, van de Bemt BJF, Ensing HT, Bouvy ML, Blom L, van Dijk L. Patient-provider interaction during medication encounters: A study in outpatient pharmacies in the Netherlands. PATIENT EDUCATION AND COUNSELING 2015; 98:843-848. [PMID: 25825256 DOI: 10.1016/j.pec.2015.03.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 03/03/2015] [Accepted: 03/07/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To describe communication between pharmacy staff and patients at the counter in outpatient pharmacies. Both content and communication style were investigated. METHODS Pharmaceutical encounters in three outpatient pharmacies in the Netherlands were video-recorded. Videos were analyzed based on an observation protocol for the following information: content of encounter, initiator of a theme and pharmacy staff's communication style. RESULTS In total, 119 encounters were recorded which concerned 42 first prescriptions, 16 first refill prescriptions and 61 follow-up refill prescriptions. During all encounters, discussion was mostly initiated by pharmacy staff (85%). In first prescription encounters topics most frequently discussed included instructions for use (83%) and dosage instructions (95%). In first refill encounters, patient experiences such as adverse effects (44%) and beneficial effects (38%) were regularly discussed in contrast to follow-up refills (7% and 5%). Patients' opinion on medication was hardly discussed. CONCLUSION Pharmacy staff in outpatient pharmacies generally provide practical information, less frequently they discuss patients' experiences and seldom discuss patients' perceptions and preferences about prescribed medication. PRACTICE IMPLICATIONS This study shows there is room for improvement, as communication is still not according to professional guidelines. To implement professional guidelines successfully, it is necessary to identify underlying reasons for not following the guidelines.
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Affiliation(s)
- Ellen S Koster
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands.
| | - Marijke M van Meeteren
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Marloes van Dijk
- Netherlands Institute of Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Bart J F van de Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands; Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hendrikus T Ensing
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands; Utrecht University of Applied Sciences, Research Group Process Innovations in Pharmaceutical Care, Hogeschool Utrecht, Utrecht, The Netherlands; Zorggroep Almere, Outpatient Pharmacy "de Brug 24/7", Flevoziekenhuis, The Netherlands
| | - Marcel L Bouvy
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Lyda Blom
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Liset van Dijk
- Netherlands Institute of Health Services Research (NIVEL), Utrecht, The Netherlands
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Parker MM, Moffet HH, Adams A, Karter AJ. An algorithm to identify medication nonpersistence using electronic pharmacy databases. J Am Med Inform Assoc 2015; 22:957-61. [PMID: 26078413 DOI: 10.1093/jamia/ocv054] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/22/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Identifying patients who are medication nonpersistent (fail to refill in a timely manner) is important for healthcare operations and research. However, consistent methods to detect nonpersistence using electronic pharmacy records are presently lacking. We developed and validated a nonpersistence algorithm for chronically used medications. MATERIALS AND METHODS Refill patterns of adult diabetes patients (n = 14,349) prescribed cardiometabolic therapies were studied. We evaluated various grace periods (30-300 days) to identify medication nonpersistence, which is defined as a gap between refills that exceeds a threshold equal to the last days' supply dispensed plus a grace period plus days of stockpiled medication. Since data on medication stockpiles are typically unavailable for ongoing users, we compared nonpersistence to rates calculated using algorithms that ignored stockpiles. RESULTS When using grace periods equal to or greater than the number of days' supply dispensed (i.e., at least 100 days), this novel algorithm for medication nonpersistence gave consistent results whether or not it accounted for days of stockpiled medication. The agreement (Kappa coefficients) between nonpersistence rates using algorithms with versus without stockpiling improved with longer grace periods and ranged from 0.63 (for 30 days) to 0.98 (for a 300-day grace period). CONCLUSIONS Our method has utility for health care operations and research in prevalent (ongoing) and new user cohorts. The algorithm detects a subset of patients with inadequate medication-taking behavior not identified as primary nonadherent or secondary nonadherent. Healthcare systems can most comprehensively identify patients with short- or long-term medication underutilization by identifying primary nonadherence, secondary nonadherence, and nonpersistence.
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Affiliation(s)
- Melissa M Parker
- Kaiser Permanente, Division of Research, Oakland, California, USA
| | - Howard H Moffet
- Kaiser Permanente, Division of Research, Oakland, California, USA
| | - Alyce Adams
- Kaiser Permanente, Division of Research, Oakland, California, USA
| | - Andrew J Karter
- Kaiser Permanente, Division of Research, Oakland, California, USA
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Davis T, Teaster PB, Thornton A, Watkins JF, Alexander L, Zanjani F. Primary Care Providers' HIV Prevention Practices Among Older Adults. J Appl Gerontol 2015; 35:1325-1342. [PMID: 25736425 DOI: 10.1177/0733464815574093] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 01/24/2015] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To explore primary care providers' HIV prevention practices for older adults. Primary care providers' perceptions and awareness were explored to understand factors that affect their provision of HIV prevention materials and HIV screening for older adults. DESIGN AND METHOD Data were collected through 24 semistructured interviews with primary care providers (i.e., physicians, physician assistants, and nurse practitioners) who see patients older than 50 years. RESULTS Results reveal facilitators and barriers of HIV prevention for older adults among primary care providers and understanding of providers' HIV prevention practices and behaviors. Individual, patient, institutional, and societal factors influenced HIV prevention practices among participants, for example, provider training and work experience, lack of time, discomfort in discussing HIV/AIDS with older adults, stigma, and ageism were contributing factors. Furthermore, factors specific to primary and secondary HIV prevention were identified, for instance, the presence of sexually transmitted infections influenced providers' secondary prevention practices. IMPLICATIONS HIV disease, while preventable, is increasing among older adults. These findings inform future research and interventions aimed at increasing HIV prevention practices in primary care settings for patients older than 50.
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Affiliation(s)
| | - Pamela B Teaster
- Virginia Polytechnic Institue and State University, Blacksburg, VA, USA
| | | | - John F Watkins
- Virginia Polytechnic Institue and State University, Blacksburg, VA, USA
| | - Linda Alexander
- Virginia Polytechnic Institue and State University, Blacksburg, VA, USA
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