Patient and visit characteristics related to physicians' participatory decision-making style. Results from the Medical Outcomes Study

Shared decision-making to improve attention-deficit hyperactivity disorder care

OBJECTIVE

To examine the effect of a shared decision-making intervention with parents of children newly diagnosed with attention-deficit/hyperactivity disorder.

METHODS

Seven pediatricians participated in a pre/post open trial of decision aids for use before and during the office visit to discuss diagnosis and develop a treatment plan. Encounters pre- (n=21, control group) and post-intervention implementation (n=33, intervention group) were compared. We video-recorded encounters and surveyed parents.

RESULTS

Compared to controls, intervention group parents were more involved in shared decision-making (31.2 vs. 43.8 on OPTION score, p<0.01), more knowledgeable (6.4 vs. 8.1 questions correct, p<0.01), and less conflicted about treatment options (16.2 vs. 10.7 on decisional conflict total score, p=0.06). Visit duration was unchanged (41.0 vs. 41.6min, p=0.75). There were no significant differences in the median number of follow-up visits (0 vs. 1 visits, p=0.08), or the proportion of children with medication titration (62% vs. 76%, p=0.28), or parent-completed behavior rating scale to assess treatment response (24% vs. 39%, p=0.36).

CONCLUSIONS

Our intervention increased shared decision-making with parents. Parents were better informed about treatment options without increasing visit duration.

PRACTICE IMPLICATIONS

Interventions are available to prepare parents for visits and enable physicians to elicit parent preferences and involvement in decision-making.

Reducing racial/ethnic disparities in diabetes: the Coached Care (R2D2C2) project

BACKGROUND

Despite numerous efforts to change healthcare delivery, the profile of disparities in diabetes care and outcomes has not changed substantially over the past decade.

OBJECTIVE

To understand potential contributors to disparities in diabetes care and glycemic control.

DESIGN

Cross sectional analysis.

SETTING

Seven outpatient clinics affiliated with an academic medical center.

PATIENTS

Adult patients with type 2 diabetes who were Mexican American, Vietnamese American or non-Hispanic white (n = 1,484).

MEASUREMENTS

Glycemic control was measured as hemoglobin A1c (HbA1c) level. Patient, provider and system characteristics included demographic characteristics; access to care; quality of process of care including clinical inertia; quality of interpersonal care; illness burden; mastery (diabetes management confidence, passivity); and adherence to treatment.

RESULTS

Unadjusted HbA1c values were significantly higher for Mexican American patients (n = 782) (mean = 8.3 % [SD:2.1]) compared with non-Hispanic whites (n = 389) (mean = 7.1 % [SD:1.4]). There were no significant differences in HbA1c values between Vietnamese American and non-Hispanic white patients. There were no statistically significant group differences in glycemic control after adjustment for multiple measures of access, and quality of process and interpersonal care. Disease management mastery and adherence to treatment were related to glycemic control for all patients, independent of race/ethnicity.

LIMITATIONS

Generalizability to other minorities or to patients with poorer access to care may be limited.

CONCLUSIONS

The complex interplay among patient, physician and system characteristics contributed to disparities in HbA1c between Mexican American and non-Hispanic white patients. In contrast, Vietnamese American patients achieved HbA1c levels comparable to non-Hispanic whites and adjustment for numerous characteristics failed to identify confounders that could have masked disparities in this subgroup. Disease management mastery appeared to be an important contributor to glycemic control for all patient subgroups.

Importance of therapeutic patient education in ichthyosis: results of a prospective single reference center study

BACKGROUND

Ichthyoses are a heterogeneous group of rare genodermatoses. Patients and their families face difficulties related to daily care and management that may be aggravated by social isolation.

OBJECTIVES

To evaluate the impact of therapeutic educational programs in improving the knowledge of ichthyosis patients, and their relatives, about their disease.

PATIENTS AND METHODS

We organized a two sessions-program of "know-how" dedicated to the overall management of ichthyoses. These sessions were conducted based on a tool specifically designed for the study, which addressed our various areas of expertise through a collective game. The participants (patients and their parents and siblings) were divided into groups, and the questions were tailored according to the participants' age. The program was conceived as a knowledge reinforcement program that took place during a weekend of education and rest, organized away from healthcare structures. Our aim was to facilitate the program in a neutral place to encourage respite care and to ensure the availability of a multidisciplinary healthcare team.

RESULTS

After the reinforcement session, children aged from 6 to 12 years and their families acquired the targeted know-how and social skills.

CONCLUSION

Benefits of TPE in the management of ichthyoses are the following: (1) the trust between patients their families and the caregivers was strengthened; (2) the context of the program encouraged self-expression, answered questions and provided mutual aid; and (3) the more self-sufficient families could better manage emergencies.

Pairing physician education with patient activation to improve shared decisions in prostate cancer screening: a cluster randomized controlled trial

BACKGROUND

Most expert groups recommend shared decision making for prostate cancer screening. Most primary care physicians, however, routinely order a prostate-specific antigen (PSA) test with little or no discussion about whether they believe the potential benefits justify the risk of harm. We sought to assess whether educating primary care physicians and activating their patients to ask about prostate cancer screening had a synergistic effect on shared decision making, rates and types of discussions about prostate cancer screening, and the physician's final recommendations.

METHODS

Our study was a cluster randomized controlled trial among primary care physicians and their patients, comparing usual education (control), with physician education alone (MD-Ed), and with physician education and patient activation (MD-Ed+A). Participants included 120 physicians in 5 group practices, and 712 male patients aged 50 to 75 years. The interventions comprised a Web-based educational program for all intervention physicians and MD-Ed+A patients compared with usual education (brochures from the Centers for Disease Control and Prevention). The primary outcome measure was patients' reported postvisit shared decision making regarding prostate cancer screening; secondary measures included unannounced standardized patients' reported shared decision making and the physician's recommendation for prostate cancer screening.

RESULTS

Patients' ratings of shared decision making were moderate and did not differ between groups. MD-Ed+A patients reported that physicians had higher prostate cancer screening discussion rates (MD-Ed+A = 65%, MD-Ed = 41%, control=38%; P <.01). Standardized patients reported that physicians seeing MD-Ed+A patients were more neutral during prostate cancer screening recommendations (MD-Ed+A=50%, MD-Ed=33%, control=15%; P <.05). Of the male patients, 80% had had previous PSA tests.

CONCLUSIONS

Although activating physicians and patients did not lead to significant changes in all aspects of physician attitudes and behaviors that we studied, interventions that involved physicians did have a large effect on their attitudes toward screening and in the discussions they had with patients, including their being more likely than control physicians to engage in prostate cancer screening discussions and more likely to be neutral in their final recommendations.

Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

OBJECTIVES

The objective of this article is to update previous evidence-based recommendations for evaluation and management of individuals with solid pulmonary nodules and to generate new recommendations for those with nonsolid nodules.

METHODS

We updated prior literature reviews, synthesized evidence, and formulated recommendations by using the methods described in the "Methodology for Development of Guidelines for Lung Cancer" in the American College of Chest Physicians Lung Cancer Guidelines, 3rd ed.

RESULTS

We formulated recommendations for evaluating solid pulmonary nodules that measure > 8 mm in diameter, solid nodules that measure ≤ 8 mm in diameter, and subsolid nodules. The recommendations stress the value of assessing the probability of malignancy, the utility of imaging tests, the need to weigh the benefits and harms of different management strategies (nonsurgical biopsy, surgical resection, and surveillance with chest CT imaging), and the importance of eliciting patient preferences.

CONCLUSIONS

Individuals with pulmonary nodules should be evaluated and managed by estimating the probability of malignancy, performing imaging tests to better characterize the lesions, evaluating the risks associated with various management alternatives, and eliciting their preferences for management.

Problems and processes in medical encounters: the cases method of dialogue analysis

OBJECTIVE

To develop methods to reliably capture structural and dynamic temporal features of clinical interactions.

METHODS

Observational study of 50 audio-recorded routine outpatient visits to HIV specialty clinics, using innovative analytic methods. The comprehensive analysis of the structure of encounters system (CASES) uses transcripts coded for speech acts, then imposes larger-scale structural elements: threads--the problems or issues addressed; and processes within threads--basic tasks of clinical care labeled presentation, information, resolution (decision making) and Engagement (interpersonal exchange). Threads are also coded for the nature of resolution.

RESULTS

61% of utterances are in presentation processes. Provider verbal dominance is greatest in information and resolution processes, which also contain a high proportion of provider directives. About half of threads result in no action or decision. Information flows predominantly from patient to provider in presentation processes, and from provider to patient in information processes. Engagement is rare.

CONCLUSIONS

In this data, resolution is provider centered; more time for patient participation in resolution, or interpersonal engagement, would have to come from presentation.

PRACTICE IMPLICATIONS

Awareness of the use of time in clinical encounters, and the interaction processes associated with various tasks, may help make clinical communication more efficient and effective.

Patient reported interpersonal processes of care and perceived social position: the Diabetes Study of Northern California (DISTANCE)

OBJECTIVE

A patient's sense of his/her standing in the social hierarchy may impact interpersonal processes of care (IPC) within the patient-provider encounter. We investigated the association of perceived social position with patient-reported IPC.

METHODS

We used survey data from the Diabetes Study of Northern California (DISTANCE), studying 11,105 insured patients with diabetes cared for in an integrated healthcare delivery system. Perceived social position was based on the MacArthur subjective social status ladder. Patient-reported IPC was based on a combined scale adapted from the Consumer Assessment of Health Plans Study provider communication subscale and the Trust in Physicians scale.

RESULTS

Lower perceived social position was associated with poorer reported IPC (p<0.001). The relationship remained statistically significant after controlling for age, sex, race/ethnicity, depressive symptoms, physical functioning, income and education.

CONCLUSION

Beyond objective measures of SES, patients' sense of where they fall in the social hierarchy may represent a pathway between social position and patient satisfaction with the quality of patient-provider communication in chronic disease.

PRACTICE IMPLICATIONS

Interventions to address disparities in communication in primary care should incorporate notions of patients' social position.

Provider-patient adherence dialogue in HIV care: results of a multisite study

Few studies have analyzed physician-patient adherence dialogue about ARV treatment in detail. We comprehensively describe physician-patient visits in HIV care, focusing on ARV-related dialogue, using a system that assigns each utterance both a topic code and a speech act code. Observational study using audio recordings of routine outpatient visits by people with HIV at specialty clinics. Providers were 34 physicians and 11 non-M.D. practitioners. Of 415 patients, 66% were male, 59% African-American. 78% reported currently taking ARVs. About 10% of utterances concerned ARV treatment. Among those using ARVs, 15% had any adherence problem solving dialogue. ARV problem solving talk included significantly more directives and control parameter utterances by providers than other topics. Providers were verbally dominant, asked five times as many questions as patients, and made 21 times as many directive utterances. Providers asked few open questions, and rarely checked patients' understanding. Physicians respond to the challenges of caring for patients with HIV by adopting a somewhat physician-centered approach which is particularly evident in discussions about ARV adherence.

Further examination of the impact of patient participation on physicians' communication style

OBJECTIVE

Previous research in primary care has shown that physicians are more informative and/or patient-centered when they interact with high participation patients (e.g., those who ask questions, express preferences and concerns). This study contributes to this literature by examining parents' participation and physicians' discourse in a pediatric surgery context.

METHODS

The audiotapes of 7 pediatric surgeons and 68 of their patients' parents/guardians were coded and examined for physicians' information exchange and support utterances as they interacted with parents/guardians with varying degrees of participation.

RESULTS

The results of a multilevel regression analysis showed, consistent with related research, that the same physicians were more informative overall and provided more information in response to parents' questions when interacting with high participation parents. However, participation was not associated with physicians' volunteered information, general explanations, or support utterances.

DISCUSSION AND CONCLUSION

The results are discussed with respect to the impact of participation on physicians' information provision and implications for future research, particularly with respect to general explanations, volunteered information, and medical context.

PRACTICE IMPLICATIONS

This study suggests that surgeons may provide more detailed information to patients who are active participants in the preoperative interview, thereby improving the adequacy and validity of informed consent for surgical procedures.

Affective interactions in medical visits: ethnic differences among American Indian older adults

OBJECTIVE

Investigate influence of ethnicity on older American Indian patients' interpretations of providers' affective behaviors.

METHOD

Using data from 115 older American Indian patients, random effects ordered logit models related patient ratings of providers' respect, empathy, and rapport first to separate measures of American Indian and White American ethnicity, then to "ethnic discordance," or difference between providers' and patients' cultural characteristics.

RESULTS

In models accounting for patients' ethnicity only, high scores for American Indian ethnicity were linked to reduced evaluations for providers' respect; high scores on White ethnicity were associated with elevated ratings for empathy and rapport. In models accounting for provider-patient ethnic discordance, high discordance on either ethnicity scale was associated with reduced ratings for the same behaviors.

DISCUSSION

Findings support "orthogonal ethnic identity" theory and extend "cultural health capital" theory, suggesting a pathway by which ethnicity becomes relevant to experience of health care among older adults.

A pilot randomized controlled trial of a decision support tool to improve the quality of communication and decision-making in individuals with atrial fibrillation

OBJECTIVES

To design a tool for nonvalvular atrial fibrillation (NVAF) to inform individuals of their individual stroke and bleeding risks, assist in clarifying priorities, and promote communication.

DESIGN

Clustered randomized controlled trial.

SETTING

Primary care clinics.

PARTICIPANTS

Individuals with NVAF (N = 135).

INTERVENTION

Completion of tool before regularly scheduled visit.

MEASUREMENTS

Primary outcomes included the 100-point informed and values clarity subscales of the decisional conflict scale (lower scores indicate individual is more informed and has greater clarity). Secondary outcomes included knowledge, patient-clinician communication, and change in treatment.

RESULTS

Sixty-nine individuals were enrolled in the intervention group and 66 in the control group. After their visit, intervention participants had lower scores on the informed (mean difference = -11.9, 95% confidence interval (CI) = -21.1 to -2.7) and values clarity subscales (mean difference = -14.6, 95% CI = -22.6 to -6.6). Greater proportions of intervention participants knew medications for reducing stroke risk (61% vs 31%, P < .001) and side effects (49% vs 37%, P = .07). Stroke (71% vs 12%) and bleeding risk (69% vs 20%) were discussed more frequently in the intervention than control group (P < .001). Five intervention participants expressed a preference for medication that was not concordant with their current treatment plan. There was no change in treatment plan in either group.

CONCLUSION

The tool was effective in improving perceived and actual knowledge and values clarity and in increasing physician-patient communication but did not change treatment.

Breast cancer treatment decision making among Latinas and non-Latina Whites: a communication model predicting decisional outcomes and quality of life

OBJECTIVE

Deciding among medical treatment options is a pivotal event following cancer diagnosis, a task that can be particularly daunting for individuals uncomfortable with communication in a medical context. Few studies have explored the surgical decision-making process and associated outcomes among Latinas. We propose a model to elucidate pathways through which acculturation (indicated by language use) and reports of communication effectiveness specific to medical decision making contribute to decisional outcomes (i.e., congruency between preferred and actual involvement in decision making, treatment satisfaction) and quality of life among Latinas and non-Latina White women with breast cancer.

METHODS

Latinas (N = 326) and non-Latina Whites (N = 168) completed measures six months after breast cancer diagnosis, and quality of life was assessed 18 months after diagnosis. Structural equation modeling was used to examine relationships between language use, communication effectiveness, and outcomes.

RESULTS

Among Latinas, 63% reported congruency in decision making, whereas 76% of non-Latina Whites reported congruency. In Latinas, greater use of English was related to better reported communication effectiveness. Effectiveness in communication was not related to congruency in decision making, but several indicators of effectiveness in communication were related to greater treatment satisfaction, as was greater congruency in decision making. Greater treatment satisfaction predicted more favorable quality of life. The final model fit the data well only for Latinas. Differences in quality of life and effectiveness in communication were observed between racial/ethnic groups.

CONCLUSIONS

Findings underscore the importance of developing targeted interventions for physicians and Latinas with breast cancer to enhance communication in decision making.

Comparative effectiveness of standard versus patient-centered collaborative care interventions for depression among African Americans in primary care settings: the BRIDGE Study

OBJECTIVE

To compare the effectiveness of standard and patient-centered, culturally tailored collaborative care (CC) interventions for African American patients with major depressive disorder (MDD) over 12 months of follow-up.

DATA SOURCES/STUDY SETTING

Twenty-seven primary care clinicians and 132 African American patients with MDD in urban community-based practices in Maryland and Delaware.

STUDY DESIGN

Cluster randomized trial with patient-level, intent-to-treat analyses.

DATA COLLECTION/EXTRACTION METHODS

Patients completed screener and baseline, 6-, 12-, and 18-month interviews to assess depression severity, mental health functioning, health service utilization, and patient ratings of care.

PRINCIPAL FINDINGS

Patients in both interventions showed statistically significant improvements over 12 months. Compared with standard, patient-centered CC patients had similar reductions in depression symptom levels (-2.41 points; 95 percent confidence interval (CI), -7.7, 2.9), improvement in mental health functioning scores (+3.0 points; 95 percent CI, -2.2, 8.3), and odds of rating their clinician as participatory (OR, 1.48, 95 percent CI, 0.53, 4.17). Treatment rates increased among standard (OR = 1.8, 95 percent CI 1.0, 3.2), but not patient-centered (OR = 1.0, 95 percent CI 0.6, 1.8) CC patients. However, patient-centered CC patients rated their care manager as more helpful at identifying their concerns (OR, 3.00; 95 percent CI, 1.23, 7.30) and helping them adhere to treatment (OR, 2.60; 95 percent CI, 1.11, 6.08).

CONCLUSIONS

Patient-centered and standard CC approaches to depression care showed similar improvements in clinical outcomes for African Americans with depression; standard CC resulted in higher rates of treatment, and patient-centered CC resulted in better ratings of care.

Influence of race and socioeconomic status on engagement in pediatric primary care

OBJECTIVE

To understand the association of race/ethnicity with engagement in pediatric primary care and examine how any racial/ethnic disparities are influenced by socioeconomic status.

METHODS

Visit videos and parent surveys were obtained for 405 children who visited for respiratory infections. Family and physician engagement in key visit tasks (relationship building, information exchange, and decision making) were coded. Two parallel regression models adjusting for covariates and clustering by physician were constructed: (1) race/ethnicity only and (2) race/ethnicity with SES (education and income).

RESULTS

With and without adjustment for SES, physicians seeing Asian families spoke 24% fewer relationship building utterances, compared to physicians seeing White, non-Latino families (p<0.05). Latino families gathered 24% less information than White, non-Latino families (p<0.05), but accounting for SES mitigates this association. Similarly, African American families were significantly less likely to be actively engaged in decision making (OR=0.32; p<0.05), compared to White, non-Latino families, but adjusting for SES mitigated this association.

CONCLUSION

While engagement during pediatric visits differed by the family's race/ethnicity, many of these differences were eliminated by accounting for socioeconomic status.

PRACTICE IMPLICATIONS

Effective targeting and evaluation of interventions to reduce health disparities through improving engagement must extend beyond race/ethnicity to consider socioeconomic status more broadly.

A study of racial/ethnic differences in treatment preferences among lupus patients

Objectives. To determine whether there are racial/ethnic differences in the willingness of SLE patients to receive CYC or participate in clinical trials, and whether demographic, psychosocial and clinical characteristics contribute to these differences.

Methods. Data from 120 African-American and 62 white lupus patients were evaluated. Structured telephone interviews were conducted to determine treatment preferences, as well as to study characteristics and beliefs that may affect these preferences. Data were analysed using serial hierarchical multivariate logistic regression and deviances were calculated from a saturated model.

Results. Compared with their white counterparts, African-American SLE patients expressed less willingness to receive CYC (67.0% vs 84.9%, P = 0.02) if their lupus worsened. This racial/ethnic difference remained significant after adjusting for socioeconomic and psychosocial variables. Logistic regression analysis showed that African-American race [odds ratio (OR) 0.29, 95% CI 0.10, 0.80], physician trust (OR 1.05, 95% CI 1.00, 1.12) and perception of treatment effectiveness (OR 1.40, 95% CI 1.22, 1.61) were the most significant determinants of willingness to receive CYC. A trend in difference by race/ethnicity was also observed in willingness to participate in a clinical trial, but this difference was not significant.

Conclusion. This study demonstrated reduced likelihood of accepting CYC in African-American lupus patients compared with white lupus patients. This racial/ethnic variation was associated with belief in medication effectiveness and trust in the medical provider, suggesting that education about therapy and improved trust can influence decision-making among SLE patients.

The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care

OBJECTIVES

We examined the associations of clinicians' implicit attitudes about race with visit communication and patient ratings of care.

METHODS

In a cross-sectional study of 40 primary care clinicians and 269 patients in urban community-based practices, we measured clinicians' implicit general race bias and race and compliance stereotyping with 2 implicit association tests and related them to audiotape measures of visit communication and patient ratings.

RESULTS

Among Black patients, general race bias was associated with more clinician verbal dominance, lower patient positive affect, and poorer ratings of interpersonal care; race and compliance stereotyping was associated with longer visits, slower speech, less patient centeredness, and poorer ratings of interpersonal care. Among White patients, bias was associated with more verbal dominance and better ratings of interpersonal care; race and compliance stereotyping was associated with less verbal dominance, shorter visits, faster speech, more patient centeredness, higher clinician positive affect, and lower ratings of some aspects of interpersonal care.

CONCLUSIONS

Clinician implicit race bias and race and compliance stereotyping are associated with markers of poor visit communication and poor ratings of care, particularly among Black patients.

The social gradient in doctor-patient communication

OBJECTIVE

In recent years, the importance of social differences in the physician-patient relationship has frequently been the subject of research. A 2002 review synthesised the evidence on this topic. Considering the increasing importance of social inequalities in health care, an actualization of this review seemed appropriate.

METHODS

A systematic search of literature published between 1965 and 2011 on the social gradient in doctor-patient communication. In this review social class was determined by patient's income, education or occupation.

RESULTS

Twenty original research papers and meta-analyses were included. Social differences in doctor-patient communication were described according to the following classification: verbal behaviour including instrumental and affective behaviour, non-verbal behaviour and patient-centred behaviour.

CONCLUSION

This review indicates that the literature on the social gradient in doctor-patient communication that was published in the last decade, addresses new issues and themes. Firstly, most of the found studies emphasize the importance of the reciprocity of communication.Secondly, there seems to be a growing interest in patient's perception of doctor-patient communication.

PRACTICE IMPLICATIONS

By increasing the doctors' awareness of the communicative differences and by empowering patients to express concerns and preferences, a more effective communication could be established.

Patient-centered care: the influence of patient and resident physician gender and gender concordance in primary care

BACKGROUND

Patient-centered care (PCC) is thought to significantly influence the process of care and its outcomes and has been identified as part of a comprehensive strategy for improving our nation's healthcare delivery system. Patient and physician gender, as well as gender concordance, may influence the provision of PCC.

METHODS

Patients (315 women, 194 men) were randomized to care by primary care resident physicians (48 women, 57 men). Sociodemographic information, history of health risk behaviors (tobacco use, alcoholism, and obesity), and self-reported global pain and health status were collected before the first visit. That visit and subsequent patient visits to the primary care physician (PCP) were videotaped during the year-long study period. PCC was measured by coding all videotapes using a modified version of the Davis Observation Code.

RESULTS

No significant gender differences in PCC were found between the male and female patients; however, female physicians provided increased PCC to their patients. The greatest amount of PCC was seen in the female patient-female physician gender dyad. Regression analyses, controlling for other patient variables, confirmed that female concordant dyads were associated with a greater amount of PCC. There was no significant relationship for the male patient-male physician concordance (vs. disconcordance).

CONCLUSIONS

These findings highlight the influence of gender in the process of care and provision of PCC. Gender concordance in female patient-female physician dyads demonstrated significantly more PCC. Further research in other clinical settings using other measures of PCC is needed. A public mandate to provide care that is patient-centered has implications for medical education.

Impact of patient-doctor race concordance on rates of weight-related counseling in visits by black and white obese individuals

The objective of this study was to assess the impact of patient-provider race concordance on weight-related counseling among visits by obese patients. We hypothesized that race concordance would be positively associated with weight-related counseling. We used clinical encounter data obtained from the 2005-2007 National Ambulatory Medical Care Surveys (NAMCS). The sample size included 2,231 visits of black and white obese individuals (ages 20 and older) to their black and white physicians from the specialties of general/family practice and general internal medicine. Three outcome measures of weight-related counseling were explored: weight reduction, diet/nutrition, and exercise. Logistic regression was used to model the outcome variables of interest. Wald tests were used to statistically compare whether physicians of each race provided counseling at different rates for obese patients of different races. We did not observe a positive association between patient-physician race concordance and weight-related counseling. We found that visits by black obese patients to white doctors had a lower odds of exercise counseling as compared to visits by white obese patients to white doctors (odds ratio (OR) = 0.54; 95% confidence interval (CI): 0.31, 0.95), and visits by black obese patients to black physicians had lower odds of receiving weight-reduction counseling than visits among white obese patients seeing black physicians (OR = 0.34; 95% CI: 0.13, 0.90). Black obese patients receive less exercise counseling than white obese patients in visits to white physicians and may be less likely than white obese patients to receive weight-reduction counseling in visits to black physicians.

Perceived barriers to care and attitudes towards shared decision-making among low socioeconomic status parents: role of health literacy

OBJECTIVE

Although low parent health literacy (HL) has been linked to poor child health outcomes, it is not known whether differences in perceptions related to access to care and provider-parent partnership in care are potential contributing factors. We sought to assess whether parent HL is associated with differences in perceived barriers to care and attitudes regarding participatory decision-making with the provider.

METHODS

This was a cross-sectional analysis of data collected from parents presenting with their child to an urban public hospital pediatric clinic in New York City. Dependent variables were caregiver-reported barriers to care (ability to reach provider at night/on weekends, difficult travel to clinic) and attitudes towards participatory decision-making (feeling like a partner, relying on doctor's knowledge, leaving decisions up to the doctor, being given choices/asked opinion). The primary independent variable was caregiver HL (Short Test of Functional Health Literacy in Adults [S-TOHFLA]).

RESULTS

A total of 823 parents were assessed; 1 in 4 (27.0%) categorized as having low HL. Parents with low HL were more likely to report barriers to care than those with adequate HL: trouble reaching provider nights/weekends, 64.9% vs. 49.6%, (p < 0.001, adjusted odds ratio [AOR] 1.7, 95% confidence interval [95% CI] 1.2-2.4); difficult travel, 15.3% vs. 8.0%, (p = 0.004, AOR 1.8, 95% CI 1.1-3.0). Low HL was also associated with not feeling like a partner (28.8% vs. 17.1%; AOR 2.0; 95% CI 1.4-3.0), preference for relying on the doctor's knowledge (68.9% vs. 52.2%; AOR 1.7; 95% CI 1.2-2.4), and preference for leaving decisions up to the doctor (57.7% vs. 33.3%; AOR 2.2; 95% CI 1.6-3.1).

CONCLUSIONS

Addressing issues of parent HL may be helpful in ameliorating barriers to care and promoting provider-parent partnership in care.

Expressing uncertainty in clinical interactions between physicians and older patients: what matters?

OBJECTIVE

Uncertainty is one key factor influencing physician and patient behavior. We examined the propensity to express uncertainty on mental health versus biomedical issues by elderly patients (>65 years) and physicians during primary care visits.

METHODS

385 videotaped visits were coded according to "topics," which are issues raised by any participant during the visit. This approach allowed us to examine if uncertainty was expressed in biomedical, mental health or other topics, and the factors associated with expressions of uncertainty.

RESULTS

We found that patients expressed uncertainty in 20.21% of topics compared to physicians expressing uncertainty in 11.73% of topics discussed in all visits. Patients expressed uncertainty in 22% of biomedical and 46.5% (p<0.01) of mental health topics. Similar statistics were found in physicians' expression of uncertainty with more uncertainty being expressed with mental health topics (23.9%) than biomedical topics (12.56%, p<0.05).

CONCLUSION

Patients expressed more uncertainties than physicians during visits. Patients and physicians both expressed more uncertainties on mental health topics suggesting that patients and primary care physicians felt less knowledgeable or less confident about dealing with mental health issues.

PRACTICE IMPLICATIONS

Understanding the inherent uncertainties in medicine can help physicians and patients engage in more productive discussion about both biomedical and mental health topics.

Physicians' shared decision-making behaviors in attention-deficit/hyperactivity disorder care

OBJECTIVES

To describe the amount of shared decision-making (SDM) behavior exhibited during treatment-planning encounters for children newly diagnosed as having attention-deficit/hyperactivity disorder and to explore relationships between participant characteristics and the amount of SDM.

DESIGN

Prospective cohort study.

SETTING

Seven community-based primary care pediatric practices in the Cincinnati, Ohio; northern Kentucky; and southeast Indiana regions from October 5, 2009, through August 9, 2010.

PARTICIPANTS

Ten pediatricians and 26 families with a 6- to 10-year-old child newly diagnosed as having attention-deficit/hyperactivity disorder.

OUTCOME MEASURE

The amount of SDM behavior exhibited during videorecorded encounters, as coded by 2 independent raters using the validated Observing Patient Involvement (OPTION) scale, which was adapted for use in pediatric settings and produces a score ranging from 0 (no parental involvement) to 100 (maximal parental involvement).

RESULTS

Treatment decisions focused on initiation of medication treatment. The mean (SD) total OPTION score was 28.5 (11.7). More SDM was observed during encounters involving families with white vs nonwhite children (adjusted mean difference score, 14.9; 95% confidence interval [CI], 10.2-19.6; P < .001), private vs public health insurance coverage (adjusted mean difference score, 15.1; 11.2-19.0; P < .001), mothers with at least some college education vs high school graduate or less (adjusted mean difference score, 12.3; 7.2-17.4; P < .001), and parents who did not screen positive for serious mental illness vs those who did (adjusted mean difference score, 15.0; 11.9-18.1; P < .001).

CONCLUSIONS

Low levels of SDM were observed. Exploratory analyses identified potential disparities and barriers. Interventions may be needed to foster SDM with all parents, especially those of nonwhite race, of lower socioeconomic status, of lower educational level, and with serious mental illness.

Provider factors and patient-reported healthcare discrimination in the Diabetes Study of California (DISTANCE)

OBJECTIVE

We examined provider-level factors and reported discrimination in the healthcare setting.

METHODS

With data from the Diabetes Study of Northern California (DISTANCE) - a race-stratified survey of diabetes patients in Kaiser Permanente Northern California - we analyzed patient-reported racial/ethnic discrimination from providers. Primary exposures were characteristics of the primary care provider (PCP, who coordinates care in this system), including specialty/type, and patient-provider relationship variables, including racial concordance.

RESULTS

Subjects (n=12,151) included 20% black, 20% Latino, 23% Asian, 30% white, and 6% other patients, with 2-8% reporting discrimination by racial/ethnic group. Patients seeing nurse practitioners as their PCP (OR=0.09; 95% CI: 0.01-0.67) and those rating their provider higher on communication (OR=0.70; 95% CI: 0.66-0.74) were less likely to report discrimination, while those with more visits (OR=1.10; 95% CI: 1.03-1.18) were more likely to report discrimination. Racial concordance was not significant once adjusting for patient race/ethnicity.

CONCLUSIONS

Among diverse diabetes patients in managed care, provider type and communication were significantly related to patient-reported discrimination.

PRACTICE IMPLICATIONS

Given potential negative impacts on patient satisfaction and treatment decisions, future studies should investigate which interpersonal aspects of the provider-patient relationship reduce patient perceptions of unfair treatment.

Caregiver rating of provider participatory decision-making style and caregiver and child satisfaction with pediatric asthma visits

OBJECTIVE

The purpose of this study was to examine the relationship between caregiver ratings of provider use of a participatory decision-making style and caregiver and child satisfaction with their pediatric asthma visits.

METHODS

Children ages 8 through 16 with persistent asthma and their caregivers were recruited at five pediatric practices. Children were interviewed and caregivers completed questionnaires after their child's medical visits. Generalized estimating equations were used to analyze the data.

RESULTS

Three hundred and twenty children were recruited. Caregivers were significantly more satisfied with providers who they perceived as using more of a participatory decision-making style (beta=17.80, p<0.001). Children (beta=-0.10, p<0.05) and caregivers (beta=-0.21, p<0.01) were significantly more satisfied with younger providers. Children were significantly more satisfied with providers who knew them better as a person (beta=2.87, p<0.001).

CONCLUSIONS

Caregivers were more satisfied with providers who they perceived as involving them more during treatment decisions made during pediatric asthma visits.

PRACTICE IMPLICATIONS

Providers should attempt to use a more participatory decision-making style with families during pediatric asthma visits.

A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients

BACKGROUND

African Americans and persons with low socioeconomic status (SES) are disproportionately affected by hypertension and receive less patient-centered care than less vulnerable patient populations. Moreover, continuing medical education (CME) and patient-activation interventions have infrequently been directed to improve the processes of care for these populations.

OBJECTIVE

To compare the effectiveness of patient-centered interventions targeting patients and physicians with the effectiveness of minimal interventions for underserved groups.

DESIGN

Randomized controlled trial conducted from January 2002 through August 2005, with patient follow-up at 3 and 12 months, in 14 urban, community-based practices in Baltimore, Maryland.

PARTICIPANTS

Forty-one primary care physicians and 279 hypertension patients.

INTERVENTIONS

Physician communication skills training and patient coaching by community health workers.

MAIN MEASURES

Physician communication behaviors; patient ratings of physicians' participatory decision-making (PDM), patient involvement in care (PIC), reported adherence to medications; systolic and diastolic blood pressure (BP) and BP control.

KEY RESULTS

Visits of trained versus control group physicians demonstrated more positive communication change scores from baseline (-0.52 vs. -0.82, p = 0.04). At 12 months, the patient+physician intensive group compared to the minimal intervention group showed significantly greater improvements in patient report of physicians' PDM (β = +6.20 vs. -5.24, p = 0.03) and PIC dimensions related to doctor facilitation (β = +0.22 vs. -0.17, p = 0.03) and information exchange (β = +0.32 vs. -0.22, p = 0.005). Improvements in patient adherence and BP control did not differ across groups for the overall patient sample. However, among patients with uncontrolled hypertension at baseline, non-significant reductions in systolic BP were observed among patients in all intervention groups-the patient+physician intensive (-13.2 mmHg), physician intensive/patient minimal (-10.6 mmHg), and the patient intensive/physician minimal (-16.8 mmHg), compared to the patient+physician minimal group (-2.0 mmHg).

CONCLUSION

Interventions that enhance physicians' communication skills and activate patients to participate in their care positively affect patient-centered communication, patient perceptions of engagement in care, and may improve systolic BP among urban African-American and low SES patients with uncontrolled hypertension.

Determinants and outcomes of patient-centered care

OBJECTIVE

This paper defines an interactional analysis instrument to characterize patient-centered care and identify associated variables.

METHODS

In this study, 509 new adult patients were randomized to care by family physicians and general internists. An adaption of the Davis Observation Code was used to measure a patient-centered practice style. The main outcome measures were visit-specific satisfaction and healthcare resource utilization.

RESULTS

In initial primary care visits, patient-centered practice style was positively associated with higher patient self-reported physical health status (p=0.0328), higher educational level (p=0.0050), and non-smoking status (p=0.0108); it was also observed more often in the interactions of family physicians compared to internists (p=0.0003). Controlling for patient sociodemographic variables, self-reported health status, pain, health risk behaviors (obesity, alcohol abuse, and smoking), and clinic assignment, patient satisfaction was not related to the provision of patient-centered care. Moreover, a higher average amount of patient-centered care recorded in visits throughout the one-year study period was significantly related to lower annual medical charges (p=0.0003).

CONCLUSIONS

Patient-centered care was observed more often with family physician caring for healthier, more educated patients, and was associated with lower charges.

PRACTICE IMPLICATIONS

Reduced annual medical care charges are an important outcome of patient-centered medical visits.

Posthospital Heart-Healthy Behaviors in Adults With Comorbid Diabetes

The purpose of these secondary analyses was to examine relationships between patient factors and patient-provider decision-making style (PDM) on heart-healthy behavior changes in 142 adults with diabetes after hospitalization for an acute coronary syndrome (ACS). A clinical trial randomized adults to either control or a telephone coaching intervention. Generalized estimating equations were used to analyze the relationship between patient factors and PDM style on longitudinal postdischarge changes in three heart-healthy behaviors, avoiding high fat foods, weight loss, and increased physical activity. Neither PDM style nor telephone coaching intervention affected heart-healthy behaviors in this population. Although adults with diabetes preferred collaborative patient-provider decision-making, present levels of provider engagement were not sufficient to support behavior change. Results suggest the need for sustained and tailored nursing interventions to facilitate heart-healthy behavior changes in adults with diabetes after ACS hospitalization.

Does questionnaire-based patient feedback reflect the important qualities of clinical consultations? Context, benefits and risks

OBJECTIVE

To explore perceptions of clinical consultations and how they relate to questionnaire-based patient feedback.

METHODS

Telephone interviews with 35 junior doctors and 40 general practice patients who had used the Doctors' Interpersonal Skills Questionnaire (DISQ).

RESULTS

Doctors and patients had similar views of 'good consultations' as relying on doctors' listening and explaining skills. Preferences for a consultation style focused on an outcome or on the doctor-patient relationship may be independent of informational and/or affective consultation content. Respondents felt the important consultation elements were similar in different contexts, and so DISQ feedback would be useful in different settings. Benefits of feedback were identified in the form of patient empowerment and doctors' learning. Risks were identified in the inappropriate use of feedback, both inadvertent and deliberate.

CONCLUSION

The style and content of consultations may be considered as separate dimensions, an approach that may help doctors adapt their communication appropriately to different consultations. Patient feedback focused on communication skills is appropriate, but there are potential risks.

PRACTICE IMPLICATIONS

Doctors should consider the transactional or relational preference of a patient in approaching a consultation. Patient feedback can deliver benefits to doctors and patients, but risks must be acknowledged and mitigated against.

An exploration of factors promoting patient participation in primary care medical interviews

Street's (2003) ecological model of communication in medical encounters was used to select and examine factors that potentially promote or retard patient participation. Patient participation was defined as information seeking and provision, assertive utterances, and emotional expressions. Patient participation discourse scores were used as the dependent variable in a multilevel regression analysis with 19 predictor variables representing cultural, organizational, and interpersonal factors of the ecological model. The analysis revealed eight significant predictors of patient participation. The results were discussed with respect to other research using the ecological model and their implications for continued study of factors that promote or retard patient participation.

Patient gender affects the referral and recommendation for total joint arthroplasty

BACKGROUND

Rates of use of total joint arthroplasty among appropriate and willing candidates are lower in women than in men. A number of factors may explain this gender disparity, including patients' preferences for surgery, gender bias influencing physicians' clinical decision-making, and the patient-physician interaction.

QUESTIONS/PURPOSES

We propose a framework of how patient gender affects the patient and physician decision-making process of referral and recommendation for total joint arthroplasty and consider potential interventions to close the gender gap in total joint arthroplasty utilization.

METHODS

The process involved in the referral and recommendation for total joint arthroplasty involves eight discrete steps. A systematic review is used to describe the influence of patient gender and related clinical and nonclinical factors at each step. WHERE ARE WE NOW?: Patient gender plays an important role in the process of referral and recommendation for total joint arthroplasty. Female gender primarily affects Steps 3 through 8, suggesting barriers unique to women exist in the patient-physician interaction. WHERE DO WE NEED TO GO?: Developing and evaluating interventions that improve the quality of the patient-physician interaction should be the focus of future research. HOW DO WE GET THERE?: Potential interventions include using decision support tools that facilitate shared decision-making between patients and their physicians and promoting cultural competency and shared decision-making skills programs as a core component of medical education. Increasing physicians' acceptance and awareness of the unconscious biases that may be influencing their clinical decision-making may require additional skills programs.

Police officer, deal-maker, or health care provider? Moving to a patient-centered framework for chronic opioid management

How we frame our thoughts about chronic opioid therapy greatly influences our ability to practice patient-centered care. Even providers who strive to be nonjudgmental may approach clinical decision-making about opioids by considering if the pain is real or they can trust the patient. Not only does this framework potentially lead to poor or unshared decision-making, it likely adds to provider and patient discomfort by placing the provider in the position of a police officer or a judge. Similarly, providers often find themselves making deals with patients using a positional bargaining approach. Even if a compromise is reached, this framework can potentially inadvertently weaken the therapeutic relationship by encouraging the idea that the patient and provider have opposing goals. Reframing the issue can allow the provider to be in a more therapeutic role. As recommended in the American Pain Society/American Academy of Pain Medicine guidelines, providers should decide whether the benefits of opioid therapy are likely to outweigh the harms for a specific patient (or sometimes, for society) at a specific time. This article discusses how providers can use a benefit-to-harm framework to make and communicate decisions about the initiation, continuation, and discontinuation of opioids for managing chronic nonmalignant pain. Such an approach focuses decisions and discussions on judging the treatment, not the patient. It allows the provider and the patient to ally together and make shared decisions regarding a common goal. Moving to a risk-benefit framework may allow providers to provide more patient-centered care, while also increasing provider and patient comfort with adequately monitoring for harm.

Patient-provider communication differs for black compared to white HIV-infected patients

Poor patient-provider interactions may play a role in explaining racial disparities in the quality and outcomes of HIV care in the United States. We analyzed 354 patient-provider encounters coded with the Roter Interaction Analysis System across four HIV care sites in the United States to explore possible racial differences in patient-provider communication. Providers were more verbally dominant in conversations with black as compared to white patients. This was largely due to black patients' talking less than white patients. There was no association between race and other measures of communication. Black and white patients rated their providers' communication similarly. Efforts to more effectively engage patients in the medical dialogue may lead to improved patient-provider relationships, self-management, and outcomes among black people living with HIV/AIDS.

Patient understanding of diabetes self-management: participatory decision-making in diabetes care

OBJECTIVE

Our aim was to determine whether patient participation in decision-making about diabetes care is associated with understanding of diabetes self-management and subsequent self-care practices. We also identified issues that would impact messaging for use in mobile diabetes communication.

RESEARCH DESIGN AND METHODS

A cross-sectional observational study was conducted with type 2 diabetes patients (n = 81) receiving their care at the University of Maryland Joslin Diabetes Center. A convenience sample of patients were eligible to participate if they were aged 25-85 years, had type 2 diabetes, spoke English, and visited their physician diabetes manager within the past 6 months. In-person patient interviews were conducted at the time of clinic visits to assess patient understanding of diabetes management, self-care practices, and perceptions of participation in decision-making about diabetes care.

RESULTS

African Americans reported fewer opportunities to participate in decision-making than Caucasians, after controlling for education [mean difference (MD) = -2.4, p = .02]. This association became insignificant after controlling for patient-physician race concordance (MD = -1.5, p = .21). Patient understanding of self-care was predicted by having greater than high school education (MD = 3.6, p = .001) and having physicians who involved them in decision-making about their care. For each unit increase in understanding of diabetes self-care, the mean patient self-care practice score increased by 0.16 (p = .003), after adjustment for patient race and education.

CONCLUSIONS

Patient participation in decision-making is associated with better understanding of care. Participation in decision-making plays a key role in patient understanding of diabetes self-management and subsequent self-care practices. Patients with limited education need specific instruction in foot care, food choices, and monitoring hemoglobin A1c.

Are there racial differences in patients' shared decision-making preferences and behaviors among patients with diabetes?

BACKGROUND

In the United States, African Americans are more likely to experience lower quality patient/provider communication and less shared decision making (SDM) than whites, which may be an important contributor to racial health disparities. Patient factors have not been fully explored as a potential contributor to communication disparities.

METHODS

The authors analyzed cross-sectional data from a survey of 974 patients with diabetes seen at 34 community health centers (HC) in 17 midwestern and west-central states. They used ordinal and logistic regression models to investigate racial differences in patients' preferences for SDM and in patients' behaviors that may facilitate SDM (initiating discussions about diabetes care).

RESULTS

The response rate was 67%. In bivariate and multivariate analyses, race was not associated with patient preference for a shared role in the 3 measured SDM domains: agenda setting (odds ratio [OR]: 1.13 [0.86, 1.49]), information sharing (OR: 1.26 [0.97, 1.64]), or decision making (OR: 1.16 [0.85, 1.59]). African Americans were more likely to report initiating discussions with their physicians about 4 of 6 areas of diabetes care-blood pressure measurement (66% v. 52%, P < 0.001), foot examination (54% v. 47%, P = 0.04), eye examination (57% v. 46%, P = 0.002), and microalbumin testing (38% v. 29%, P = 0.01)-but not HbA1c testing (39% v. 43%, P = 0.31) or cholesterol testing (53% v. 51%, P = 0.52). In multivariate analysis, African Americans were still more likely to report initiating conversations about diabetes care (OR: 1.78 [1.10, 2.89]).

CONCLUSIONS

The authors found that African Americans in this study preferred shared decision making as much as whites and were more likely to report initiating more discussions with their doctors about their diabetes care. This research suggests that, among diabetes patients receiving care at community health centers, patient preference or patient behaviors may be an unlikely cause of racial differences in shared decision making.

Perceived risk of cancer and patient reports of participation in decisions about screening: the DECISIONS study

BACKGROUND

Health behavior theories suggest that high perceived risk for cancer will be associated with screening, but few studies have examined how perceived risk relates to the screening decision process.

OBJECTIVE

To examine relationships between perceived risk of cancer and behaviors during decision making for 3 screening tests.

DESIGN

Cross-sectional survey conducted between November 2006 and May 2007.

SETTING

Nationwide random-digit dial telephone survey.

PARTICIPANTS

A total of 1729 English-speaking US adults aged 40 y and older who reported making a cancer screening decision (about breast, colon, or prostate tests) in the previous 2 y.

MEASUREMENTS

Participants completed measures of perceived risk, information seeking, and shared decision-making tendencies.

RESULTS

As perceived risk for cancer increased, patients were more likely to seek information about screening on their own (e.g., 35% of participants who perceived a high risk of cancer searched the Internet compared with 18% for those who perceived a low risk, P < 0.001) and in interactions with their physicians. As perceived risk increased, patients were also more likely to consult with more than 1 provider. Gender moderated the shared decision-making preference such that men with high perceived risks were more likely than women with high perceived risks to report they would have preferred more involvement in the decision (35% v. 9%, P = 0.001).

LIMITATIONS

Cross-sectional data limit causal inferences.

CONCLUSIONS

Higher perceived risk was associated with greater patient participation, as shown by more information seeking and greater desire for decisional involvement (moderated by gender). The results suggest that perceived risk of cancer could influence patient behavior when deciding about screening.

Gender differences in thyroid cancer: a critical review

It has long been known that the incidence of thyroid cancer in women is significantly higher than that in men. The objective of this article is to review gender differences in thyroid cancer, as well as epidemiological, clinical and experimental research on the role of sex hormones, their receptors and other molecular factors in this well-established thyroid cancer gender discrepancy. Although more common in women, thyroid cancer typically presents at a more advanced stage and with a worse disease prognosis in men. Clinical evidence on the impact of estrogen and other sex hormones on thyroid cancer has remained inconclusive, although numerous experimental studies have suggested that these hormones and their receptors may play a role in tumorigenesis and tumor progression. Studies of thyroid cancer cell lines suggest that an imbalance between the two estrogen receptor (ER) isoforms, α and β, may be responsible for the cell proliferation seen with estrogen treatment. Expression studies on thyroid tumors indicate that they express ER and possibly progesterone receptors and androgen receptors, but there is conflicting evidence as to whether or not there is a difference in receptor status between thyroid cancers, benign thyroid lesions and normal thyroid tissue. There have been few studies evaluating the ERα/ERβ profiles in thyroid tumors and normal thyroid tissue. Our understanding of the underlying basis for sex differences in thyroid cancer has improved over the last few decades, but the relationship between gender and thyroid cancer risk has remained elusive. Areas for future research include ERα/ERβ profiling of normal and neoplastic thyroid tissue, association between ER status and tumor dedifferentiation, and evaluation of the signaling pathways by which estrogen and other sex steroids exert their effects on thyroid cancer cells. Sex steroid receptors, and then downstream signaling pathways, represent promising future therapeutic targets for thyroid cancer treatment, and further study is required.

Problematic hospital experiences among adult patients with sickle cell disease

BACKGROUND

Adults with sickle cell disease (SCD) have often reported difficulties obtaining care during vaso-occlusive crisis (VOC) in qualitative studies.

METHODS

We measured the experiences of 45 SCD patients who received in-hospital care for VOC using the Picker Patient Experience Questionnaire (PPE-15), and used the one sample binomial test to compare with national norms.

RESULTS

Most SCD patients reported that they were insufficiently involved in decisions (86%), staff gave conflicting information (64%), it wasn't easy to find someone to discuss concerns (61%), doctors' answers to questions were not clear (58%), nurses' answers to questions were not clear (56%), doctors did not always discuss fears and anxieties (53%), and nurses did not always discuss fears and anxieties (52%). A greater percentage of SCD patients than the U.S. sample in 9 of 12 areas reported problems.

CONCLUSIONS

Further research is needed to determine the consequences of and potential interventions to improve these poor experiences.

Roles of sex and ethnicity in procurement coordinator--family communication during the organ donation discussion

CONTEXT

Interpersonal relations with health care providers influence families' decisions to consent to solid-organ donation. However, previous research has been based on retrospective interviews with donation-eligible families and has not directly examined the interpersonal interactions between families and organ procurement coordinators.

OBJECTIVE

To increase understanding of the interpersonal interaction between procurement coordinators and families during the organ donation discussion, with special attention to the influence of the sex and race of the procurement coordinator and the race of the potential donor's family.

DESIGN

A descriptive study in which standardized patients portrayed family members interacting with actual procurement coordinators in simulated donation request scenarios.

SETTING AND PARTICIPANTS

Thirty-three videotaped interactions between standardized patients and 17 procurement coordinators involving 2 different scenarios depicting deceased donation were evaluated.

MAIN OUTCOME MEASURES

Video recordings were rated by independent coders. Coders completed the Impact Message Inventory-Form C, the Participatory Style of Physician Scale, and the Siminoff Communication and Content and Affect Program-Global Observer Ratings scale.

RESULTS AND CONCLUSIONS

African American procurement coordinators, particularly African American women, were rated as more controlling and work-oriented than white procurement coordinators. Male procurement coordinators were more affiliative with the white family than the African American family, whereas female procurement coordinators were slightly less affiliative with the white family. African American procurement coordinators expressed more positive affect when interacting with the African American family than the white family, whereas the opposite was true for white procurement coordinators. Research is needed to cross-validate these exploratory findings and further examine cultural mistrust between procurement coordinators and families of ethnic minorities, especially given the negative attitudes of many minorities toward donation.

Quality of life information and trust in physicians among families of children with life-limiting conditions

Purpose:

To examine information that parents of children with life-limiting conditions want to discuss with children’s physicians to assist decision-making, and whether the desire for this information is associated with parents’ trust in physicians.

Study design:

A cross-sectional study using a telephone survey.

Patients and methods:

Subjects comprised a random sample of 266 parents whose children were enrolled in Florida’s Medicaid Program. Parents were asked if they wanted to discuss information related to their children’s treatment, including quality of life (QOL), pain relief, spiritual beliefs, clinical diagnosis/laboratory data, changes in the child’s behavior due to treatment, changes in the child’s appearance due to treatment, chances of recovery, and advice from the physician and family/friends. The Wake Forest Physician Trust Scale was used to measure parents’ trust in physicians. We tested the relationships between parents’ age, race/ethnicity, education, parent-reported children’s health status, and the desired information. We also tested whether the desire for information was associated with greater trust in physicians.

Results:

Most parents wanted information on their children’s QOL (95%), followed by chance of recovery (88%), and pain relief (84%). Compared with nonHispanic whites, nonHispanic blacks and Hispanics showed a greater desire for information and a chance to discuss QOL information had greater trust in their children’s physicians than other information after adjusting for covariates (P < 0.05).

Conclusions:

Among children with life-limiting conditions, QOL is the most frequently desired information that parents would like to receive from physicians as part of shared decision-making. Parents’ desire for QOL information is associated with greater trust in their children’s physicians.

Dialysis practices that distinguish facilities with below- versus above-expected mortality

BACKGROUND AND OBJECTIVES

Mortality rates vary widely among dialysis facilities even after adjustment with standardized mortality ratios (SMRs). This variation may occur because top-performing facilities use practices not shared by others, because the SMR fails to capture key patient characteristics, or both. Practices were identified that distinguish top- from bottom-performing facilities by SMR.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A cross-sectional survey was performed of staff across three organizations. Staff members rated the perceived quality of their units' patient-, provider-, and facility-level practices using a six-point Likert scale. Facilities were divided into those with above- versus below-expected mortality on the basis of SMRs from U.S. Renal Data Service facility reports. Mean Likert scores were computed for each practice using t tests. Practices that were statistically significant (P ≤ 0.05) and achieved at least a medium effect size of ≥0.4 were reported. Significant predictors were entered into a linear regression model.

RESULTS

Dialysis facilities with below-expected mortality reported that patients in their unit were more activated and engaged, physician communication and interpersonal relationships were stronger, dieticians were more resourceful and knowledgeable, and overall coordination and staff management were superior versus facilities with above-expected mortality. Staff ratings of these practices explained 31% of the variance in SMRs.

CONCLUSIONS

Patient-, provider-, and facility-level practices partly explain SMR variation among facilities. Improving SMRs may require processes that reflect a coordinated, multidisciplinary environment (i.e., no one group, practice, or characteristic will drive facility-level SMRs). Understanding and improving SMRs will require a holistic view of the facility.

Developing a cardiology-oncology clinical practice guideline

Clinical Practice Guidelines (CPG) have become an increasingly common method to assist practitioner and patient decisions about health care for specific medical problems. CPGs generally address a single medical diagnosis or syndrome leaving practitioners and patients with little guidance when two major medical diagnoses exist such as in the case of heart disease and cancer. As cancer and heart disease are both diseases of the elderly and share many common risk factors it is likely they will coexist in many patients. Thus screening for and preventing and treating heart disease in the cancer patient assumes increasing importance as aggressive cancer therapies are applied to older patients and as a growing number of cardiovascular side effects of anti-cancer therapy are described. Careful evaluation of heart disease in the cancer patient will likely improve quality of life but may also improve mortality as the presence or development of heart disease may significantly limit life-saving cancer therapies. The rationale, potential problems, and important steps in developing a cardiology-oncology guideline are discussed.

Configural frequency analysis as a method of determining patients' preferred decision-making roles in dialysis

BACKGROUND

Numerous studies examined factors in promoting a patient preference for active participation in treatment decision making with only modest success. The purpose of this study was to identify types of patients wishing to participate in treatment decisions as well as those wishing to play a completely active or passive role based on a Germany-wide survey of dialysis patients; using a prediction typal analysis method that defines types as configurations of categories belonging to different attributes and takes particularly higher order interactions between variables into account.

METHODS

After randomly splitting the original patient sample into two halves, an exploratory prediction configural frequency analysis (CFA) was performed on one-half of the sample (n = 1969) and the identified types were considered as hypotheses for an inferential prediction CFA for the second half (n = 1914). 144 possible prediction types were tested by using five predictor variables and control preferences as criterion. An α-adjustment (0.05) for multiple testing was performed by the Holm procedure.

RESULTS

21 possible prediction types were identified as hypotheses in the exploratory prediction CFA; four patient types were confirmed in the confirmatory prediction CFA: patients preferring a passive role show low information seeking preference, above average trust in their physician, perceive their physician's participatory decision-making (PDM)-style positive, have a lower educational level, and are 56-75 years old (Type 1; p < 0.001) or > 76 years old (Type 2; p < 0.001). Patients preferring an active role show high information seeking preference, a higher educational level, and are < 55 years old. They have either below average trust, perceive the PDM-style negative (Type 3; p < 0.001) or above average trust and perceive the PDM-style positive (Type 4; p < 0.001).

CONCLUSIONS

The method prediction configural frequency analysis was newly introduced to the research field of patient participation and could demonstrate how a particular control preference role is determined by an association of five variables.

Roles of Sex and Ethnicity in Procurement Coordinator—Family Communication during the Organ Donation Discussion

Context

Interpersonal relations with health care providers influence families' decisions to consent to solid-organ donation. However, previous research has been based on retrospective interviews with donation-eligible families and has not directly examined the interpersonal interactions between families and organ procurement coordinators.

Objective

To increase understanding of the interpersonal interaction between procurement coordinators and families during the organ donation discussion, with special attention to the influence of the sex and race of the procurement coordinator and the race of the potential donor's family.

Design

A descriptive study in which standardized patients portrayed family members interacting with actual procurement coordinators in simulated donation request scenarios.

Setting and Participants

Thirty-three videotaped interactions between standardized patients and 17 procurement coordinators involving 2 different scenarios depicting deceased donation were evaluated.

Main Outcome Measures

Video recordings were rated by independent coders. Coders completed the Impact Message Inventory-Form C, the Participatory Style of Physician Scale, and the Siminoff Communication and Content and Affect Program–Global Observer Ratings scale.

Results and Conclusions

African American procurement coordinators, particularly African American women, were rated as more controlling and work-oriented than white procurement coordinators. Male procurement coordinators were more affiliative with the white family than the African American family, whereas female procurement coordinators were slightly less affiliative with the white family. African American procurement coordinators expressed more positive affect when interacting with the African American family than the white family, whereas the opposite was true for white procurement coordinators. Research is needed to cross-validate these exploratory findings and further examine cultural mistrust between procurement coordinators and families of ethnic minorities, especially given the negative attitudes of many minorities toward donation.

Effect of patient and patient-oncologist relationship characteristics on communication about health-related quality of life

OBJECTIVE

To test the effects of patient and patient-oncologist relationship factors on the time spent communicating about health-related quality of life (HRQOL) during outpatient clinic encounters between oncologists and their patients with advanced cancer.

METHODS

Using mixed methods, we coded for duration of HRQOL talk in a subset of audio-recorded conversations from the Study of Communication in Oncologist-Patient Encounters (SCOPE) Trial. Multivariable linear regression modeling was used to investigate the relationship between duration of HRQOL talk and gender concordance, race concordance, patient education status, patient marital status, and length of the patient-oncologist relationship (i.e. number of previous visits).

RESULTS

Sixty-six encounters were analyzed that involved 63 patients and 34 oncologists. Patients were more likely to be female (51%), white (86%), married (78%), and possess a college or more advanced degree (33%). Most oncologists were male (82%) and white (82%). Mean ages were 58.8 years for patients and 44.9 years for oncologists. Regression results showed that the number of a patient's previous visits with their oncologist was significantly associated with a longer duration of HRQOL talk during their audio-recorded clinic visit. The remaining independent variables, gender concordance, race concordance, patient education status, and patient marital status were not significant predictors of duration of HRQOL talk.

CONCLUSIONS

Our findings suggest that length of the patient-oncologist relationship is related to duration of HRQOL talk. Improvements in HRQOL communication may best be achieved through efforts directed at those in earlier stages of the doctor-patient relationship.

Differences in patient-provider communication for Hispanic compared to non-Hispanic white patients in HIV care

BACKGROUND

Hispanic Americans with HIV/AIDS experience lower quality care and worse outcomes than non-Hispanic whites. While deficits in patient-provider communication may contribute to these disparities, no studies to date have used audio recordings to examine the communication patterns of Hispanic vs. non-Hispanic white patients with their health care providers.

OBJECTIVE

To explore differences in patient-provider communication for English-speaking, HIV-infected Hispanic and non-Hispanic white patients.

DESIGN

Cross-sectional analysis.

SETTING

Two HIV care sites in the United States (New York and Portland) participating in the Enhancing Communication and HIV Outcomes (ECHO) study.

SUBJECTS

Nineteen HIV providers and 113 of their patients.

MEASUREMENTS

Patient interviews, provider questionnaires, and audio-recorded, routine, patient-provider encounters coded with the Roter Interaction Analysis System (RIAS).

RESULTS

Providers were mostly non-Hispanic white (68%) and female (63%). Patients were Hispanic (51%), and non-Hispanic white (49%); 20% were female. Visits with Hispanic patients were less patient-centered (0.75 vs. 0.90, p = 0.009), with less psychosocial talk (80 vs. 118 statements, p < 0.001). This pattern was consistent among Hispanics who spoke English very well and those with less English proficiency. There was no association between patient race/ethnicity and visit length, patients' or providers' emotional tone, or the total number of patient or provider statements categorized as socioemotional, question-asking, information-giving, or patient activating. Hispanic patients gave higher ratings than whites (AOR 3.05 Hispanic vs. white highest rating of providers' interpersonal style, 95% CI 1.20-7.74).

CONCLUSION

In this exploratory study, we found less psychosocial talk in patient-provider encounters with Hispanic compared to white patients. The fact that Hispanic patients rated their visits more positively than whites raises the possibility that these differences in patient-provider interactions may reflect differences in patient preferences and communication style rather than "deficits" in communication. If these findings are replicated in future studies, efforts should be undertaken to understand the reasons underlying them and their impact on the quality and equity of care.

Improving physician-patient communication about cancer pain with a tailored education-coaching intervention

OBJECTIVE

This study examined the effect of a theoretically grounded, tailored education-coaching intervention to help patients more effectively discuss their pain-related questions, concerns, and preferences with physicians.

METHODS

Grounded in social-cognitive and communication theory, a tailored education-coaching (TEC) intervention was developed to help patients learn pain management and communication skills. In a RCT, 148 cancer patients agreed to have their consultations audio-recorded and were assigned to the intervention or a control group. The recordings were used to code for patients' questions, acts of assertiveness, and expressed concerns and to rate the quality of physicians' communication.

RESULTS

Patients in the TEC group discussed their pain concerns more than did patients in the control group. More active patients also had more baseline pain and interacted with physicians using participatory decision-making. Ratings of physicians' information about pain were higher when patients talked more about their pain concerns.

CONCLUSIONS

The study demonstrates the efficacy of a theoretically grounded, coaching intervention to help cancer patients talk about pain control.

PRACTICE IMPLICATIONS

Coaching interventions can be effective resources for helping cancer patients communicate about their pain concerns if they are theoretically grounded, can be integrated within clinical routines, and lead to improve health outcomes.