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Crowley-Matoka M, Saha S, Dobscha SK, Burgess DJ. Problems of quality and equity in pain management: exploring the role of biomedical culture. PAIN MEDICINE 2010; 10:1312-24. [PMID: 19818041 DOI: 10.1111/j.1526-4637.2009.00716.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To explore how social scientific analyses of the culture of biomedicine may contribute to advancing our understanding of ongoing issues of quality and equity in pain management. DESIGN Drawing upon the rich body of social scientific literature on the culture of biomedicine, we identify key features of biomedical culture with particular salience for pain management. We then examine how these cultural features of biomedicine may shape key phases of the pain management process in ways that have implications not just for quality, but for equity in pain management as well. SETTING AND PATIENTS We bring together a range of literatures in developing our analysis, including literatures on the culture of biomedicine, pain management and health care disparities. MEASURES We surveyed the relevant literatures to identify and inter-relate key features of biomedical culture, key phases of the pain management process, and key dimensions of identified problems with suboptimal and inequitable treatment of pain. RESULTS We identified three key features of biomedical culture with critical implications for pain management: 1) mind-body dualism; 2) a focus on disease vs illness; and 3) a bias toward cure vs care. Each of these cultural features play a role in the key phases of pain management, specifically pain-related communication, assessment and treatment decision-making, in ways that may hinder successful treatment of pain in general -- and of pain patients from disadvantaged groups in particular. CONCLUSIONS Deepening our understanding of the role of biomedical culture in pain management has implications for education, policy and research as part of ongoing efforts to ameliorate problems in both quality and equity in managing pain. In particular, we suggest that building upon the existing the cultural competence movement in medicine to include fostering a deeper understanding of biomedical culture and its impact on physicians may be useful. From a policy perspective, we identify pain management as an area where the need for a shift to a more biopsychosocial model of health care is particularly pressing, and suggest prioritization of inter-disciplinary, multimodal approaches to pain as one key strategy in realizing this shift. Finally, in terms of research, we identify the need for empirical research to assess aspects of biomedical culture that may influence physician's attitudes and behaviors related to pain management, as well as to explore how these cultural values and their effects may vary across different settings within the practice of medicine.
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Affiliation(s)
- Megan Crowley-Matoka
- University of Pittsburgh and Research Scientist, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA 15206, USA.
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152
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Arora NK, Weaver KE, Clayman ML, Oakley-Girvan I, Potosky AL. Physicians' decision-making style and psychosocial outcomes among cancer survivors. PATIENT EDUCATION AND COUNSELING 2009; 77:404-12. [PMID: 19892508 PMCID: PMC3401045 DOI: 10.1016/j.pec.2009.10.004] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2009] [Accepted: 10/05/2009] [Indexed: 05/09/2023]
Abstract
OBJECTIVE We evaluated pathways linking physicians' decision-making style with cancer survivors' health-related quality of life (HRQOL). METHODS We analyzed survey data from 623 survivors diagnosed with leukemia, colorectal, or bladder cancer in Northern California, 2-5 years prior to the study. Of these, 395 reported making a medical decision in the past 12 months and were asked about their physician's decision-making style. We evaluated the association of physician style with proximal communication outcomes (trust and participation self-efficacy), intermediate cognitive outcomes (perceived control and uncertainty), and distal health outcomes (physical and mental HRQOL). RESULTS Overall, 54% of survivors reported a sub-optimal decision-making style for their physician. With the exception of physical health, physician style was associated with all proximal, intermediate, and distal outcomes (p< or =0.01). We identified two significant pathways by which a participatory physician style may be associated with survivors' mental health: (1) by increasing survivors' participation self-efficacy and thereby enhancing their perceptions of personal control (p<0.01); (2) by enhancing survivors' level of trust and thereby reducing their perceptions of uncertainty (p<0.05). CONCLUSION A participatory physician style may improve survivors' mental health by a complex two-step mechanism of improving survivors' proximal communication and intermediate cognitive outcomes. PRACTICE IMPLICATIONS Physicians who adopt a participatory decision-making style are likely to facilitate patient empowerment and enhance patients' HRQOL.
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Affiliation(s)
- Neeraj K Arora
- Outcomes Research Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd, MSC 7344, EPN 4092, Bethesda, MD 20892-7344, USA.
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Heisler M, Spencer M, Forman J, Robinson C, Shultz C, Palmisano G, Graddy-Dansby G, Kieffer E. Participants' assessments of the effects of a community health worker intervention on their diabetes self-management and interactions with healthcare providers. Am J Prev Med 2009; 37:S270-9. [PMID: 19896029 PMCID: PMC3782259 DOI: 10.1016/j.amepre.2009.08.016] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Revised: 07/24/2009] [Accepted: 08/05/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The specific ways in which community health worker (CHW) programs affect participants' healthcare behaviors and interactions with their healthcare providers, as well as mechanisms by which CHW programs influence these outcomes, are poorly understood. A qualitative descriptive study of participants in a successful CHW diabetes self-management program was designed to examine: (1) what gaps in diabetes care, with a focus on patient-doctor interactions, participants identify; (2) how the program influences participants' diabetes care and interactions with healthcare providers, and what gaps, if any, it addresses. METHODS From November 2005 to December 2006, semi-structured interviews with 40 African- American and Latino adults were conducted and analyzed. Participants had diabetes and had completed or were active in a CHW-led diabetes self-management program developed and implemented using community-based participatory research principles in Detroit. Interviews were audiotaped, transcribed, and coded through a consensual and iterative process. RESULTS Participants reported that prior to the intervention they had received inadequate information from healthcare providers for effective diabetes self-management, had had low expectations for help from their providers, and had not felt comfortable asking questions or making requests of their healthcare providers. Key ways participants reported that the program improved their ability to manage their diabetes were by providing (1) clear and detailed information on diabetes and diabetes care; (2) education and training on specific strategies to meet diabetes care goals; (3) sustained and nonjudgmental assistance to increase their motivation and confidence; and (4) social and peer support that enabled them to better manage their diabetes. The knowledge and confidence gained through the CHW intervention increased participants' assertiveness in asking questions to and requesting necessary tests and results from their providers. CONCLUSIONS Study findings suggest ways that CHW programs that provide both one-on-one support and group self-management training sessions may be effective in promoting more effective diabetes care and patient-doctor relationships among Latino and African-American adults with diabetes. Through these mechanisms, such interventions may help to mitigate racial and ethnic disparities in diabetes care and outcomes.
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Affiliation(s)
- Michele Heisler
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan 48113, USA.
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154
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Royak-Schaler R, Gardner LD, Shardell M, Zhan M, Passmore SR, Gadalla SM, Hoy MK, Tkaczuk KHR, Nesbitt K. Evidence-based care for breast cancer survivors: communicating the Institute of Medicine Guidelines in medical practice. PATIENT EDUCATION AND COUNSELING 2009; 77:413-420. [PMID: 19883985 DOI: 10.1016/j.pec.2009.09.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Revised: 09/22/2009] [Accepted: 09/25/2009] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To investigate patient reports of physician communication about the 2006 Institute of Medicine (IOM) Guidelines for Survivorship Care, and patient follow-up care behaviors in a sample of African American and Caucasian breast cancer survivors. METHODS Fifteen-minute telephone interviews were conducted in a cross-sectional study with a sample of African American (n=30) and Caucasian (n=69) breast cancer patients, who were within 5 years of their diagnosis and primary treatment for breast cancer at two Baltimore, Maryland medical centers, during the summer of 2006. Multiple items assessed patient reports of physician discussions about IOM Guidelines, their recurrence concerns, and their follow-up treatment, screening, diet and exercise practices. RESULTS Patients with higher incomes, more education, female physicians, and of younger ages reported more complete physician discussions of the IOM Guidelines. No significant differences were noted between African American and Caucasian patients. CONCLUSION Patients at greatest risk for breast cancer recurrence - those with less education, income, and resources - report limited guidance from their physicians about evidence-based, follow-up care guidelines, designed to minimize their risk. PRACTICE IMPLICATIONS Physicians need strategies for effectively delivering the IOM Guidelines for Survivorship Care to disadvantaged breast cancer patients, to promote enhanced quality of life and reduced risk of recurrence.
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Affiliation(s)
- Renee Royak-Schaler
- Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, 660 W. Redwood St., HH 102E, Baltimore, MD 21201, USA.
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Parchman ML, Flannagan D, Ferrer RL, Matamoras M. Communication competence, self-care behaviors and glucose control in patients with type 2 diabetes. PATIENT EDUCATION AND COUNSELING 2009; 77:55-59. [PMID: 19359125 DOI: 10.1016/j.pec.2009.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 12/23/2008] [Accepted: 03/02/2009] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To examine the relationship between physician communication competence and A1c control among Hispanics and non-Hispanics seen in primary care practices. STUDY DESIGN Observational. METHODS Direct observation and audio-recording of patient-physician encounters by 155 Hispanic and non-Hispanic white patients seen by 40 physicians in 20 different primary care clinics. Audio-recordings were transcribed and coded to derive an overall communication competence score for the physician. An exit survey was administered to each patient to assess self-care activities and their medical record was abstracted for the most recent glycosylated hemoglobin (A1c) level. RESULTS Higher levels of communication competence were associated with lower levels of A1c for Hispanics, but not non-Hispanic white patients. Although communication competence was associated with better self-reported diet behaviors, diet was not associated with A1c control. Across all patients, higher levels of communication competence were associated with improved A1c control after controlling for age, ethnicity and diet adherence. CONCLUSIONS Physician's communication competence may be more important for promoting clinical success in disadvantaged patients. PRACTICE IMPLICATIONS Acquisition of communication competence skills may be an important component in interventions to eliminate Hispanic disparities in glucose control.
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Affiliation(s)
- Michael L Parchman
- Department of Family & Community Medicine, University of Texas Health Science Center, San Antonio, TX 78229-4404, USA.
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156
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Kravitz RL, Tancredi DJ, Street RL, Kalauokalani D, Grennan T, Wun T, Slee C, Evans Dean D, Lewis L, Saito N, Franks P. Cancer Health Empowerment for Living without Pain (Ca-HELP): study design and rationale for a tailored education and coaching intervention to enhance care of cancer-related pain. BMC Cancer 2009; 9:319. [PMID: 19737424 PMCID: PMC2745433 DOI: 10.1186/1471-2407-9-319] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 09/09/2009] [Indexed: 12/03/2022] Open
Abstract
Background Cancer-related pain is common and under-treated. This article describes a study designed to test the effectiveness of a theory-driven, patient-centered coaching intervention to improve cancer pain processes and outcomes. Methods/Design The Cancer Health Empowerment for Living without Pain (Ca-HELP) Study is an American Cancer Society sponsored randomized trial conducted in Sacramento, California. A total of 265 cancer patients with at least moderate pain severity (Worst Pain Numerical Analog Score >=4 out of 10) or pain-related impairment (Likert score >= 3 out of 5) were randomly assigned to receive tailored education and coaching (TEC) or educationally-enhanced usual care (EUC); 258 received at least one follow-up assessment. The TEC intervention is based on social-cognitive theory and consists of 6 components (assess, correct, teach, prepare, rehearse, portray). Both interventions were delivered over approximately 30 minutes just prior to a scheduled oncology visit. The majority of visits (56%) were audio-recorded for later communication coding. Follow-up data including outcomes related to pain severity and impairment, self-efficacy for pain control and for patient-physician communication, functional status and well-being, and anxiety were collected at 2, 6, and 12 weeks. Discussion Building on social cognitive theory and pilot work, this study aims to test the hypothesis that a brief, tailored patient activation intervention will promote better cancer pain care and outcomes. Analyses will focus on the effects of the experimental intervention on pain severity and impairment (primary outcomes); self-efficacy and quality of life (secondary outcomes); and relationships among processes and outcomes of cancer pain care. If this model of coaching by lay health educators proves successful, it could potentially be implemented widely at modest cost. Trial Registration [Clinical Trials Identifier: NCT00283166]
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Affiliation(s)
- Richard L Kravitz
- Department of Internal Medicine, University of California Davis, School of Medicine, Sacramento, CA, USA.
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157
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Bertakis KD. The influence of gender on the doctor-patient interaction. PATIENT EDUCATION AND COUNSELING 2009; 76:356-360. [PMID: 19647968 DOI: 10.1016/j.pec.2009.07.022] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Revised: 07/16/2009] [Accepted: 07/17/2009] [Indexed: 05/28/2023]
Abstract
OBJECTIVE This paper discusses the research focused on gender issues in healthcare communication. METHODS The majority of papers discussed here are based on a research study in which 509 new adult patients were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for one year of care. RESULTS There are significant differences in the practice style behaviors of female and male doctors. Female doctors provide more preventive services and psychosocial counseling; male doctors spend more time on technical practice behaviors, such as medical history taking and physical examination. The patients of female doctors are more satisfied, even after adjusting for patient characteristics and physician practice style. Female patients make more medical visits and have higher total annual medical charges; their visits include more preventive services, less physical examination, and fewer discussions about tobacco, alcohol and other substance abuse (controlling for health status and sociodemographic variables). The examination of gender concordant and discordant doctor-patient dyads provides a unique strategy for assessing the effect of gender on what takes place during the medical visit. CONCLUSION Doctor and patient gender can impact the physician-patient interaction and its outcomes. PRACTICE IMPLICATIONS The development of appropriate strategies for the implementation of knowledge about physician and patient gender differences will be crucial for the delivery of high quality gender-sensitive healthcare.
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Affiliation(s)
- Klea D Bertakis
- Department of Family and Community Medicine, University of California at Davis, CA, USA.
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158
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Bertakis KD, Franks P, Epstein RM. Patient-centered communication in primary care: physician and patient gender and gender concordance. J Womens Health (Larchmt) 2009; 18:539-45. [PMID: 19361322 DOI: 10.1089/jwh.2008.0969] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Physicians' use of patient-centered communication (PCC) affects important outcomes of care. Although there is evidence that both patient and physician gender affect the process of care, there is limited information about their impact on PCC. Our objective was to investigate the influence of patient and physician gender, as well as gender concordance between patient and physician, on the patient centeredness of primary care visits. METHODS Participating primary care physicians (100 family physicians and internists) with clinical practices in the Rochester, New York area, had two unannounced covertly audiorecorded standardized patients' visits. Encounters were analyzed using the Measure of Patient-Centered Communication (MPCC), which measures three aspects of physician communication: Component 1 (Exploring both the disease and illness experience), Component 2 (Understanding the whole person), and Component 3 (Finding common ground). RESULTS Compared with male patients, females had interactions characterized by greater PCC (total and Component 2 scores). Whereas female physicians exhibited higher Component 1 scores, male physicians had higher Component 2 scores, and gender-concordant visits also exhibited higher Component 2 scores. However, there were no significant differences in total MPCC scores for encounters of female vs. male physicians or for gender-concordant compared with discordant patient-physician dyads. CONCLUSIONS These findings add further evidence that patient gender can affect the interactions between physicians and patients. More research is needed to understand why male patients are less likely to have medical encounters in which their physicians employ a patient-centered practice style.
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Affiliation(s)
- Klea D Bertakis
- Department of Family and Community Medicine and Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California 95817, USA.
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159
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Kayaniyil S, Gravely-Witte S, Stewart DE, Higginson L, Suskin N, Alter D, Grace SL. Degree and correlates of patient trust in their cardiologist. J Eval Clin Pract 2009; 15:634-40. [PMID: 19522723 PMCID: PMC2972247 DOI: 10.1111/j.1365-2753.2008.01064.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE AND OBJECTIVES Trust in one's doctor has been associated with increased treatment adherence, patient satisfaction and improved health status. This study investigated the level and correlates of patient trust in their cardiac specialist. METHODS All 386 urban cardiologists in Southern Ontario (95 participating, response rate = 30%) were approached to recruit a sample of their coronary artery disease outpatients. A total of 1111 recent and consecutive patients consented to participate (approximately 13 patients per cardiologist, 317 female (26.7%); response rate = 60%), and clinical data were extracted from their medical charts. Participants completed a mailed survey including the Trust in Physicians scale, in addition to an assessment of socio-demographic, clinical and psychosocial correlates. RESULTS The mean trust score was equivalent to that reported in studies of primary care patients. Results of the significant multivariate model (F = 7.631, P < 0.001) revealed that less education (P < 0.001), higher systolic blood pressure (P = 0.022), less perceived cyclical/unpredictable illness timeline (P = 0.007) and greater perceived personal control over their heart condition (P = 0.004), were significant correlates of greater trust in cardiologist care. CONCLUSIONS The significance of education is corroborated by findings of lower satisfaction with cardiac care among those of higher socio-economic status, despite having generally greater access to care in Ontario. Moreover, the relationship between hypertension and greater trust may suggest that such perceptions are not based on doctor competence. Future studies should further investigate the correlates of trust, as well as the impact of trust on cardiac health outcomes.
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Affiliation(s)
- Sheena Kayaniyil
- Department of Kinesiology and Health Science, York University, Toronto, Canada
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160
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Pratt SI, Kelly SM, Mueser KT, Patterson TL, Goldman S, Bishop-Horton S. Reliability and validity of a performance-based measure of skills for communicating with doctors for older people with serious mental illness. J Ment Health 2009. [DOI: 10.1080/09638230701494894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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161
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Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mahomed NN, Wright JG. Patients' gender affected physicians' clinical decisions when presented with standardized patients but not for matching paper patients. J Clin Epidemiol 2009; 62:527-41. [PMID: 19348978 DOI: 10.1016/j.jclinepi.2008.03.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 02/22/2008] [Accepted: 09/19/2008] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To compare physicians' treatment and referral decisions for total knee arthroplasty (TKA) for standardized patients with matching paper patients. STUDY DESIGN AND SETTING Sixty-seven physicians (38 family physicians and 29 orthopedic surgeons) performed blinded assessments of two standardized patients (one man and one woman) with moderate knee osteoarthritis and otherwise identical clinical scenarios differing only in gender, and consented to including their data. Standardized patients recorded physicians' recommendations (yes/no) to refer for, or perform, TKA. Sixty physicians provided their treatment recommendations to matching paper patients. RESULTS Recommendation rates for both the male and the female standardized patients (67% and 32%, respectively) were lower compared with the matching paper patients (80% and 67%, respectively). Physicians were more likely to recommend TKA to a man than to a woman when presented with standardized patients (odds ratio, 4.2; 95% confidence interval [CI]=2.4-7.3; P<0.001). In contrast, patients' gender did not affect the same physicians' recommendations regarding referral for, or performing, TKA for the matching paper patients (odds ratio, 2.0; 95% CI=0.9-4.6; P=0.101). CONCLUSION Unlike their treatment recommendations for standardized patients, the same physicians' treatment and referral decisions for paper patients were not influenced by patients' gender, suggesting that paper patients are not a sensitive method of assessing physician bias.
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Affiliation(s)
- Cornelia M Borkhoff
- Centre for Global Health, Institute of Population Health, University of Ottawa, Ontario, Canada.
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162
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DeVoe JE, Wallace LS, Fryer GE. Measuring patients' perceptions of communication with healthcare providers: do differences in demographic and socioeconomic characteristics matter? Health Expect 2009; 12:70-80. [PMID: 19250153 DOI: 10.1111/j.1369-7625.2008.00516.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND National governments across the globe have set goals to improve healthcare delivery. Understanding patient-provider communication is essential for the development of policies that measure how well a healthcare system delivers care. OBJECTIVES This study was designed to determine which, if any, demographic factors were independently associated with how US patients perceive various aspects of communication with their healthcare providers. DESIGN AND METHODS The study was a secondary, cross-sectional analysis of nationally representative data from the 2002 Medical Expenditure Panel Survey (MEPS). Among US adults with a healthcare visit in the past year (n = approximately 16,700), we assessed the association between several covariate demographic and socioeconomic factors and four dependent measures of patient perceptions of communication with their healthcare providers. RESULTS Across all four measures of communication, older patients were more likely to report positively. Having health insurance and a usual source of care were consistent predictors of positive perceptions of communication. Hispanic patients also reported better perceptions of communication across all four measures. The most economically disadvantaged patients were less likely to report that providers always explained things so that they understood. Male patients were more likely to report that providers always spent enough time with them. CONCLUSIONS This study suggests that patient perceptions of communication in healthcare settings vary widely by demographics and other individual patient characteristics. In this paper, we discuss the relevance of these communication disparities to design policies to improve healthcare systems, both at the individual practice level and the national level.
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Affiliation(s)
- Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR 97239, USA.
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163
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Schoenthaler A, Chaplin WF, Allegrante JP, Fernandez S, Diaz-Gloster M, Tobin JN, Ogedegbe G. Provider communication effects medication adherence in hypertensive African Americans. PATIENT EDUCATION AND COUNSELING 2009; 75:185-91. [PMID: 19013740 PMCID: PMC2698021 DOI: 10.1016/j.pec.2008.09.018] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 08/20/2008] [Accepted: 09/17/2008] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To evaluate the effect of patients' perceptions of providers' communication on medication adherence in hypertensive African Americans. METHODS Cross-sectional study of 439 patients with poorly controlled hypertension followed in community-based healthcare practices in the New York metropolitan area. Patients' rating of their providers' communication was assessed with a perceived communication style questionnaire,while medication adherence was assessed with the Morisky self-report measure. RESULTS Majority of participants were female, low-income, and had high school level educations, with mean age of 58 years. Fifty-five percent reported being nonadherent with their medications; and 51% rated their provider's communication to be non-collaborative. In multivariate analysis adjusted for patient demographics and covariates (depressive symptoms, provider degree), communication rated as collaborative was associated with better medication adherence (beta=-.11, p=.03). Other significant correlates of medication adherence independent of perceived communication were age (beta=.13, p=.02) and depressive symptoms (beta=-.18, p=.001). CONCLUSION Provider communication rated as more collaborative was associated with better adherence to antihypertensive medications in a sample of low-income hypertensive African-American patients. PRACTICE IMPLICATIONS The quality of patient-provider communication is a potentially modifiable element of the medical relationship that may affect health outcomes in this high-risk patient population.
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Ozvacić Adzić Z, Katić M, Kern J, Lazić D, Cerovecki Nekić V, Soldo D. Patient, physician, and practice characteristics related to patient enablement in general practice in Croatia: cross-sectional survey study. Croat Med J 2009; 49:813-23. [PMID: 19090607 DOI: 10.3325/cmj.2008.49.813] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM To investigate the quality of general practice care in Croatia by using patient enablement as a consultation outcome measure and its association with patient, physician, and practice characteristics. METHODS A cross-sectional questionnaire-based study performed from November 2003 to March 2004 included a national stratified random sample of 350 general practitioners, who were asked to collect data on 50 consecutive consultations with their patients aged > or =18 years. Patients provided data on patient enablement (Patient Enablement Instrument, score range 0-12), consultation length, sociodemographic data, how well they knew the physician, health self-assessment, quality of life, and reason for the visit. Physicians provided data on age, sex, vocational training, working experience, educational work, average number of patients per day, and type of practice. RESULTS In 5527 patients, the mean score (+/-standard deviation) for enablement at consultation was 6.6+/-3.3 and the mean consultation length was 11.5+/-5.5 minutes. Logistic regression analysis showed that lack of continuity of care (men: OR, 0.56; 95% CI, 0.47-0.67; women: OR, 0.52; 95% CI, 0.45-0.61), poor self-perceived health (men: OR, 1.76; 95% CI, 1.49-2.07; women: OR, 1.77; 95% CI, 1.53-2.04), low educational level, low quality of life for both sexes and older age in male patients predicted low enablement (P<0.05 for each). Physician age, sex, and average number of patients per day were significantly correlated with enablement for male patients and physician working experience with enablement for female patients (P<0.05 for each). CONCLUSION Patient enablement score in Croatia is high in comparison with countries such as the UK and Poland. Enablement at consultations was related to the continuity of care and patient health status, and other patient, physician, and practice characteristics, suggesting that these parameters should be considered when assessing quality of care in general practice.
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Affiliation(s)
- Zlata Ozvacić Adzić
- Department of Family Medicine, Andrija Stampar School of Public Health, Zagreb University School of Medicine, Rockefellerova 4, Zagreb, Croatia.
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165
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Cooper LA. A 41-year-old African American man with poorly controlled hypertension: review of patient and physician factors related to hypertension treatment adherence. JAMA 2009; 301:1260-72. [PMID: 19258571 PMCID: PMC2846298 DOI: 10.1001/jama.2009.358] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Mr R is an African American man with a long history of poorly controlled hypertension and difficulties with adherence to recommended treatments. Despite serious complications such as hypertensive emergency requiring hospitalization and awareness of the seriousness of his illness, Mr R says at times he has ignored his high blood pressure and his physicians' recommendations. African Americans are disproportionately affected by hypertension and its complications. Although most pharmacological and dietary therapies for hypertension are similarly efficacious for African Americans and whites, disparities in hypertension treatment persist. Like many patients, Mr R faces several barriers to effective blood pressure control: societal, health system, individual, and interactions with health professionals. Moreover, evidence indicates that patients' cognitive, affective, and attitudinal factors and the patient-physician relationship play critical roles in improving outcomes and reducing racial disparities in hypertension control.
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Affiliation(s)
- Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Cooper LA, Roter DL, Bone LR, Larson SM, Miller ER, Barr MS, Carson KA, Levine DM. A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045. Implement Sci 2009; 4:7. [PMID: 19228414 PMCID: PMC2649892 DOI: 10.1186/1748-5908-4-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Accepted: 02/19/2009] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Disparities in health and healthcare are extensively documented across clinical conditions, settings, and dimensions of healthcare quality. In particular, studies show that ethnic minorities and persons with low socioeconomic status receive poorer quality of interpersonal or patient-centered care than whites and persons with higher socioeconomic status. Strong evidence links patient-centered care to improvements in patient adherence and health outcomes; therefore, interventions that enhance this dimension of care are promising strategies to improve adherence and overcome disparities in outcomes for ethnic minorities and poor persons. OBJECTIVE This paper describes the design of the Patient-Physician Partnership (Triple P) Study. The goal of the study is to compare the relative effectiveness of the patient and physician intensive interventions, separately, and in combination with one another, with the effectiveness of minimal interventions. The main hypothesis is that patients in the intensive intervention groups will have better adherence to appointments, medication, and lifestyle recommendations at three and twelve months than patients in minimal intervention groups. The study also examines other process and outcome measures, including patient-physician communication behaviors, patient ratings of care, health service utilization, and blood pressure control. METHODS A total of 50 primary care physicians and 279 of their ethnic minority or poor patients with hypertension were recruited into a randomized controlled trial with a two by two factorial design. The study used a patient-centered, culturally tailored, education and activation intervention for patients with active follow-up delivered by a community health worker in the clinic. It also included a computerized, self-study communication skills training program for physicians, delivered via an interactive CD-ROM, with tailored feedback to address their individual communication skills needs. CONCLUSION The Triple P study will provide new knowledge about how to improve patient adherence, quality of care, and cardiovascular outcomes, as well as how to reduce disparities in care and outcomes of ethnic minority and poor persons with hypertension.
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Affiliation(s)
- Lisa A Cooper
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA.
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167
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Cortes DE, Mulvaney-Day N, Fortuna L, Reinfeld S, Alegría M. Patient--provider communication: understanding the role of patient activation for Latinos in mental health treatment. HEALTH EDUCATION & BEHAVIOR 2009; 36:138-54. [PMID: 18413668 PMCID: PMC3538365 DOI: 10.1177/1090198108314618] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article highlights results from the Right Question Project-Mental Health (RQP-MH), an intervention designed to teach skills in question formulation and to increase patients' participation in decisions about mental health treatment. Of participants in the RQP-MH intervention, 83% were from a Latino background, and 75% of the interviews were conducted in Spanish. The authors present the steps participants undertook in the process of becoming "activated" to formulate effective questions and develop decision-making skills in relation to their care. Findings suggest that patient activation and empowerment are interdependent because many of the skills (i.e., question formulation, direct patient-provider communication) required to become an "activated patient" are essential to achieve empowerment. Also, findings suggest that cultural and contextual factors can influence the experience of Latinos regarding participation in health care interactions. The authors provide recommendations for continued research on the patient activation process and further application of this strategy in the mental health field, especially with Latinos.
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Affiliation(s)
- Dharma E Cortes
- Center for Multicultural Mental Health Research, Cambridge Health Alliance, Somerville, MA 02143, USA
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168
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Baumhäkel M, Müller U, Böhm M. Influence of gender of physicians and patients on guideline-recommended treatment of chronic heart failure in a cross-sectional study. Eur J Heart Fail 2009; 11:299-303. [PMID: 19158153 DOI: 10.1093/eurjhf/hfn041] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Clinical outcomes of patients with chronic heart failure (CHF) have improved, but evidence-based treatment appears to be imbalanced depending on patients' and physicians' gender. We aimed to determine the interactions of gender with medical treatment of CHF. METHODS AND RESULTS Consecutive patients with CHF (n = 1857) were evaluated regarding co-morbidities, New York Heart Association classification, current medical treatment, and dosage of angiotensin-converting enzyme-inhibitors (ACE-Is) and beta-blockers. Gender of patients and treating physicians was recorded. Baseline characteristics of patients and physicians were comparable for males and females. Female patients were less frequently treated with ACE-Is, angiotensin-receptor blockers, or beta-blockers. Achieved doses were lower in female compared with male patients. Guideline-recommended drug use and achieved target doses tended to be higher in patients treated by female physicians. There was no different treatment for male or female patients by female physicians, whereas male physicians used significantly less medication and lower doses in female patients. In multivariable analysis, female gender of physicians was an independent predictor of use of beta-blockers. CONCLUSION Treatment of CHF is influenced by patients', but also physicians' gender with regard to evidenced-based drugs and their dosage. Physicians should be aware of this problem in order to avoid gender-related treatment imbalances.
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Affiliation(s)
- Magnus Baumhäkel
- Department of Cardiology, University Hospital of the Saarland, Kirrbergerstr. 1, 66421 Homburg/Saar, Germany.
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169
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Blose JE, Mack RW. The impact of denying a direct-to-consumer advertised drug request on the patient/physician relationship. Health Mark Q 2009; 26:315-332. [PMID: 19916097 DOI: 10.1080/07359680903304294] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Using a scenario-based approach, an experiment is conducted to test whether the decision a physician makes to deny a prescription request (when a patient has requested a drug he or she has seen in a direct-to-consumer [DTC] ad) significantly impacts patient outcomes such as patient satisfaction and compliance intentions. The results suggest physicians can expect patient response to the denial of such a request to vary by the patient's gender in addition to the criticality of the condition being treated. The results also suggest, when treating less critical conditions, a physician can mitigate the negative effects of a denial with relatively little additional effort.
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Affiliation(s)
- Julia E Blose
- School of Business and Economics, College of Charleston, Charleston, South Carolina 29424, USA.
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170
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Powers BJ, Olsen MK, Oddone EZ, Thorpe CT, Bosworth HB. Literacy and blood pressure--do healthcare systems influence this relationship? A cross-sectional study. BMC Health Serv Res 2008; 8:219. [PMID: 18947408 PMCID: PMC2600788 DOI: 10.1186/1472-6963-8-219] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Accepted: 10/23/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Limited literacy is common among patients with chronic conditions and is associated with poor health outcomes. We sought to determine the association between literacy and blood pressure in primary care patients with hypertension and to determine if this relationship was consistent across distinct systems of healthcare delivery. METHODS We conducted a cross-sectional study of 1224 patients with hypertension utilizing baseline data from two separate, but similar randomized controlled trials. Patients were enrolled from primary care clinics in the Veterans Affairs healthcare system (VAHS) and a university healthcare system (UHS) in Durham, North Carolina. We compared the association between literacy and the primary outcome systolic blood pressure (SBP) and secondary outcomes of diastolic blood pressure (DBP) and blood pressure (BP) control across the two different healthcare systems. RESULTS Patients who read below a 9th grade level comprised 38.4% of patients in the VAHS and 27.5% of the patients in the UHS. There was a significant interaction between literacy and healthcare system for SBP. In adjusted analyses, SBP for patients with limited literacy was 1.2 mmHg lower than patients with adequate literacy in the VAHS (95% CI, -4.8 to 2.3), but 6.1 mmHg higher than patients with adequate literacy in the UHS (95% CI, 2.1 to 10.1); (p = 0.003 for test of interaction). This literacy by healthcare system interaction was not statistically significant for DBP or BP control. CONCLUSION The relationship between patient literacy and systolic blood pressure varied significantly across different models of healthcare delivery. The attributes of the healthcare delivery system may influence the relationship between literacy and health outcomes.
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Affiliation(s)
- Benjamin J Powers
- Center for Health Services Research in Primary Care, Durham VAMC, Durham NC, USA.
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171
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Berthold HK, Gouni-Berthold I, Bestehorn KP, Böhm M, Krone W. Physician gender is associated with the quality of type 2 diabetes care. J Intern Med 2008; 264:340-50. [PMID: 18397244 DOI: 10.1111/j.1365-2796.2008.01967.x] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Patient gender influences the quality of medical care whilst the role of physician gender is not well established. To investigate the influence of physician gender on quality of care in patients with type 2 diabetes. DESIGN AND METHODS Cross-sectional study in 51 053 outpatients (48.6% male), treated by 3096 office-based physicians (66.3% male; 74.0% general practitioners, 21.8% internists and 4.2% diabetologists). Outcome measures included processes of care, intermediate outcomes and medical management. Quality of care measures were based on current ADA guidelines. Hierarchical regression models were used to avoid case-mix bias and to correct for physician-level clustering. Adjusted odds ratios were calculated controlling for age, gender, disease duration and presence of atherosclerotic disease. RESULTS The patients of female physicians were more often women, more obese, older and had more often atherosclerotic disease (34% in the total cohort). The patients of female physicians more often reached target values in glycaemic control (HbA1c < 6.5%; OR 1.14; 1.05-1.24, P = 0.002), blood lipoproteins (LDL-C < 100 mg dL(-1); OR 1.16; 1.06-1.27, P = 0.002), and blood pressure (systolic values < 130 mmHg; OR 1.11; 1.02-1.22, P = 0.018). They were more likely to receive antihypertensive drug therapy in general (OR 1.35; 1.24-1.46, P < 0.0001) and angiotensin converting enzyme (ACE) inhibitors in particular (OR 1.17; 1.09-1.25, P < 0.0001). The patients of female physicians less often performed glucose self-monitoring (OR 0.83; 0.76-0.91, P < 0.0001) and less often received oral hypoglycaemic agents (OR 0.88; 0.82-0.95, P = 0.001). CONCLUSIONS Physician gender influences quality of care in patients with type 2 diabetes. Female physicians provide an overall better quality of care, especially in prognostically important risk management.
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Affiliation(s)
- H K Berthold
- Clinical Pharmacology Division, Medical Faculty, University of Bonn, Bonn, Germany
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172
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Rodriguez KL, Appelt CJ, Switzer GE, Sonel AF, Arnold RM. Veterans' decision-making preferences and perceived involvement in care for chronic heart failure. Heart Lung 2008; 37:440-8. [PMID: 18992627 DOI: 10.1016/j.hrtlng.2008.02.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 01/17/2008] [Accepted: 02/08/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with heart failure require a great deal of information about their disease, but it is also important to know about their preferences for involvement in medical decision making and about factors that may influence their preferences so that patients' needs, values, and preferences can be met by clinicians. OBJECTIVES We assessed patients' preferred role and perceived level of involvement in medical decision making and tested the effects of patients' age and role preference on perceived involvement in medical decision making. METHODS We conducted a telephone survey of 90 adults being treated for heart failure by a Veterans Affairs primary care provider or cardiologist. Patients' preferred role in treatment decisions was assessed using the Control Preferences Scale. Perceptions about their involvement in decision making during the most recent clinic visit was measured using a subscale of the Perceived Involvement in Care Scale. Descriptive, correlational, and generalized linear regression analyses were conducted. RESULTS Most patients were elderly (mean = 70.1 years), male (94.4%), and white (85.6%), and had New York Heart Association class II disease (55.6%). Forty-three patients (47.8%) preferred a passive role in decision making, 19 patients (21.1%) preferred an active role, and 28 patients (31.1%) preferred a collaborative role. Most patients believed that their decision-making involvement was relatively passive, as indicated by a mean score of .96 (range, 0-4) on the Perceived Involvement in Care Scale decision-making subscale. Older age was associated with passive role preference (r = .263; P < .05) and less perceived involvement in decision making (r = -.279; P < .01). In addition, less perceived involvement in decision making during the last clinic visit was associated with a preference for a more passive decision-making role (r = rho.355; P < .01). Generalized linear regression analysis indicated that when patients' perceived decision-making involvement was regressed on age and patients' role preferences, age was no longer significantly associated with involvement (beta = -.196; P = .061), but that control preferences continued to exhibit an independent effect on perceived involvement in medical decision making (beta = -.341; P = .003). CONCLUSION The results suggest that the preferences of patients with heart failure for a more passive role in decision making may be a stronger independent predictor of patients' perceived involvement in decision making than patients' age.
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Affiliation(s)
- Keri L Rodriguez
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania 15206, USA
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173
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Myklebust M, Pradhan EK, Gorenflo D. An Integrative Medicine Patient Care Model and Evaluation of Its Outcomes: The University of Michigan Experience. J Altern Complement Med 2008; 14:821-6. [DOI: 10.1089/acm.2008.0154] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Daniel Gorenflo
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI
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174
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Abstract
OBJECTIVE We assessed the frequency that patients are incorrectly used as the unit of analysis among studies of physicians' patient care behavior in articles published in high impact journals. METHODS We surveyed 30 high-impact journals across 6 medical fields for articles susceptible to unit of analysis errors published from 1994 to 2005. Three reviewers independently abstracted articles using previously published criteria to determine the presence of analytic errors. RESULTS One hundred fourteen susceptible articles were found published in 15 journals, 4 journals published the majority (71 of 114 or 62.3%) of studies, 40 were intervention studies, and 74 were noninterventional studies. The unit of analysis error was present in 19 (48%) of the intervention studies and 31 (42%) of the noninterventional studies (overall error rate 44%). The frequency of the error decreased between 1994-1999 (N = 38; 65% error) and 2000-2005 (N = 76; 33% error) (P = 0.001). CONCLUSIONS Although the frequency of the error in published studies is decreasing, further improvement remains desirable.
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175
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Cox ED, Raaum SE. Discussion of alternatives, risks and benefits in pediatric acute care. PATIENT EDUCATION AND COUNSELING 2008; 72:122-129. [PMID: 18343624 DOI: 10.1016/j.pec.2008.01.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 12/12/2007] [Accepted: 01/28/2008] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Across adult healthcare, discussions of alternatives, risks and benefits vary in inclusiveness or are even absent. We examine these discussions and their associated factors in pediatric visits. METHODS Coders noted speaker and recipient for alternatives, risks and benefits from 98 videotaped visits. Outcomes included discussion of alternatives, risks or benefits (yes/no) and involvement of parent or child in discussions (active or passive). Bivariate techniques were used to relate visit factors to outcomes. RESULTS Most visits included discussion of alternatives (58% of visits), risks (54%) and benefits (69%). Longer visits were more likely to include risk discussions. For alternatives, active parent/child involvement was more likely with college graduate parents; for risks active involvement was more likely with female and more experienced physicians. Parents and children raised risks more frequently than benefits, often focusing on disadvantages such as taste or frequency/duration of therapy. CONCLUSION Most pediatric visits include alternatives, risks and benefits but parent/child involvement in raising these topics is limited. PRACTICE IMPLICATIONS When parents or children initiate these discussions, they often mention risks salient to adherence. Future work could explore whether longer visits or interventions targeted for specific participants could foster such discussions.
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Affiliation(s)
- Elizabeth D Cox
- Center for Women's Health Research, University of Wisconsin School of Medicine and Public Health, Madison, WI 53715, United States
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176
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Racial differences in blood pressure control: potential explanatory factors. J Gen Intern Med 2008; 23:692-8. [PMID: 18288540 PMCID: PMC2324164 DOI: 10.1007/s11606-008-0547-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Revised: 12/28/2007] [Accepted: 01/26/2008] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The objective of the study was to identify potential explanatory factors for racial differences in blood pressure (BP) control. DESIGN The design of the study was a cross-sectional study PATIENTS/PARTICIPANTS The study included 608 patients with hypertension who were either African American (50%) or white (50%) and who received primary care in Durham, NC. MEASUREMENTS AND MAIN RESULTS Baseline data were obtained from the Take Control of Your Blood pressure study and included clinical, demographic, and psychosocial variables potentially related to clinic BP measures. African Americans were more likely than whites to have inadequate baseline clinic BP control as defined as greater than or equal to 140/90 mmHg (49% versus 34%; unadjusted odds ratio [OR] 1.8; 95% confidence interval [CI] 1.3-2.5). Among factors that may explain this disparity, being older, reporting hypertension medication nonadherence, reporting a hypertension diagnosis for more than 5 years, reporting high levels of stress, being worried about hypertension, and reporting an increased number of medication side effects were related to inadequate BP control. In adjusted analyses, African Americans continue to have poor BP control relative to whites; the magnitude of the association was reduced (OR = 1.5; 95% CI 1.0-2.1). Medication nonadherence, worries about hypertension, and older age (>70) continued to be related to poor BP control. CONCLUSIONS In this sample of hypertensive patients, there were a number of factors associated with poor BP control that partially explained the observed racial disparity in hypertension control including age, medication nonadherence, and worry about BP. Medication nonadherence is of particular interest because it is a potentially modifiable factor that might be used to reduce the racial disparity in BP control.
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177
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Sleath B, Callahan LF, Devellis RF, Beard A. Arthritis patients' perceptions of rheumatologists' participatory decision-making style and communication about complementary and alternative medicine. ACTA ACUST UNITED AC 2008; 59:416-21. [PMID: 18311753 DOI: 10.1002/art.23307] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To examine if patients with arthritis who reported using complementary and alternative medicine (CAM) were more likely to tell their physicians about their CAM use if they rated their rheumatologist as using a more participatory decision-making style and what reasons patients gave for telling or not telling their rheumatologist about their CAM use. METHODS A survey that asked about CAM use, health status, demographics, physician use of a participatory decision-making style, and medical skepticism was sent to individuals with arthritis who saw 23 rheumatologists at universities and private practice clinics in North Carolina. Generalized estimating equations were used to analyze the data. RESULTS A total of 92% of patients reported using CAM for their arthritis and 54% of these patients discussed their CAM use with their rheumatologist. Women, patients who used more types of CAM, and patients who rated their rheumatologist as using a more participatory decision-making style were significantly more likely to tell their physicians about their CAM use. CONCLUSION Our findings suggest that if rheumatologists use more participatory styles of decision making with patients and involve them when making treatment decisions, patients are more likely to tell them about their CAM use.
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Affiliation(s)
- Betsy Sleath
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7590, USA.
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178
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Goodlin SJ, Quill TE, Arnold RM. Communication and Decision-Making About Prognosis in Heart Failure Care. J Card Fail 2008; 14:106-13. [DOI: 10.1016/j.cardfail.2007.10.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Revised: 10/28/2007] [Accepted: 10/30/2007] [Indexed: 10/22/2022]
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Heisler M, Cole I, Weir D, Kerr EA, Hayward RA. Does physician communication influence older patients' diabetes self-management and glycemic control? Results from the Health and Retirement Study (HRS). J Gerontol A Biol Sci Med Sci 2008; 62:1435-42. [PMID: 18166697 DOI: 10.1093/gerona/62.12.1435] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Effective chronic disease self-management among older adults is crucial for improved clinical outcomes. We assessed the relative importance of two dimensions of physician communication-provision of information (PCOM) and participatory decision-making (PDM)-for older patients' diabetes self-management and glycemic control. METHODS We conducted a national cross-sectional survey among 1588 older community-dwelling adults with diabetes (response rate: 81%). Independent associations were examined between patients' ratings of their physician's PCOM and PDM with patients' reported diabetes self-management (medication adherence, diet, exercise, blood glucose monitoring, and foot care), adjusting for patient sociodemographics, illness severity, and comorbidities. Among respondents for whom hemoglobin A1c (HbA1c) values were available (n=1233), the relationship was assessed between patient self-management and HbA1c values. RESULTS In separate multivariate regressions, PCOM and PDM were each associated with overall diabetes self-management (p<.001) and with all self-management domains (p<.001 in all models), with the exception of PDM not being associated with medication adherence. In models with both PCOM and PDM, PCOM alone predicted medication adherence (p=.001) and foot care (p=.002). PDM alone was associated with exercise and blood glucose monitoring (both p<.001) and was a stronger independent predictor than PCOM of diet. Better patient ratings of their diabetes self-management were associated with lower HbA1c values (B= -.10, p=.005). CONCLUSION Among these older adults, both their diabetes providers' provision of information and efforts to actively involve them in treatment decision-making were associated with better overall diabetes self-management. Involving older patients in setting chronic disease goals and decision-making, however, appears to be especially important for self-care areas that demand more behaviorally complex lifestyle adjustments such as exercise, diet, and blood glucose monitoring.
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Affiliation(s)
- Michele Heisler
- Veterans Affairs Center for Practice Management & Outcomes Research, VA Ann Arbor Healthcare System, Michigan 48109, USA.
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180
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Mojica CM, Bastani R, Ponce NA, Boscardin WJ. Latinas with abnormal breast findings: patient predictors of timely diagnostic resolution. J Womens Health (Larchmt) 2008; 16:1468-77. [PMID: 18062762 DOI: 10.1089/jwh.2006.0324] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Incomplete or delayed diagnostic resolution of breast abnormalities suspicious for cancer may contribute to poor breast cancer outcomes among ethnic minority women. We examine the effects of socioeconomic characteristics, knowledge, barriers to healthcare, communication, and clinical variables on diagnostic resolution in Latina women with breast abnormalities at two Los Angeles County public hospitals. METHODS We analyzed telephone survey data for 714 women. The outcome--timely diagnostic resolution--was based on medical record data and defined as receipt of a definitive diagnosis (malignant or benign) within 6 months of the index referral. Predictors of the outcome were obtained from a telephone survey and examined with bivariate and multivariable logistic regression models. RESULTS Only 60% of women received timely diagnostic resolution; however, the proportion was higher at hospital B (73%) compared with hospital A (56%). In the total sample, the odds of timely diagnostic resolution increased by 8% for every point increase in the scale of satisfaction with how physicians explained the breast abnormality. At hospital B, the odds of timely resolution increased by 57% for every 10-year increase in age. CONCLUSIONS Consistent with findings of other studies, our data indicate low diagnostic resolution among Latina women. Satisfaction with how physicians explained breast abnormalities and the interaction of hospital with age affected timely diagnostic resolution. Future research might focus on developing interventions that offer concrete communication strategies to patients and providers. Health systems must also establish systems that facilitate effective patient-provider communication.
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Affiliation(s)
- Cynthia M Mojica
- School of Public Health and Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California 90095, USA.
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181
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Diette GB, Rand C. The contributing role of health-care communication to health disparities for minority patients with asthma. Chest 2008; 132:802S-809S. [PMID: 17998344 DOI: 10.1378/chest.07-1909] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Asthma is a common, chronic illness with substantial morbidity, especially for racial and ethnic minorities in the United States. The care of the patient with asthma is complex and depends ideally on excellent communication between patients and health-care providers. Communication is essential for the patient to communicate the severity of his or her illness, as well as for the health-care provider to instruct patients on pharmacologic and nonpharmacologic care. This article describes evidence for poor provider/patient communication as a contributor to health-care disparities for minority patients with asthma. Communication problems stem from issues with patients, health-care providers, and health-care systems. It is likely that asthma disparities can be improved, in part, by improving patient/provider communication. While much is known presently about the problem of patient/provider communication in asthma, there is a need to improve and extend the evidence base on the role of effective communication of asthma care and the links to outcomes for minorities. Additional studies are needed that document the extent to which problems with doctor/patient communication lead to inadequate care and poor outcomes for minorities with asthma, as well as mechanisms by which these disparities occur.
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Affiliation(s)
- Gregory B Diette
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 5th Floor, 1830 E Monument St, Baltimore, MD 21205, USA.
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182
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Barnabei VM, O'Connor JJ, Nimphius NM, Vierkant RA, Eaker ED. The Effects of a Web-Based Tool on Patient-Provider Communication and Satisfaction with Hormone Therapy: A Randomized Evaluation. J Womens Health (Larchmt) 2008; 17:147-58. [DOI: 10.1089/jwh.2007.0369] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | | | - Elaine D. Eaker
- Eaker Epidemiologic Enterprises, LLC, Gaithersburg, Maryland
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183
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The Provider’s Voice: Patient Satisfaction and the Content-filtered Speech of Nurses and Physicians in Primary Medical Care. JOURNAL OF NONVERBAL BEHAVIOR 2007. [DOI: 10.1007/s10919-007-0038-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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184
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Receiving advice about child mental health from a primary care provider: African American and Hispanic parent attitudes. Med Care 2007; 45:1076-82. [PMID: 18049348 DOI: 10.1097/mlr.0b013e31812da7fd] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary care providers (PCPs) play a critical role in the identification and treatment of child and adolescent mental health problems but few studies have examined parents' attitudes on receiving advice about child mental health from a PCP and whether attitudes are associated with race or ethnicity. OBJECTIVE To determine if race and ethnicity were associated with parents' attitudes on receiving advice about child mental health from a PCP. SUBJECTS Data were collected during 773 visits to 54 PCPs in 13 diverse clinics. Families were 56.5% white, 33.3% African American, and 10.1% Hispanic. MEASURES The parent reported attitudes associated with receiving advice about child mental health from the PCP. The parent completed the Strengths and Difficulties Questionnaire to report youth mental health. PCPs completed measures of psychosocial orientation, confidence in mental health treatment skills, and the accessibility of mental health specialists. RESULTS Hispanics were more likely than Non-Hispanics to agree that PCPs should treat child mental health and were more willing to allow their child to receive medications or visit a therapist for a mental health problem if recommended by the PCP. African Americans were significantly less willing than whites and Hispanics to allow their child to receive medication for mental health but did not differ in their willingness to visit a therapist. CONCLUSIONS Race and ethnicity were associated with parents' attitudes on receiving advice about child mental health from a PCP. Primary care may be a good point of intervention for Hispanic youth with mental health needs.
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186
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Hayano K. [Practice of internal medicine and a woman physician]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2007; 96:2843-2846. [PMID: 18297787 DOI: 10.2169/naika.96.2843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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187
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Sohler NL, Fitzpatrick LK, Lindsay RG, Anastos K, Cunningham CO. Does patient-provider racial/ethnic concordance influence ratings of trust in people with HIV infection? AIDS Behav 2007; 11:884-96. [PMID: 17351738 DOI: 10.1007/s10461-007-9212-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Accepted: 01/29/2007] [Indexed: 10/23/2022]
Abstract
Despite widely available and effective treatments, there are racial/ethnic disparities in HIV-related mortality rates. The reason for inadequate HIV/AIDS management among minority populations is not fully understood, however recent research indicates that patients rate the quality of their health care higher if they are racially/ethnically concordant with their providers. As trust plays prominently on health care ratings, we examined whether racial/ethnicity concordance was associated with two dimensions of trust, trust in the provider and mistrust in the health care system, in 380 HIV infected people New York City. In this sample, concordance was associated with lower mistrust in the health care system, but not with trust in provider. We conclude that in this patient population and within the health care system available to them, racial/ethnic concordance might be more important for helping patients to understand and navigate the health care system rather than in interpersonal relationships with a single provider.
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Affiliation(s)
- Nancy Lynn Sohler
- Sophie Davis Medical School, City University of New York, 138th Street and Convent Avenue, City College Campus, New York, NY 10031, USA.
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188
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Abstract
Few child asthma studies address the specific content and techniques needed to enhance child communication during asthma preventive care visits. This study examined the content of child and parent communications regarding their asthma management during a medical encounter with their primary care provider (PCP). The majority of parents and children required prompting to communicate symptom information to the PCP during the clinic visit. Some high-risk families may require an asthma advocate to ensure that the clinician receives an accurate report of child's asthma severity and asthma control to ensure prescribing of optimal asthma therapy.
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Affiliation(s)
- Arlene M Butz
- The Johns Hopkins University School of Medicine, Department of Pediatrics, Baltimore, Maryland 21287, USA.
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189
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Gould MK, Fletcher J, Iannettoni MD, Lynch WR, Midthun DE, Naidich DP, Ost DE. Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007; 132:108S-130S. [PMID: 17873164 DOI: 10.1378/chest.07-1353] [Citation(s) in RCA: 385] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Pulmonary nodules are spherical radiographic opacities that measure up to 30 mm in diameter. Nodules are extremely common in clinical practice and challenging to manage, especially small, "subcentimeter" nodules. Identification of malignant nodules is important because they represent a potentially curable form of lung cancer. METHODS We developed evidence-based clinical practice guidelines based on a systematic literature review and discussion with a large, multidisciplinary group of clinical experts and other stakeholders. RESULTS We generated a list of 29 recommendations for managing the solitary pulmonary nodule (SPN) that measures at least 8 to 10 mm in diameter; small, subcentimeter nodules that measure < 8 mm to 10 mm in diameter; and multiple nodules when they are detected incidentally during evaluation of the SPN. Recommendations stress the value of risk factor assessment, the utility of imaging tests (especially old films), the need to weigh the risks and benefits of various management strategies (biopsy, surgery, and observation with serial imaging tests), and the importance of eliciting patient preferences. CONCLUSION Patients with pulmonary nodules should be evaluated by estimation of the probability of malignancy, performance of imaging tests to characterize the lesion(s) better, evaluation of the risks associated with various management alternatives, and elicitation of patient preferences for treatment.
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Affiliation(s)
- Michael K Gould
- VA Palo Alto Health Care System, 3801 Miranda Ave (111P), Palo Alto, CA 94304, USA.
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190
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A multicenter, randomized, open study to evaluate the impact of an electronic data capture system on the care of patients with rheumatoid arthritis. Curr Med Res Opin 2007; 23:1967-79. [PMID: 17626700 DOI: 10.1185/030079907x210624] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the impact of an electronic data capture system on patient satisfaction and patient-physician interactions in a rheumatology clinical setting. STUDY DESIGN In this multicenter study, 1079 patients with rheumatoid arthritis completed questionnaires quarterly about their health and satisfaction with care using a computer. At 6 months, 901 eligible patients were randomized 2:1 to receive or not to receive graphical summarized health information or Health Tracker (HT) reports. Data collected at each visit included patient satisfaction with care; patient-physician interaction assessments; a 56-joint self-assessment for patients; a 28-joint assessment for physicians; patient pain, fatigue, and global assessments (visual analogue scale, physician global assessment, Health Assessment Questionnaire, and Short Form-12) all of which were cumulatively recorded in the HT report. RESULTS Patient demographics at baseline were similar between groups. Changes from baseline to 1 year showed that patients in the HT-viewers group were significantly more satisfied with their care (p < 0.001) than those in the HT-nonviewers group (p = 0.131). Physicians reported improved interactions with patients at 1 year in both the HT-viewers (p < 0.001) and HT-nonviewers groups (p = 0.002); however, the improvement was significantly larger for the HT-viewers group than for the HT-nonviewers group (p < 0.001). Adverse events were comparable between groups. CONCLUSIONS Patient access to systematically collected patient data reports promoted self-involvement and improved patient satisfaction and patient-physician interactions more in the HT-viewers than in HT-nonviewers groups at 1 year (p < 0.001). This was an open, observational study; no formal hypothesis testing was conducted. The HT system was not validated and some bias may have existed with respect to patient comfort level with a computer, user error, and timing of data entry of the physicians' assessments.
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191
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Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med 2007; 22:1429-33. [PMID: 17674111 PMCID: PMC2305862 DOI: 10.1007/s11606-007-0279-0] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2006] [Revised: 05/22/2007] [Accepted: 06/21/2007] [Indexed: 11/29/2022]
Abstract
CONTEXT In primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed. OBJECTIVE To test an intervention to reduce patients' unmet concerns. DESIGN Cross-sectional comparison of 2 experimental questions, with videotaping of office visits and pre and postvisit surveys. SETTING Twenty outpatient offices of community-based physicians equally divided between Los Angeles County and a midsized town in Pennsylvania. PARTICIPANTS A volunteer sample of 20 family physicians (participation rate = 80%) and 224 patients approached consecutively within physicians (participation rate = 73%; approximately 11 participating for each enrolled physician) seeking care for an acute condition. INTERVENTION After seeing 4 nonintervention patients, physicians were randomly assigned to solicit additional concerns by asking 1 of the following 2 questions after patients presented their chief concern: "Is there anything else you want to address in the visit today?" (ANY condition) and "Is there something else you want to address in the visit today?" (SOME condition). MAIN OUTCOME MEASURES Patients' unmet concerns: concerns listed on previsit surveys but not addressed during visits, visit time, unanticipated concerns: concerns that were addressed during the visit but not listed on previsit surveys. RESULTS Relative to nonintervention cases, the implemented SOME intervention eliminated 78% of unmet concerns (odds ratio (OR) = .154, p = .001). The ANY intervention could not be significantly distinguished from the control condition (p = .122). Neither intervention affected visit length, or patients'; expression of unanticipated concerns not listed in previsit surveys. CONCLUSIONS Patients' unmet concerns can be dramatically reduced by a simple inquiry framed in the SOME form. Both the learning and implementation of the intervention require very little time.
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Affiliation(s)
- John Heritage
- Department of Sociology, University of California, Los Angeles, CA 90095-1551, USA.
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192
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Abstract
BACKGROUND Patient and physician gender may impact the process of medical care and its outcomes. Our objective was to investigate the influence of patient gender on what takes place during initial primary care visits while controlling for other variables previously demonstrated to affect the physician-patient interaction, such as physician gender and specialty, patient health status, pain, depression, obesity, age, education, and income. METHODS New patients (315 women, 194 men) were randomized for care by 105 primary care physicians. Sociodemographic information, self-reported health status and pain measures, a depression evaluation, screening for alcoholism, history of tobacco use, and measured body mass index (BMI) were collected during a previsit interview. The entire medical visit was videotaped, and then analyzed using the Davis Observation Code (DOC) system. RESULTS There was no significant difference in the visit length or work intensity (number of behavioral codes) for female patients compared with male patients; however, women's visits had more discussions regarding the results of the therapeutic interventions, more preventive services, less physical examination, and fewer discussions about tobacco, alcohol, and other substance abuse. CONCLUSIONS There are significant differences in the process of care between female and male patients. Physicians may be making medical decisions based on gender-related considerations. Strategies for implementing knowledge about these gender differences are crucial for the delivery of gender-sensitive care.
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Affiliation(s)
- Klea D Bertakis
- Department of Family and Community Medicine, University of California, Davis, Sacramento, California 95817, USA.
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193
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Bastiaens H, Van Royen P, Pavlic DR, Raposo V, Baker R. Older people's preferences for involvement in their own care: a qualitative study in primary health care in 11 European countries. PATIENT EDUCATION AND COUNSELING 2007; 68:33-42. [PMID: 17544239 DOI: 10.1016/j.pec.2007.03.025] [Citation(s) in RCA: 192] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2006] [Revised: 03/28/2007] [Accepted: 03/29/2007] [Indexed: 05/15/2023]
Abstract
OBJECTIVE The aim of the study was to explore the views of people aged over 70 years on involvement in their primary health care in 11 different European countries. METHODS Older patients were asked about their views on patient involvement in a face-to-face interview. All interviews were audio-recorded, transcribed and analysed in accordance with the principles of 'qualitative content analysis'. An international code list was used. RESULTS Four hundred and six primary care patients aged between 70 and 96 years were interviewed. Their views could be categorized into four major groups: doctor-patient interaction, GP related topics, patient related issues and contextual factors. CONCLUSION People over 70 do want to be involved in their care but their definition of involvement is more focussed on the 'caring relationship', 'person-centred approach' and 'receiving information' than on 'active participation in decision making'. PRACTICE IMPLICATIONS The desire for involvement in decision making is highly heterogeneous so an individual approach for each patient in the ageing population is needed. Future research and medical education should focus on methods and training to elicit older patients' preferences. The similar views in 11 countries suggest that methods for enhancing patient involvement in older people could be internationally developed and exchanged.
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Affiliation(s)
- Hilde Bastiaens
- Department of General Practice (S5), University of Antwerp, Universiteitsplein 1, 2600 Wilrijk, Belgium
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194
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Abstract
Using the Wisconsin Longitudinal Study Graduate Survey (N = 5,830), a population-based cohort of older adults (most aged 63-66 years), we explored relationships between five factors of personality and four preference types that account for multiple components of the health care decision-making process (information exchange, deliberation, and selection of treatment choice). After adjustment for personal, health, social, and economic factors, we found that increased conscientiousness and openness to experience and decreased agreeableness and neuroticism corresponded to preferring the most active decision-making style compared with the least active. A better understanding of how personality traits relate to patient decision-making styles may help clinicians tailor treatment discussions to the needs and preferences of individual patients.
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Affiliation(s)
- Kathryn E Flynn
- Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA.
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195
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Beach MC, Duggan PS, Moore RD. Is patients' preferred involvement in health decisions related to outcomes for patients with HIV? J Gen Intern Med 2007; 22:1119-24. [PMID: 17514382 PMCID: PMC2305727 DOI: 10.1007/s11606-007-0241-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Revised: 04/05/2007] [Accepted: 04/30/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Previous studies suggest that patients who are more involved in their medical care have better outcomes. OBJECTIVES We sought to compare health care processes and outcomes for patients with HIV based on their preferred level of involvement in health decisions. DESIGN Cross-sectional analysis of audio computer-assisted interviews with patients at an urban HIV clinic. PATIENTS One thousand and twenty-seven patients awaiting an appointment with their primary care provider. MEASURES Patients were asked how they preferred to be involved in decisions (doctor makes most or all decisions, doctor and patient share decisions, patient makes all decisions). We also asked patients to rate the quality of communication with their HIV provider, and their self-reported receipt of and adherence to HAART. RESULTS Overall, 23% patients preferred that their doctor make all or most decisions, 63% preferred to share decisions with their doctor, and 13% preferred to make all final decisions alone. Compared to patients who prefer to share decisions with their HIV provider, patients who prefer that their provider make all/most decisions were significantly less likely to adhere to HAART (OR [odds ratio] 0.57, 95% CI 0.38-0.86) and patients who preferred to make decisions alone were significantly less likely to receive HAART or to have undetectable HIV RNA in unadjusted analyses (OR 0.52, 95% CI 0.31-0.87 for receipt of HAART; OR 0.64, 95% CI 0.44-0.95 for undetectable HIV RNA). After controlling for potentially confounding patient characteristics and differences in patient ratings of communication quality, patients who preferred that their provider make all/most decisions remained significantly less likely to adhere to HAART (OR 0.58, 95% CI 0.38-0.89); however, the associations with receipt of HAART and undetectable HIV RNA were no longer significant (OR 0.60, 95% CI 0.34-1.05 for receipt of HAART; OR 0.80, 95% C.I 0.53-1.20 for undetectable HIV RNA). CONCLUSIONS Although previous research suggests that more patient involvement in health care decisions is better, this benefit may be reduced when the patient wants to make decisions alone. Future research should explore the extent to which this preference is modifiable so as to improve outcomes.
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Affiliation(s)
- Mary Catherine Beach
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 2024 East Monument Street, Suite 2-500, Baltimore, MD 21287, USA.
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196
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Abstract
OBJECTIVE Patient participation during decision-making can improve health outcomes and satisfaction, even for routine pediatric concerns. The tasks that are involved in decision-making include both information exchange and deliberation about potential options, yet deliberation (ie, the process of expressing and evaluating potential options to reach a decision) is often assessed subjectively, if at all. We objectively assessed the amount of deliberation; the involvement of parents and children in deliberation; and how deliberation is associated with child, physician, parent, and visit characteristics. METHODS From videotapes of 101 children's acute care visits to 1 of 15 physicians, we coded the speaker, recipient, and timing of proposed plans (ie, options) and agreements or disagreements with the plans. Reliability of measures was assessed with Cohen's kappa or intraclass correlation coefficients; validity was assessed with Spearman correlations. Outcome measures included number of plans proposed, deliberation length, and parent/child involvement in deliberation as either active (child or parent proposed a plan or disagreed with a plan) or passive (physician alone proposed plans). Multivariable models that accounted for clustering by physician were used to relate child, physician, parent, and visit factors to deliberation measures. RESULTS The mean number of plans proposed was 4.1, and deliberation time averaged 2.9 minutes per visit. Passive involvement of parents/children occurred in 65% of visits. After adjustment, more plans were proposed in visits by girls, and shorter deliberations occurred with college-graduate parents. Longer visits were associated with more plans proposed, longer deliberation, and reduced odds for passive parent/child involvement. CONCLUSIONS Using a reliable and valid technique, deliberation was demonstrated to occupy a substantial portion of the visit and include multiple proposed plans, yet passive involvement of parents and children predominated. Results support the need to develop interventions to improve parent and child participation in deliberation.
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Affiliation(s)
- Elizabeth D Cox
- Center for Women's Health Research, University of Wisconsin School of Medicine and Public Health, 610 Walnut St, Madison, WI 53726, USA
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197
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Stewart AL, Nápoles-Springer AM, Gregorich SE, Santoyo-Olsson J. Interpersonal processes of care survey: patient-reported measures for diverse groups. Health Serv Res 2007; 42:1235-56. [PMID: 17489912 PMCID: PMC1955252 DOI: 10.1111/j.1475-6773.2006.00637.x] [Citation(s) in RCA: 160] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To create a patient-reported, multidimensional physician/patient interpersonal processes of care (IPC) instrument appropriate for patients from diverse racial/ethnic groups that allows reliable, valid, and unbiased comparisons across these groups. DATA SOURCE/DATA COLLECTION: Data were collected by telephone interview. The survey was administered in English and Spanish to adult general medicine patients, stratified by race/ethnicity and language (African Americans, English-speaking Latinos, Spanish-speaking Latinos, non-Latino whites) (N=1,664). STUDY DESIGN/METHODS In this cross-sectional study, items were designed to be appropriate for diverse ethnic groups based on focus groups, our prior framework, literature, and cognitive interviews. Multitrait scaling and confirmatory factor analysis were used to examine measurement invariance; we identified scales that allowed meaningful quantitative comparisons across four race/ethnic/language groups. PRINCIPAL FINDINGS The final instrument assesses several subdomains of communication, patient-centered decision making, and interpersonal style. It includes 29 items representing 12 first-order and seven second-order factors with equivalent meaning (metric invariance) across groups; 18 items (seven factors) allowed unbiased mean comparison across groups (scalar invariance). Final scales exhibited moderate to high reliability. CONCLUSIONS The IPC survey can be used to describe disparities in interpersonal care, predict patient outcomes, and examine outcomes of quality improvement efforts to reduce health care disparities.
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Affiliation(s)
- Anita L Stewart
- Center for Aging in Diverse Communities, Medical Effectiveness Research Center for Diverse Populations, Institute for Health and Aging, University of California San Francisco, San Francisco, CA 94118-1944, USA
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198
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Frantsve LME, Kerns RD. Patient-provider interactions in the management of chronic pain: current findings within the context of shared medical decision making. PAIN MEDICINE 2007; 8:25-35. [PMID: 17244101 DOI: 10.1111/j.1526-4637.2007.00250.x] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This article reviews the literature on patient-provider interactions among patients with chronic pain conditions with an emphasis on shared medical decision making. RESULTS Key findings suggest that: 1) patients with chronic pain and health care providers are likely to have opposing attitudes and goals, with patients seeking "to be understood as individuals" and struggling to have their pain concerns legitimized while their health care providers may place a greater focus on diagnosis and treatment than quality of life concerns; and 2) female patients may face additional challenges when communicating their pain concerns with providers. Increased emphasis on communication training and efforts to promote a shared decision making process are proposed as possible mechanisms to improve patient-provider interactions. CONCLUSIONS Treatment of chronic pain is often complex and may be further complicated when patients and health care providers have differing goals and attitudes concerning treatment. Difficulties in engaging in collaborative treatment decision making may result. Efforts to enhance patient-provider communication as well as to systematically examine nonspecific treatment factors are likely to promote effective management of chronic pain.
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Affiliation(s)
- Lisa Maria E Frantsve
- Psychology Service, VA Connecticut Healthcare System, Yale University School of Medicine, West Haven, Connecticut 06516, USA.
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199
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Bosworth HB, Olsen MK, McCant F, Harrelson M, Gentry P, Rose C, Goldstein MK, Hoffman BB, Powers B, Oddone EZ. Hypertension Intervention Nurse Telemedicine Study (HINTS): testing a multifactorial tailored behavioral/educational and a medication management intervention for blood pressure control. Am Heart J 2007; 153:918-24. [PMID: 17540191 DOI: 10.1016/j.ahj.2007.03.004] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Accepted: 03/02/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Only 31% of Americans with hypertension have their blood pressure (BP) under effective control. We describe a study that tests 3 different interventions in a randomized controlled trial using home BP telemedicine monitoring. METHODS A sample of hypertensive patients with poor BP control at baseline (N = 600) are randomized to 1 of 4 arms: (1) control group--a group of hypertensive patients who receive usual care; (2) nurse-administered tailored behavioral intervention; (3) nurse-administered medication management according to a hypertension decision support system; (4) combination of the 2 interventions. The interventions are triggered based on home BP values transmitted via telemonitoring devices over standard telephone lines. The tailored behavioral intervention involves promoting adherence with medication and health behaviors. Patients randomized to the medication management or the combined arm have their hypertension regimen changed by the study team using a validated hypertension decision support system based on evidence-based hypertension treatment guidelines and individualized to patients' comorbid illnesses. The primary outcome is BP control: < or = 140/90 mm Hg (nondiabetic) and < or = 130/80 mm Hg (diabetics) measured at 6-month intervals over 18 months (4 total measurements). CONCLUSIONS Given the increasing prevalence of hypertension and our inability to achieve adequate BP control using traditional models of care, testing novel interventions in patients' homes may improve access, quality, and outcomes.
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Affiliation(s)
- Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham VAMC, Durham, NC 27705, USA.
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200
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Holmes WC, Pace JL, Frank I. Appropriateness of antiretroviral therapy in clients of an HIV/AIDS case management organization. AIDS Care 2007; 19:273-81. [PMID: 17364410 DOI: 10.1080/09540120600966141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We sought to assess appropriateness of antiretroviral therapy (ART) reported by clients of an HIV/AIDS case management organization and identify variables associated with appropriate ART receipt. A total of 295 such clients were mailed a survey asking them to identify antiretroviral medications they were taking. Of them 220 (75%) returned surveys; 201 (93%) were taking antiretrovirals. Of these, 159 were on appropriate and 36 on inappropriate ART, as determined by guidelines created by the CDC, the International AIDS Society (USA Panel), and the Panel on Clinical Practices for Treatment of HIV Infection. In unadjusted analyses, age, sex, race, sexual orientation, history of injection drug use, history of sexual risk, and HIV knowledge were associated (p< or =0.10) with appropriate ART and entered into one of two logistic regression models. The first model indicated that women (p=0.003) and heterosexuals (p=0.001) were less likely to receive appropriate ART than men and gay/bisexuals (and variables interacted, p=0.001). HIV knowledge--a proxy indicator determined by self-report of a CD4 cell count and viral load--was added to variables retained in first model to create a second model. Only sexual orientation was retained in this second model (p=0.02, in the same direction as in the first model), and those with less versus more HIV knowledge (p=0.04) were found to be less likely to receive appropriate ART (and variables interacted, p=0.04). Findings suggest that heterosexual men are less likely than women who, in turn, are less likely than gay/bisexual men to receive appropriate ART. HIV-related knowledge appears to increase likelihood of receiving appropriate ART and it attenuates the effect of sex.
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Affiliation(s)
- W C Holmes
- University of Pennsylvania School of Medicine, USA.
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