Preferences for medical collaboration: patient-physician congruence and patient outcomes

Randomized trial of the leadership and organizational change for implementation (LOCI) strategy in substance use treatment clinics

INTRODUCTION

Evidence-based practice (EBP) implementation represents a strategic change that requires alignment of leadership and support throughout organizations. Leadership and Organizational Change for Implementation (LOCI) is a multifaceted implementation strategy that aims to improve implementation leadership and climate within organizations through iterative cycles of leadership and climate assessment and feedback, leadership training and coaching, and strategic planning with upper-level leaders. This study tested the effects of LOCI on transformational and implementation leadership, implementation climate, implementation citizenship behavior, and EBP reach.

METHODS

A multiple cohort, cluster randomized trial tests the effect of LOCI in 60 clinics across nine behavioral health organizations in California and Arizona, USA. The study randomized clinics within organizations to either LOCI or a leadership training webinar control condition in three consecutive cohorts. Repeated web-based surveys of direct service providers (nLOCI = 201, nControl = 179) assessed leadership, implementation climate, and implementation citizenship over time. Multilevel autoregressive modeling was the primary statistical analysis such that providers (level-1) were nested within clinics (level-2). The study predicted between-condition differences at 4-, 8-, and 12-month follow-up assessments. Provider engagement in a fidelity monitoring process assessed reach of motivational interviewing (i.e., number of sessions recorded/submitted for fidelity coding). An independent sample t-test explored between condition differences in motivational interviewing reach.

RESULTS

Results indicated between condition differences at 4 months for implementation leadership, implementation climate, and implementation citizenship behavior such that greater improvements were evidenced in the LOCI condition compared to the control condition. Reach of MI was significantly greater in the LOCI vs control condition such that LOCI providers were significantly more likely to engage in the fidelity monitoring process (chi-square (1, n = 370) = 5.59, p = .018).

CONCLUSIONS

LOCI was developed based on organizational theories of strategic leadership and climate to affect organizational change processes that communicate that innovation implementation is expected, supported, and recognized as a value of the organization. The LOCI implementation strategy resulted in more positive hypothesized outcomes compared to the control condition. Organizational change strategies have utility for implementing health innovations in complex, multilevel contexts and for greater sustainment of facilitative leader behaviors, strategic implementation climate, and improved implementation outcomes.

TRIAL REGISTRATION

This study is registered with Clinicaltrials.gov gov (NCT03042832, 2 February 2017; retrospectively registered).

Listening to Patients Makes Sense: Soliciting and Purposefully Addressing Written Patient Expectations at a Provider Visit Improve Patient Satisfaction

Patient satisfaction is an important aspect of medical care. This study aimed to assess if patient satisfaction improved when patients shared their expectations with the provider in writing before a visit, and providers purposefully addressed those expectations during the visit. We gave 2 types of questionnaires to 343 patients: Version 1 asked for written expectations before the visit and assessed the visit quality after addressing those expectations, while Version 2 only evaluated the visit without soliciting expectations. Patient satisfaction and meeting expectations were measured on a 1-10 Likert-type scale. The grouped that shared written expectations before the visit (n = 169) showed a significantly higher patient satisfaction score (9.88) compared to the group without shared expectations (n = 136, score 9.43, P < .0001). Conveying written expectations to healthcare providers before the visit improved patient satisfaction, potentially enhancing compliance and overall medical outcomes.

'The way you talk, do I have a choice?' Patient narratives of medication decision-making during hospitalization

OBJECTIVE

Based on the principle of the autonomy of the patient, shared decision-making (SDM) is the ideal approach in clinical encounters. In SDM, patients and healthcare professionals (HCPs) share knowledge and power when faced with the task of making decisions. However, patients are often not involved in the decision-making process. In this study, we explore medication decision-making during hospitalization and how power in the specific patient-HCP relationship is articulated, as analysed by Foucauldian theory.

METHODS

A qualitative case study, comprising observations of patient-HCP encounters at an internal medicines ward at a university hospital in Norway, followed by semi-structured interviews. The narratives (n = 4 patients) were selected from a larger study (n = 15 patients). The rationale behind the choice of these patients was to include diverse and rich accounts. The four patients in their 40s-70s were included close to the day of presumed discharge.

RESULTS

The narratives provide an insight into the patients as persons, their perspectives, including what mattered to them during their hospitalization, especially in relation to medications. Overall, SDM was not observed in this study. Even though all the participants actively tried to keep their autonomous capacity and to resist the HCPs' use of power, they were not able to change the established dynamics. Moreover, they were not allowed an equal voice to those of HCPs and thus not to escape the system's objectification and subjectification of them.

CONCLUSION

There is a need for HCPs to get more familiarized with SDM. The healthcare system and the individual HCP need to make more room for dialogue with the patients about their preferences. A part of this is also how health care systems are structured and scheduled, thus, it is important to empower patients and HCPs alike.

Patient-physician agreement on function and pain is associated with long-term outcomes in sarcoma: findings from a longitudinal study

PURPOSE

We aimed to describe the level of agreement between patients and physicians on the ratings of daily functioning and pain in a cohort of sarcoma patients and assess how (dis)agreement and its change over time predicted patient-reported outcomes in survivorship.

METHOD

We performed secondary analysis of longitudinal data from a sarcoma-specialty clinic in Montreal, Canada. Demographics, clinical characteristics and patient-physician agreement were summarized descriptively. Linear mixed models were used to assess the effects of time, baseline agreement, change in agreement over time, interaction of time and change in agreement and 12-month daily functioning, quality of life, and fatigue.

RESULTS

Data were available for 806 patients (57.7% male, x̄ = 53.3 years) who completed at least one questionnaire. Patient-physician disagreement was common on the level of function (43.4%) and pain (45.7%). Baseline physician-patient agreement was associated with better 12-month outcomes. Improvement in agreement on function over time was significantly associated with daily functioning (F(2, 212) = 3.18, p = 0.043) and quality of life (F(2, 212) = 3.17, p < 0.044). The pattern was similar though less pronounced for the agreement on pain.

CONCLUSIONS

Our study offers novel insights into the importance of patient-physician agreement and communication's role in long-term patient-reported outcomes in sarcoma.

IMPLICATIONS FOR CANCER SURVIVORS

The results emphasize the importance of mutual understanding of symptoms and patients' needs and suggest that further consultation in cases of discordance of ratings and opinions might be beneficial for optimal survivorship.

Are parents of high caries risk Dutch children motivated to brush their children's teeth? An assessment using the health action process approach questionnaire

PURPOSE

To assess the social cognitive constructs of the Health Action Process Approach (HAPA) of parents of high caries risk children to be treated under intravenous sedation (IVS) or with behavioural guidance techniques (BGT), and to assess the changes in these constructs for each treatment group after treatment.

DESIGN

In this cohort study, 160 children aged 3-10 years were allocated by their paediatric dentist to either IVS (77.4%) or BGT. Their parents filled out a HAPA questionnaire, before (T1, n = 160), immediately (T2, n = 108) and three months (T3, n = 71) after their children's dental rehabilitation.

RESULTS

Before treatment, all parents had high scores on all social cognitive constructs. There were no differences in mean HAPA scores between the treatment groups (p > 0.05). After treatment, mean scores changed in both groups. In the BGT group, action self-efficacy changed from 3.64 (T1) to 3.36(T2) (p = 0.027) and to 3.13 (T3) (p = 0.021) and coping self-efficacy changed from 3.63 (T1) to 3.23 (T2) (p = 0.015). In the IVS group, action planning changed from 3.25 (T1) to 3.05(T3) (p = 0.036) and action control changed from 2.58 (T1) to 2.82 (T2) (p = 0.012) and to 2.87 (T3) (p = 0.006).

CONCLUSIONS

High scores on social cognitive constructs of parents of children referred to a paediatric dentist showed that they seem to be motivated to brush their children's teeth, irrespective of the treatment group. Small changes were observed in the HAPA constructs, however, these are not considered clinically relevant.

Patient Attitudes Regarding Health Care Clinician Communication in Adolescents With Cystic Fibrosis

BACKGROUND

The quality of health care clinician (HCC) communication varies, yet few studies evaluate ways to improve communication among adolescents with cystic fibrosis (CF). We sought to characterize the attitudes of adolescents and young adults (AYA) with CF about HCC communication and describe the components important for high-quality communication.

METHODS

AYA with CF aged 12-20 years from a single large pediatric CF care center participated in a brief survey and semi-structured individual and group virtual interviews that were recorded, transcribed, coded, and analyzed with a combined deductive and inductive approach. Discrepancies were resolved by consensus.

RESULTS

Among the 39 survey respondents, most were White (77%), male (51%), and averaged 15.51 years (range 12-20 years). Many (40%) perceived their health status as " neutral " and over half (61%) were " very satisfied " with HCC communication. Overall, among the 17 interviews (averaged 53.6 min, range 31.5-74 min), participants reported a desire to be actively engaged in discussions about their health and included in the decision-making process with HCC to support adolescent autonomy and cultivate trust. Some factors detract (loss of control and fear of diagnosis), and others strengthen (transition to adult care and external motivators) adolescent autonomy. Some factors detract (perceived lack of interdisciplinary communication, statements of noncompliance, and being compared to others) and others strengthen (inherent trust and familiarity over time) the cultivation of trust.

CONCLUSIONS

The development of adolescent autonomy and the cultivation and maintenance of trust between the patient and HCC are 2 essential components of quality communication that should inform future communication-focused interventions.

Getting specific: participation preference in urooncological decision-making

BACKGROUND

Shared decision-making is the gold standard for good clinical practice, and thus, psychometric instruments have been established to assess patients' generic preference for participation (e.g., the Autonomy Preference Index, API). However, patients' preferences may vary depending on the specific disease and with respect to the specific decision context. With a modified preference index (API-Uro), we assessed patients' specific participation preference in preference-sensitive decisions pertaining to urological cancer treatments and compared this with their generic participation preference.

METHODS

In Study 1, we recruited (N = 469) urological outpatients (43.1% urooncological) at a large university hospital. Participation preference was assessed with generic measures (API and API case vignettes) and with the disease-specific API-Uro (urooncological case vignettes describing medical decisions of variable difficulty). A polychoric exploratory factor analysis was used to establish factorial validity and reduce items. In Study 2, we collected data from N = 204 bladder cancer patients in a multicenter study to validate the factorial structure with confirmatory factor analysis. Differences between the participation preference for different decision contexts were analyzed.

RESULTS

Study 1: Scores on the specific urooncological case vignettes (API-Uro) correlated with the generic measure (r = .44) but also provided incremental information. Among the disease-specific vignettes of the API-Uro, there were two factors with good internal consistency (α ≥ .8): treatment versus diagnostic decisions. Patients desired more participation for treatment decisions (77.8%) than for diagnostic decisions (22%), χ²(1) = 245.1, p ≤ .001. Study 2: Replicated the correlation of the API-Uro with the API (r = .39) and its factorial structure (SRMR = .08; CFI = .974). Bladder cancer patients also desired more participation for treatment decisions (57.4%) than for diagnostic decisions (13.3%), χ²(1) =84, p ≤ .001.

CONCLUSIONS

The desire to participate varies between treatment versus diagnostic decisions among urological patients. This underscores the importance of assessing participation preference for specific contexts. Overall, the new API-Uro has good psychometric properties and is well suited to assess patients' preferences. In routine care, measures of participation preference for specific decision contexts may provide incremental, allowing clinicians to better address their patients' individual needs.

Understanding older adults' intention to use patient-accessible electronic health records: Based on the affordance lens

Background

Given the aging population and the rapid development of the digital society, concerns about promoting older adults' health skills are increasing. Patient-accessible electronic health records (PAEHRs) are implemented globally for aging health safeguards. The demand for using health-related information communication technologies (ICTs) among older adults and the factors that promote their usage intention of PAEHRs need to be studied.

Methods

Drawing upon affordance theory, we constructed a research model that integrates four affordance types, aggregation, interactivity, collaboration, and communication, to identify the effects of affordances and attachment to platforms and doctors that contribute to older adults' usage intention on PAEHRs. Online survey data from 498 older adults (above 60 years) were collected and analyzed using partial least square-structural equation modeling.

Results

Our findings demonstrated how PAEHR's affordances facilitate older adults' attachment to platforms and doctors. We found that aggregation (γ = 0.417, P < 0.001) and interactivity (γ = 0.397, P < 0.001) can positively influence older adults' attachment to the PAEHR platform, and collaboration (γ = 0.407, P < 0.001) affordance can positively influence older adults' attachment to doctors on the PAEHR platform. Furthermore, seniors' attachment to the platform (γ = 0.598, P < 0.001) and attachment to the doctor (γ = 0.156, P < 0.01) can both positively influence their usage intention, and attachment to the platform had a positive relationship with attachment to doctors (γ = 0.230, P < 0.001) on the PAEHR.

Conclusion

This study enriched the understanding of elders' attachment to doctors on PAEHRs and contributed to the literature on health-related ICT usage targets of older adults. Our findings also shed light on inspiring operators of health-related ICTs to formulate appropriate strategies for aging-friendly design to guide older adults to adopt health-related ICTs in their everyday health information practices.

Patient Satisfaction Scores Are a Poor Metric of Orthopedic Care

Patient satisfaction scores are a popular metric used to evaluate orthopedic care. There is little consistency with how satisfaction is described in the orthopedic literature. Online physician reviews are a growing trend that directly and indirectly affect a surgeon's reputation. There is little correlation of higher satisfaction with improved surgical outcomes, so rating surgical care may be misguided and possibly dangerous. Patient satisfaction is an important part of the patient-centered care model, so rating systems should directly reflect quality. More research is needed to determine the relationship between patient satisfaction and the delivery of quality care. [Orthopedics. 2022;45(3):e127-e133.].

When Doctors Swear, Do Patients Care? Two Experiments Examining Physicians Cursing in the Presence of Patients

Swearing in everyday conversation has become more normalized in recent years; but less certain, however, is how accepting Americans are when a doctor swears in their presence. Two online experiments (Study 1: n = 497; Study 2: n = 1,224) were conducted with US participants to investigate the impact of a doctor swearing in the course of examining a patient's infected wound (i.e., "You've got a lot of nasty [shit/stuff] in there that we're going to want to flush out"), or swearing when dropping papers in a patient's presence while varying the intensity of a swear (i.e., "[Shit!/Damn!/Whoops!]"), with or without an apology (i.e., "I'm sorry"). Overall findings reveal a main effect for swearing, with a swearing doctor generally seen as less likable, and in Study 1, less trustworthy, approachable, and less of an expert. However, the majority of participants exposed to a swearing doctor still said they would visit that physician again. Open-ended responses from these participants revealed that they perceived a swearing doctor as more human. Results from Study 2 also found that if a doctor swore, the negative impact was lessened if the doctor apologized immediately after cursing. While results from these studies indicate it is wise for doctors to refrain from swearing, most participants were still willing to make a future appointment with a cursing doctor.

Patient preferences for breast cancer treatments: a discrete choice experiment in France, Ireland, Poland, Spain

Aim: To understand breast cancer patients' trade-offs when choosing treatments and to identify the most important treatment attributes which drive decisions. Materials & methods: A discrete choice experiment was conducted in France, Ireland, Poland and Spain. Progression-free survival, febrile neutropenia, pain, functional well-being and out-of-pocket payment were the treatment attributes. Results: 371 patients were willing to pay €6896 per year for 1 additional year of progression-free survival, €17,288 per year for perfect functional well-being and €15,138 for one pain-free year. Patients are willing to trade off progression-free survival months for better functional abilities and less pain. Conclusion: Patient preferences should be considered by regulatory agencies, reimbursement bodies, payors and clinicians for best treatment choices for the individuals.

Provider Personal and Demographic Characteristics and Patient Satisfaction in Orthopaedic Surgery

INTRODUCTION

Patient satisfaction has increasingly been used to assess physician performance and quality of care. Although there is evidence that patient satisfaction is associated with patient-reported health outcomes and communication-related measures, there is debate over the use of patient satisfaction in reimbursement policy. Patient characteristics that influence satisfaction have been studied, but the effects of personal and demographic characteristics of physicians on patient satisfaction have yet to be explored.

METHODS

Outpatient satisfaction scores from 11,059 patients who rated 25 orthopaedic surgeons from a single institution were studied. In this study, we sought to explore the relationship between nonmodifiable physician characteristics, such as sex and race, and patient satisfaction with outpatient orthopaedic surgery care, as expressed in the Press Ganey Satisfaction Scores. Univariate logistic regression models were used to test the associations between each provider characteristic and patient satisfaction on the Press Ganey patient satisfaction questionnaire.

RESULTS

Three nonmodifiable physician personal and demographic characteristics were markedly associated with lower patient satisfaction scores across overall satisfaction, communication, and empathy domains: (1) female gender, (2) Asian ethnicity, and (3) being unmarried. Asian ethnicity reduced the odds of receiving a 5-star rating for likelihood to recommend the provider by nearly 40%, but none of these nonmodifiable physician personal and demographic characteristics affected the likelihood to recommend the practice.

DISCUSSION

Sex, ethnicity, and marital status are nonmodifiable provider characteristics, each associated with markedly lower odds of receiving a 5-star rating on Press Ganey patient satisfaction survey. These data reveal inherent patient biases that negatively affect physician-patient interactions and may exacerbate the lack of diversity in orthopaedic surgery. More research is necessary before using patient satisfaction ratings to evaluate surgeons or as quality measures that affect reimbursement policies.

Translation and cultural adaptation of a romanian version of the communication assessment tool (CAT_Ro)

BACKGROUND

The communication between health providers and patients influences the quality of medical care. The Communication Skills Assessment (CAT) is a reliable, validated tool, which was developed to assess interpersonal communication skills between physicians and patients. The purpose of this study was to obtain a Romanian version of the CAT (CAT_Ro), using a controlled and systematic process to translate and cross-culturally adapt the original questionnaire, since there are no validated instruments to assess healthcare professionals' communication capability in Romania.

METHODS

The study was conducted in two Departments of Internal Medicine and Rheumatology from Bucharest, Romania, using a rigorous scientific methodology for the translation process, according to literature recommendations, implicating conceptual evaluation, semantics, and cultural adaptation, which involved several steps. The updated version was pre-tested in a pilot study, which included 89 outpatients.

RESULTS

The results showed a narrow range of variability in item interpretation, without differences in patients' responses according to variables such as age, gender, education, disease type, number of previous visits with the same doctor.

CONCLUSION

CAT-Ro is the result of a comprehensive process study. It represents the first translation and cultural adaptation in Romanian of an instrument able to assess the health providers' communication skills, which was validated in a pilot study and is to be used in more extensive studies with patients from several specialties.

Improper Communication Makes for Squat: A Qualitative Study of the Health-Care Processes Experienced By Older Adults in a Clinical Trial for Back Pain

BACKGROUND

The study focused on perceptions of older adults toward the healthcare processes they experienced during a clinical trial for back pain that involved family medicine residents and licensed chiropractors.

METHODS

Individual semi-structured interviews were conducted with 115 older adults after a 12-week, 3-arm, randomized controlled trial. Two researchers conducted thematic analysis with inductive coding using qualitative software to identify participants' salient experiences of the doctor-patient relationship, healthcare process, and collaboration between study providers. Investigators categorized thematic codes within an existing framework of clinical excellence in primary care.

RESULTS

Participants emphasized provider communication and interpersonal relationships, professionalism and passion for patient care, clinical and diagnostic acumen, and skillful negotiation of the health-care system. Older adults also described the importance of interdisciplinary collaboration and their preferences for receiving hands-on treatments for musculoskeletal conditions.

CONCLUSION

These older adults valued doctors who communicated clearly and spent time listening to their concerns. Many participants appreciated clinicians who supported an active role for patients in their health-care and who provided touch-based care for musculoskeletal conditions.

How patient-generated health data and patient-reported outcomes affect patient-clinician relationships: A systematic review

Introduction:

Many patients use mobile devices to track health conditions by recording patient-generated health data. However, patients and clinicians may disagree how to use these data.

Objective:

To systematically review the literature to identify how patient-generated health data and patient-reported outcomes collected outside of clinical settings can affect patient–clinician relationships within surgery and primary care.

Methods:

Six research databases were queried for publications documenting the effect of patient-generated health data or patient-reported outcomes on patient–clinician relationships. We conducted thematic synthesis of the results of the included publications.

Results:

Thirteen of the 3204 identified publications were included for synthesis. Three main themes were identified: patient-generated health data supported patient–clinician communication and health awareness, patients desired for their clinicians to be involved with their patient-generated health data, which clinicians had difficulty accommodating, and patient-generated health data platform features may support or hinder patient–clinician collaboration.

Conclusion:

Patient-generated health data and patient-reported outcomes may improve patient health awareness and communication with clinicians but may negatively affect patient–clinician relationships.

Patient and service-related barriers and facitators to the acceptance and use of interventions to promote communication in health and social care: a realist review

Background

More people living into old age with dementia. The complexity of treatment and care, particularly those with multiple health problems, can be experienced as disjointed. As part of an evaluation of a ‘healthcare passport’ for people living with dementia we undertook a realist review of communication tools within health and social care for people living with dementia.

Aims

To explore how a ‘healthcare passport’ might work in the ‘real world’ of people living with dementia through a better understanding of the theoretical issues related to, and the contextual issues that facilitate, successful communication.

Methods

A realist review was considered the most appropriate methodology to inform the further development and evaluation of the healthcare passport. We undertook a purposive literature search related to communication tools to identify (a) underlying programme theories; (b) published reports and papers on their use in various healthcare settings; (c) evidence on barriers and facliitators of their use.

Results

Communication tools were noted as a way of improving communication and outcomes through: (1) improvement of service user autonomy; (2) strengthening the therapeutic alliance; and (3) building integrated care. However, while intuitively perceived to of benefit, evidence on their use is limited and key barriers to their acceptance and use include: (1) difficulties in clearly defining purpose, content, ownership and usage; (2) understanding the role of family caregivers; and (3) preparation among healthcare professionsals.

Conclusion

Patient-held communication tools may be helpful to some people living with dementia but will require considerable preparation and engagement with key stakeholders.

A Clinician and Service User's Perspective on Managing MS: Pleasure, Purpose, Practice

There is a growing body of evidence that points to an important role for modification of lifestyle factors and promotion of health-related quality of life in the secondary prevention of disease progression in multiple sclerosis (D'Hooghe et al., 2010; Weiland et al., 2014; Hadgkiss et al., 2015). As a clinical psychologist diagnosed with multiple sclerosis in 2012 I have gained a unique insight into ways in which people living with MS and clinicians can usefully integrate evidence-based lifestyle modifications that enhance self-efficacy and self-management to improve wider psychological and physical health. The framework presented here enables clinicians to engage in salutogenic health promotion by placing value upon the importance of healthy, evidence-based behavior change. Furthermore, the framework provides a structure which can empower and provide guidance for people living with MS on what and how to implement and sustain behavior change and emotional wellbeing in the face of this life-changing diagnosis.

Elderly patients' decision-making embedded in the social context: a mixed-method analysis of subjective norms and social support

Background

Older patients are increasingly encouraged to be actively involved but how they perceive their role in the decision-making process varies according to their health care providers and their health situation. Their role could be influenced by their social context but more specifically by subjective norms (i.e. patients’ view of the role that significant others expect them to play in the decision-making process) and perceived social support. We explore how social context (i.e. subjective norms and social support) relates to how the patient perceives their role in the decision-making process. Also, we explore the level of alignment on subjective norms between patients and their informal caregivers and nurses.

Methods

Mixed-method study among older patients, informal caregivers and nurses. For the quantitative questionnaire, a home care organisation randomly selected patients. The patients were asked to identify their informal caregiver and the home care organisation was asked to identify the nurse who was most involved in their care. In total 133 patients, 64 informal caregivers and 72 nurses were questioned. Participants for the qualitative interviews were selected using convenience sampling, resulting in the inclusion of ten patients, five informal caregivers and six nurses. Subjective norms were based on a previous study. Social support was measured with the ‘social support for health scale’ of the Health Literacy Questionnaire. The Control Preference Scale was used as outcome variable. The interviews focused on subjective norms, social support and how the patient perceived their role. Quantitative analysis included the calculation of subjective norm difference scores between respondent groups, one-way analysis of variance and multinomial logistic regression analysis. Directed content analysis was applied to the interviews using Atlas TI.

Results

Lower difference scores were found for patient-informal caregiver dyads (mean = 0.95), implying more alignment than in patient-nurse dyads (mean = 2.12). Patients perceiving themselves to have a shared or passive role tend to believe that they are expected to leave decision-making to the health care provider. Higher social support scores related more to a shared role. Alignment relates to: familiarity with the patient’s preferences, overprotectiveness or valuing the care provider’s opinion and the severity of the patient’s medical history.

Conclusion

Patients and informal caregivers align on whether the patient should make decisions. The more patients believe that they are expected to leave decision-making to the health care provider, the more they perceive themselves as having a passive role. The more patients who feel they have support, the more they perceive themselves as having a shared role. Patients and caregivers could be facilitated to make role expectations explicit. Examining support resources in the social network is desirable.

Impact of electrodiagnostic (EMG/NCS) tests on clinical decision-making and patient perceived benefit in the outpatient physical therapy practice

BACKGROUND

Utilizing Electromyography and Nerve Conduction Study (EMG/NCS) tests, when indicated, may have implications for efficient patient management and assist in more efficient referral to appropriate providers or specialists.

OBJECTIVE

To investigate the impact of Electromyography and Nerve Conduction Studies (EMG/NCS) on clinical decision-making and patient perspectives within PT practice settings.

METHODS

462 patients, who were candidates for diagnostic testing (EMG/NCS) were included in this outcome study and questionnaire-based survey design. Pre-test diagnosis was compared to post-test diagnosis. Post-test, patients were asked to rate their perceived benefit of the testing.

RESULTS

Management was changed in 60.61% of patients post EMG/NCS testing (p < 0.0001). The diagnosis was changed post-EMG/NCS test in 39% of the patients with a change in management, which is greater than expected (p < 0.0004). There was no effect of gender or age (p > 0.05) on change in treatment (tx) or diagnosis (dx). 89.8% of patients agreed, or strongly agreed, that they were better able to understand their condition; 92.4% strongly agreed, or agreed, that they were reassured about their condition; 89.1% strongly agreed, or agreed, that they were better able to manage their condition and 92% reported very high, or high, value perceived from the EMG/NCS test administered.

CONCLUSION

This study demonstrates that EMG/NCS testing appears to have a significant impact on clinical decision-making, and higher scores on the patient perceived benefit.

Sexism Interacts with Patient-Physician Gender Concordance in Influencing Patient Control Preferences: Findings from a Vignette Experimental Design

BACKGROUND

Patient preferences regarding their involvement in shared treatments decisions is fundamental in clinical practice. Previous evidences demonstrated a large heterogeneity in these preferences. However, only few studies have analysed the influence of patients' individual differences, contextual and situational qualities, and their complex interaction in explaining this variability.

METHODS

We assessed the role of the interaction of patient's sociodemographic and psychological factors with a physician's gender. Specifically, we focused on patient gender and attitudes toward male or female physicians. One hundred fifty-three people participated in this randomised controlled study and were randomly assigned to one of two experimental conditions in which they were asked to imagine discussing their treatment with a male and a female doctor.

RESULTS

Analyses showed an interplay between attitude towards women and the gender of patients and doctors, explaining interindividual variability in patient preferences.

CONCLUSIONS

In conclusion, patients' attitudes toward the physicians' gender constitutes a relevant characteristic that may influence the degree of control patients want to have and the overall patient-physician relationship.

Provider behaviors that predict motivational statements in adolescents and young adults with HIV: a study of clinical communication using the Motivational Interviewing framework

Medical care providers' use of Motivational Interviewing (MI) is linked to improved medication adherence, viral load, and associated behaviors in adolescents and young adults living with HIV. Mastering MI is difficult for busy providers; however, tailoring MI training to the specific MI communication strategies most relevant for HIV treatment context may be a strategy to increase proficiency. The present study aimed to identify communication strategies likely to elicit motivational statements among adolescent-young adult patients living with HIV. Language used by MI-exposed providers during 80 HIV medical clinic visits was transcribed and coded to characterize patient-provider communication within the MI framework. Sequential analysis, an approach to establish empirical support for the order of behavioral events, found patients were more likely to express motivational statements after provider questions phrased to elicit motivation, reflections of motivational statements, and statements emphasizing patients' decision-making autonomy. Patients were more likely to express amotivational statements when providers asked questions phrased to elicit amotivational statements or reflected amotivational language. Training providers to strategically phrase their questions and reflections to elicit change language and to emphasize patients' autonomy may be critical skills for working with adolescents and young adults living with HIV.

Preferences for surrogate designation and decision-making process in older versus younger adults with cancer: A comparative cross-sectional study

OBJECTIVE

To compare the preferences of older (≥70 years old) versus younger (<70 years old) cancer patients regarding surrogate designation and decision making.

METHODS

A cross-sectional survey. Patient characteristics and information about surrogacy and involvement in decision making were collected. Associations between patient characteristics and preferences were examined.

RESULTS

The study included 130 patients aged ≥70 years (mean age 80 years) and 102 patients aged <70 years (mean age 55) and. Factors independently associated with surrogate knowledge (66%): younger age, more children living nearby, high income; factors associated with having already designated a surrogate (62%): younger age, decreased number of daily medications; factors associated with designating a surrogate after questionnaire administration (40%): low education, metastasis. Patients requiring an informed consent for any intervention was associated with older age (adjusted OR [aOR]_{per year} = 1.04[95% confidence interval 1.00-1.08]), not living alone (aOR = 2.52[1.00-6.36]), and having children (aOR = 4.49[1.13-17.81]).

CONCLUSION

All cancer patients, wanted to be fully informed and 72% wanted to be involved in medical decisions. Preferences for decision control vary between age groups, depending on family members' presence and living alone.

PRACTICE IMPLICATIONS

Sharing complete and clear information should be an important key in the process of cancer patients' care, regardless of patient age.

Utilizing a 3S (strategies, source and setting) approach to understand the patient's preferences when addressing medication non-adherence in patients with diabetes: a focus group study in a primary outpatient clinic

OBJECTIVE

Non-adherence with diabetes medicines is a challenge. Approximately 54% of patients are non-adherent with their diabetes medicines. The objective of this study was to understand patients' preferences when addressing non-adherence based on the 3S approach-strategies (what approaches can be used in addressing non-adherence), settings (when and where should the intervention happen) and sources (who should provide the intervention).

DESIGN

A focus group research design was used.

SETTING

A primary outpatient clinic from an integrated healthcare system in the USA.

PARTICIPANTS

Patients who were non-adherent with diabetes medicines.

DATA COLLECTION

The focus group guide was based on the Medication Adherence Reasons Scale, which has 19 reasons identified for non-adherence. For each item in the scale, patients were asked for strategies that can be used in addressing that issue, the setting in which the interventions should be provided and the source to provide the interventions.

DATA ANALYSIS

Open coding and content analysis.

RESULTS

Two focus groups, each group having seven patients, were conducted. The major strategies identified were patient education, self-responsibility of patients, family support, reminders and societal support. The key educational needs were dealing with side effects and learning to use insulin properly, and a need for different learning styles when offering education. For the source, the major ones were physicians and pharmacists, having a continuous dialogue about the disease and medicines, and individuality in managing the disease. Respondents also recommended using a peer support group. For the setting, the patients preferred continuity of patient education throughout the disease.

CONCLUSION

The 3S approach was able to elicit several recommendations from patients to improve their adherence with diabetes medicines. Educational strategies were identified as the foremost approach coming from physicians and pharmacists throughout their disease journey, in addition to peer support.

A comparison of professional and private time preferences of General Practitioners

In a perfect agency relationship, doctors consider all information and select the patient's 'utility maximising' option given the patient's preferences. The patient's time preferences are important as treatments vary in the timing and length of their benefits. However, doctors often do not have full information on patients' preferences and may apply their own preferences. This has generated empirical interest in estimating doctors' time preferences. However, these studies generally elicit doctors' private preferences (preferences for their own health) rather than professional preferences (preferences for the patient). We hypothesise that private and professional preferences may differ. Professional time preferences may be 'taught' in medical school or learned through repeated interactions with patients. If preferences differ then estimates of doctors' private preferences are less informative for medical decision-making. This study compares private and professional time preferences for health in a national sample of General Practitioners, using a between sample design. Time discounting is explored using exponential and quasi-hyperbolic models. We elicit time preferences using multiple price lists. We find no significant difference between the time preference for the self or the patient. This result holds for axiomatic discounting classification and maximum likelihood estimates. We do not find evidence of present-bias. There are a high proportion of increasingly impatient GPs, potentially implying a maximum 'willingness to wait' for treatment benefits. GPs value the health state differently between themselves or for a patient. These results suggest that we can use estimates of private preferences from doctors to inform medical decision-making.

A perspective on nonadherence to drug therapy: psychological barriers and strategies to overcome nonadherence

Medication adherence represents an inefficiency and ongoing challenge within medical care. The problem has been long-recognized - indeed, the research literature contains thousands of articles on the topic. Nonetheless, because of the complex nature of the problem, it still cannot be considered to be solved. Reasons for nonadherence are myriad but psychological barriers to adherence are most difficult to mitigate and, thus, are the focus of this paper. The present narrative review sketches a summary of theoretical models commonly utilized to understand and help address medication nonadherence; uses a patient-centered care approach to contextualize the problem of nonadherence to drug therapies; and then outlines a set of best-practice recommendations based on the extant data and framed from the perspective of the Information-Motivation-Strategy model.

Effectiveness of a multi-level implementation strategy for ASD interventions: study protocol for two linked cluster randomized trials

BACKGROUND

The Centers for Disease Control (2018) estimates that 1 in 59 children has autism spectrum disorder, and the annual cost of ASD in the U.S. is estimated to be $236 billion. Evidence-based interventions have been developed and demonstrate effectiveness in improving child outcomes. However, research on generalizable methods to scale up these practices in the multiple service systems caring for these children has been limited and is critical to meet this growing public health need. This project includes two, coordinated studies testing the effectiveness of the Translating Evidence-based Interventions (EBI) for ASD: Multi-Level Implementation Strategy (TEAMS) model. TEAMS focuses on improving implementation leadership, organizational climate, and provider attitudes and motivation in order to improve two key implementation outcomes-provider training completion and intervention fidelity and subsequent child outcomes. The TEAMS Leadership Institute applies implementation leadership strategies and TEAMS Individualized Provider Strategies for training applies motivational interviewing strategies to facilitate provider and organizational behavior change.

METHODS

A cluster randomized implementation/effectiveness Hybrid, type 3, trial with a dismantling design will be used to understand the effectiveness of TEAMS and the mechanisms of change across settings and participants. Study #1 will test the TEAMS model with AIM HI (An Individualized Mental Health Intervention for ASD) in publicly funded mental health services. Study #2 will test TEAMS with CPRT (Classroom Pivotal Response Teaching) in education settings. Thirty-seven mental health programs and 37 school districts will be randomized, stratified by county and study, to one of four groups (Standard Provider Training Only, Standard Provider Training + Leader Training, Enhanced Provider Training, Enhanced Provider Training + Leader Training) to test the effectiveness of combining standard, EBI-specific training with the two TEAMS modules individually and together on multiple implementation outcomes. Implementation outcomes including provider training completion, fidelity (coded by observers blind to group assignment) and child behavior change will be examined for 295 mental health providers, 295 teachers, and 590 children.

DISCUSSION

This implementation intervention has the potential to increase quality of care for ASD in publicly funded settings by improving effectiveness of intervention implementation. The process and modules will be generalizable to multiple service systems, providers, and interventions, providing broad impact in community services.

TRIAL REGISTRATION

This study is registered with Clinicaltrials.gov ( NCT03380078 ). Registered 20 December 2017, retrospectively registered.

Religious Affiliation, Religiosity, and Spirituality in Pediatric Residents: Effects on Communication and Self-Efficacy with Adolescents in a Clinical Setting

Religion and spirituality are known influences on medical providers' care of patients, but no studies have assessed resident beliefs related to patient perception of clinical care. The main objective of our study was to assess resident religious affiliation, religiosity, and spirituality in relation to self-efficacy and communication with patients during adolescent clinic visits. We found that religious affiliation and religiosity appear to affect patient perception of communication with residents during adolescent visits; spirituality had little noted effect. Further research is warranted, especially regarding resident and patient gender correlations and differences in religious affiliation effects on patient perception of care.

Evolution of gender representation among Canadian OTL-HNS residents: a 27-year analysis

Background

The proportion of females enrolling into medical schools has been growing steadily. However, the representation of female residents among individual specialties has shown considerable variation. The purpose of this study was to compare the trends of gender representation in Otolaryngology – Head and Neck Surgery (OTL-HNS) residency programs with other specialty training programs in Canada. In order to contextualize these findings, a second phase of analysis examined the success rate of applicants of different genders to OTL-HNS residency programs.

Method

Anonymized data were obtained from the Canadian Residency Matching Service (CaRMS) and from the Canadian Post-M.D. Education Registry (CAPER) from 1988 to 2014. The differences in gender growth rates were compared to other subspecialty programs of varying size. Descriptive analysis was used to examine gender representation among OTL-HNS residents across years, and to compare these trends with other specialties. Bayesian hierarchical models were fit to analyze the growth in program rates in OTL-HNS based on gender.

Results

CaRMS and CAPER data over a 27 year period demonstrated that OTL-HNS has doubled its female representation from 20% to 40% between 1990 and 1994 and 2010-2014. The difference in annual growth rate of female representation versus male representation in OTL-HNS over this time period was 2.7%, which was similar to other large specialty programs and surgical subspecialties. There was parity in success rates of female and male candidates ranking OTL-HNS as their first choice specialty for most years.

Conclusions

Female representation in Canadian OTL-HNS residency programs is steadily increasing over the last 27 years. Large variation in female applicant acceptance rates was observed across Canadian universities, possibly attributable to differences in student body or applicant demographics. Factors influencing female medical student career selection to OTL-HNS require further study to mitigate disparities in gender representation and identify barriers to prospective female OTL-HNS applicants.

The changing role of the health care customer: review, synthesis and research agenda

Purpose

The purpose of this paper is to synthesize findings from health care research with those in service research to identify key conceptualizations of the changing role of the health care customer, to identify gaps in theory, and to propose a compelling research agenda.

Design/methodology/approach

This study combines a meta-narrative review of health care research, and a systematic review of service research, using thematic analysis to identify key practice approaches and the changing role of the health care customer.

Findings

The review reveals different conceptualizations of the customer role within the ten key practice approaches, and identifies an increased activation of the role of the health care customer over time. This change implies a re-orientation, that is, moving away from the health care professional setting the agenda, prescribing and delivering treatment where the customer merely complies with orders, to the customer actively contributing and co-creating value with service providers and other actors in the ecosystem to the extent the health care customer desires.

Originality/value

This study not only identifies key practice approaches by synthesizing findings from health care research with those in service research, it also identifies how the role of the health care customer is changing and highlights effects of the changing role across the practice approaches. A research agenda to guide future health care service research is also provided.

Testing the leadership and organizational change for implementation (LOCI) intervention in substance abuse treatment: a cluster randomized trial study protocol

BACKGROUND

Evidence-based practice (EBP) implementation represents a strategic change in organizations that requires effective leadership and alignment of leadership and organizational support across organizational levels. As such, there is a need for combining leadership development with organizational strategies to support organizational climate conducive to EBP implementation. The leadership and organizational change for implementation (LOCI) intervention includes leadership training for workgroup leaders, ongoing implementation leadership coaching, 360° assessment, and strategic planning with top and middle management regarding how they can support workgroup leaders in developing a positive EBP implementation climate.

METHODS

This test of the LOCI intervention will take place in conjunction with the implementation of motivational interviewing (MI) in 60 substance use disorder treatment programs in California, USA. Participants will include agency executives, 60 program leaders, and approximately 360 treatment staff. LOCI will be tested using a multiple cohort, cluster randomized trial that randomizes workgroups (i.e., programs) within agency to either LOCI or a webinar leadership training control condition in three consecutive cohorts. The LOCI intervention is 12 months, and the webinar control intervention takes place in months 1, 5, and 8, for each cohort. Web-based surveys of staff and supervisors will be used to collect data on leadership, implementation climate, provider attitudes, and citizenship. Audio recordings of counseling sessions will be coded for MI fidelity. The unit of analysis will be the workgroup, randomized by site within agency and with care taken that co-located workgroups are assigned to the same condition to avoid contamination. Hierarchical linear modeling (HLM) will be used to analyze the data to account for the nested data structure.

DISCUSSION

LOCI has been developed to be a feasible and effective approach for organizations to create a positive climate and fertile context for EBP implementation. The approach seeks to cultivate and sustain both effective general and implementation leadership as well as organizational strategies and support that will remain after the study has ended. Development of a positive implementation climate for MI should result in more positive service provider attitudes and behaviors related to the use of MI and, ultimately, higher fidelity in the use of MI.

TRIAL REGISTRATION

This study is registered with Clinicaltrials.gov ( NCT03042832 ), 2 February 2017, retrospectively registered.

Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action

Deprescribing can be defined as the process of withdrawal or dose reduction of medications which are considered inappropriate in an individual. The aim of this narrative review is to provide an overview of "deprescribing"; firstly discussing the potential benefits and harms followed by the barriers to and enablers of deprescribing. We also provide practical recommendations to recognise opportunities and strategies for deprescribing in practice. Studies focused on minimizing polypharmacy indicate that deprescribing may be associated with potential benefits including resolution of adverse drug reactions, improved quality of life and medication adherence and a reduction in drug costs. While the data on the benefits is inconsistent, deprescribing appears to be safe. There are, however, potential harms including return of medical conditions or symptoms and adverse drug withdrawal reactions which emphasise the need for the process to be supervised and monitored by a health care professional. Taking action on deprescribing can be facilitated by knowledge of potential barriers, implementing a deprescribing process (utilising developed tools and resources) and identifying opportunities for deprescribing through engaging with patients and caregivers and other health care professionals and considering deprescribing in a variety of populations. Important areas for future research include the suitability of deprescribing of certain medications in specific populations, how to implement deprescribing processes into clinical care in a feasible and cost effective manner and how to engage consumers throughout the process to achieve positive health and quality of life outcomes.

Psychosocial predictors of DMARD adherence in the first three months of treatment for early arthritis

OBJECTIVES

To induce disease remission, early arthritis patients should adhere to their disease-modifying antirheumatic drugs (DMARD) in the first months after diagnosis. It remains unknown why some patients are non-adherent. We aimed to identify patients at risk for non-adherence in the first 3 months of treatment.

METHODS

Adult DMARD-naive early arthritis patients starting synthetic DMARDs filled out items on potential adherence predictors at baseline. Adherence was measured continuously. Non-adherence was defined as not opening the electronically monitored pill bottle when it should have been. Items were reduced and clustered using principal component analysis. The most discriminating items were identified with latent trait models. We used a multivariable logistic regression model to find non-adherence predictors.

RESULTS

301 patients agreed to participate. Adherence was high and declined over time. Principal component analysis led to 7 dimensions, while subsequent latent trait models analyses led to 15 dimensions. Two dimensions were associated with adherence, one dimension was associated with non-adherence.

CONCLUSIONS

Information seeking behavior and positive expectations about the course of the disease are associated with adherence. Patients who become passive because of pain are at risk for non-adherence.

PRACTICE IMPLICATIONS

Rheumatologists have cues to identify non-adherence, and may intervene on non-adherence through implementing shared decision making techniques.

Enhancing Health Communication Outcomes Among Ethnic Minority Patients: The Effects of the Match Between Participation Preferences and Perceptions and Doctor-Patient Concordance

Ethnic minority patients are less participative in medical consultations compared to ethnic majority patients. It is thus important to find effective strategies to enhance ethnic minority patients' participation and improve subsequent health outcomes. This study therefore aimed to investigate the relation between the match between patients' preferred and perceived participation and doctor-patient concordance in preferred doctor-patient relationship on patient satisfaction, fulfillment of information needs, and understanding of information among Turkish-Dutch and Dutch patients. Pre- and postconsultation questionnaires were filled out by 136 Dutch and 100 Turkish-Dutch patients in the waiting rooms of 32 general practitioners (GPs). GPs completed a questionnaire too. Results showed that a match between patients' preferred and perceived participation was related to higher patient satisfaction, more fulfillment of information needs, and more understanding of information than a mismatch for both patient groups. For doctor-patient concordance a conditional main effect on all outcome measures emerged only among Turkish-Dutch patients. That is, for patients who were discordant with their GP, higher perceived participation was related to lower satisfaction, worse fulfillment of information needs, and worse understanding of the information. In order to improve medical communication GPs should thus primarily be trained to tailor their communication styles to match patients' preferences for participation.

Medication adherence among pregnant women with hypothyroidism-missed opportunities to improve reproductive health? A cross-sectional, web-based study

OBJECTIVE

To evaluate patterns of and factors associated with a lack of pharmacotherapy as well as low adherence to treatment of hypothyroidism in pregnancy.

METHODS

This multinational, cross-sectional, internet-based study recruited pregnant woman in 18 countries. Data about women's socio-demographic and medical characteristics, medication adherence (8-item Morisky Medication Adherence Scale), beliefs about medication (Beliefs about Medicine Questionnaire), and personality traits (Big Five Personality Trait questionnaire) were collected via an online questionnaire.

RESULTS

229 of 5095 women had hypothyroidism during pregnancy; of these, 93% reported hypothyroidism pharmacotherapy. Adherence was low among 17% (95% CI: 12.5-22.5%) of medicated women, whilst it was moderate and high among 44% and 39%, respectively. Not using folic acid and not living in a stable relationship were associated with an increased likelihood for untreated hypothyroidism. Younger maternal age and not using folic acid in pregnancy were factors significantly associated with low adherence. Conscientiousness and the perception that the benefit of pharmacotherapy outweighed the risks were associated with higher levels of adherence.

CONCLUSION

There is room for improvement of adherence to hypothyroidism treatment in pregnancy.

PRACTICE IMPLICATIONS

Counselling of women with hypothyroidism in pregnancy should include a proper risk communication and information framing, to ameliorate maternal and foetal health.

The evaluation of a healthcare passport to improve quality of care and communication for people living with dementia (EQuIP): a protocol paper for a qualitative, longitudinal study

Background

There is an urgent need for the development of simple communication tools that convey the strengths, assets, and healthcare needs of people living with dementia. A Healthcare Passport may improve communication with range of health and social support services, enhancing quality and continuity of care, and to permit a consideration of the challenges and how these might be managed effectively and compassionately. This study aims to evaluate the acceptability and use of this type of intervention for people living with dementia and their carers.

Methods/Design

This is a qualitative longitudinal study informed by a critical realist review. The participants will be individuals identified as having mild-moderate dementia and informal carers. The in-depth interviews will occur at three points over the course of 18 months as they use the passport. This will be supplemented by analysis of the content of the passports and information from health and social care providers on the daily practicalities of using the passport in a range of healthcare settings.

Discussion

By using a critical realist review and a qualitative, longitudinal approach, the study allows for the assessment of a complex intervention in a manner which goes beyond evaluating the basic efficacy of the passport, but looking more deeply at how it worked, for whom, and in what context. It has the potential to develop new data on how interventions improve communication across a range of service providers, while encouraging health and social care professionals to respect and encourage the development of self-management and retention of personhood throughout the progression of life-limiting illnesses.

Providing Patient-Centered Culturally Sensitive Health Care

This article describes the literature-based, testable, formative Patient-Centered Culturally Sensitive Health Care Model that explains the associations between patient-centered culturally sensitive health care, health-promoting treatment behaviors, and health outcomes and statuses. An intervention program based on the model and its foundational research are also described. In addition, the article summarizes research concerning the ongoing evaluation of the model and the intervention program as well as the development of pilot inventories to assess patient-centered culturally sensitive health care in community-based primary care clinics.

Perceptions of the quality of the therapeutic alliance in chiropractic care in The Netherlands: a cross-sectional survey

Background

Research in various medical fields demonstrates a consistent and positive association between clinical outcomes and the quality of the therapeutic alliance between the patient and clinician. The aim of this study was to explore how well chiropractors and their patients in The Netherlands perceive the quality of their working relationship.

Methods

A nationwide survey of chiropractors and their patients was conducted in The Netherlands, using a validated Dutch translation of the Working Alliance Inventory (WAV-12). Data were collected over a 5-week period in September-October 2014. Both patients and chiropractors were requested to reflect on 12 statements about to how well they perceived their collaboration in reaching consensus on treatment goals and treatment strategies, and how well they perceived the existence of an affective bond in their working relationship. A 5-point Likert scale was used to answer each question. Higher ratings reflected a more positive perception of the therapeutic alliance. Furthermore, levels of agreement between patients’ and chiropractors’ perceptions of the quality of their therapeutic alliance were determined.

Results

In total, 207 working relationships between patients and their chiropractor were analysed. The quality of the therapeutic alliance was perceived as being very positive for both patients (n = 183, mean 49.14 ± 7.12) and chiropractors (n = 202, mean 50.48 ± 4.97). There was no difference in patients’ perceptions whether treated by a male or female chiropractor, nor in relation to the chiropractor’s years of experience. Nevertheless, poor agreement was found between perceptions of patients and chiropractors in the same relationship (ICC = 0.13).

Conclusions

Both patients and chiropractors perceived the quality of the therapeutic alliance as being very positive. Despite these positive results, patient and chiropractor pairs perceived the level of collaboration in order to reach agreement on treatment goals and strategies and the quality of their affective bond very differently. Clinically, these results suggest that chiropractors should, during the course of treatment, continue to collaborate with their patient and frequently verify whether their patient continues to agree with the treatment goals and treatment plan applied to further develop, improve and maintain a positive therapeutic alliance.

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-016-0100-4) contains supplementary material, which is available to authorized users.

Effective Patient-Provider Communication in Pediatric Obesity

Effective patient-provider communication is not a primary focus of medical school curricula. Motivational interviewing (MI) is a patient-centered, directive communication framework appropriate for in health care. Research on MI's causal mechanisms has established patient change talk as a mediator of behavior change. Current MI research focuses on identifying which provider communication skills are responsible for evoking change talk. MI recommends informing, asking, and listening. Research provides evidence that asking for and reflecting patient change talk are effective communication strategies, but cautions providers to inform judiciously. Supporting a patient's decision making autonomy is an important strategy to promote health behaviors.

When do cancer patients regret their treatment decision? A path analysis of the influence of clinicians' communication styles and the match of decision-making styles on decision regret

OBJECTIVE

To test the influence of physician empathy (PE), shared decision making (SDM), and the match between patients' preferred and perceived decision-making styles on patients' decision regret.

METHODS

Patients with breast or colon cancer (n=71) completed questionnaires immediately following (T1) and three months after a consultation (T2). Path analysis was used to examine the relationships among patient demographics, patient reports of PE, SDM, the match between preferred and perceived decision-making styles, and patient decision regret at T2.

RESULTS

After controlling for clinician clusters, higher PE was directly associated with more SDM (β=0.43, p<0.01) and lower decision regret (β=-0.28, p<0.01). The match between patients' preferred and perceived roles was negatively associated with decision regret (β=-0.33, p<0.01). Patients who participated less than desired reported more decision regret at T2. There was no significant association between SDM and decision regret (β=0.03, p=0.74).

CONCLUSION

PE and the match between patients' preferred and perceived roles in medical decision making are essential for patient-centered cancer consultations and treatment decisions.

PRACTICE IMPLICATIONS

Ways to enhance PE and matching the consultation style to patients' expectations should be encouraged.

Italian translation and cultural adaptation of the communication assessment tool in an outpatient surgical clinic

Background

The aim of the study is to translate and cross-culturally adapt, for use in the Italian context, the Communication Assessment Tool (CAT) developed by Makoul and colleagues.

Methods

The study was performed in the out-patient clinic of the Surgical Department of Cardarelli Hospital in Naples, Italy. It involved a systematic, standardized, multi-step process adhering to internationally accepted and recommended guidelines. Corrections and adjustments to the translation addressed both linguistic factors and cultural components.

Results

The CAT was translated into Italian by two independent Italian mother-tongue translators. The consensus version was then back-translated by an English mother-tongue translator. This translation process was followed by a consensus meeting between the authors of translation and investigators, and then by two comprehension tests on a total of 65 patients.

Conclusions

Results of the translation and cross-cultural adaptation were satisfactory and indicate that the Italian translation of the CAT can be used with confidence in the Italian context.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1411-9) contains supplementary material, which is available to authorized users.

Implementing Treat-to-Target Practices for Chronic Pain Through Shared Decision Making: Requisites, Prospects, and Challenges

OBJECTIVE

Treat-to-target (T2T) includes a target or goal, standard symptom assessment, and a treatment decision. In specialties that threat chronic pain, T2T is expected to be implemented collaboratively. The ability of patients to participate fully has been questioned, but these concerns have not been demonstrated empirically. The current study examined how patient self-assessed symptom measures and illness beliefs affect their willingness to change their current treatment.

METHODS

A total of 157 patients with rheumatoid arthritis completed a standard "disease activity" (DA) battery consisting of current joint pain, recent pain, daily functioning, and generality disability assessments, along with an illness belief questionnaire and a willingness to change measure. Data were collected at 2-month intervals over a 6-month period. Single and multiple influences on willingness to change were examined using linear mixed models.

RESULTS

Willingness is strongly and directly associated with DA scores. Beliefs that were significant as single factors became nonsignificant once DA scores were introduced. The findings established a strong and consistent link between DA scores and willingness, and ruled out the prospect that illness beliefs mediate or moderate this relationship. It was also found that willingness to change is directly related to the number of significant self-reported symptoms.

CONCLUSION

Concerns about the ability of patients to participate in a collaborative implementation of T2T were not substantiated. Future studies can examine the subtle interplay of goals, assessments, and treatment decisions and clarify outstanding issues about the practice of clinical decision making.

Patients' and rheumatologists' preferences for the attributes of biological agents used in the treatment of rheumatic diseases in Spain

PURPOSE

To define importance values assigned to attributes of biological agents (BAs) by Spanish patients with rheumatic diseases (rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis) and rheumatologists.

PATIENTS AND METHODS

This was an observational, cross-sectional design based upon a rank-based full-profile conjoint analysis. A literature review and four focus groups were undertaken to identify attributes and levels. An orthogonal matrix, combining the selected levels of attributes, was used to define scenarios. Participants ranked eight scenarios from 1 (most preferred) to 8 (least preferred). The relative importance (RI) of attributes was calculated. Multivariate regression analysis was performed to identify the characteristics that influenced the values of RI. A total of 488 patients (male 50.9%, mean age 50.6 [standard deviation {SD} 12.06] years, rheumatoid arthritis 33.8%, ankylosing spondylitis 32.4%, psoriatic arthritis 33.8%; mean time since diagnosis 12.6 [SD 8.2] years) and 136 rheumatologists (male 50.4%, mean age 46.4 [SD 9.1] years, mean time of practice 16.7 [SD 8.8] years) participated.

RESULTS

The ideal BAs for patients and physicians, respectively, should allow pain relief and improvement of functional capacity (RI 39% and 44.7%), with low risk of adverse events (RI 24.9% and 30.5%), a long time prior to perceiving the need for a new dose (RI 16.4% and 12.4%), and self-administration at home (RI 19.7% and 12.5%), as identified through their preferences.

CONCLUSION

Although efficacy and safety are paramount for patients and rheumatologists to make a choice regarding BAs, the need for a low frequency of administration and the administration method also play a role as preference attributes for BAs.

"We can't provide season tickets to the opera": Staff perceptions of providing preference based person centered care

Knowledge of a nursing home resident's everyday living preferences provides the foundation for ongoing individualized care planning.

OBJECTIVE

The purpose of this study is to identify nursing home (NH) staff perceptions of facilitators and barriers to learning about and meeting residents' preferences and reasons why staff feel residents change their minds about preferences.

METHODS

Focus group sessions and interviews were conducted with 36 NH staff members working in a facility that has been actively assessing resident preferences for five years.

RESULTS

Thematic codes classifying facilitators, barriers, and dependencies were identified. Staff shared ways they are able to help meet residents' preferences as well as barriers to fulfilling resident preferences through their own behaviors, facility characteristics, the social environment, and resident characteristics. In addition, staff believe that residents change their minds about important preferences 'depending on' several factors including; global environmental characteristics, social environment, resident characteristics, and general staff perceptions.

CONCLUSIONS

This work identifies key facilitators and barriers to consider when implementing quality improvement efforts designed to improve the person-centered nature of care in nursing homes and is intended to further inform the culture change movement, which aims to transform NHs by empowering staff and delivering person-centered care.

Non-adherence to disease-modifying antirheumatic drugs is associated with higher disease activity in early arthritis patients in the first year of the disease

Introduction

Non-adherence to disease-modifying antirheumatic drugs (DMARDs) hampers the targets of rheumatoid arthritis (RA) treatment, obtaining low disease activity and decreasing radiological progression. This study investigates if, and to what extent, non-adherence to treatment would lead to a higher 28-joint count disease activity score (DAS28) in the first year after diagnosis.

Methods

Adult patients from an ongoing cohort study on treatment adherence were selected if they fulfilled the EULAR/ACR2010 criteria for RA, and were to start with their first DMARDs. Clinical variables were assessed at baseline and every 3 months. Non-adherence was continuously electronically measured and was defined as the proportion of days with a negative difference between expected and observed openings of the medication container out of the 3-month period before DAS28 measurement. Generalized linear mixed models were used to investigate whether the DAS28 related to non-adherence. Covariates included were age, sex, baseline DAS28, rheumatoid factor positivity, anti-cyclic citrullinated peptide antibodies (ACPA) positivity, anxiety, depression, weeks of treatment, number of DMARDs used, education level, use of subcutaneous methotrexate and biological use.

Results

One hundred and twenty patients met the inclusion criteria for RA. During the study period 17 patients became lost to follow-up. There was a decline in adherence over time for all DMARDs except for prednisone. Non-adherence is a predictor of disease activity in the first 6 months of therapy, adjusted for weeks of treatment, baseline DAS28, and baseline anxiety.

Conclusions

Non-adherence relates to disease activity. Therefore, interventions towards enhancing adherence can improve disease outcome.

Physician behavioral adaptability: A model to outstrip a "one size fits all" approach

OBJECTIVE

Based on a literature review, we propose a model of physician behavioral adaptability (PBA) with the goal of inspiring new research. PBA means that the physician adapts his or her behavior according to patients' different preferences. The PBA model shows how physicians infer patients' preferences and adapt their interaction behavior from one patient to the other. We claim that patients will benefit from better outcomes if their physicians show behavioral adaptability rather than a "one size fits all" approach.

METHOD

This literature review is based on a literature search of the PsycINFO(®) and MEDLINE(®) databases.

RESULTS

The literature review and first results stemming from the authors' research support the validity and viability of parts of the PBA model. There is evidence suggesting that physicians are able to show behavioral flexibility when interacting with their different patients, that a match between patients' preferences and physician behavior is related to better consultation outcomes, and that physician behavioral adaptability is related to better consultation outcomes.

PRACTICE IMPLICATIONS

Training of physicians' behavioral flexibility and their ability to infer patients' preferences can facilitate physician behavioral adaptability and positive patient outcomes.

Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process

Inappropriate use of medication is widespread, especially in older people, and is associated with risks, including adverse drug reactions, hospitalization and increased mortality. Optimization of appropriate medication use to minimize these harms is an ongoing challenge in healthcare. The term 'deprescribing' has been used to describe the complex process that is required for safe and effective cessation of medication. Patients play an important role in their own health and, while they may complain about the number of medications they have to take, they may also be reluctant to cease a medication when given the opportunity to do so. A review of previously proposed deprescribing processes and relevant literature was used to develop the patient-centred deprescribing process, which is a five-step cycle that encompasses gaining a comprehensive medication history, identifying potentially inappropriate medications, determining whether the potentially inappropriate medication can be ceased, planning the withdrawal regimen (e.g. tapering where necessary) and provision of monitoring, support and documentation. This is the first deprescribing process developed using knowledge of the patients' views of medication cessation; it focuses on engaging patients throughout the process, with the aim of improving long-term health outcomes. Despite a comprehensive review of the literature, there is still a lack in the evidence base on which to conduct deprescribing. The next step in broadening the evidence to support deprescribing will be to test the developed process to determine feasibility in the clinical setting.