A patient self-assessment tool to measure communication behaviors during doctor visits about hypertension

Evaluation of a Multimodal, Direct-to-Patient Educational Intervention Targeting Barriers to Osteoporosis Care: A Randomized Clinical Trial

Osteoporosis treatment rates are declining, even among those with past fractures. Novel, low-cost approaches are needed to improve osteoporosis care. We conducted a parallel group, controlled, randomized clinical trial evaluating a behavioral intervention for improving osteoporosis medication use. A total of 2684 women with self-reported fracture history after age 45 years not using osteoporosis therapy from US Global Longitudinal Study of Osteoporosis in Women (GLOW) sites were randomized 1:1 to receive a multimodal, tailored, direct-to-patient, video intervention versus usual care. The primary study outcome was self-report of osteoporosis medication use at 6 months. Other outcomes included calcium and vitamin D supplementation, bone mineral density (BMD) testing, readiness for behavioral change, and barriers to treatment. In intent-to-treat analyses, there were no significant differences between groups (intervention versus control) in osteoporosis medication use (11.7% versus 11.4%, p = 0.8), calcium supplementation (31.8% versus 32.6%, p = 0.7), vitamin D intake (41.3% versus 41.9%, p = 0.8), or BMD testing (61.8% versus 57.1%, p = 0.2). In the intervention group, fewer women were in the precontemplative stage of behavior change, more women reported seeing their primary care provider, had concerns regarding osteonecrosis of the jaw, and difficulty in taking/remembering to take osteoporosis medications. We found differences in BMD testing among the subgroup of women with no prior osteoporosis treatment, those who provided contact information, and those with no past BMD testing. In per protocol analyses, women with appreciable exposure to the online intervention (n = 257) were more likely to start nonbisphosphonates (odds ratio [OR] = 2.70; 95% confidence interval [CI] 1.26-5.79) compared with the usual care group. Although our intervention did not increase the use of osteoporosis therapy at 6 months, it increased nonbisphosphonate medication use and BMD testing in select subgroups, shifted participants' readiness for behavior change, and altered perceptions of barriers to osteoporosis treatment. Achieving changes in osteoporosis care using patient activation approaches alone is challenging. © 2018 American Society for Bone and Mineral Research.

A multi-modal intervention for Activating Patients at Risk for Osteoporosis (APROPOS): Rationale, design, and uptake of online study intervention material

OBJECTIVE

To develop an innovative and effective educational intervention to inform patients about the need for osteoporosis treatment and to determine factors associated with its online uptake.

METHODS

Postmenopausal women with a prior fracture and not currently using osteoporosis therapy were eligible to be included in the Activating Patients at Risk for OsteoPOroSis (APROPOS). Four nominal groups with a total of 18 racially/ethnically diverse women identified osteoporosis treatment barriers. We used the Information, Motivation, Behavior Skills conceptual model to develop a direct-to-patient intervention to mitigate potentially modifiable barriers to osteoporosis therapy. The intervention included videos tailored by participants' race/ethnicity and their survey responses: ranked barriers to osteoporosis treatment, deduced barriers to treatment, readiness to behavior change, and osteoporosis treatment history. Videos consisted of "storytelling" narratives, based on osteoporosis patient experiences and portrayed by actresses of patient-identified race/ethnicity. We also delivered personalized brief phone calls followed by an interactive voice-response phone messages aimed to promote uptake of the videos.

RESULTS

To address the factors associated with online intervention uptake, we focused on participants assigned to the intervention arm (n = 1342). These participants were 92.9% Caucasian, with a mean (SD) age 74.9 (8.0) years and the majority (77.7%) had some college education. Preference for natural treatments was the barrier ranked #1 by most (n = 130; 27%), while concern about osteonecrosis of the jaw was the most frequently reported barrier (at any level; n = 322; 67%). Overall, 28.1% (n = 377) of participants in the intervention group accessed the videos online. After adjusting for relevant covariates, the participants who provided an email address had 6.07 (95% CI 4.53-8.14) higher adjusted odds of accessing their online videos compared to those who did not.

CONCLUSION

We developed and implemented a novel tailored multi-modal intervention to improve initiation of osteoporosis therapy. An email address provided on the survey was the most important factor independently associated with accessing the intervention online. The design and uptake of this intervention may have implications for future studies in osteoporosis or other chronic diseases.

Question Prompt Lists in health consultations: A review

OBJECTIVES

This review examines the use and effectiveness of Question Prompt Lists (QPL) as communication aids to enhance patient question asking, information provision to patients and patient participation in health and medical consultations.

METHODS

A systematic search was undertaken to identify relevant literature concerning QPLs including academic databases, Google-based and snowball searching. Forty-two relevant studies reporting 50 interventions were identified.

RESULTS

Although findings varied there was some evidence that a QPL endorsed by the physician increased total question asking. Using a QPL increased question asking concerning specific content areas (e.g. prognosis). There was some evidence that physicians provided more information during consultations. There were no consistent findings concerning effects on patient knowledge recall, anxiety and satisfaction or consultation time. Some interventions that increased question asking had longer consultation times.

CONCLUSION

There is evidence that an appropriate QPL, endorsed by the physician and provided immediately before the consultation, may increase patient question asking and lead to more information being provided by the physician.

PRACTICE IMPLICATIONS

There is increasing evidence to support QPL use in routine practice. Further trials might address the issues identified including an assessment of QPL optimal length and QPL adaptation for cultural and special needs groups.

Clinical Governance Infrastructures and Relational Mechanisms of Control in Healthcare Organizations

This review paper aims to identify and discuss the dominant themes surrounding the governance initiatives in the context of medical markets relying on the two most common search strategies, namely the keyword search technique and the ancestry approach. In an in-depth examination of the recently published research in the field we uncover an emergent decoupling between the governance initiatives formulated at the macro- and micro-levels in today’s institutions of healthcare provision. The macro-level initiatives are associated with clinical governance infrastructures directed towards the attainment of medical performance targets, whereas the micro-level endeavors refer to relational governance mechanisms for overseeing the relationship between the patient and the physician. Acknowledging the importance of monitoring micro-level interactions that may contribute to the achievement of macro-level objectives, a more comprehensive integration of relational governance devices under the broader system of clinical governance is advocated in this paper with the purpose of enhancing the effectiveness of healthcare organizations.

Patient communication competence: development of a German questionnaire and correlates of competent patient behavior

OBJECTIVE

The aim of our study was to design and psychometrically test a patient questionnaire to capture patient communication competence in the context of patient-provider interaction (CoCo questionnaire). We also aimed to determine patient characteristics associated with competent patient behavior.

METHODS

To assure content validity, we initially conducted 17 focus groups (n=97) made up of patients and providers. In the main study n=1.264 patients with chronic back pain, chronic-ischemic heart disease or breast cancer who underwent inpatient rehabilitation were surveyed at the end of rehabilitation.

RESULTS

The CoCo questionnaire contains four scales (patient adherence in communication, critical and participative communication, communication about personal circumstances, active disease-related communication) and 28 items addressing competent patient behavior. We provide evidence of unidimensionality, local independence, reliability, a Rasch-Model fit, the absence of differential item functioning, and signs of construct validity. The most important correlates of communication competence are health literacy and communication self-efficacy.

CONCLUSION

The CoCo questionnaire has good psychometric properties in German. Future research should examine CoCo's responsiveness and analyze criterion validity by means of observation data.

PRACTICE IMPLICATIONS

The CoCo questionnaire can be recommended for use in evaluating patient communication training programs.

The positive mental health instrument: development and validation of a culturally relevant scale in a multi-ethnic Asian population

Background

Instruments to measure mental health and well-being are largely developed and often used within Western populations and this compromises their validity in other cultures. A previous qualitative study in Singapore demonstrated the relevance of spiritual and religious practices to mental health, a dimension currently not included in exiting multi-dimensional measures. The objective of this study was to develop a self-administered measure that covers all key and culturally appropriate domains of mental health, which can be applied to compare levels of mental health across different age, gender and ethnic groups. We present the item reduction and validation of the Positive Mental Health (PMH) instrument in a community-based adult sample in Singapore.

Methods

Surveys were conducted among adult (21-65 years) residents belonging to Chinese, Malay and Indian ethnicities. Exploratory and confirmatory factor analysis (EFA, CFA) were conducted and items were reduced using item response theory tests (IRT). The final version of the PMH instrument was tested for internal consistency and criterion validity. Items were tested for differential item functioning (DIF) to check if items functioned in the same way across all subgroups. Results: EFA and CFA identified six first-order factor structure (General coping, Personal growth and autonomy, Spirituality, Interpersonal skills, Emotional support, and Global affect) under one higher-order dimension of Positive Mental Health (RMSEA = 0.05, CFI = 0.96, TLI = 0.96). A 47-item self-administered multi-dimensional instrument with a six-point Likert response scale was constructed. The slope estimates and strength of the relation to the theta for all items in each six PMH subscales were high (range:1.39 to 5.69), suggesting good discrimination properties. The threshold estimates for the instrument ranged from -3.45 to 1.61 indicating that the instrument covers entire spectrums for the six dimensions. The instrument demonstrated high internal consistency and had significant and expected correlations with other well-being measures. Results confirmed absence of DIF.

Conclusions

The PMH instrument is a reliable and valid instrument that can be used to measure and compare level of mental health across different age, gender and ethnic groups in Singapore.