Physician–patient communication following invasive procedures: an analysis of post-angiogram consultations

The Relationship of Race/Ethnicity Concordance to Physician-Patient Communication: A Mixed-Methods Systematic Review

The concept of race or ethnic concordance between health care provider and patient has emerged as a dimension of the patient-physician relationship that could influence health outcomes for patients from minoritized groups, particularly through differences in the way physicians communicate with patients based on race or ethnicity. However, two decades of study on concordance and physician-patient communication have produced contradictory results. Given the heightened societal awareness of racism and the persistence of health disparities, there is a need for a comprehensive review of the current state of knowledge. This review sets out to determine how communication patterns differ in race/ethnicity concordant versus discordant patient-physician medical encounters. Thirty-three studies employing a range of methodologies were identified. In most analyses, after accounting for covariates, no relationship was found between race/ethnicity concordance and communication variables. Race/ethnicity concordance with their physician does not appear to influence the quality of communication for most patients from minoritized groups. A number of methodological weaknesses were identified in existing research, among them: few studies investigated potential explanatory variables, the heterogeneity of ethnic and cultural experience was over-simplified, there was little consistency in operationalization of communication variables, and the physician-patient dynamic was inadequately conceptualized.

Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): a Qualitative Analysis of a Tailored Coaching Program for Black Patients with Chronic Pain

BACKGROUND

Racial inequities in pain treatment are well-documented and persist despite national priorities focused on health equity. The COOPERATE (Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity) intervention was a patient-centered, tailored intervention aimed at improving health equity by targeting patient activation-the knowledge and confidence to manage one's health. COOPERATE led to significant and sustained increases in patient activation, significant short-term increases in communication self-efficacy (confidence to communicate with clinicians), and more intervention participants experienced clinically significant (≥ 30%) reductions in pain at 3 months than control group participants.

OBJECTIVE

To understand how participants experienced the intervention, including their perspectives on its effects on their health and healthcare experiences.

DESIGN

Semi-structured qualitative interviews.

PARTICIPANTS

Black veterans with chronic pain who participated in the COOPERATE intervention.

KEY RESULTS

Participants described acquiring new tools and cultivating skills to use in their clinic visits, including preparing for their visit (writing an agenda, listing questions); asking focused, effective questions; and expressing concerns and communicating goals, values, and preferences. Participants indicated that by putting these tools to use, they felt more confident and able to take ownership of their own pain care; for some, this led to better pain management and improved pain. Participants expressed mixed views of disparities in pain care, with some believing race and racism did not play a role in their care, while others valued being part of an intervention that helped equip them with tools to exercise autonomy over their healthcare.

CONCLUSIONS

Black patients with chronic pain described gaining greater confidence to self-manage and communicate with their clinicians after participating in the COOPERATE intervention. With its focus on empowering individuals, the COOPERATE intervention represents a promising approach to help advance equity in pain care.

Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): a randomized clinical trial

ABSTRACT

Racialized disparities in chronic pain care are well-documented and persist despite national priorities focused on health equity. Similar disparities have been observed in patient activation (ie, having the knowledge, confidence, and skills to manage one's health). As such, interventions targeting patient activation represent a novel approach to addressing and reducing disparities in pain care. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity is a randomized controlled trial of a 6-session telephone-delivered intervention to increase patient activation for Black patients with chronic pain. Two hundred fifty Black patients from a Midwestern Veterans Affairs medical center were randomized to the intervention or attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline and at 3 (primary endpoint), 6, and 9 months (sustained effects). Analyses used an intent-to-treat approach. Compared with baseline, patient activation increased 4.6 points at 3 months (versus +0.13 in control group, 95% CI: 0.48, 7.34; P = 0.03). These improvements in the intervention group were sustained, with +7 from baseline at 6 months and +5.77 at 9 months, and remained statistically significant from the control group. Communication self-efficacy increased significantly relative to the control group from baseline to 3 months. Pain intensity and interference improved at 3 months, but differences were not significant after adjusting for multiple comparisons. Most other secondary outcomes improved, but group differences were not statistically significant after controlling for multiple comparisons. Results suggest that increasing patient activation is a potentially fruitful path toward improving pain management and achieving health equity.

The Effect of Race and Area Deprivation on Symptom Profiles over the Course of Early-Stage Breast Cancer

Purpose

This study compared common symptoms (fatigue, pain), overall physical functioning and changes over time between Black and White women receiving early-stage breast cancer (ESBC) chemotherapy.

Methods

A longitudinal, repeated measures comparative design was employed. Time points of symptom measurement (PROMIS domains) at baseline, mid and end point were adjusted as per patient chemotherapy schedule.

Analyses

Linear mixed models were applied.

Results

There were 147 patients, 36% Black 64% White (54±12 years) recommended to receive early-stage breast cancer chemotherapy with adequate data for symptom analysis.

Pain

Main effect of race was significant (F(1, 390) = 29.43, p<.001) for pain with Black patients experiencing significantly higher pain scores compared to White patients at pretherapy (Mean Difference; MD=3.7, p=.034), midpoint (MD=5.8, p=.002), and endpoint (MD=7.8, p<.001).

Fatigue

Fatigue significantly increased (deteriorated) at endpoint (MDT1-T3= 8.7, p<.001) for Black patients. Among White patients, fatigue significantly increased at midpoint (MDT1-T2= 5.7) and at endpoint (MDT1-T3=10.1, p<.001; MDT2-T3=4.3, p= .017). Physical function: Black patients had significantly lower physical function scores compared to White patients at midpoint (MD=4.0, p=.027). Physical function decreased by endpoint in Black (MDT1-T3=7.8, p<.001), and White patients (MDT1-T3=7.7, p<.001).

Conclusion

Symptom burden significantly increased over the course of chemotherapy for all patients. Scores for pain and physical function were higher overall for Black patients and deteriorated at a greater rate for Black vs. White women over the course of chemotherapy. This assessment holds implication for proactive assessment and mitigation strategies.

Neighborhood disadvantage and pediatric inpatient opioid prescription patterns

BACKGROUND

To explore the role of children's residential environment on opioid prescribing patterns in a predominantly Latinx sample.

METHODS

We connected geocoded data from electronic medical records in a diverse sample of pediatric patients to neighborhood environments constructed using latent profile modeling techniques. We then estimated a series of multilevel models to determine whether opioid prescribing patterns vary by residential context.

RESULTS

A stepwise pattern exists between neighborhood disadvantage and pediatric opioid prescription patterns, such that higher levels of disadvantage associate with a greater likelihood of opioid prescription, independent of the patient's individual profile.

CONCLUSION

In a largely Latinx sample of children, the neighborhood in which a child lives influences whether or not they will receive opioids. Considering the differences in patient residential environment may reduce variation in opioid dispensing rates among pediatric patients.

Racial disparities in time to laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Disparities in healthcare exist, yet few data are available on racial differences in time from admission to surgery. This study aimed to compare time from admission to laparoscopic cholecystectomy for acute cholecystitis between non-Hispanic Black and non-Hispanic White patients.

METHODS

Patients who underwent laparoscopic cholecystectomy for acute cholecystitis from 2010 to 2020 were identified using NSQIP. Time to surgery and additional preoperative, operative, and postoperative variables were analyzed.

RESULTS

In the univariate analysis, 19.4% of Black patients experienced a time to surgery >1 day compared with 13.4% of White patients (p < 0.0001). In the multivariable analysis, controlling for potential confounding factors, Black patients were found to be more likely than White patients to experience a time to surgery >1 day (OR 1.23, 95% CI 1.17-1.30, p < 0.0001).

CONCLUSIONS

Further investigation is indicated to better define the nature and significance of gender, race, and other biases in surgical care. Surgeons should be aware that biases may adversely impact patient care and should strive to identify and proactively address them to promote health equity in surgery.

Healthcare Access and Delivery During the COVID-19 Pandemic for Black Veterans with Chronic Pain: a Qualitative Study

BACKGROUND

The COVID-19 pandemic led to significant disruptions in healthcare and rapid increases in virtual healthcare delivery. The full effects of these shifts remain unknown. Understanding effects of these disruptions is particularly relevant for patients with chronic pain, which typically requires consistent engagement in treatment to maximize benefit, and for Black patients, given documented racial disparities in pain treatment and telehealth delivery.

OBJECTIVE

To understand how Black patients with chronic pain experienced pandemic-related changes in healthcare delivery.

DESIGN

In-depth, semi-structured qualitative interviews PARTICIPANTS: Black veterans with chronic pain.

KEY RESULTS

Participants described decreased ability to self-manage their chronic pain, obtain nonpharmacological services such as physical therapy, see their primary care providers, and schedule surgery. Most did not believe telehealth met their needs, describing feeling inadequately assessed for their pain and noting that beyond renewing prescriptions, telehealth visits were not that useful. Some believed their communication with their providers suffered from a lack of in-person contact. Others, however, were willing to accept this tradeoff to prevent possible exposure to COVID-19, and some appreciated the convenience of being able to access healthcare from home.

CONCLUSIONS

Black patients with chronic pain described mostly negative effects from the shift to telecare after the pandemic's onset. Given existing disparities and likely persistence of virtual care, research on the longer-term effects of virtual pain care for Black patients is needed.

Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): Rationale, study design, methods, and sample characteristics

BACKGROUND

Chronic pain is associated with profound negative effects, and racial disparities are well-documented in chronic pain treatment. In addition, Black patients report poorer communication with providers and exhibit lower levels of patient activation (self-management self-efficacy) than White patients. Although the causes of healthcare disparities are complex and require intervention at multiple levels, empowering patients is one critical path to achieving health equity. The current study is a coaching intervention focused on increasing patient activation and building communication skills for Black patients with chronic pain.

METHODS

In this randomized controlled trial, 250 Black patients with chronic pain were randomized to either the coaching intervention or an attention control arm. Intervention patients attended 6 telephone-delivered individual coaching sessions over 12 weeks. Coaching focused on clarifying and prioritizing goals and on communication skills, such as agenda setting. The primary outcome is patient activation. Secondary outcomes include communication self-efficacy, pain intensity and interference, and psychological functioning.

DISCUSSION

Having the knowledge and confidence to participate in one's pain care, coupled with the skills needed to effectively communicate with providers, is essential to optimize chronic pain care. This is particularly important for Black patients who often experience lower quality pain care. Interventions such as COOPERATE hold promise for helping patients to acquire the requisite tools to take greater control of their chronic pain care.

TRIAL REGISTRATION

clinicaltrials.gov, # NCT03562793.

Pre-implementation Evaluation of PARTNER-MH: A Mental Healthcare Disparity Intervention for Minority Veterans in the VHA

To design PARTNER-MH, a peer-led, patient navigation program for implementation in Veterans Health Administration (VHA) mental health care settings, we conducted a pre-implementation evaluation during intervention development to assess stakeholders' views of the intervention and to explore implementation factors critical to its future adoption. This is a convergent mixed-methods study that involved qualitative semi-structured interviews and survey data. Data collection was guided by the Consolidated Framework for Implementation Research (CFIR). We interviewed and administered the surveys to 23 peers and 10 supervisors from 12 midwestern VHA facilities. We used deductive and inductive approaches to analyze the qualitative data. We also conducted descriptive analysis and Fisher Exact Test to compare peers and supervisors' survey responses. We triangulated findings to refine the intervention. Overall, participants viewed PARTNER-MH favorably. However, they saw the intervention's focus on minority Veterans and social determinants of health framework as potential barriers, believing this could negatively affect the packaging of the intervention, complicate its delivery process, and impact its adoption. They also viewed clinic structures, available resources, and learning climate as potential barriers. Peers and supervisors' selections and discussions of CFIR items were similar. Our findings informed PARTNER-MH development and helped identify factors that could impact its implementation. This project is responsive to the increasing recognition of the need to incorporate implementation science in healthcare disparities research. Understanding the resistance to the intervention's focus on minority Veterans and the potential barriers presented by contextual factors positions us to adjust the intervention prior to testing, in an effort to maximize implementation success.

"They are talking from the Encyclopedia Britannica brain": diabetes patients' perceptions of barriers to communicating with physicians

Background

Understanding patients’ beliefs about their role communicating in medical visits is an important pre-requisite to encourage patients’ use of active participatory communication, and these beliefs may be particularly relevant for patients with diabetes.

Methods

Focus groups were conducted to examine patients with diabetes view of their role communicating in medical encounters. Patients had type 2 diabetes, A1C ≥ 8% (64 mmol/mol), and were from an inner-city VA hospital. Guiding questions for the focus groups were based on theoretical models of patient-physician communication. Focus group transcripts were analyzed with the constant comparative method.

Results

Four focus groups were conducted with a total of 20 male Veterans. Participants mean age was 61 years, 65% self-identified as black or African-American, 80% completed high school or higher education, and mean A1C was 10.3% (89 mmol/mol). Eight themes were identified as to why patients might have difficulty communicating with physicians. These themes were grouped into three overarching categories explaining reasons why patients might avoid participatory communication and included patients’ view about their condition; about physician’s communication behaviors; and about external influences on patient-physician communication. For example, patients described how use of the EHR may deter patients’ use of active participatory communication.

Conclusions

These results are important for understanding how patients’ use of active participatory communication is influenced by their beliefs and expectations, physicians’ behaviors, and structural factors. The results may be useful for educational efforts to increase patient, physician, and healthcare systems awareness of problems that patients perceive when communicating with physicians.

Pregnant women's experiences and perceptions of participating in the EVERREST prospective study; a qualitative study

BACKGROUND

The EVERREST Prospective Study is a multicentre observational cohort study of pregnancies affected by severe early-onset fetal growth restriction. The study recruits women with singleton pregnancies where the estimated fetal weight is less than the 3rd centile and below 600 g, between 20 + 0 and 26 + 6 weeks of pregnancy, in the absence of a known chromosomal, structural or infective cause.

METHOD

The reported study was retrospective descriptive qualitative interview study of women who had participated in the EVERREST Prospective Study. The aim of this study was to explore the experiences and perceptions of pregnant women taking part in research during a pregnancy affected by severe early-onset fetal growth restriction. Audio-recorded semi-structured telephone interviews were conducted with a purposive sample of 12 women, at least 1 year after delivery of their baby. Two of these pregnancies had ended in stillbirth and one in neonatal death, reflecting the outcomes seen in the EVERREST Prospective Study. Participants gave informed consent, were 16 years or older and were interviewed in English. A topic guide was used to ensure a consistent approach. Questions focused on pregnancy experiences, involvement with the EVERREST study and potential involvement in future research. Recordings were transcribed verbatim for thematic analysis using NVivo10.

RESULTS

Four broad themes were identified; 'before joining the EVERREST Prospective Study', 'participating in research', 'information and support' and 'looking back and looking forwards'. Each broad theme incorporated several subthemes. All participants recalled their reaction to being told their baby was smaller than expected. The way this news was given had a lasting impact. A range of benefits of participation in the EVERREST Prospective Study were described and the participants were positive about the way it was conducted. As a consequence, they were receptive to participating in future research. However, the findings suggest that research teams should be sensitive when approaching families at a difficult time or when they are already participating in other research.

CONCLUSIONS

This study highlights the willingness of pregnant women to participate in research and identifies strategies for researchers to engage participants.

Improving youth question-asking and provider education during pediatric asthma visits

OBJECTIVE

We conducted a pragmatic randomized controlled trial to test the effectiveness of an asthma question prompt list with video intervention to increase youth question-asking and provider education during visits.

METHODS

English or Spanish-speaking youth ages 11-17 with persistent asthma and their parents were enrolled from four rural and suburban pediatric clinics. Youth were randomized to the intervention or usual care groups. Intervention group adolescents watched the video on an iPad and then completed an asthma question prompt list before their visits. Generalized estimating equations were used to analyze the data.

RESULTS

Forty providers and 359 patients participated. Intervention group youth were significantly more likely to ask one or more questions about medications, triggers, and environmental control than usual care youth. Providers were significantly more likely to educate intervention group youth about rescue medications, triggers, and environmental control. Intervention group caregivers were not significantly more likely to ask questions.

CONCLUSION

The intervention increased youth question-asking and provider education about medications, triggers, and environmental control. The intervention did not impact caregiver question-asking.

PRACTICE IMPLICATIONS

Providers/practices should consider having youth complete question prompt lists and watch the video with their parents before visits to increase youth question-asking during visits.

Inpatient satisfaction with medical information received from caregivers: an observational study on the effect of social deprivation

BACKGROUND

The main objective of this study was to explore the relationships between inpatients' social differentiation and satisfaction with the medical information delivered by caregivers.

METHODS

In four departments of a teaching hospital, patients were enrolled as well as their attending physician and one of the nurses assigned to them. Structured survey questionnaires were administered face-to-face to patients and caregivers. Patients were asked to rate their satisfaction with the medical information received, the quality and duration of the interactions with the caregivers, and their experience regarding their involvement in medical decision-making. Caregivers were asked to rate their perception of the patients' social position and involvement in medical decision-making. Social deprivation was assessed using the EPICES score in particular. The statistical analysis was mainly descriptive and completed by a structural equation model.

RESULTS

A sample of 255 patients, 221 pairs of patient-physician and 235 pairs of patient-nurse were considered. One third of the patients (32.7%) were identified as socially deprived. They were significantly less satisfied with the information they received on their health status or their treatment; 56.7% of patients thought that they received sufficient explanations without having to ask. This proportion was significantly lower in socially deprived patients (42.3%) compared to not deprived patients (63.6%, p < 0.01). Patients' reported involvement in medical decision-making was significantly lower for socially deprived patients (75.0% vs 89.0%, p < 0.001). The structural equation model showed that the main determinant of patients' satisfaction regarding medical information was their perceived involvement in informed medical decision-making (CFI = 0.998, RMSEA = 0.022).

CONCLUSIONS

These findings suggest that physicians and nurses need training on communication targeted towards vulnerable patients, in order to improve the accessibility of medical information, and thus to reduce health inequalities.

Effect of the Tool to Reduce Inappropriate Medications on Medication Communication and Deprescribing

OBJECTIVES

To examine the effect of the Tool to Reduce Inappropriate Medications (TRIM), a web tool linking an electronic health record (EHR) to a clinical decision support system, on medication communication and prescribing.

DESIGN

Randomized clinical trial.

SETTING

Primary care clinics at a Veterans Affairs Medical Center.

PARTICIPANTS

Veterans aged 65 and older prescribed seven or more medications randomized to receipt of TRIM or usual care (N = 128).

INTERVENTION

TRIM extracts information on medications and chronic conditions from the EHR and contains data entry screens for information obtained from brief chart review and telephonic patient assessment. These data serve as input for automated algorithms identifying medication reconciliation discrepancies, potentially inappropriate medications (PIMs), and potentially inappropriate regimens. Clinician feedback reports summarize discrepancies and provide recommendations for deprescribing. Patient feedback reports summarize discrepancies and self-reported medication problems.

MEASUREMENTS

Primary: subscales of the Patient Assessment of Care for Chronic Conditions (PACIC) related to shared decision-making; clinician and patient communication. Secondary: changes in medications.

RESULTS

29.7% of TRIM participants and 15.6% of control participants provided the highest PACIC ratings; this difference was not significant. Adjusting for covariates and clustering of patients within clinicians, TRIM was associated with significantly more-active patient communication and facilitative clinician communication and with more medication-related communication among patients and clinicians. TRIM was significantly associated with correction of medication discrepancies but had no effect on number of medications or reduction in PIMs.

CONCLUSION

TRIM improved communication about medications and accuracy of documentation. Although there was no association with prescribing, the small sample size provided limited power to examine medication-related outcomes.

Integrating Multidisciplinary Results to Produce New Knowledge About the Physician-Patient Relationship: A Methodology Applied to the INTERMEDE Project

The INTERMEDE Project brought together a number of research teams to study the interaction between a patient and their general practitioner, and how this can produce social inequalities in health. The ultimate objective of the project was to formalize a core of common findings by integrating qualitative and quantitative results. The methodology chosen for the integration was inspired by the Delphi participatory method. It involves several rounds of questions and feedback in writing between all members of project teams, in order to compare contradictory opinions and identify key concepts arising from the project. This interdisciplinary research has provided a more nuanced understanding of the mechanisms underlying physician-patient interaction by revealing the convergences of the various disciplinary approaches.

The Effects of Race and Racial Concordance on Patient-Physician Communication: A Systematic Review of the Literature

OBJECTIVE

Racial disparities exist in health care, even when controlling for relevant sociodemographic variables. Recent data suggest disparities in patient-physician communication may also contribute to racial disparities in health care. This study aimed to systematically review studies examining the effect of black race and racial concordance on patient-physician communication.

METHODS

A comprehensive search using the PRISMA guidelines was conducted across seven online databases between 1995 and 2016. The search resulted in 4672 records for review and 40 articles for final inclusion in the review. Studies were included when the sample consisted of black patients in healthcare contexts and the communication measure was observational or patient-reported. Data were extracted by pairs of authors who independently coded articles and reconciled discrepancies. Results were synthesized according to predictor (race or racial concordance) and communication domain.

RESULTS

Studies were heterogeneous in health contexts and communication measures. Results indicated that black patients consistently experienced poorer communication quality, information-giving, patient participation, and participatory decision-making than white patients. Results were mixed for satisfaction, partnership building, length of visit, and talk-time ratio. Racial concordance was more clearly associated with better communication across all domains except quality, for which there was no effect.

CONCLUSIONS

Despite mixed results due to measurement heterogeneity, results of the present review highlight the importance of training physicians and patients to engage in higher quality communication with black and racially discordant patients by focusing on improving patient-centeredness, information-giving, partnership building, and patient engagement in communication processes.

The information-giving skills of resident physicians: relationships with confidence and simulated patient satisfaction

BACKGROUND

Sharing information is crucial for discussion of problems and treatment decision making by patients and physicians. However, the focus of communication skills training in undergraduate medical education has been on building the relationship and gathering information; thus, resident physicians tend to be less confident about sharing information and planning treatment. This study evaluated the medical interviews conducted by resident physicians with a focus on information giving, and investigated its relationships with their confidence in communication and simulated patient (SP) satisfaction.

METHODS

Among 137 junior resident physicians at a university hospital in Japan who participated in a survey of communication skills, 25 volunteered to conduct simulated medical interviews. The medical interviews were video-recorded and analyzed using the Roter Interaction Analysis System, together with additional coding to explore specific features of information giving. The SPs evaluated their satisfaction with the medical interview.

RESULTS

Resident physicians who were more confident in their communication skills provided more information to the patients, while SP satisfaction was associated only with patient-prompted information giving. SPs were more satisfied when the physicians explained the rationales for their opinions and recommendations.

CONCLUSION

Our findings underscore the importance of providing relevant information in response to the patient requests, and explaining the rationales for the opinions and recommendations. Further investigation is needed to clinically confirm our findings and develop an appropriate communication skills training program.

Factors Influencing Communication with Doctors via the Internet: A Cross-Sectional Analysis of 2014 HINTS Survey

Based on Street's (2003) ecological framework of communication in medical encounters, this study examined personal, interpersonal, and media factors that could influence patients' use of the Internet to communicate with doctors. Results from data analysis of responses from the 2014 Health Information National Trends Survey showed that patient activation and ease of Internet access were two positive predictors of online doctor-patient communication. In addition, patients' trust in doctors positively moderated the relationships between patient activation and online doctor-patient communication, and between perceived health status and online doctor-patient communication. Finally, the quality of patients' past experiences communicating with doctors had a positive moderation effect on the association between health information seeking behavior and online doctor-patient communication. Implications and limitations are discussed.

Individualized patient decision-aid for immunosuppressive drugs in women with lupus nephritis: study protocol of a randomized, controlled trial

BACKGROUND

Systemic Lupus erythematosus (SLE), also commonly referred to as lupus, is a rare, but sometimes, fatal disease, that primarily affects young women. Lupus nephritis, a common manifestation of lupus, is more common and more devastating in patients of minority race/ethnicity. Patients have negative views of immunosuppressive drugs for lupus nephritis due to a concern about side effects and under-appreciation of its benefit. We designed a study to assess the effectiveness of individualized, computerized patient decision-aid for immunosuppressive drugs for lupus nephritis compared to a standard pamphlet for patient decision-making.

METHODS

Adult women with lupus nephritis, with a current lupus nephritis flare or at risk of a future lupus nephritis flare will be randomized to individualized, computerized patient decision-aid for immunosuppressive drugs vs. standard pamphlet with information about lupus and its treatment including immunosuppressive drugs and outcomes. Patients will complete outcome assessments immediately after the intervention has been administered. Patients will be followed at 3-months with a brief survey, either in person or on the phone, and at 6-months with medical record review for exploratory outcomes. Co-primary outcomes are decisional conflict and informed choice regarding immunosuppressive drugs (combines values, knowledge and choice). Secondary outcomes include: (1) assessment of patient-physician communication by assessing audio-taped physician-patient communication after intervention administration; (2) concordance between patient's desired and actual role in immunosuppressive drugs decision-making using the control preference scale (CPS); and (3) patient perception of physician interaction using the interpersonal process of care- short form (IPC-SF).

DISCUSSION

This is one of the first studies to evaluate the effectiveness of an educational intervention targeting minorities with lupus nephritis. This patient-centered lupus nephritis decision-aid will be available in the public domain in English and Spanish.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02319525 ; registered on November 5, 2014.

How Physicians, Patients, and Observers Compare on the Use of Qualitative and Quantitative Measures of Physician-Patient Communication

The purpose of this study was to compare several different measures of physician-patient communication. We compared data derived from different measures of three communication behaviors, patient participation, physician information giving, and physician participatory decision-making (PDM) style, from 83 outpatient visits to oncology or thoracic surgery clinics for pulmonary nodules or lung cancer. Communication was measured with rating scales completed by patients and physicians after the consultation and by two different groups of external observers who used rating scales or coded the frequency of communication behaviors, respectively, after listening to an audio recording of the consultation. Measures were compared using Pearson's correlations. Correlations of patients' and physicians' ratings of patient participation (r = .04) and physician PDM style (r = .03) were low and not significant (p > .0083, Bonferroni-adjusted). Correlations of observers' ratings with patients' or physicians' ratings for patient participation and physician PDM style were moderate or low (r = .15, .27, .07, and .01, respectively) but were not statistically significant (p > .0083, Bonferroni-adjusted). Correlations between observers' ratings and frequency measures were .31, .52, and .63 and were statistically significant with p values .005, <.0001, and <.0001, respectively, for PDM style, information giving, and patient participation. Our findings highlight the potential for using observers' ratings as an alternate measure of communication to more labor intensive frequency measures.

Persisting Racial Disparities in Total Shoulder Arthroplasty Utilization and Outcomes

OBJECTIVE

The purpose was to study whether racial disparities in total shoulder arthroplasty (TSA) utilization and outcomes have declined over time.

METHODS

We used the US Nationwide Inpatient Sample from 1998 to 2011.We used chi-squared test to compare characteristics, Cochran-Armitage test to compare utilization rates, and Cochran-Armitage test and logistic regression to compare time-trends in outcomes by race.

RESULTS

From 1998 to 2011, 176,141 Whites and 7694 Blacks underwent TSA. Compared to Whites, Blacks who underwent TSA were younger (69.1 vs. 64.2 years; p<0.0001), more likely to be female (54.9 vs. 71.0 %; p<0.0001), and have rheumatoid arthritis or avascular necrosis as the underlying diagnosis (1.7 vs. 3.0%and 1.7 vs. 6.1 %; p<0.0001 for both) and a Deyo-Charlson index of 2 or higher (8.5 vs. 16.7 %; p<0.0001). Compared to Whites, Blacks had much lower TSA utilization rate/100,000 in 1998 (2.97 vs. 0.83; p<0.0001) and in 2011 (12.27 vs. 3.33; p<0.0001); racial disparities increased from 1998 to 2011 (p<0.0001). A higher proportion of Blacks than Whites had a hospital stay greater than median in 1998-2000, 62 vs. 51.4 % (p=0.02), and in 2009-2011, 34.4 vs. 27.3 % (p<0.0001); disparities did not change over time (p=0.31). These disparities in utilization were borderline significant in adjusted analyses. There were no racial differences in proportion discharged to inpatient medical facility in 1998-2000, 15.2 vs. 15.0 % (p=0.95), and in 2009-2011, 12.3 vs. 11.1%(p=0.37), respectively.

CONCLUSIONS

We found increasing racial disparities in TSA utilization. Some disparities in outcomes exist as well. Patients, surgeons, and policy-makes should be aware of these findings and take action to reduce racial disparities.

The role of psychology in a pediatric outpatient cardiology setting: preliminary results from a new clinical program

The aim of this study was to provide a descriptive analysis of a new clinical program integrating psychology services within a pediatric outpatient cardiology clinic. Patients with congenital heart disease (CHD) (n = 79) were referred for psychological services by their pediatric cardiologist. Parents completed the child behavior checklist, and the pediatric quality of life inventory generic core scales (PedsQL parent report). Teachers completed the teacher report form. Reasons for referral included: emotional problems (29%); attention problems (25%); learning problems (22%); behavior problems (16%); and developmental delay (8%). Parents and teachers reported higher rates of behavior problems and lower quality of life scores than the general population. Psychological evaluation suggested that incorporating a psychologist within a pediatric cardiology clinic may be beneficial for children with CHD in order to optimize their psychosocial functioning. Practice implications for implementing psychology services within a pediatric outpatient cardiology program are discussed.

Refining the Practice of Prescribing: Teaching Physician Learners How to Talk to Patients About a New Prescription

BACKGROUND

Clinician counseling about medication can improve patient understanding and adherence. This study developed a teaching session for physician learners about medication prescribing and communication, with evaluation at the physician and patient levels.

OBJECTIVE

We analyzed whether patients would perceive and report more comprehensive clinician presentation of medication information when receiving prescriptions from their physician in the intervention clinic.

METHODS

We conducted a single site, prospective intervention study that included lectures, role play, an objective standardized clinical examination (OSCE), and reminders displayed in patient care areas. For physician-level assessment, pretests and posttests included a written case presentation and a OSCE. For patient-level assessment, we used a cross-sectional observational design that included study of patient recall information, and assessment of patient satisfaction before and after intervention.

RESULTS

Twenty-seven family medicine residents and sports medicine fellows participated in the teaching session, focused on presenting patients the reasons, risks, and regimen of prescribed medication. In written testing, learners presented significantly more comprehensive information in posttests. In the OSCE (n  =  14), all learners presented risks and regimen information. However, patient-level assessment showed no significant difference between before and after intervention. Notably, the covariates patient activation and satisfaction with communication both had a significant association with patient recall information.

CONCLUSIONS

Our intervention improved learner presentation of medication information. However, patient recall of the information conveyed did not change. Although physician training did not have a positive effect on patient recall, patient activation emerged as a critical influence of patients' perceptions of medication discussions.

Racial differences in veterans' satisfaction with examination of disability from posttraumatic stress disorder

OBJECTIVE

The examination that determines if a veteran has service-connected posttraumatic stress disorder (PTSD) affects veterans' lives for years. This study examined factors potentially associated with veterans' perception of their examination's quality.

METHODS

Veterans (N=384) being evaluated for an initial PTSD service-connection claim were randomly assigned to receive either a semistructured interview or the examiner's usual interview. Immediately after the interview, veterans completed confidential ratings of the examinations' quality and of their examiners' interpersonal qualities and competence. Extensive data characterizing the veterans, the 33 participating examiners, and the examinations themselves were collected.

RESULTS

Forty-seven percent of Caucasian veterans and 34% of African-American veterans rated their examination quality as excellent. African Americans were less likely than Caucasians to assign a higher quality rating (odds ratio=.61, 95% confidence interval=.38-.99, p=.047). Compared with Caucasians, African Americans rated their examiners as having significantly worse interpersonal qualities but not lower competence. Ratings were not significantly related to the veterans' age, gender, marital status, eventual diagnosis of PTSD, Global Assessment of Functioning score, the examiner's perception of the prevalence of malingering, or the presence of a third party during the examination.

CONCLUSIONS

Ratings of disability examinations were generally high, although ratings were less favorable among African-American veterans than among Caucasian veterans.

Is perceived social distance between the patient and the general practitioner related to their disagreement on patient's health status?

OBJECTIVE

To ascertain whether disagreement between patients and general practitioners (GP) on the patient's health status varies according to their respective perceived social distance (PSD).

METHODS

The analysis used the Intermede project's quantitative data collected from 585 patients and 27 doctors via mirrored questionnaires. GPs and patients ranked their own perceived social position (PSP) in society, and their patients' and their GP respectively. PSD was calculated as the PSP's subtraction from the patients' and GPs' assessments.

RESULTS

Disagreement between GPs and patients regarding the patient's health status was associated with PSD by the GP whereas it was not associated with PSD by the patient. In the multilevel analysis, disagreement whereby GPs overestimate patient's health status increased within PSD by the GP: OR:2.9 (95%CI = 1.0-8.6, p = 0.055) for low PSD, OR:3.4 (95%CI = 1.1-10.2, p < 0.05) for moderate PSD and OR:3.8 (95%CI = 1.1-13.1, p < 0.05) for high PSD (reference: no distance).

CONCLUSIONS

Patients perceived with a lower social position by their GP and who consider themselves to have poor health are less likely to be identified in the primary care system.

PRACTICE IMPLICATIONS

Physicians need to be conscious that their own perception influences the quality of the interaction with their patients, potentially resulting in unequal health care trajectories.

Racial and gender disparities among patients with gout

Gout affects 8.3 million Americans according to NHANES 2007-2008, approximately 3.9 % of the US population. Gout has substantial effect on physical function, productivity, health-related quality of life (HRQOL), and health care costs. Uncontrolled gout is also associated with significant use of emergency care services. Women are less likely to have gout than men, but in the postmenopausal years the gender difference in disease incidence decreases. Compared with whites, racial and/or ethnic minorities, especially blacks, have higher prevalence of gout. Blacks are also less likely to receive quality gout care, leading to disproportionate morbidity. Women are less likely than men to receive allopurinol, and less likely to undergo joint aspirations for crystal analysis to establish diagnosis, but those on urate-lowering therapy are as likely as, or more likely than, men to undergo serum urate check within six months of initiation. Although a few studies provide the knowledge related to gender and race and/or ethnicity disparities for gout, several knowledge gaps exist in gout epidemiology and outcomes differences by gender and race and/or ethnicity. These should be investigated in future studies.

The role of unconscious bias in surgical safety and outcomes

Racial, ethnic, and gender disparities in health outcomes are a major challenge for the US health care system. Although the causes of these disparities are multifactorial, unconscious bias on the part of health care providers plays a role. Unconscious bias occurs when subconscious prejudicial beliefs about stereotypical individual attributes result in an automatic and unconscious reaction and/or behavior based on those beliefs. This article reviews the evidence in support of unconscious bias and resultant disparate health outcomes. Although unconscious bias cannot be entirely eliminated, acknowledging it, encouraging empathy, and understanding patients' sociocultural context promotes just, equitable, and compassionate care to all patients.

A study of politeness strategies adopted in pediatric clinics in Taiwan

Drawing on Brown and Levinson's (1987) politeness theory, this study investigates the communicative interaction behaviors of physicians, patients, and patients' parents in pediatrics in Taiwan. Thirty outpatients and six senior physicians from three different levels of hospital participated in the study. The analysis results indicate that most of the communicative politeness strategies used in pediatrics are bald-on-record, direct, and non-redressed. In addition, physicians adopt a higher percentage of bald-on-record and negative politeness strategies than patients. In contrast, patients' parents use more positive politeness and off-record strategies. These results indicate that while physicians display lower levels of politeness and often communicate directly, patients' parents express more supportive opinions and adopt more indirect communication strategies. The results reveal a preference for efficiency in pediatric clinics, with physicians adopting a dominant role in the communication process. These results also demonstrate an inherently asymmetric power balance between physician and patient. Our findings indicate the presence of several commonly seen politeness strategies and dialogue patterns that encourage greater self-awareness and self-observation for physicians and patients, leading to more effective communication in the clinical context. Finally, also discussed are the possible influences of Chinese culture such as face work, harmony, and power.

Form and semantics of communication in dental encounters: oral health, probability and time

The purpose of this article is twofold. First, it introduces a new method for capturing the intricacy of communication in contemporary healthcare encounters. The method, termed 'form analysis', was developed from the systems theory of Niklas Luhmann. It is hoped that the paper will introduce form analysis as a new method to help understand complex communications in health systems. Second, the paper demonstrates an application of form analysis in communications in dental encounters. Data were collected through 36 observed encounters between five dentists and 20 patients in UK NHS primary and secondary care dental clinics. The study found a range of semantic forms relevant for these encounters, three of which are discussed at length in this article. The forms of communications illustrate how the dichotomy of dental professional and patient perspectives transforms into complex, non-linear observations about oral health. Dentistry, it seems, remains up to date not only through the emergence of new technologies, but also through reflexivity in observing and assessing oral health. These observations are exposed to the contingency of clinical decisions and the temporal aspects of the clinical system.

Feasibility of a patient-driven approach to recruiting older adults, caregivers, and clinicians for provider-patient communication research

PURPOSE

This report describes the implementation of a novel, patient-driven approach to recruitment for a study of interpersonal communication in a primary care setting involving persons with Alzheimer's disease (AD), their family caregivers, and their primary care providers (PCPs).

DATA SOURCES

Patients and caregivers were centrally recruited from a university-based memory clinic, followed by the recruitment of patient's individual PCPs. Recruitment tracking, naturalistic observation, and survey methods were used to evaluate recruitment success.

CONCLUSIONS

About half of the patients and caregivers (n = 54; 51%) and most of the PCPs (n = 31; 76%) who we approached agreed to an audiorecording of the patient's next PCP visit. Characteristics of patient, caregiver, and PCP participants were compared to those of nonparticipants. Patient characteristics did not differ by participation status. Caregivers who volunteered for the study were more likely to be female and married than were those who declined to participate. Compared to nonparticipants, PCPs who agreed to the study were appraised slightly more favorably by patients' caregivers on a measure of satisfaction with care on the day of the visit. The vast majority of participating PCPs (95%) reported that the study had little or no impact on the flow of routine clinical operations.

IMPLICATIONS FOR RESEARCH

Findings support the feasibility of a patient-driven approach to recruitment for studies involving multiple linked participants. Our discussion highlights possible advantages of such an approach, including the potential to empower patient participants while achieving maximum variability within the pool of clinician participants.

Predictors of rheumatoid arthritis patient-physician communication about medication costs during visits to rheumatologists

OBJECTIVE

To examine the frequency with which medication costs are discussed, and the predictors of these discussions, during visits between rheumatologists and their patients with rheumatoid arthritis (RA).

METHODS

Audiotapes of medical visits, patient questionnaires, medical records, and physician questionnaires were collected from March 2003 to December 2005. Data were collected from 200 RA patients from 4 rheumatology clinics. Audiotapes were coded for the presence of communication about medication costs using a detailed coding instrument. The final analysis sample included 193 patients and 8 rheumatologists. Stepwise multivariable logistic regression was used to examine the role of patient, physician, medication, and relationship characteristics on discussions of medication costs.

RESULTS

Despite medication changes being made in more than 50% of the visits, only 34% of those visits included discussions of medication-related costs; 48% of these discussions were initiated by patients. In multivariable logistic regression models, communication about medication costs occurred more often when patients were white (compared with nonwhite) and reported an annual income of $20,000-$59,999 (compared with those earning > or =$60,000). Discussions about medication costs also were more common when physicians were white.

CONCLUSION

Although medication changes were common, medication costs were only discussed in one-third of the visits. Communication about medication costs was more common among patients who were white and in a middle income category. Disparities in communication about medication costs have the potential to negatively impact prescribing and subsequent medication use. Further research should examine potential disparities in communication about medication costs.

Stereotype threat and health disparities: what medical educators and future physicians need to know

Patients' experience of stereotype threat in clinical settings and encounters may be one contributor to health care disparities. Stereotype threat occurs when cues in the environment make negative stereotypes associated with an individual's group status salient, triggering physiological and psychological processes that have detrimental consequences for behavior. By recognizing and understanding the factors that can trigger stereotype threat and understanding its consequences in medical settings, providers can prevent it from occurring or ameliorate its consequences for patient behavior and outcomes. In this paper, we discuss the implications of stereotype threat for medical education and trainee performance and offer practical suggestions for how future providers might reduce stereotype threat in their exam rooms and clinics.

Are racial differences in patient-physician cancer communication and information explained by background, predisposing, and enabling factors?

Research shows that African Americans tend to have poorer and less informative patient-physician communication than Whites. We analyzed survey data from 248 African American and 244 White cancer patients to examine whether this disadvantage could be explained by race variability on several other variables commonly reported to affect communication. These variables were organized into background, enabling, and predisposing factors, based on the Precede-Proceed Model. Multivariate regressions were used to test whether race differences in communication and information variables persisted after successively controlling for background, enabling, and predisposing factors. African American patients had higher interpersonal communication barriers than Whites, but this difference did not persist after controlling for background factors. African Americans also had higher unmet information needs and were less likely to receive the name of a cancer expert. These differences persisted after controlling for all other factors. Future research should focus on the informational disadvantages of African American patients and how such disadvantages may affect cancer treatment decisions.

The analysis of verbal interaction sequences in dyadic clinical communication: a review of methods

OBJECTIVE

To identify methods available for sequential analysis of dyadic verbal clinical communication and to review their methodological and conceptual differences.

METHODS

Critical review, based on literature describing sequential analyses of clinical and other relevant social interaction.

RESULTS

Dominant approaches are based on analysis of communication according to its precise position in the series of utterances that constitute event-coded dialogue. For practical reasons, methods focus on very short-term processes, typically the influence of one party's speech on what the other says next. Studies of longer-term influences are rare. Some analyses have statistical limitations, particularly in disregarding heterogeneity between consultations, patients or practitioners. Additional techniques, including ones that can use information about timing and duration of speech from interval-coding are becoming available.

CONCLUSION

There is a danger that constraints of commonly used methods shape research questions and divert researchers from potentially important communication processes including ones that operate over a longer-term than one or two speech turns. Given that no one method can model the complexity of clinical communication, multiple methods, both quantitative and qualitative, are necessary.

PRACTICE IMPLICATIONS

Broadening the range of methods will allow the current emphasis on exploratory studies to be balanced by tests of hypotheses about clinically important communication processes.

Patient-physician interaction in general practice and health inequalities in a multidisciplinary study: design, methods and feasibility in the French INTERMEDE study

Background

The way in which patients and their doctors interact is a potentially important factor in optimal communication during consultations as well as treatment, compliance and follow-up care. The aim of this multidisciplinary study is to use both qualitative and quantitative methods to explore the 'black box' that is the interaction between the two parties during a general practice consultation, and to identify factors therein that may contribute to producing health inequalities. This paper outlines the original multidisciplinary methodology used, and the feasibility of this type of study.

Methods and design

The study design combines methodologies on two separate samples in two phases. Firstly, a qualitative phase collected ethnographical and sociological data during consultation, followed by in-depth interviews with both patients and doctors independently. Secondly, a quantitative phase on a different sample of patients and physicians collected data via several questionnaires given to patients and doctors consisting of specific 'mirrored' questions asked post-consultation, as well as collecting information on patient and physician characteristics.

Discussion

The design and methodology used in this study were both successfully implemented, and readily accepted by doctors and patients alike. This type of multidisciplinary study shows great potential in providing further knowledge into the role of patient/physician interaction and its influence on maintaining or producing health inequalities. The next challenge in this study will be implementing the multidisciplinary approach during the data analysis.

Gender Disparities in Physician-Patient Communication Among African American Patients in Primary Care

This study investigates the role of gender in physician-patient communication among African American patients in primary care. Patients (N = 137) aged 33 to 67 were nested within 79 southern California primary care physicians' practices. In 48 interactions (35%), the physician was female and/or a member of a minority group. The study directly assessed gender differences through audiotaped physician-patient interactions as well as by measuring patients' and physicians' perceptions of their visit. This study employed a multi-informant design, in which independent raters assessed both physician and patient in audiotaped interactions, and both physician and patient self-reported on aspects of their visit. Discussions of prevention and health promotion were found to be significantly more common with male patients than with female patients but only when the physician was a nonminority male; these disparities disappeared when the physician was female and/or minority. Findings are discussed in terms of physician training, particularly for men and nonminorities.

Psychological responses to cardiac diagnosis: changes in illness representations immediately following coronary angiography

OBJECTIVE

Coronary angiography is a commonly used diagnostic test for ischemic heart disease. Little is known, however, about how undergoing the procedure impacts on the ways in which individuals perceive their illness. We sought to explore patients' reactions to an angiogram in terms of changes in symptom appraisal, perceived consequences of their condition, and patients' illness concern and emotional response to their condition after the receiving diagnostic results.

METHODS

The Brief IPQ was administered to patients undergoing a diagnostic coronary angiogram (N=57) before and immediately following the procedure. Changes in illness representations were then compared between patients diagnosed with diseased arteries and patients with normal arteries.

RESULTS

We found that the number of symptoms patients associated with their condition, illness consequences, and illness emotion decreased for patients receiving normal results but remained unchanged for patients receiving results showing diseased arteries. Illness concern decreased significantly for both patient groups.

CONCLUSIONS

The results demonstrate that diagnostic results can have clear and immediate effects on how patients' view and emotionally respond to their symptoms. The results also suggest that patients cognitively prepare themselves to receive an unfavorable diagnosis and the pattern suggests those receiving normal results modify their perceptions in a positive direction rather than those receiving an unfavorable diagnosis.

Missed opportunities for interval empathy in lung cancer communication

BACKGROUND

Empathy is important in patient-physician communication and is associated with improved patient satisfaction and adherence to physicians' recommendations.

METHODS

To evaluate empathic opportunities and physician responses, we conducted a qualitative thematic analysis of 20 audiorecorded, transcribed consultations between patients with lung cancer and their thoracic surgeons or oncologists, from a larger observational study of 137 patients in a Veterans Affairs hospital in the southern United States. Using qualitative analysis, we collaboratively developed themes and subthemes until saturation. Then, each transcript was coded, using grounded theory methods, until consensus was achieved, counting and sequentially analyzing patient empathic opportunities and physician responses.

RESULTS

Subthemes regarding patients' statements about lung cancer included (1) morbidity or mortality concerns, (2) cancer-related symptoms, (3) relationship to smoking, (4) decisions about treatment, (5) beliefs about or mistrust of medical care, (6) factors limiting ability to treat cancer, and (7) confusion regarding cancer status and treatment. We identified 384 empathic opportunities and found that physicians had responded empathically to 39 (10%) of them. Otherwise, physicians provided little emotional support, often shifting to biomedical questions and statements. We defined this phenomenon as missed opportunities for "interval empathy." When empathy was provided, 50% of these statements occurred in the last one-third of the encounter, whereas patients' concerns were evenly raised throughout the encounter.

CONCLUSIONS

Physicians rarely responded empathically to the concerns raised by patients with lung cancer, and empathic responses that did occur were more frequently in the last third of the encounter. Our results may provide a typologic approach to help physicians recognize empathic opportunities and with further development may aid in improving physicians' communication skills.

Physicians' and Nurses' Perceptions of Patient Involvement in Myocardial Infarction Care

BACKGROUND

Patients' involvement in their healthcare has been associated with better health outcomes. However, few studies have examined whether patient involvement affects the work of healthcare professionals. A better understanding of professionals' views and behaviour is necessary for improving clinical practice and optimizing patient involvement.

AIM

To measure perceptions and behaviour regarding patient involvement among physicians and nursing staff caring for patients with acute myocardial infarction.

METHODS

A questionnaire study conducted in 2005 among cardiology staff at twelve Swedish hospitals. The questionnaire included six scales measuring staff views and behaviour.

RESULTS

Physicians, registered nurses, and practical nurses did not differ significantly in their views of patient involvement, but did differ significantly in behaviour (p<.001). All three groups felt that an actively involved patient enriched their work, at the same time increasing their work load and taking time from other tasks. Physicians discussed daily activities and lifestyle changes with myocardial infarction patients before hospital discharge to a greater extent than nursing staff (p<.001).

CONCLUSION

Physicians and registered nurses viewed time constraints as a hinder for patient involvement, while practical nurses felt unsure in communicating with patients. Considering these organizational and professional issues may improve patient involvement and health outcomes in myocardial infarction care.

Understanding concordance in patient-physician relationships: personal and ethnic dimensions of shared identity

PURPOSE

Although concordance by race and sex in physician-patient relationships has been associated with patient ratings of better care, mechanisms through which concordance leads to better outcomes remains unknown. This investigation examined (1) whether patients' perceptions of similarity to their physicians predicted their ratings of quality of care and (2) whether perceived similarity was influenced by racial and sexual concordance and the physician's communication.

METHODS

The research design was a cross-sectional study with 214 patients and 29 primary care physicians from 10 private and public outpatient clinics. Measures included postvisit patient ratings of similarity to the physician; satisfaction, trust, and intent to adhere; and audiotape analysis of patient involvement and physicians' patient-centered communication.

RESULTS

Factor analysis revealed 2 dimensions of similarity, personal (in beliefs, values) and ethnic (in race, community). Black and white patients in racially concordant interactions reported more personal and ethnic similarity (mean score, 87.6 and 78.8, respectively, on a 100-point scale) to their physicians than did minority patients (mean score, 81.4 and 41.2, respectively) and white patients (mean score, 84.4 and 41.9, respectively) in racially discordant encounters. In multivariable models, perceived personal similarity was predicted by the patient's age, education, and physicians' patient-centered communication, but not by racial or sexual concordance. Perceived personal similarity and physicians' patient-centered communication predicted patients' trust, satisfaction, and intent to adhere.

CONCLUSIONS

The physician-patient relationship is strengthened when patients see themselves as similar to their physicians in personal beliefs, values, and communication. Perceived personal similarity is associated with higher ratings of trust, satisfaction, and intention to adhere. Race concordance is the primary predictor of perceived ethnic similarity, but several factors affect perceived personal similarity, including physicians' use of patient-centered communication.

Racial and ethnic disparities in the VA health care system: a systematic review

OBJECTIVES

To better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the "equal access" Veterans Affairs (VA) health care system.

METHODS

We systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA.

RESULTS

Racial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient-provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients' medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups.

CONCLUSIONS

Existing evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.

Staff Views and Behaviour Regarding Patient Involvement in Myocardial Infarction Care: Development and Evaluation of a Questionnaire

Background: Healthcare legislation in several nations now dictates the responsibility of health care professionals to involve patients in decisions concerning care and treatment. However, few studies have examined the impact of patient involvement on the work of health care professionals. A better understanding of staff views and behaviour might enhance patient involvement.

Aim: The aim of this study was to develop and validate a questionnaire for measuring views and behaviour regarding patient involvement among physicians and nursing staff caring for patients with myocardial infarction.

Methods: Focus groups among cardiology staff provided the basis for the construction of the questionnaire. Questionnaire validity and reliability were evaluated in a small pilot study and a larger cross-sectional study among cardiology staff at twelve Swedish hospitals.

Results: The questionnaire demonstrated good validity and reliability, with two factors measuring staff views and four measuring behaviour.

Conclusion: The questionnaire appears to be a useful tool for evaluating the perceptions and behaviour of physicians and nursing staff regarding patient involvement in myocardial infarction care. Use of this questionnaire may provide insight regarding areas of staff–patient interaction that need improvement, as well as implications of patient involvement for the work of each professional group on cardiology wards.