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Powell DS, Wu MMJ, Nothelle S, Smith JM, Gleason K, Oh ES, Lum HD, Reed NS, Wolff JL. The Medicare annual wellness visit: An opportunity to improve health system identification of hearing loss? J Am Geriatr Soc 2024. [PMID: 39058421 DOI: 10.1111/jgs.19111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 06/02/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Hearing loss is prevalent and consequential but under-diagnosed and managed. The Medicare Annual Wellness Visit (AWV) health risk assessment elicits patient-reported hearing concerns but whether such information affects documentation, diagnosis, or referral is unknown. METHODS We use 5 years of electronic medical record (EMR) data (2017-2022) for a sample of 13,776 older primary care patients. We identify the first (index) AWV indication of hearing concerns and existing and subsequent hearing loss EMR diagnoses (visit diagnoses or problem list diagnoses) and audiology referrals. For a 20% random sample of AWV notes (n = 474) we compared hearing loss EMR diagnoses to documentation of (1) hearing concerns, (2) hearing loss/aid use, and (3) referrals for hearing care. RESULTS Of 3845 (27.9%) older adults who identified hearing concerns (mean age 79.1 years, 57% female, 75% white) 24% had an existing hearing diagnosis recorded. Among 474 patients with AWV clinical notes reviewed, 90 (19%) had an existing hearing loss diagnosis. Clinicians were more likely to document hearing concerns or hearing loss/aid use for those with (vs. without) an existing EMR diagnosis (50.6% vs. 35.9%, p = 0.01; 68.9% vs. 37.5%, p < 0.001, respectively). EMR diagnoses of hearing loss were recorded for no more than 40% of those with indicated hearing concerns. Among those without prior diagnosis 38 (9.9%) received a hearing care referral within 1 month. Subgroup analysis suggest greater likelihood of documenting hearing concerns for patients age 80+ (OR:1.51, 95% confidence interval [CI]: 1.03, 2.19) and decreased likelihood of documenting known hearing loss among patients with more chronic conditions (OR: 0.49, 95% CI: 0.27, 0.9), with no differences observed by race. CONCLUSION Documentation of hearing loss in EMR and AWV clinical notes is limited among older adults with subjective hearing concerns. Systematic support and incorporation of hearing into EMR and clinical notes may increase hearing loss visibility by care teams.
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Affiliation(s)
- Danielle S Powell
- Department of Hearing and Speech Sciences, University of Maryland, College Park, Maryland, USA
| | - Mingche M J Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stephanie Nothelle
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jamie M Smith
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kelly Gleason
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Esther S Oh
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nicholas S Reed
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Yang Z, Wang X. Patients' Problem Presentation in China's Primary Care. HEALTH COMMUNICATION 2024:1-11. [PMID: 38214127 DOI: 10.1080/10410236.2024.2303530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Identifying patients' reasons for visiting is the central task at medical openings, the structure of which has been well studied in Western primary care, but much under-researched in China's mainland. Drawing on conversation analysis of 91 audio-recorded primary care consultations in China, this study explores interactional features of patients' problem presentation at medical openings in terms of sequential positions, forms, and contextual contingencies, which has implications for the model of medical service encounters in Chinese primary care openings. Although problem description is commonly solicited by doctors across cultures, Chinese patients' problem presentation often takes forms other than problem description. Nearly two thirds of problem presentation in our data are designed as a request-making action (57/91 cases), being more often self-initiated than solicited. This blurs the boundary between medical visits for new and non-new problems. The analysis of Chinese patients' problem presentation points to a high degree of patient agency in primary care in China, suggesting a strong orientation to the "provider-consumer" (vs. "professional-client") model of service encounters in the opening structure of doctor-patient interaction.
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Affiliation(s)
- Zi Yang
- School of Foreign Studies, University of Science and Technology Beijing
| | - Xueming Wang
- School of English Studies, University of International Business and Economics
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3
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Jautz S, Graf EM, Fleischhacker M, Dionne F. Agenda-setting in first sessions of business coaching-a focus on coaches' practices to manage the agenda and establish the working alliance. Front Psychol 2023; 14:1232090. [PMID: 37876847 PMCID: PMC10590917 DOI: 10.3389/fpsyg.2023.1232090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/12/2023] [Indexed: 10/26/2023] Open
Abstract
Introduction Agenda-setting is a central communicative task for professionals and a joint activity of all participants particularly at the onset of helping interactions such as coaching. Agreeing on goal(s) and assigning tasks alongside establishing a trustful bond prepare the ground for the success of the interaction. The professional agent initiates and sets the agenda as part of their professional role and responsibility, i.e., based on their professional epistemic and deontic authority. Concurrently, by orienting to clients' epistemic authority and by yielding power, control, and agency to clients to co-manage the ensuing interaction, agenda-setting is the first opportunity for client-centeredness, which is a central characteristic and success factor for the working alliance in coaching. Procedure and Methods We take first steps in filling a research gap by providing a first analysis of the interactional unfolding of agenda-setting in coaching and by showcasing that and how agenda-setting as a joint activity of coach and client contributes to their working alliance. More precisely, we investigate agenda-management practices in five first sessions of business coaching to (1) document and analyze how the joint activity 'agenda-setting' is implemented via various (coach-initiated) social actions, (2) detail their contribution to establishing the working alliance, and (3) to interpret the emerging practices of agenda-management against the concept of 'client-centeredness'. For the analysis, we draw on conceptual and methodological resources from interactional linguistics alongside linguistic pragmatics and conversation analysis. Results We found 117 instances of 'agenda-setting' in our data which can be assigned to the seven social actions "Delivering Agenda Information", "Requesting Agenda Information", "Requesting Agenda Agreement", "Requesting Agenda Action", "Suggesting Agenda Action", "Offering Agenda Action" and "Proposing Agenda Action". Discussion The social actions display that agenda-setting serves to establish a common ground regarding goals, tasks and the relational bond of coach and client, and (after this has been achieved) to negotiate future coaching actions. Thus, the joint activity of 'doing' agenda-setting can be shown to be 'doing' working alliance at the same time.
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Affiliation(s)
- Sabine Jautz
- Department of English, Faculty of Arts and Humanities, University of Siegen, Siegen, Germany
| | - Eva-Maria Graf
- Department of English, Faculty of Humanities and Education, University of Klagenfurt, Klagenfurt, Austria
| | - Melanie Fleischhacker
- Department of English, Faculty of Humanities and Education, University of Klagenfurt, Klagenfurt, Austria
| | - Frédérick Dionne
- Department of English, Faculty of Humanities and Education, University of Klagenfurt, Klagenfurt, Austria
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Allgood S, Park J, Soleiman K, Saha S, Han D, McArthur A, Moore RD, Beach MC. Taxonomy and effectiveness of clinician agenda-setting questions in routine ambulatory encounters: A mixed method study. PATIENT EDUCATION AND COUNSELING 2023; 115:107889. [PMID: 37480792 DOI: 10.1016/j.pec.2023.107889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/28/2023] [Accepted: 07/06/2023] [Indexed: 07/24/2023]
Abstract
OBJECTIVES Despite decades of communication training, studies repeatedly demonstrate that clinicians fail to elicit patients' agendas. Our goal was to provide clinicians with actionable guidance about the effectiveness of agenda-soliciting questions. METHODS We coded clinician agenda-soliciting questions and patient responses in audio-recorded ambulatory encounters at an urban academic hospital. To evaluate the association between question type and odds of the patient raising a concern, we performed mixed-effects logistic regression. RESULTS We identified 346 agenda-soliciting questions within 138 visits (mean 2.51/visit; range 0-9). Agenda-soliciting questions were categorized as personal state inquiries (37%, "How are you?"), feeling-focused (5% "How're you feeling?"), problem-focused (12%; "Are you having any problems"), direct solicitations (3%; "Anything you want to discuss today?"), "what else" (3%), "anything else" (14%), leading (16%; "Nothing else today?"), and space-reducing (11% "Anything else? Smoking?"). Patients raised a concern in response to 107 clinician questions (27%). Patients were more likely to raise a concern to direct solicitation (OR 22.95, 95% CI 2.62-200.70) or "what else" (OR 4.68, 95% CI 1.05-20.77) questions. CONCLUSIONS The most effective agenda-soliciting questions are used least frequently by clinicians. PRACTICE IMPLICATIONS Clinicians should elicit patient agendas by using direct language, and solicit additional concerns using "what else" vs. "anything else" questions.
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Affiliation(s)
| | - Jenny Park
- Oregon Health & Science University, Portland, OR, USA
| | | | | | - Dingfen Han
- Johns Hopkins University, Baltimore, MD, USA
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Golembiewski EH, Espinoza Suarez NR, Maraboto Escarria AP, Yang AX, Kunneman M, Hassett LC, Montori VM. Video-based observation research: A systematic review of studies in outpatient health care settings. PATIENT EDUCATION AND COUNSELING 2023; 106:42-67. [PMID: 36207219 DOI: 10.1016/j.pec.2022.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 09/13/2022] [Accepted: 09/30/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To examine the use of video-based observation research in outpatient health care encounter research. METHODS We conducted a systematic search of MEDLINE, Scopus, Cochrane and other databases from database inception to October 2020 for reports of studies that used video recording to investigate ambulatory patient-clinician interactions. Two authors independently reviewed all studies for eligibility and extracted information related to study setting and purpose, participant recruitment and consent processes, data collection procedures, method of analysis, and participant sample characteristics. RESULTS 175 articles were included. Most studies (65%) took place in a primary care or family practice setting. Study objectives were overwhelmingly focused on patient-clinician communication (81%). Reporting of key study elements was inconsistent across included studies. CONCLUSION Video recording has been used as a research method in outpatient health care in a limited number and scope of clinical contexts and research domains. In addition, reporting of study design, methodological characteristics, and ethical considerations needs improvement. PRACTICE IMPLICATIONS Video recording as a method has been relatively underutilized within many clinical and research contexts. This review will serve as a practical resource for health care researchers as they plan and execute future video-based studies.
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Affiliation(s)
| | - Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Department of Family Medicine and Emergency Medicine Laval University Quebec, Canada.
| | - Andrea P Maraboto Escarria
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Department of Obstetrics and Gynecology Hospital Angeles Lomas Mexico City, Mexico.
| | - Andrew X Yang
- Mayo Clinic Alix School of Medicine Rochester, MN, USA.
| | - Marleen Kunneman
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Medical Decision Making, Department of Biomedical Data Sciences Leiden University Medical Center Leiden, the Netherlands.
| | - Leslie C Hassett
- Division of Endocrinology, Diabetes, Metabolism and Nutrition Department of Medicine Mayo Clinic, Rochester, MN, USA.
| | - Victor M Montori
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Mayo Clinic Libraries Mayo Clinic, Rochester, MN, USA.
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Chapman CR, Woo NT, Maluf KS. Preferred Communication Strategies Used by Physical Therapists in Chronic Pain Rehabilitation: A Qualitative Systematic Review and Meta-Synthesis. Phys Ther 2022; 102:6623303. [PMID: 35778939 PMCID: PMC9455645 DOI: 10.1093/ptj/pzac081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 03/12/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Lack of clarity regarding effective communication behaviors in chronic pain management is a barrier for implementing psychologically informed physical therapy approaches that rely on competent communication by physical therapist providers. This study aimed to conduct a systematic review and meta-synthesis to inform the development of a conceptual framework for preferred communication behaviors in pain rehabilitation. METHODS Ten databases in the health and communication sciences were systematically searched for qualitative and mixed-method studies of interpersonal communication between physical therapists and adults with chronic pain. Two independent investigators extracted quotations with implicit and explicit references to communication and study characteristics following Standards for Reporting Qualitative Research and Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Methodological quality for individual studies was assessed with Critical Appraisal Skills Programme, and quality of evidence was evaluated with GRADE-CERQual. An inductive thematic synthesis was conducted by coding each quotation, developing descriptive themes, and then generating behaviorally distinct analytical themes. RESULTS Eleven studies involving 346 participants were included. The specificity of operationalizing communication terms varied widely. Meta-synthesis identified 8 communication themes: (1) disclosure-facilitating, (2) rapport-building, (3) empathic, (4) collaborative, (5) professional accountability, (6) informative, (7) agenda-setting, and (8) meta-communication. Based on the quality of available evidence, confidence was moderate for 4 themes and low for 4 themes. CONCLUSION This study revealed limited operationalization of communication behaviors preferred by physical therapists in chronic pain rehabilitation. A conceptual framework based on 8 communication themes identified from the literature is proposed as a preliminary paradigm to guide future research. IMPACT This proposed evidence-based conceptual framework for preferred communication behaviors in pain rehabilitation provides a framework for clinicians to reflect on their own communication practices and will allow researchers to identify if and how specific communication behaviors impact clinical outcomes.
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Affiliation(s)
- Chelsea R Chapman
- Joint Doctoral Program in Public Health, San Diego State University and University of California San Diego, San Diego, California, USA
| | - Nathan T Woo
- Department of Communication, University of Arizona, Tucson, Arizona, USA
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Guassora AD, Johansen ML, Malterud K. Agenda navigation in consultations covering multiple topics. A qualitative case study from general practice. Scand J Prim Health Care 2021; 39:339-347. [PMID: 34435549 PMCID: PMC8475129 DOI: 10.1080/02813432.2021.1958472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To explore how agenda navigation may be accomplished underway in consultations covering multiple topics, we identified and analyzed one GP's communicative strategies. DESIGN, SETTING, AND SUBJECTS A qualitative observational case study with linguistic microanalysis of an exemplary consultation between a female patient with diabetes and her male GP. We used speech act theory to identify communicative actions that indicated agenda navigation by the GP in transitions between episodes concerning ten topics. RESULTS Microanalysis revealed different aspects of agenda navigation by the GP using speech acts, especially ways of opening or closing an episode. The opening of episodes was characterized by speech acts accepting the patient's request to discuss a topic, mostly at the beginning of the consultation. Speech acts to inform or to request information from the patient dominated later in the consultation. The GP closed all episodes using speech acts to instruct or appraise the patient, or to make agreements and plans. CONCLUSION AND PRACTICE IMPLICATIONS Skilful agenda navigation is an important tool for consultations covering multiple issues and could be further developed for medical education. The opening and closing of episodes were vital communicative strategies supporting patient-centered communication in a complex consultation while maintaining the focus of the consultation agenda.KEY POINTSWhile traditional consultation models cover one health problem, GP consultations often include many patient issues in each session.Linguistic microanalysis of speech acts helped to identify communication strategies in a GP consultation with multiple topics.The GP conducted agenda navigation by distinctly opening and closing episodes concerning specific topics.Episodes were opened by accepting, informing, and requesting and closed by instruction, appraisal, making agreements, or plans.
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Affiliation(s)
- Ann Dorrit Guassora
- The Research Unit and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- CONTACT Ann Dorrit Guassora The Research Unit and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - May-Lill Johansen
- The Research Unit for General Practice, Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Kirsti Malterud
- The Research Unit and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Norway
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Arreskov AB, Lindell JF, Davidsen AS. General practitioner responses to concerns in chronic care consultations for patients with a history of cancer. J Health Psychol 2021; 27:2261-2275. [PMID: 34219544 DOI: 10.1177/13591053211025593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We investigated general practitioners' (GPs') responses to patients' concerns in chronic care consultations. Video recordings of 14 consultations were analyzed with conversation analysis. We found two categories of responses: exiting and exploring the patient's concerns. Most GPs exited the concern by interrupting the patient, acknowledging the concern but then referring back to the progression of the consultation, or affiliating with the concern without exploring it. Only a few raised concerns were explored, and then most often the somatic rather than the emotional aspects of them. The findings point to the risk of missing patients' voiced concerns in consultations with a fixed agenda.
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Roberts L, Osborn-Jenkins L. Delivering remote consultations: Talking the talk. Musculoskelet Sci Pract 2021; 52:102275. [PMID: 33132068 PMCID: PMC7573651 DOI: 10.1016/j.msksp.2020.102275] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/02/2020] [Accepted: 09/19/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION There is an increasing affinity for remote health consultations (including telephone and virtual platforms), enabling new models of accessing services to evolve. Whilst many key skills are transferable from traditional to remote consultations, there is even greater emphasis on verbal communication skills during these interactions. PURPOSE This masterclass considers the communication skills required for delivering remote health care consultations, in particular focussing on: 12 interactional features in an opening sequence of a remote call; active listening; how to offer advice using the Ask-Offer-Ask framework; and subtleties in phrasing and prosody when closing a call that may indicate a level of satisfaction (or otherwise). IMPLICATIONS In planning for digitally-enabled services to become mainstream, the differences in communication between remote and face-to-face consultations must be recognised and embraced.
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Affiliation(s)
- L.C. Roberts
- School of Health Sciences, University of Southampton, Southampton, UK,Therapy Services, University Hospital Southampton NHS Foundation Trust, Southampton, UK,Corresponding author. School of Health Sciences, University of Southampton, Mailpoint 11, Room AA101, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
| | - L. Osborn-Jenkins
- School of Health Sciences, University of Southampton, Southampton, UK,Therapy Services, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Adults With Diabetes Distress Often Want to Talk With Their Health Professionals About It: Findings From an Audit of 4 Australian Specialist Diabetes Clinics. Can J Diabetes 2020; 44:473-480. [DOI: 10.1016/j.jcjd.2020.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/19/2020] [Accepted: 02/10/2020] [Indexed: 11/23/2022]
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Ison R, Kisan V, Cole C, Angus-Leppan H. The Epilepsy Risk Awareness (ERA) Scale: A New Era for Holistic Risk Assessment in Epilepsy. Front Neurol 2020; 11:465. [PMID: 32595587 PMCID: PMC7300212 DOI: 10.3389/fneur.2020.00465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/29/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: Best care in epilepsy balances protecting people with epilepsy from risks and avoiding undue restrictions in order to improve quality of life. To date, no single risk assessment tool has been widely adopted by both people with epilepsy and health-care professionals such as specialist epilepsy nurses. The present research refined the Epilepsy Risk Awareness (ERA) Scale, a validated and holistic risk assessment tool, by assessing test-retest reliability of each question and incorporating suggestions from patients regarding design and content. Methods: The draft clinical scale was administered to 102 adult participants from the Epilepsy Service at the Royal Free London National Health Service (NHS) Foundation Trust on two occasions. Quantitative and qualitative analyses were conducted-intraclass correlation coefficient (ICC) estimates were used to assess test-retest reliability of questions, and thematic analysis was used to analyze participants' comments and feedback. Following analysis, the ERA Scale was amended. Of the 102 participants, 32 conducted a further review of the revised ERA Scale to test completion time and provide final comments. Results: ICC reliability level estimates varied from "poor to moderate" to "good to excellent," and four qualitative themes were identified. The ERA Scale was amended accordingly to enhance practicality and usefulness, reducing completion time to approximately 5 min. Significance: The ERA Scale is a validated tool that aims to change clinical practice by standardizing risk assessment in epilepsy, providing a holistic approach that focuses on improved safety and quality of life.
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Affiliation(s)
- Rachel Ison
- Clinical Neurosciences, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Virad Kisan
- University College London Medical School, London, United Kingdom
| | - Christine Cole
- Harrow Neurology Specialist Nursing Service, Middlesex, United Kingdom
| | - Heather Angus-Leppan
- Clinical Neurosciences, Royal Free London NHS Foundation Trust, London, United Kingdom.,UCL Queen Square Institute of Neurology, London, United Kingdom
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Begh R, Coleman T, Yardley L, Barnes R, Naughton F, Gilbert H, Ferrey A, Madigan C, Williams N, Hamilton L, Warren Y, Grabey J, Clark M, Dickinson A, Aveyard P. Examining the effectiveness of general practitioner and nurse promotion of electronic cigarettes versus standard care for smoking reduction and abstinence in hardcore smokers with smoking-related chronic disease: protocol for a randomised controlled trial. Trials 2019; 20:659. [PMID: 31779689 PMCID: PMC6883522 DOI: 10.1186/s13063-019-3850-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 10/25/2019] [Indexed: 02/05/2023] Open
Abstract
Background Despite the clear harm associated with smoking tobacco, many people with smoking-related chronic diseases or serious mental illnesses (SMI) are unwilling or unable to stop smoking. In many cases, these smokers have tried and exhausted all methods to stop smoking and yet clinicians are repeatedly mandated to offer them during routine consultations. Providing nicotine through electronic cigarettes (e-cigarettes) may reduce the adverse health consequences associated with tobacco smoking, but these are not currently offered. The aim of this study is to examine the feasibility, acceptability and effectiveness of general practitioners (GPs) and nurses delivering a brief advice intervention on e-cigarettes and offering an e-cigarette starter pack and patient support resources compared with standard care in smokers with smoking-related chronic diseases or SMI who are unwilling to stop smoking. Methods/design This is an individually randomised, blinded, two-arm trial. Smokers with a smoking-related chronic condition or SMI with no intention of stopping smoking will be recruited through primary care registers. Eligible participants will be randomised to one of two groups if they decline standard care for stopping smoking: a control group who will receive no additional support beyond standard care; or an intervention group who will receive GP or nurse-led brief advice about e-cigarettes, an e-cigarette starter pack with accompanying practical support booklet, and telephone support from experienced vapers and online video tutorials. The primary outcome measures will be smoking reduction, measured through changes in cigarettes per day and 7-day point-prevalence abstinence at 2 months. Secondary outcomes include smoking reduction, 7-day point-prevalence abstinence and prolonged abstinence at 8 months. Other outcomes include patient recruitment and follow-up, patient uptake and use of e-cigarettes, nicotine intake, contamination of randomisation and practitioner adherence to the delivery of the intervention. Qualitative interviews will be conducted in a subsample of practitioners, patients and the vape team to garner their reactions to the programme. Discussion This is the first randomised controlled trial to investigate whether e-cigarette provision alongside a brief intervention delivered by practitioners leads to reduced smoking and abstinence among smokers with smoking-related chronic diseases or SMI. Trial registration ISRCTN registry, ISRCTN59404712. Registered 28/11/17.
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Affiliation(s)
- Rachna Begh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK.
| | - Tim Coleman
- Division of Primary Care, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Lucy Yardley
- Academic Unit of Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, SO17 1BJ, UK.,School of Experimental Psychology, University of Bristol, Bristol, BS8 1TU, UK
| | - Rebecca Barnes
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Felix Naughton
- School of Health Sciences, University of East Anglia, Norwich, NR4 7UL, UK
| | - Hazel Gilbert
- Research Department of Primary Care and Population Health, University College London, Royal Free and University College Medical School, London, NW3 2PF, UK
| | - Anne Ferrey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Claire Madigan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Nicola Williams
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Louisa Hamilton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Yolanda Warren
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Jenna Grabey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Miranda Clark
- Division of Primary Care, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Anne Dickinson
- Division of Primary Care, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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White AEC. Patient-initiated additional concerns in general surgery visits. PATIENT EDUCATION AND COUNSELING 2018; 101:2219-2225. [PMID: 30131264 DOI: 10.1016/j.pec.2018.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/06/2018] [Accepted: 08/08/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To understand how and when patients initiate additional concerns in general surgery visits. METHODS 175 video-recorded visits of a general surgery practice in rural Texas were collected, coded, and analyzed using Conversation analysis. RESULTS Patients initiated 377 additional concerns, with 2 or more concerns raised in 80 visits, and 1 concern raised in 37 visits. Three methods of initiation were identified: fitted-to-topic (66%), fitted-to-activity (14%), and disjunctive (20%). Sixty percent of patient-initiated concerns occurred i) before the physical examination, compared to 14% after the physical exam, and ii) in pre-operative visits. CONCLUSIONS In contrast to the research on acute, primary care visits, patients in general surgery visits do not wait to present "door knob concerns." Instead, patients in general surgery visits are more likely to initiate concerns early in the visit. Patients most frequently find and create opportunities to introduce new concerns by fitting them to the ongoing talk or activity. PRACTICE IMPLICATIONS Physicians should spend more time on the physical exam, as this phase creates a unique opportunity for patients to initiate concerns.
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Affiliation(s)
- Anne Elizabeth Clark White
- Department of Internal Medicine, University of California Davis, 4150 V St #3100, Sacramento, CA, 95817, USA.
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Leydon GM, Stuart B, Summers RH, Little P, Ekberg S, Stevenson F, Chew-Graham CA, Brindle L, Heritage J, Drew P, Moore MV. Findings from a feasibility study to improve GP elicitation of patient concerns in UK general practice consultations. PATIENT EDUCATION AND COUNSELING 2018; 101:1394-1402. [PMID: 29627268 DOI: 10.1016/j.pec.2018.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 02/28/2018] [Accepted: 03/07/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To establish: a) feasibility of training GPs in a communication intervention to solicit additional patient concerns early in the consultation, using specific lexical formulations ("do you have 'any' vs. 'some' other concerns?") noting the impact on consultation length, and b) whether patients attend with multiple concerns and whether they voiced them in the consultation. METHODS A mixed-methods three arm RCT feasibility study to assess the feasibility of the communication intervention. RESULTS Intervention fidelity was high. GPs can be trained to solicit additional concerns early in the consultation (once patients have presented their first concern). Whilst feasible the particular lexical variation of 'any' vs 'some' seemed to have no bearing on the number of patient concerns elicited, on consultation length or on patient satisfaction. The level of missing questionnaire data was low, suggesting patients found completion of questionnaires acceptable. CONCLUSION GPs can solicit for additional concerns without increasing consultation length, but the particular wording, specifically 'any' vs. 'some' may not be as important as the placement of the GP solicitation. PRACTICE IMPLICATIONS GPs can solicit early for additional concerns and GPs can establish patients' additional concerns in the opening of the consultation, which can help to plan and prioritise patients multiple concerns.
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Affiliation(s)
- Geraldine M Leydon
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, UK.
| | - Beth Stuart
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, UK
| | | | - Paul Little
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, UK
| | - Stuart Ekberg
- Faculty of Health, School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia
| | - Fiona Stevenson
- E-Health Unit, Primary Care & Population Health, University College London, UK
| | | | - Lucy Brindle
- Faculty of Health Sciences, University of Southampton, UK
| | - John Heritage
- Social Sciences, University of California at Los Angeles, USA
| | - Paul Drew
- Social Sciences, Loughborough University, UK
| | - Michael V Moore
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, UK
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Syed A, Mohd Don Z, Ng CJ, Lee YK, Khoo EM, Lee PY, Lim Abdullah K, Zainal A. Using a patient decision aid for insulin initiation in patients with type 2 diabetes: a qualitative analysis of doctor-patient conversations in primary care consultations in Malaysia. BMJ Open 2017; 7:e014260. [PMID: 28490553 PMCID: PMC5623402 DOI: 10.1136/bmjopen-2016-014260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To investigate whether the use of apatient decision aid (PDA) for insulin initiation fulfils its purpose of facilitating patient-centred decision-making through identifying how doctors and patients interact when using the PDA during primary care consultations. DESIGN Conversation analysis of seven single cases of audio-recorded/video-recorded consultations between doctors and patients with type 2 diabetes, using a PDA on starting insulin. SETTING Primary care in three healthcare settings: (1) one private clinic; (2) two public community clinics and (3) one primary care clinic in a public university hospital, in Negeri Sembilan and the Klang Valley in Malaysia. PARTICIPANTS Clinicians and seven patients with type 2 diabetes to whom insulin had been recommended. Purposive sampling was used to select a sample high in variance across healthcare settings, participant demographics and perspectives on insulin. PRIMARY OUTCOME MEASURES Interaction between doctors and patients in a clinical consultation involving the use of a PDA about starting insulin. RESULTS Doctors brought the PDA into the conversation mainly by asking information-focused 'yes/no' questions, and used the PDA for information exchange only if patients said they had not read it. While their contributions were limited by doctors' questions, some patients disclosed issues or concerns. Although doctors' PDA-related questions acted as a presequence to deliberation on starting insulin, their interactional practices raised questions on whether patients were informed and their preferences prioritised. CONCLUSIONS Interactional practices can hinder effective PDA implementation, with habits from ordinary conversation potentially influencing doctors' practices and complicating their implementation of patient-centred decision-making. Effective interaction should therefore be emphasised in the design and delivery of PDAs and in training clinicians to use them.
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Affiliation(s)
- Ayeshah Syed
- Department of English Language, Faculty of Languages and Linguistics, University of Malaya, Kuala Lumpur, Malaysia
| | - Zuraidah Mohd Don
- Department of English Language, Faculty of Languages and Linguistics, University of Malaya, Kuala Lumpur, Malaysia
- Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yew Kong Lee
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ping Yein Lee
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Khatijah Lim Abdullah
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Azlin Zainal
- Department of English Language, Faculty of Languages and Linguistics, University of Malaya, Kuala Lumpur, Malaysia
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16
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Dang BN, Westbrook RA, Njue SM, Giordano TP. Building trust and rapport early in the new doctor-patient relationship: a longitudinal qualitative study. BMC MEDICAL EDUCATION 2017; 17:32. [PMID: 28148254 PMCID: PMC5288896 DOI: 10.1186/s12909-017-0868-5] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 01/24/2017] [Indexed: 05/15/2023]
Abstract
BACKGROUND New patients are a particularly vulnerable population because they are at high risk of missing a subsequent visit or dropping out of care completely. However, few data exist on what new patients value in the beginning of a relationship with a new provider. Persons with HIV infection may be an ideal population to study the drivers of a positive initial patient-provider relationship, as it is a chronic and serious condition that requires a reliable, ongoing relationship with a provider. Informed by patients' real experiences, this study aims to identify what patients see as the most critical elements for building trust and rapport from the outset. METHODS We conducted longitudinal, in-person interviews with 21 patients new to the HIV clinic at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, from August 2013 to March 2015. Patients were interviewed across three time points: once before their first provider visit, a second time within two weeks after the first visit, and a third time at 6 to 12 months after the first provider visit. RESULTS We conducted 61 h of patient interviews. The mean age was 53 years; 52% were non-Hispanic white, 23% were non-Hispanic black and 19% were Hispanic. Patients described significant anxiety and vulnerability not just from HIV itself, but also in starting a relationship as a new patient to a new provider. Our analysis of these experiences revealed five actions providers can take to reduce their patients' anxiety and build trust early in the first visit: 1) provide reassurance to patients, 2) tell patients it's okay to ask questions, 3) show patients their lab results and explain what they mean, 4) avoid language and behaviors that are judgmental of patients, and 5) ask patients what they want [i.e., treatment goals and preferences]. CONCLUSIONS Our study incorporates direct input from patients and highlights the unique psychological challenges that patients face in seeking care from a new provider. The actionable opportunities cited by patients have the potential to mitigate patients' feelings of anxiety and vulnerability, and thereby improve their overall health care experience.
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Affiliation(s)
- Bich N. Dang
- VA Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Houston, TX USA
- Michael E. DeBakey Veterans Affairs Medical Center (152), 2002 Holcombe Blvd, Houston, TX 77030 USA
- Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Robert A. Westbrook
- Jesse H. Jones Graduate School of Business, Rice University, Houston, TX USA
| | - Sarah M. Njue
- VA Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Houston, TX USA
- Michael E. DeBakey Veterans Affairs Medical Center (152), 2002 Holcombe Blvd, Houston, TX 77030 USA
- Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Thomas P. Giordano
- VA Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Houston, TX USA
- Michael E. DeBakey Veterans Affairs Medical Center (152), 2002 Holcombe Blvd, Houston, TX 77030 USA
- Department of Medicine, Baylor College of Medicine, Houston, TX USA
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