Patient and visit characteristics related to physicians' participatory decision-making style. Results from the Medical Outcomes Study

Which clinician responses to emotion are associated with more positive patient experiences of communication?

OBJECTIVES

To identify communication strategies that may improve clinician-patient interactions, we assessed the association between clinician response to emotion and patient ratings of communication.

METHODS

From a cohort of 1817 clinician-patient encounters, we designed a retrospective case-control study by identifying 69 patients who rated their interpersonal care as low-quality and 69 patients who rated their care as high-quality. We used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to identify patient emotional expressions and clinician responses. Using mixed-effects logistic regression, we evaluated the association between clinician responses to patients' emotions and patient ratings of their interpersonal care.

RESULTS

In adjusted analyses, explicit responses that reduced space for further emotional communication were associated with high ratings of care (OR 1.94, 95% CI 1.25, 2.99); non-explicit responses providing additional space were associated with low ratings (OR 0.54, 95% CI 0.36-0.82). In terms of specific response types, neutral/passive responses were associated with low ratings (OR 0.59, 95% CI 0.39-0.90), whereas giving information/advice was associated with high ratings (OR, 95% 1.91 CI 1.17-3.1).

CONCLUSIONS

Patients may prefer responses to their expressed emotions that demonstrate clinician engagement, with or without expressions of empathy.

PRACTICE IMPLICATIONS

These findings may inform educational interventions to improve clinician-patient communication.

Association of surgeon-patient sex concordance with postoperative outcomes following complex cancer surgery

BACKGROUND AND OBJECTIVES

Sex concordance may impact the therapeutic relationship and provider-patient interactions. We sought to define the association of surgeon-patient sex concordance on postoperative patient outcomes following complex cancer surgery.

METHODS

Patients who underwent surgery for lung, breast, hepato-pancreato-biliary, or colorectal cancer between 2014 and 2020 were identified from the Medicare Standard Analytic Files. The impact of surgeon-patient sex concordance or discordance on achieving an optimal postoperative textbook outcome (TO) was assessed using multivariable logistic regression.

RESULTS

Among 495 628 patients, 241 938 (48.8%) patients were sex concordant with their surgeon while 253 690 (51.2%) patients were sex discordant. Sex discordance between surgeon and patient was associated with a decreased likelihood to achieve a postoperative TO (odds ratio [OR]: 0.95, 95% CI: 0.93-0.97; p < 0.001). Sex discordance was associated with a higher risk of complications (OR: 1.05, 95% CI: 1.03-1.07; p < 0.001) and 90-day mortality (OR: 1.05, 95% CI: 1.01-1.09; p = 0.011). Of note, male patients treated by female surgeons (OR: 0.96, 95% CI: 0.93-0.99; p = 0.017) had a similar lower likelihood to achieve a TO as female patients treated by male surgeons (OR: 0.90, 95% CI: 0.86-0.93; p < 0.001).

CONCLUSIONS

Sex discordance was associated with a reduced likelihood of achieving an "optimal" postoperative course following complex cancer surgery.

Validating computer-generated measures of linguistic style matching and accommodation in patient-clinician communication

OBJECTIVE

To explore the validity of computer-analyzed linguistic style matching (LSM) in patient-clinician communication.

METHODS

Using 330 transcribed HIV patient encounters, we quantified word use with Linguistic Inquiry and Word Count (LIWC), a dictionary-based text analysis software. We measured LSM by calculating the degree to which clinicians matched patients in the use of LIWC "function words" (e.g., articles, pronouns). We tested associations of different LSM metrics with patients' perceptions that their clinicians spoke similiarly to them.

RESULTS

We developed 3 measures of LSM: 1) at the whole-visit level; (2) at the turn-by-turn level; and (3) using a "rolling-window" approach, measuring matching between clusters of 8 turns per conversant. None of these measures was associated with patient-rated speech similarity. However, we found that increasing trajectories of LSM, from beginning to end of the visit, were associated with higher patient-rated speech similarity (β 0.35, CI 0.06, 0.64), compared to unchanging trajectories.

CONCLUSIONS

Our findings point to the potential value of clinicians' adapting their communication style to match their patients, over the course of the visit.

PRACTICE IMPLICATIONS

With further validation, computer-based linguistic analyses may prove an efficient tool for generating data on communication patterns and providing feedback to clinicians in real time.

Prostate volume, baseline urinary function, and their association with treatment choice and post-treatment urinary function in men treated for localized prostate cancer

BACKGROUND

Benign prostatic hyperplasia, lower urinary tract symptoms, and prostate cancer often co-occur. Their effect on urinary function is an important consideration regarding prostate cancer treatment choices. While prostate volume (PV) and urinary symptoms are commonly used in treatment choice decision making, their association with post-treatment urinary function is unknown. We evaluated the associations between PV and baseline urinary function with treatment choice and post-treatment urinary function among men with localized prostate cancer.

METHODS

We identified 1647 patients from CEASAR, a multicenter population-based, prospective cohort study of men with localized prostate cancer, for analysis. Primary outcomes were treatment choice and health-related quality of life (HRQOL) assessed by the 26-item Expanded Prostate Index Composite (EPIC-26) at pre-specified intervals up to 5 years. Multivariable analysis was performed, controlling for demographic and clinicopathologic features.

RESULTS

Median baseline PV was 36 mL (IQR 27-48), and baseline urinary irritative/obstructive domain score was 87 (IQR 75-100). There was no observed clinically meaningful association between PV and treatment choice or post-treatment urinary function. Among patients with poor baseline urinary function, treatment with radiation or surgery was associated with statistically and clinically significant improvement in urinary function at 6 months which was durable through 5 years (improvement from baseline at 5 years: radiation 20.4 points, surgery 24.5 points).

CONCLUSIONS

PV was not found to be associated with treatment modality or post-treatment urinary irritative/obstructive function among men treated for localized prostate cancer. Men with poor baseline urinary irritative/obstructive function improve after treatment with surgery or radiation therapy.

Concerns raised by people treated for head and neck cancer: a secondary analysis of audiotaped consultations in a health services follow-up clinic

PURPOSE

People treated for head and neck cancer (HNC) face various barriers in communicating concerns with consultants. Our aim was to investigate the number of concerns raised between patients using the Patient Concerns Inventory (PCI) and those who did not. The PCI is a 57-item prompt list used in routine HNC follow-up clinics. Additionally, we aimed to examine whether who initiated the concerns differed between groups and the factors that may predict this initiation.

METHODS

Secondary data analysis included 67 participants across 15 HNC consultants from specialist cancer centres in Liverpool and Leeds. Seven consultants utilised the PCI and eight did not, assigned by preferential and random assignment.

RESULTS

Patients in the PCI group raised on average 2.5 more concerns than patients in the non-PCI group (p < .001). There was no significant relationship between group and who initiated the first concern (p = .28). A mixed-effects logistic regression was found to significantly predict who initiated the first concern in consultations (p < .05).

DISCUSSION

The number of concerns raised by patients increased when the PCI was introduced pre-HNC consultation. A number of factors were shown to predict the number of concerns raised in consultations by both patient and consultant. As concerns may not be raised further following the concern mentioned, we propose that the discussion of concerns needs to be maintained by the clinician throughout the consultation and not solely at the start.

CONCLUSION

The PCI promoted the sharing of concerns in follow-up consultations between patient and consultant.

Provider use of a participatory decision-making style with African American patients with glaucoma

OBJECTIVE

To examine whether non-adherent African American patients with glaucoma who received a question prompt list and video intervention were more likely to be given treatment options, have their input included into treatment regimens, and rate their providers as using more of a participatory decision-making style.

METHODS

African American patients with glaucoma taking one or more glaucoma medications and reported being non-adherent were randomized to a pre-visit video and glaucoma question prompt list intervention or usual care.

RESULTS

189 African American patients with glaucoma participated. Providers gave patients treatment choices during 5.3% of visits and included patient input into treatment regimen decisions during 2.1% of visits. Male patients and patients with more years of education were significantly more likely to rate their providers as using more of a participatory decision-making style.

CONCLUSION

African American patients with glaucoma rated their providers high on using a participatory decision-making style. Yet, providers infrequently presented non-adherent patients with medication treatment options, and it was rare for providers to include patient input into treatment decisions.

PRACTICE IMPLICATIONS

Providers should provide non-adherent patients with different glaucoma treatment options. Non-adherent African American patients with glaucoma should be encouraged to ask their providers for different medication treatment options.

Design, methods, and recruitment outcomes of the Veterans' Pain Care Organizational Improvement Comparative Effectiveness (VOICE) study

The Veterans' Pain Care Organizational Improvement Comparative Effectiveness (VOICE) study is a 12-month pragmatic randomized comparative effectiveness trial conducted at ten United States Veterans Affairs (VA) health care sites. The overall goal was to test interventions to improve pain while reducing opioid use among VA patients with moderate-severe chronic pain despite treatment with long-term opioid therapy (LTOT). Aims were 1) to compare lower-intensity telecare collaborative pain management (TCM) versus higher-intensity integrated pain team management (IPT), and 2) to test the option of switching to buprenorphine (versus no option) in a high-dose subgroup. Recruitment challenges included secular trends in opioid prescribing and the COVID-19 pandemic. Participants were recruited over 3.5 years. Of 6966 potentially eligible patients, 4731 (67.9%) were contacted for telephone eligibility interview; of those contacted, 3398 (71.8%) declined participation, 359 (7.6%) were ineligible, 821 (24.2%) enrolled, and 820 (24.1%) were randomized. The most common reason for declining was satisfaction with pain care (n = 731). The most common reason for ineligibility was not having moderate-severe chronic pain (n = 110). Compared with the potentially eligible population, randomized participants were slightly younger, more often female, had similar prescribed opioids, and had similar or higher rates of pain and mental health diagnoses. The enrolled patient number was lower than the original target, but sufficient to power planned analyses. In conclusion, the VOICE trial enrolled a diverse sample similar to the population of VA patients receiving LTOT. Results will add substantially to limited existing evidence for interventions to improve pain while reducing opioid use. ClinicalTrials.gov identifier: NCT03026790.

Protocol for the pilot quasi-experimental controlled trial of a gender-responsive implementation strategy with providers to improve HIV outcomes in Uganda

BACKGROUND

Antiretroviral treatment (ART) is the most effective clinical intervention for reducing morbidity and mortality among persons living with HIV. However, in Uganda, there are disparities between men and women in viral load suppression and related HIV care engagement outcomes, which suggests problems with the implementation of ART. Gender norms are a known driver of HIV disparities in sub-Saharan Africa, and patient-provider relationships are a key factor in HIV care engagement; therefore, the role of gender norms is important to consider in interventions to achieve the equitable provision of treatment and the quality of ART counseling.

METHODS

The overall research objective of this study is to pilot test an implementation strategy (i.e., methods to improve the implementation of an evidence-based intervention) to increase providers' capacity to provide gender-responsive treatment and counseling to men and women on HIV treatment in Uganda. Delivered to HIV providers, this group training adapts evidence-based strategies to reduce gender biases and increase skills to deliver gender-specific and transformative HIV counseling to patients. The implementation strategy will be piloted through a quasi-experimental controlled trial. Clinics will be randomly assigned to either the intervention or control conditions. The trial will assess feasibility and acceptability and explore barriers and facilitators to implementation and future adoption while gathering preliminary evidence on the implementation strategy's effectiveness by comparing changes in patient (N = 240) and provider (N = 80-140) outcomes across intervention and control clinics through 12-month follow-up. Quantitative data will be descriptively analyzed, qualitative data will be analyzed through thematic analysis, and these data will be mixed during the presentation and interpretation of results where appropriate.

DISCUSSION

This pilot intervention trial will gather preliminary evidence on the acceptability, feasibility, and potential effect of a novel implementation strategy to improve men and women's HIV care engagement, with the potential to reduce gender disparities in HIV outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05178979 , retrospectively registered on January 5, 2022.

Shared Decision Making in Health Care: Theoretical Perspectives for Why It Works and For Whom

Applying both theoretical perspectives and empirical evidence, we address 2 key questions regarding shared decision making (SDM): 1) When should SDM be more patient driven, and when should it be more provider driven? and 2) Should health care providers match their SDM style/strategy to patient needs and preferences? Self-determination theory, for example, posits a distinction between autonomy and independence. A patient may autonomously seek their health care provider's input and guidance, perhaps due to low perceived competence, low coping resources, or high emotional arousal. Given their need state, they may autonomously require nonindependence. In this case, it may be more patient centered and need supportive to provide more provider-driven care. We discuss how other patient characteristics such as personality attributes, motivational state, and the course of illness and other parameters such as time available for an encounter may inform optimal provider decision-making style and strategy. We conclude that for some types of patients and clinical circumstances, a more provider-driven approach to decision making may be more practical, ethical, and efficacious. Thus, while all decision making should be patient centered (i.e., it should consider patient needs and preferences), it does not always have to be patient driven. We propose a flexible model of SDM whereby practitioners are encouraged to tailor their decision making behaviors to patient needs, preferences, and other attributes. Studies are needed to test whether matching decision-making behavior based on patient states and traits (i.e., achieving concordance) is more effective than simply providing all patients with the same type of decision making, which could be tested using matching/mismatching designs.

Closing the Gap: Training Experiences and Career Outcomes for Underrepresented Minorities in Plastic Surgery

Background:

The present study assesses training characteristics, scholastic achievements, and traditional career accomplishments of ethnically underrepresented in medicine (UIM) plastic and reconstructive surgery (PRS) faculty relative to non-UIM PRS faculty.

Method:

A cross-sectional analysis of core PRS faculty appointed to accredited United States residency training programs (n = 99) was performed.

Results:

Of the 949 US PRS faculty, a total of 51 (5.4%) were identified as UIM. Compared with non-UIM faculty, there were few differences when evaluating medical education, residency training, pursuit of advanced degrees, and attainment of subspecialty fellowship training. UIM faculty were more likely than non-UIM faculty to have graduated from a medical school outside the United States (25% versus 13%, P = 0.014). In addition, UIM faculty did not differ from non-UIM counterparts in traditional career accomplishments, including promotion to full professor, obtaining NIH funding, serving as program director, receiving an endowed professorship, appointment to a peer-reviewed editorial board, scholarly contributions (H-index and number of publications), and appointment to chief/chair of their division/department.

Conclusions:

The historical lack of ethnic diversity that comprise US academic PRS faculty persists. This study reveals that those UIM faculty who are able to obtain faculty appointments are equally successful in achieving scholastic success and traditional career accomplishments as their non-UIM counterparts. As we strive toward increasing representation of UIM physicians in academic plastic surgery, the field will benefit from efforts that promote a pipeline for underrepresented groups who traditionally face barriers to entry.

Expanding the Scope of the Visit: Which Patient-Initiated Additional Concerns Receive Help?

This study examines patient-initiated additional concern presentations in general surgery visits to assess which factors contribute to them getting "helped." Concern presentations were analyzed for a variety of design features (e.g., social action (inquiry vs. informing), when patients initiate during a visit, how patients fit topic to previous talk or activity) and contextual factors (e.g., concern falls inside or outside surgeon's domain of expertise, chronic vs. acute concern-types, the history of the patient-physician relationship). This study uses a mixed-methods approach, combining case-level conversation analysis and aggregate-level statistical analysis. Data are video recordings of office visits from 2013-2015, with a longitudinal focus of following the same patients across time. In total, 62 patients spanning 175 visits were analyzed. 377 patient-initiated additional concerns were found, and 188 received help. Several factors were found to increase the likelihood of patients' concerns getting helped such as designing the concern as an inquiry, raising the concern early in the visit, and mentioning the concern more than once. These findings can help guide patients on how to better design additional concerns presentations to receive help and can benefit physicians by identifying more subtle practices patients are already using to broach concerns to help reduce unnoticed or unhelped concerns.

Diversity of the physician workforce: Specialty choice decisions during medical school

Background

Despite efforts to increase the overall diversity of the medical student body, some medical specialties have a less diverse applicant pool based on both gender and race than would be expected based on medical graduate demographics.

Objectives

To identify whether women and Underrepresented in Medicine (URiM) medical students have baseline differences in their career interests or if their career plans change more during medical school when compared to men and non-URIM students.

Methods

Secondary data analyses of all medical students who applied through ERAS from 2005–2010 was conducted. Binary logistic regression models with the response being a planned career in one of four medical specialties (internal medicine, pediatrics, OB/GYN, and general surgery/surgical specialties) at medical school entry and graduation. Regression models included demographics, student attitudes, debt, academic metrics, and medical school experiences.

Results

Comparatively, women were less likely to be interested in internal medicine and surgery and more interested in pediatrics and OB/GYN at matriculation. URiM students expressed more interest in OB/GYN and surgery when starting medical school. At graduation, women were less likely to plan for internal medicine and surgery and were more interested in pursuing OB/GYN and pediatrics. URiM students were more likely to plan for a career in internal medicine and less likely to choose pediatrics.

Conclusions

From matriculation to graduation, women have relatively stable preferences regarding planned medical specialties. In contrast, URiM students’ specialty plans shifted over time among the four specialties, with variation in preferences occurring between matriculation and graduation.

Is Patient-Physician Gender Concordance Related to the Quality of Patient Care Experiences?

BACKGROUND

There is great interest in identifying factors that are related to positive patient experiences such as physician communication style. Documented gender-specific physician communication and patient behavior differences raise the question of whether gender concordant relationships (i.e., both the provider and patient share the same gender) might affect patient experiences.

OBJECTIVE

Assess whether patient experiences are more positive in gender concordant primary care relationships.

DESIGN

Statewide telephone surveys. Linear mixed regression models to estimate the association of CAHPS scores with patient gender and gender concordance.

SUBJECTS

Two probability samples of primary care Medicaid patients in Connecticut in 2017 (5/17-7/17) and 2019 (7/19-10/19).

MAIN MEASURES

Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey augmented with questions about aspects of care most salient to PCMH-designated organizations and two questions to assess access to mental health services.

KEY RESULTS

There were no significant effects of gender concordance and differences in experiences by patient gender were modest.

CONCLUSIONS

This study did not support the suggestion that patient and physician gender and gender concordance have an important effect on patient experiences.

Examining the Racial Disparities in Prostate Cancer

Currently, Black men in the United States are greater than 1.5 times as likely to be diagnosed with prostate cancer and more than twice as likely to succumb to the disease. While racial disparities in prostate cancer have been well documented, we must analyze these disparities in the correct context. Discussion of these disparities without correctly describing race as a social construct and acknowledging the impact of structural racism is insufficient. This article reviews the disparities seen in screening, treatment, outcomes, and clinical trial participation. We conclude by outlining future steps to help understand and study disparities, as we strive toward equitable outcomes.

Primary care experience among older adults in the United States: a retrospective cross-sectional study

BACKGROUND

While the importance of primary care becomes more imminent for older adults to manage multi-morbidities, the perception of primary care among this group is not well examined.

AIM

To evaluate the primary care experience among older adults in the United States (US).

METHODS

We conducted a retrospective cross-sectional study examining four domains of primary care: first contact, longitudinality, comprehensiveness, and coordination. Using survey responses from Medical Expenditure Panel Survey (MEPS), we used propensity score matching method to compare the percentage of geriatric (≥65 years old) and non-geriatric (< 65 years old) who answered favorably to questions that supported each domain from 2014 to 2016. Using multivariate regression, we also assessed the impact of each domain on various demographic and perceived need for care features of older adults.

RESULTS

A total of 12,982 surveys were analyzed for geriatric, compared to 62,694 surveys for non-geriatric. Overall, older adults answered more favorably than younger adults for all four domains. However, uninsured older adults, Black older adults and older adults with limitation in activities, cognitive impairments, and multiple comorbidities were more likely to have difficulties in accessing their usual source of care (USC). Additionally, Black, Hispanic, and Asian older adults and cognitively impaired adults perceived less contribution in their own treatment management.

CONCLUSION

Older adults in the US generally experience good quality of primary care, compared to younger adults. However, establishing and maintaining access (first contact) and being involved in disease management (coordination) were perceived as poor by several cohorts of older adults.

Disparity in physician-patient communication by ethnicity: evidence from Bangladesh

Background

Physician-patient communication behavior (PPCB) is the primary process by which medical decision-making occurs and health outcome depends. Physician-patient communication differences may partly from the ethnic disparities. To examine this problem, this study aims to explore whether physician-patient communication differs by ethnicity during primary care medical consultations.

Methods

The study was conducted among the Bengali and ethnic minority patients (N = 850) who visited a physician for medical consultations. Data were collected using a structured post-consultation questionnaire. T-test was conducted to compare the communication between the Bengali and ethnic minority patients. Multiple linear regression analyses were performed to identify the factors associated with favorable communication behavior from the physicians.

Results

Bengali patients received more supportive communication behaviors from the Bengali doctors than that of ethnic minority patients including physicians’ cheerful greetings, encouraging patients to express health problems and asking questions, listening carefully, responding to questions and concerns, explaining to patients about medical examination procedures, medication, probable side effects, discussing treatment options, involved the patients in decisions, and spending adequate time. Results of linear regression showed that respondents’ level of education, internet use, knowledge about the health issue, having a pre-organized plan about the content of medical consultation, information seeking about the health problem, visiting female doctors, and a quiet ambience of the doctor’s room are significantly associated with a better PPCB score for the Bengali patients. In contrast, age, being the resident of an urban area, perception of affecting a minor health problem, having a pre-organized plan about the content of medical consultation, patients’ involvement in physicians’ decision-making about the treatment, and talking time resulted in better physician-patient communication for the ethnic minority patients.

Conclusion

This study suggests that reducing disparity in the socio-economic status of the ethnic minority groups through development programs and educating healthcare providers on how to use patient-centered communication skills to engage with their patients is one solution to improve equity in the delivery of healthcare and ensure than patients are receiving high-quality treatment, no matter their race or ethnicity.

Demographic Variations in Patient Populations and Regional Distributions Between Male and Female Ophthalmologists in the United States: Cross-Sectional Analysis

Purpose: To determine if patient demographics differ by ophthalmologist gender.Methods: Demographic data on U.S. ophthalmologists were collected from the 2017 Medicare Physician and Other Supplier National Provider Identifier Aggregate Report.Results: Of the 17,230 ophthalmologists included, female ophthalmologists (23.7%) provided care for a smaller proportion of White patients (77.4% ± 24.9% female, 81.0% ± 22.1% male; p < .001), had younger beneficiaries (73.8 ± 3.2 years old females, 74.8 ± 2.9 years old males; p < .001) and had a higher proportion of female beneficiaries per provider (61.1% ± 4.6% females, 59.6% ± 4.0% males; p < .001). Average age of beneficiaries and number of beneficiaries were correlated with years since medical school (rho = 0.283, rho = 0.148; both p < .001). The number of Medicare beneficiaries, proportion of female beneficiaries, years since medical school and group practice size were independently associated with physician gender (p < .001).Conclusion: Female ophthalmologists saw a larger proportion of ethnically diverse, younger, female patients.

Five-year outcomes from a prospective comparative effectiveness study evaluating external-beam radiotherapy with or without low-dose-rate brachytherapy boost for localized prostate cancer

BACKGROUND

To inform patients who are in the process of selecting prostate cancer treatment, the authors compared disease-specific function after external-beam radiotherapy (EBRT) alone versus EBRT plus a low-dose-rate (LDR) brachytherapy boost (EBRT-LDR).

METHODS

For this prospective study, men who had localized prostate cancer in 2011 and 2012 were enrolled. Assessments at baseline, 0.5, 1, 3, and 5 years included the patient-reported Expanded Prostate Index Composite, the 36-item Medical Outcomes Study Short-Form Health Survey, and treatment-related regret. Regression models were adjusted for baseline function and for patient and treatment characteristics. The minimum clinically important difference in scores on the Expanded Prostate Index Composite 26-item instrument was from 5 to 7 for urinary irritation and from 4 to 6 for bowel function.

RESULTS

Six-hundred ninety-five men met inclusion criteria and received either EBRT (n = 583) or EBRT-LDR (n = 112). Patients in the EBRT-LDR group were younger (median age, 66 years [interquartile range [IQR], 60-71 years] vs 69 years [IQR, 64-74 years]; P < .001), were less likely to receive pelvic radiotherapy (10% vs 18%; P = .040), and had higher baseline 36-item Medical Outcomes Study Short-Form Health Survey physical function scores (median score, 95 [IQR, 86-100] vs 90 [IQR, 70-100]; P < .001). Over a 3-year period, compared with EBRT, EBRT-LDR was associated with worse urinary irritative scores (adjusted mean difference at 3 years, -5.4; 95% CI, -9.3, -1.6) and bowel function scores (-4.1; 95% CI, -7.6, -0.5). The differences were no longer clinically meaningful at 5 years (difference in urinary irritative scores: -4.5; 95% CI, -8.4, -0.5; difference in bowel function scores: -2.1; 95% CI, -5.7, -1.4). However, men who received EBRT-LDR were more likely to report moderate or big problems with urinary function bother (adjusted odds ratio, 3.5; 95% CI, 1.5-8.2) and frequent urination (adjusted odds ratio, 2.6; 95% CI, 1.2-5.6) through 5 years. There were no differences in survival or treatment-related regret between treatment groups.

CONCLUSIONS

Compared with EBRT alone, EBRT-LDR was associated with clinically meaningful worse urinary irritative and bowel function over 3 years after treatment and more urinary bother at 5 years.

LAY SUMMARY

In men with prostate cancer who received external-beam radiation therapy (EBRT) with or without a brachytherapy boost (EBRT-LDR), EBRT-LDR was associated with clinically worse urinary irritation and bowel function through 3 years but resolved after 5 years. Men who received EBRT-LDR continued to report moderate-to-big problems with urinary function bother and frequent urination through 5 years. There was no difference in treatment-related regret or survival between patients who received EBRT and those who received EBRT-LDR. These intermediate-term estimates of function may facilitate counseling for men who are selecting treatment.

Association of pneumococcal and influenza vaccination with patient-physician communication in older adults: A nationwide cross-sectional study from the JAGES 2016

Background

Increasing the coverage of vaccinations recommended by the World Health Organization in the older adult population is an urgent issue, especially in the context of avoiding co-epidemics during the current coronavirus disease 2019 crisis. The aim of this study was to examine factors associated with the quality of perceived patient–physician communication and whether this variable was associated with increased odds of vaccination.

Methods

We used cross-sectional data from the Japan Gerontological Evaluation Study conducted from October 2016 to January 2017. The participants were 22,253 physically and cognitively independent individuals aged 65 or older living in 39 municipalities in Japan. Multilevel logit models were used to estimate the odds of vaccination.

Results

Among the participants, 40.0% and 58.8% had received pneumococcal and influenza vaccinations as per the recommended schedule, respectively. People with low educational levels were more likely to have a family physician but rate their experience in asking questions lower than those with higher educational levels. Having a family physician and high rating for physicians’ listening attitude were positively associated with increased odds of pneumococcal and influenza vaccinations. High rating for patients’ questioning attitude and shared decision-making, compared to an ambiguous attitude toward medical decision-making, were positively associated with increased odds of pneumococcal vaccination.

Conclusion

The results suggest that promotion of having a family physician, better patient–physician communication, and shared decision-making may encourage older adults to undergo recommended vaccinations.

Patient-Centered Appointment Scheduling: a Call for Autonomy, Continuity, and Creativity

When making an appointment, patients are generally unaware of how much clinician time is available to address their concerns. Similarly, the primary care clinician is often unaware of what the patient expects to accomplish during the visit, leading to uncertainty about how much time they can allot to each sequentially appearing concern, and whether they can reasonably expect to address necessary preventive services and chronic disease management. Neither patient nor clinician expectations can be adequately managed through standardized scheduling templates, which assign a fixed appointment length based on a single stated reason for the visit. As such, standardized appointment scheduling may contribute to inefficient use of valuable face-to-face time, patient and clinician dissatisfaction, and low-value care. Herein, we suggest several potential mechanisms for improving the scheduling process, including (1) entrusting scheduling to the primary care team; (2) advance visit planning; (3) pro-active engagement of ancillary team members including behavioral health, nursing, social work, and pharmacy; and (4) application of innovative, technologically advanced solutions such as telehealth and artificial intelligence to the scheduling process. These changes have the potential to improve efficiency, patient and clinician satisfaction, and health outcomes, while decreasing low-value testing and return visits for unaddressed concerns.

Impact of Patients' Companions on Clinical Encounters Between Black Patients and Their Non-Black Oncologists

PURPOSE

The presence of caregivers or companions during clinical encounters influences the dynamics and outcomes of the encounters. Most prior studies of companions in clinical encounters focus on non-Hispanic White patients. However, there is generally lower-quality patient-physician communication during encounters with Black patients; these communication differences may contribute to racial health disparities. The purpose of the present study was to examine effects of the presence and active participation of companions on encounters between Black patients with cancer and non-Black oncologists.

METHODS

This was a secondary analysis of data collected during a larger intervention study. Participants were Black patients with breast, colon, or lung cancer who had a treatment-discussion encounter with a participating non-Black medical oncologist. Video recordings of encounters were coded for patient, companion, and oncologist communication. After the encounter, patients reported perceptions of the recommended treatment; patients and oncologists reported perceptions of each other.

RESULTS

Data from 114 patients and 19 oncologists were included in analyses. Only 47% of patients brought a companion to the encounter. Oncologists spent more time with accompanied Black patients, used more patient-centered communication with them, and perceived them as having more social support compared with unaccompanied Black patients. Oncologists reported that accompanied patients asked more questions. When companions participated more actively in the encounter, oncologists used more patient-centered communication.

DISCUSSION

Bringing a companion to oncology appointments may be beneficial to Black patients because oncologists spend more time with patients, use more patient-centered communication, and perceive patients more positively, all of which may ultimately improve patient health and well-being outcomes.

Communication patterns in the doctor-patient relationship: evaluating determinants associated with low paternalism in Mexico

BACKGROUND

Paternalism/overprotection limits communication between healthcare professionals and patients and does not promote shared therapeutic decision-making. In the global north, communication patterns have been regulated to promote autonomy, whereas in the global south, they reflect the physician's personal choices. The goal of this study was to contribute to knowledge on the communication patterns used in clinical practice in Mexico and to identify the determinants that favour a doctor-patient relationship characterized by low paternalism/autonomy.

METHODS

A self-report study on communication patterns in a sample of 761 mental healthcare professionals in Central and Western Mexico was conducted. Multiple ordinal logistic regression models were used to analyse paternalism and associated factors.

RESULTS

A high prevalence (68.7% [95% CI 60.0-70.5]) of paternalism was observed among mental health professionals in Mexico. The main determinants of low paternalism/autonomy were medical specialty (OR 1.67 [95% CI 1.16-2.40]) and gender, with female physicians being more likely to explicitly share diagnoses and therapeutic strategies with patients and their families (OR 1.57 [95% CI 1.11-2.22]). A pattern of highly explicit communication was strongly associated with low paternalism/autonomy (OR 12.13 [95% CI 7.71-19.05]). Finally, a modifying effect of age strata on the association between communication pattern or specialty and low paternalism/autonomy was observed.

CONCLUSIONS

Among mental health professionals in Mexico, high paternalism prevailed. Gender, specialty, and a pattern of open communication were closely associated with low paternalism/autonomy. Strengthening health professionals' competencies and promoting explicit communication could contribute to the transition towards more autonomist communication in clinical practice in Mexico. The ethical implications will need to be resolved in the near future.

Older individuals' views on their personal screening results for complex health problems: a qualitative study

Background

Providing older persons with information about their health status may increase their involvement in their own health and enhance self-management. However, we need a better understanding of how older persons view their personal results after completing a screening questionnaire on complex health, of their (lack of) motivation and their subsequent action.

Methods

In this qualitative study community-dwelling older persons (≥80 years, n = 13) who completed a screening questionnaire on complex health problems were interviewed regarding their perception of the results, the actions they considered taking and their personal motivations. Data were analysed thematically (qualitative content analyses).

Results

Participants expressed interest in feedback, as an objective questionnaire might substantiate their own views regarding their personal health. They were mostly unsurprised by the results and/or had already taken precautions and were therefore not inclined to undertake additional action. They admitted difficulty with and appreciated advice from a professional regarding preparation of an action plan. Unexpected negative results would lead them to discuss matters with family and/or their general practitioner, provided they had a good relationship with their GP.

Conclusion

Older people were interested in direct feedback regarding their screening questionnaire results and in subsequent advice on possible additional measures. General practices could consider inviting older persons to complete a screening questionnaire and discuss activities and personal goals. This information could serve to better shape future interventions aimed at increasing self-management amongst older persons.

"Having a Normal Life": A Qualitative Study on Client Goal-Setting Within a Health Care and Social Needs Navigation Program

Client goals within healthcare and social needs navigation programs are neither well understood nor incorporated into ambulatory care practices. This study provides a qualitative analysis of client-established goals within the Interprofessional Care Access Network (I-CAN), a community-based health care and social needs navigation program. One hundred eleven client goal lists were analyzed using conventional content analysis. Twenty-two codes were developed and grouped into 4 main categories including Physical/Mental Health, Social/Social Services, Health Care System, and Daily Living. The results of this study offer insight into client goals within health care and social needs navigation programs and provide suggestions for future research.

Participatory decision-making for cancer care in a high-risk sample of low income Mexican-American breast cancer survivors: The role of acculturation

Background

Despite declining cancer incidence and mortality rates, Latina patients continue to have lower 5-year survival rates compared to their non-Hispanic white counterparts. Much of this difference has been attributed to lack of healthcare access and poorer quality of care. Research, however, has not considered the unique healthcare experiences of Latina patients.

Methods

Latina women with prior diagnoses of stage 0-III breast cancer were asked to complete a cross-sectional survey assessing several socio-demographic factors along with their experiences as cancer patients. Using a series of linear regression models in a sample of 68 Mexican-American breast cancer survivors, we examined the extent to which patients' ratings of provider interpersonal quality of care were associated with patients' overall healthcare quality, and how these associations varied by acculturation status.

Results

Findings for Latina women indicated that both participatory decision-making (PDM) (β = 0.62, p < .0001) and trust (β = 0.53, p = .02) were significantly associated with patients' ratings of healthcare quality. The interaction between acculturation and PDM further suggested that participating in the decision-making process mattered more for less acculturated than for more acculturated patients (β = -0.51, p ≤ .01).

Conclusions

The variation across low and high acculturated Latinas in their decision-making process introduces a unique challenge to health care providers. Further understanding the relationship between provider-patient experiences and ratings of overall healthcare quality is critical for ultimately improving health outcomes.

A Population-Based Investigation of Health-Care Needs and Preferences in American Adults With Multiple Sclerosis

Background

Comprehensive and effective multiple sclerosis (MS) health care requires understanding of patients' needs, preferences, and priorities.

Objective

To evaluate priorities of patients with MS for their MS care.

Methods

Participants included 3003 Americans with MS recruited through the National MS Society and the North American Research Committee on Multiple Sclerosis patient registry. Participants completed a comprehensive questionnaire on aspects of their health-care experiences.

Results

Participants identified the top 3 health-care priorities as (1) the affordability of MS health care, (2) ensuring that non-MS health-care providers have more education about MS and how it can interact with other conditions, and (3) access to an MS center or specialized MS clinic with MS health-care professionals together in one place. Participants receiving care in an MS center rated the quality and their satisfaction with care higher than those receiving care in other settings. Although having the opportunity to evaluate their health-care quality was important to the participants, only 36.4% had been provided the opportunity in the past year.

Conclusions

This study identifies health-care priorities and concerns for Americans with MS.

Towards ending the human immunodeficiency virus epidemic in the US: State of human immunodeficiency virus screening during physician and emergency department visits, 2009 to 2014

Human immunodeficiency virus (HIV) testing is important for prevention and treatment. Ending the HIV epidemic is unattainable if significant proportions of people living with HIV remain undiagnosed, making HIV testing critical for prevention and treatment. The Centers for Disease Control and Prevention (CDC) recommends routine HIV testing for persons aged 13 to 64 years in all health care settings. This study builds on prior research by estimating the extent to which HIV testing occurs during physician office and emergency department (ED) post 2006 CDC recommendations.We performed an unweighted and weighted cross-sectional analysis using pooled data from 2 nationally representative surveys namely National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 2009 to 2014. We assessed routine HIV testing trends and predictive factors in physician offices and ED using multi-stage statistical survey procedures in SAS 9.4.HIV testing rates in physician offices increased by 105% (5.6-11.5 per 1000) over the study period. A steeper increase was observed in ED with a 191% (2.3-6.7 per 1000) increase. Odds ratio (OR) for HIV testing in physician offices were highest among ages 20 to 29 ([OR] 7.20, 99% confidence interval [CI: 4.37-11.85]), males (OR 1.34, [CI: 0.91-0.93]), African-Americans (OR 2.97, [CI: 2.05-4.31]), Hispanics (OR 1.80, [CI: 1.17-2.78]), and among visits occurring in the South (OR 2.06, [CI: 1.23-3.44]). In the ED, similar trends of higher testing odds persisted for African Americans (OR 3.44, 99% CI 2.50-4.73), Hispanics (OR 2.23, 99% CI 1.65-3.01), and Northeast (OR 2.24, 99% CI 1.10-4.54).While progress has been made in screening, HIV testing rates remains sub-optimal for ED visits. Populations visiting the ED for routine care may suffer missed opportunities for HIV testing, which delays their entry into HIV medical care. To end the epidemic, new approaches for increasing targeted routine HIV testing for populations attending health care settings is recommended.

Am I Disadvantaged? How Applicants Decide Whether to Use the Disadvantaged Status in the American Medical College Application Service

PURPOSE

To add to the limited research on the Disadvantaged Status, a component in the American Medical College Application Service (AMCAS) primary application, the authors explored how applicants to a medical school between 2014 and 2016 determined whether they were disadvantaged and whether to apply as such.

METHOD

The authors used case study methodology to explore the experiences of students at a medical school in the Northeast. The authors derived data from transcripts of semistructured interviews with students and the students' AMCAS applications. Transcripts and applications were analyzed using a constant comparative approach and considered in the context of social comparison and impression management theories.

RESULTS

Overall, the 15 student participants (8 used the Disadvantaged Status) had difficulty determining whether they were disadvantaged and how applying as such would affect their prospects. Contributing factors included ambiguity around both the term disadvantaged and its use in the admissions process. Simply experiencing hardship during childhood was insufficient for most participants to deem themselves disadvantaged. Participants' decision processes were confounded by the need to rely on social comparisons to determine whether they were disadvantaged and impression management to decide whether to apply as such.

CONCLUSIONS

The ambiguous nature of the Disadvantaged Status, comparisons with even more disadvantaged peers, and uncertainty about how shared information might affect admission decisions distorted participants' understandings of identity within the context of the application. The authors believe that many applicants who have experienced significant hardships/barriers are not using the Disadvantaged Status.

Modifiable Determinants of Exercise Use in a Diverse Ethnic Population With Osteoarthritis

OBJECTIVE

To determine the extent of ethnic differences in the use of exercise for therapy and identify relevant modifiable determinants of exercise use among patients with knee/hip osteoarthritis (OA).

METHODS

Knee/hip OA study participants were identified. Surveys were administered to collect patient sociodemographic and clinical information, and beliefs and attitudes about providers and treatments. Final multivariable logistic regression models were created using a fully conditional method.

RESULTS

Hispanic participants (n = 130), compared to non-Hispanic participants (n = 232), were less likely to have private medical insurance (9.2% versus 31.0%) or to report having excellent/very good health (40.7% versus 52.6%). They were also less likely to report using exercise for OA treatment in the last 6 months (56% versus 73%; P = 0.003). When adjusted for age and disease severity, the difference in exercise use among ethnicities remained significant (odds ratio [OR] 0.59 [95% confidence interval (95% CI) 0.36-0.99]). In a multivariable logistic regression model designed to determine the most important determinants of exercise use for OA treatment, in the last 6 months the following were all associated with exercise use: having knee instead of hip OA (OR 2.83 [95% CI 1.51-5.29]), having family/friends who exercise (OR 3.20 [95% CI 1.76-5.84]), having a good understanding of what happens after exercise (OR 2.19 [95 CI 1.15-4.19]), and higher perceived benefit of exercise (OR 2.24 [95% CI 1.64-3.04]).

CONCLUSION

Among patients with knee/hip OA, Hispanics were less likely to exercise for OA treatment. Increased knowledge about the benefits of exercise for treatment and improved familiarity with exercise as treatment for OA may increase exercise use.

The Development of a Screening Tool to Identify and Classify Nonadherence in Inflammatory Bowel Disease

Background

Medication nonadherence is a challenge in chronic disease management. Tools that can both determine adherence levels and analyze patient-specific reasons for nonadherence are lacking.

Methods

Our tool was developed using 23 patient-reported items and its predictive performance was compared with the most widely used instrument in the literature.

Results

One hundred thirty-three IBD patients were included, 44 (33%) were nonadherent and 89 (67%) were adherent. Our screening question, with 87% sensitivity and 64% specificity, was followed by a 9-item survey for patients qualified as nonadherent.

Conclusions

Quantifying reasons for nonadherence can lead to more effective and personalized interventions for nonadherent patients.

Identifying the Key Elements of Racially Concordant Care in a Freestanding Birth Center

INTRODUCTION

There is empirical evidence that the quality of interpersonal care patients receive varies dramatically along racial and ethnic lines, with African American people often reporting much lower quality of care than their white counterparts. Improving the interpersonal relationship between clinicians and patients has been identified as one way to improve quality of care. Specifically, research has identified that patients feel more satisfied with the care that they receive from clinicians with whom they share a racial identity. However, little is known about how clinicians provide racially concordant care. The goal of this analysis was to identify the key components of high-quality care that were most salient for African American birthworkers providing perinatal care to African American patients.

METHODS

We conducted semistructured interviews (30 to 90 minutes) with clinicians (N = 10; midwives, student midwives, and doulas) who either worked at or worked closely with an African American-owned birth center in North Minneapolis, Minnesota. We used inductive coding methods to analyze data and to identify key themes.

RESULTS

Providing racially concordant perinatal care to African American birthing individuals required clinicians to acknowledge and center the sociocultural realities and experiences of their patients. Four key themes emerged in our analysis. The first overarching theme identified was the need to acknowledge how cultural identity of patients is fundamental to the clinical encounter. The second theme that emerged was a commitment to racial justice. The third and fourth themes were agency and cultural humility, which highlight the reciprocal nature of the clinician-patient relationship.

DISCUSSION

The most salient aspect of the care that birthworkers of color provide is their culturally centered approach. This approach and all subsequent themes suggest that achieving birth equity for pregnant African American people starts by acknowledging and honoring their sociocultural experiences.

Perceptions and observations of shared decision making during pediatric otolaryngology surgical consultations

Objective

Increased parental involvement in the decision-making process when considering elective surgeries for their children, termed shared decision-making (SDM), may lead to positive outcomes. The objective of this study was to describe perceived and observed levels of SDM during pediatric otolaryngology consultations.

Methods

One hundred and seventeen parents and their children undergoing elective surgical consultations were prospectively enrolled. The visits were videotaped and coded using the Observing Patient Involvement (OPTION) scale. Following the encounter, all participants completed a questionnaire that measured perceived levels of SDM (SDM-Q-9). Surgeons also completed a similar questionnaire (SDM-Q-Doc). Spearman’s correlation coefficient was determined to measure the associations between observed and perceived levels of SDM.

Results

The overall OPTION scores were low (median score of 14 out of 48) and not significantly correlated with perceived levels of SDM (SDM-Q-9, p = 0.415; SDM-Q-Doc, p = 0.236), surgery type (p = 0.197), or patient demographic factors. The OPTION scores were positively correlated with consultation length (p < 0.001). There was great variability in the level to which each OPTION items were observed during the consultation (not present in any visits to present in 96.6% of the visits).

Conclusions

Observed levels of SDM were consistently low, but higher levels were observed when the surgeon spent more time during the consultation. Observed levels of SDM did not match perceived levels of SDM, which were consistently rated higher by both caregivers and surgeons.

Pediatric Palliative Care in the Multicultural Context: Findings From a Workshop Conference

CONTEXT

In our increasingly multicultural society, providing sensitive and respectful pediatric palliative care is vital.

OBJECTIVES

We held a one-day workshop conference with stakeholders and pediatric clinicians to identify suggestions for navigating conflict when cultural differences are present and for informing standard care delivery.

METHODS

Participants explored cases in one of four workshops focused on differences based on race/ethnicity, economic disparity, religion/spirituality, or family values. Each workshop was facilitated by two authors; separate transcriptionists recorded workshop discussions in real time. We used content analyses to qualitatively evaluate the texts and generate recommendations.

RESULTS

Participants included 142 individuals representing over six unique disciplines, 25 of the U.S., and three nations. Although the conference focused on pediatric palliative care, findings were broadly generalizable to most medical settings. Participants identified key reasons cultural differences may create tension and then provided frameworks for communication, training, and clinical care. Specifically, recommendations included phrases to navigate emotional conflict, broken trust, unfamiliar family values, and conflict. Suggested approaches to training and clinical care included the development of core competencies in communication, history taking, needs assessment, and emotional intelligence. Important opportunities for scholarship included qualitative studies exploring diverse patient and family experiences, quantitative studies examining health disparities, and randomized clinical trials testing interventions designed to improve community partnerships, communication, or child health outcomes.

CONCLUSION

Taken together, findings provide a foundation for collaboration between patients, families, and clinicians of all cultures.

Confidentiality Discussions and Private Time With a Health-Care Provider for Youth, United States, 2016

PURPOSE

The objective of the study was to define factors associated with adolescent and young adult (AYA) experiences with private time and having discussed confidentiality and the impact of these experiences on improving delivery of clinical preventive services.

METHODS

In 2016, a nationally representative sample of 1,918 US AYAs (13- to 26-year-olds) was surveyed. Survey questionnaire domains were based on prior research and Fishers' information-motivation-behavior skills conceptual model. Data were weighted to represent US households with AYA and analyzed to identify factors independently associated with ever experiencing private time and discussions of confidentiality with a regular health-care provider (HCP). We examined the association of these experiences on AYA attitudes about health care.

RESULTS

Fifty-five percent of female and 49% of male AYA reported ever having had private time with an HCP and 55% of female and 44% of male AYA had spoken to an HCP about confidentiality. Independent predictors of having experienced private time and confidentiality included older age, race, higher household income, gender of the provider, amount of years with the provider, and involvement in risk behaviors. AYA who had experienced private time and confidentiality discussions had more positive attitudes about their providers, were more willing and comfortable discussing sensitive topics, and thought that these discussions should happen at younger ages.

CONCLUSIONS

Although confidentiality and private time are important to AYA, many are not experiencing these components of care. Providing private time and discussions of confidentiality can improve the delivery of health care for young people by enhancing positive youth attitudes about preventive care.

Patient-initiated additional concerns in general surgery visits

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.

Physicians as leaders: are we trying to fit square pegs into round holes?

The purpose of medical education has changed over the last 70 years. The modern doctor is expected to be a leader who will be skilled in people management, team working and patient engagement. Moreover, the burgeoning literature on the development of medical leadership competency frameworks as a way to inform curriculum development is evidence of a desire to empower physicians to be healthcare leaders. The movement towards developing medical students as leaders has to be contrasted against the fact that high school exam performance and academic achievement continues to be the primary basis for selection to medical school. Not surprisingly, the smart kids are studying medicine. Unfortunately, there is a person–job mismatch between the initial skills that allows an individual entry to medical school and what the job will actually entail. For example, higher levels of intelligence are associated with less effective leadership styles. Thus, we seem to have a conundrum concerning input and output. In the following paper, I will examine the degree to which we are attempting to remould ‘square’ physicians to fit them into a ‘round’ medical landscape. The purpose of the paper is twofold. First, to assess the degree to which we can realistically expect the ‘average’ medical student to be moulded into a leader, and second, to identify what practical steps we can take to enable medical students to take a leadership role.

Quality of Communication and Trust in Patients With Serious Illness: An Exploratory Study of the Relationships of Race/Ethnicity, Socioeconomic Status, and Religiosity

CONTEXT

Better understanding of clinicians' skill communicating with their patients and of patients' trust in clinicians is necessary to develop culturally sensitive palliative care interventions. Race/ethnicity, socioeconomic status, and religiosity have been documented as factors influencing quality of communication and trust.

OBJECTIVES

The objective of this study was to explore associations of seriously ill patients' race/ethnicity, socioeconomic status, and religiosity with patients' ratings of the quality of clinicians' communication and trust in clinicians.

METHODS

An observational analysis was performed using baseline data from a multicenter cluster-randomized trial of a communication intervention. We enrolled consecutive patients with chronic, life-limiting illnesses (n = 537) cared for by primary and specialty care clinicians (n = 128) between 2014 and 2016 in outpatient clinics in Seattle, Washington. We assessed patient demographics (age, gender, race/ethnicity, education, income, and self-rated health status), Duke University Religion Index, Quality of Communication Scale, and Wake Forest Physician Trust Scale. We used probit and linear regression and path analyses to examine associations.

RESULTS

Patients providing higher ratings of clinician communication included those belonging to racial/ethnic minority groups (P = 0.001), those with lower income (P = 0.008), and those with high religiosity/spirituality (P = 0.004). Higher trust in clinicians was associated with minority status (P = 0.018), lower education (P = 0.019), and clinician skill in communication (P < 0.001).

CONCLUSION

Contrary to prior studies, racial/ethnic minorities and patients with lower income rated communication higher and reported higher trust in their clinicians than white and higher income patients. More research is needed to identify and understand factors associated with quality communication and trust between seriously ill patients and clinicians to guide development of patient-centered palliative care communication interventions.

Needs and preferences of patients regarding basal cell carcinoma and cutaneous squamous cell carcinoma care: a qualitative focus group study

BACKGROUND

Despite the high and rising incidence rate of keratinocyte cancer (KC) and the importance of incorporating patient values into evidence-based care, few studies have focused on the perspectives of patients with KC.

OBJECTIVES

To identify the needs and preferences of patients with basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) regarding care.

METHODS

A qualitative study was conducted consisting of three focus groups with patients with BCC and three focus groups with patients with SCC. In total 42 patients participated. In each focus group, the patients' needs and preferences regarding treatment and follow-up were discussed, using a predefined topic list. All sessions were transcribed verbatim and analysed by two researchers.

RESULTS

The following needs and preferences were identified: (i) the need to receive all relevant, tailored information; (ii) a physician who takes you seriously and communicates well; (iii) a short waiting period and the best treatment with direct results; (iv) to be seen by the same physician; a preference for a dermatologist during (v) treatment and (vi) follow-up; (vii) a general need for structured follow-up care and (viii) a full-body skin examination during follow-up. Patients with BCC additionally expressed the need for openness and transparency and wanting to participate in shared decision making.

CONCLUSIONS

It is advocated to organize skin cancer care that is better tailored to the needs of patients with KC, providing patient-centred care. This should include investing in the patient-physician relationship, and personalizing the type and form of information and the follow-up schedules. Adding the patient's perspective to current guidelines could facilitate this process.

Gender differences in the comprehension of care plans in an emergency department setting

Background

Previous studies have shown that, in a variety of health care settings, patients often do not understand what health care professionals tell them about their diagnoses and care plans; this is particularly true among male patients. Emergency department (ED) settings present unique challenges to communication with patients due to the rapid pace of activity, substantial changes in personnel over the course of the day and the week, and the need for fast decision-making processes. The aim of our study was to investigate the extent to which patients in an Israeli ED comprehended their plan of care and whether there were gender differences in this regard.

Methods

We conducted a questionnaire-based prospective study, in which patients admitted to the ED at Rabin Medical Center were evaluated during the years 2014–2016. The primary outcome was patients’ comprehension of their plan of care, stratified by gender of patients. Plan of care included information related to diagnosis, treatment and discharge instructions. The secondary outcome was patients’ satisfaction with the instruction process.

Results

One hundred seventy seven ED patients met study criteria and were asked to participate in the study; 85% of them agreed to do so. Overall, 150 ED patients aged 18–80 were recruited [75 men (50%) and 75 women (50%)]. 80% of the respondents reported a satisfactory understanding of their plan of care. Overall, no gender-related differences were found. Differences between men and women concerning satisfaction with the instructions provided by nurses were found among non-Hebrew speakers, but not among Hebrew speakers.

Conclusion

Contrary to most earlier studies, patients at our ED demonstrated a high degree of self-reported adequate comprehension concerning their plan of care, and overall no gender-related differences were found. These finding may be due in part to improved training of the medical staff to better communicate with the patients and to answer their questions. In addition, patients may feel more comfortable than in the past about asking the medical staff questions regarding their plan of care and diagnosis. The main implication of this study is that physician education programs should continue to emphasize patient-physician communications skills and improving methods for providing patients with information.

Comparison of Patient-reported Outcomes After External Beam Radiation Therapy and Combined External Beam With Low-dose-rate Brachytherapy Boost in Men With Localized Prostate Cancer

PURPOSE

To compare patient-reported disease-specific functional outcomes after external beam radiation therapy (EBRT) and EBRT combined with low-dose-rate brachytherapy prostate boost (EB-LDR) among men with localized prostate cancer.

METHODS AND MATERIALS

The prospective, population-based Comparative Effectiveness Analysis of Surgery and Radiation study enrolled men with localized prostate cancer in 2011 to 2012. The 26-item Expanded Prostate Cancer Index Composite measured patient-reported disease-specific function at baseline and at 6, 12, and 36 months. Higher domain scores indicate better function. Minimal clinically important difference was defined as 6 for urinary incontinence, 5 for urinary irritative function, 4 for bowel function, 12 for sexual function, and 4 for hormonal function. Multivariable linear and logistic regression models were fit to estimate the effect of treatment on patient-reported outcomes.

RESULTS

Five-hundred seventy-eight men received EBRT and 109 received EB-LDR. Median patient age was 69 years, and 70% had intermediate- or high-risk disease. Men in the EB-LDR group were younger (P < .001) and less likely to receive androgen deprivation therapy (P < .001). Baseline urinary, bowel, sexual, and hormonal function was similar between treatment groups (P > .05). On multivariable analyses, men receiving EB-LDR reported worse urinary irritative function at 6 months (adjusted mean difference [AMD] -14.4, P < .001), 12 months (AMD -12.9, P < .001), and 36 months (AMD -4.7, P = .034) than men receiving EBRT. At 12 months, men receiving EB-LDR reported worse bowel function (AMD -5.8, P = .002), but these differences were not seen at 36 months. There were no significant differences in sexual or hormone function between treatment groups.

CONCLUSIONS

Men treated with EB-LDR report worse bowel function at 1 year and worse urinary irritative function through 3 years compared with men treated with EBRT alone. These side effect profiles should be discussed with patients when considering EB-LDR versus EBRT treatment.

Findings from a feasibility study to improve GP elicitation of patient concerns in UK general practice consultations

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.

Effectiveness of pregnant women's active participation in their antenatal care for the control of malaria and anaemia in pregnancy in Ghana: a cluster randomized controlled trial

BACKGROUND

The burden of malaria and anaemia in pregnancy remains high despite the availability of proven efficacious antenatal care interventions. Sub-optimal uptake of the interventions may be due to inadequate active participation of pregnant women in their antenatal care. It was hypothesized that providing opportunities for pregnant women to improve upon active participation in their antenatal care through malaria and anaemia point-of-care testing would improve adherence to ANC recommendations and interventions and lead to better pregnancy outcomes.

METHODS

Fourteen antenatal clinics in the Ashanti region of Ghana were randomized into intervention (pregnant women participating in their care plus current routine care) and control (current routine care) arms. Pregnant women attending the clinics for the first time were recruited and followed up until delivery. Haemoglobin levels and malaria parasitaemia were measured at baseline, 4-8 weeks after recruitment and at 36-40 weeks gestation. Birth weight and pregnancy outcomes were also recorded.

RESULTS

The overall mean age, gestational age and haemoglobin at baseline were 26.4 years, 17.3 weeks and 110 g/l, respectively, with no significant differences between groups; 10.7% had asymptomatic parasitaemia; 74.6% owned an ITN but only 48.8% slept under it the night before enrolment. The adjusted risk ratio by 8 weeks follow up and at 36-40 weeks gestation in the intervention versus the control was 0.97 (95% CI 0.78-1.22) and 0.92 (95% CI 0.63-1.34) for anaemia and 1.17 (95% CI 0.68-2.04) and 0.83 (95% CI 0.27-2.57) for parasitaemia. The adjusted risk ratio for low birth weight was 0.93 (95% CI 0.44-1.97) and for pregnancy complications (abortions, intrauterine fetal deaths and still births) was 0.77 (95% CI 0.17-3.52) in the intervention group versus controls.

CONCLUSION

Although its potential was evident, this study found no significant beneficial effect of women participating in their malaria and haemoglobin tests on pregnancy outcomes. Exploring factors influencing health worker compliance to health intervention implementation and patient adherence to health interventions within this context will contribute in future to improving intervention effectiveness. Trial registration ISRTCTN88917252.

Provider use of a participatory decision-making style with youth and caregivers and satisfaction with pediatric asthma visits

Background

We conducted a randomized controlled trial to test the effectiveness of an asthma question prompt list with video intervention to engage the youth during clinic visits. We examined whether the intervention was associated with 1) providers including youth and caregiver inputs more into asthma treatment regimens, 2) youth and caregivers rating providers as using more of a participatory decision-making style, and 3) youth and caregivers being more satisfied with visits.

Methods

English- or Spanish-speaking youth aged 11–17 years with persistent asthma and their caregivers were recruited from four pediatric clinics and randomized to the intervention or usual care groups. The youth in the intervention group watched the video with their caregivers on an iPad and completed a one-page asthma question prompt list before their clinic visits. All visits were audiotaped. Generalized estimating equations were used to analyze the data.

Results

Forty providers and their patients (n=359) participated in this study. Providers included youth input into the asthma management treatment regimens during 2.5% of visits and caregiver input during 3.3% of visits. The youth in the intervention group were significantly more likely to rate their providers as using more of a participatory decision-making style (odds ratio=1.7, 95% confidence interval=1.1, 2.5). White caregivers were significantly more likely to rate the providers as more participatory (odds ratio=2.3, 95% confidence interval=1.2, 4.4). Youth (beta=4.9, 95% confidence interval=3.3, 6.5) and caregivers (beta=7.5, 95% confidence interval=3.1, 12.0) who rated their providers as being more participatory were significantly more satisfied with their visits. Youth (beta=−1.9, 95% confidence interval=−3.4, −0.4) and caregivers (beta=−8.8, 95% confidence interval=−16.2, −1.3) who spoke Spanish at home were less satisfied with visits.

Conclusion

The intervention did not increase the inclusion of youth and caregiver inputs into asthma treatment regimens. However, it did increase the youth’s perception of participatory decision-making style of the providers, and this in turn was associated with greater satisfaction.

Characteristics of Treatment Decisions to Address Challenging Behaviors in Children with Autism Spectrum Disorder

OBJECTIVE

To describe the characteristics of treatment decisions to address challenging behaviors in children with autism spectrum disorder (ASD).

METHODS

Parents of children aged 4 to 15 years with ASD seen in a developmental behavioral pediatric (DBP) clinic completed validated measures to characterize their child's behaviors and their own level of stress. Parents reported their treatment priority before the visit. During the visit, we assessed shared decision making (SDM) using the Observing Patient Involvement (OPTION) scale and alignment of the clinician's treatment plan with the parent's priority. Before and after the visit, parents rated their uncertainty about the treatment plan using the Decisional Conflict Scale (DCS). We calculated descriptive statistics for the measures.

RESULTS

Fifty-four families participated. Children were a mean (SD) age of 8.8 (3.3) years, and 87% were male. Children had a variety of behavioral challenges, and parents reported high levels of stress. Commonly reported parent treatment priorities were hyperactivity, tantrums, anxiety, and poor social skills. Levels of SDM were low, with a mean (SD) OPTION score of 24.5 (9.7). Parent priorities were addressed in 65% of treatment plans. Approximately 69% of parents had elevated DCS scores before the visit. Although levels of decisional conflict were lower after the visit compared with before the visit (p < 0.03), 46% of parents continued to report high scores on the DCS.

CONCLUSION

Parents leave DBP visits with feelings of uncertainty about treatment decisions and with treatment plans that do not always address their priorities. SDM interventions hold promise to improve the quality of ASD treatment decisions.

Relationships Among Race/Ethnicity, Gender, and Mental Health Status in Patient–Provider Interactions

Patient–provider interactions are associated with improved health outcomes and are of particular importance to individuals with mental health disabilities. We examine the relation between having a severe mental health–related disability (SMD) and patient–provider interactions and whether this is moderated by patient race/ethnicity and gender. We pooled Medical Expenditure Panel Survey data over multiple years and used multivariate techniques to examine the relation between having a SMD, race/ethnicity and gender and four measures of patient/provider interactions (e.g., being treated with respect). Adults with SMD had significantly higher relative risks (RRs) of reporting poorer interactions across measures. Although some effects of race/ethnicity and gender were observed, they did not moderate SMD. Individuals with Medicaid coverage or no health insurance had higher RRs of poorer interactions, while individuals with a person as a usual source of care had lower RRs. Incorporating these process measures of care into national quality initiatives may foster improved interactions. Continued policy support of models of care such as medical homes may enhance interactions as well.

Non-Hispanic Black-White disparities in pain and pain management among newly admitted nursing home residents with cancer

Background

Racial disparities in pain management persist across health care settings and likely extend into nursing homes. No recent studies have evaluated racial disparities in pain management among residents with cancer in nursing homes at time of admission.

Methods

Using a cross-sectional study design, we compared reported pain and pain management between non-Hispanic White and non-Hispanic Black newly admitted nursing home residents with cancer (n=342,920) using the de-identified Minimum Data Set version 3.0. Pain management strategies included the use of scheduled analgesics, pro re nata analgesics, and non-pharmacological methods. Presence of pain was based on self-report when residents were able, and staff report when unable. Robust Poisson models provided estimates of adjusted prevalence ratios (aPR) and 95% CIs for reported pain and pain management strategies.

Results

Among nursing home residents with cancer, ~60% reported pain with non-Hispanic Blacks less likely to have both self-reported pain (aPR [Black versus White]: 0.98, 95% CI: 0.97–0.99) and staff-reported pain (aPR: 0.89, 95% CI: 0.86–0.93) documentation compared with Non-Hispanic Whites. While most residents received some pharmacologic pain management, Blacks were less likely to receive any compared with Whites (Blacks: 66.6%, Whites: 71.1%; aPR: 0.98, 95% CI: 0.97–0.99), consistent with differences in receipt of non-pharmacologic treatments (Blacks: 25.8%, Whites: 34.0%; aPR: 0.98, 95 CI%: 0.96–0.99).

Conclusion

Less pain was reported for Black compared with White nursing home residents and White residents subsequently received more frequent pain management at admission. The extent to which unequal reporting and management of pain persists in nursing homes should be further explored.

Effect of Prostate Cancer Severity on Functional Outcomes After Localized Treatment: Comparative Effectiveness Analysis of Surgery and Radiation Study Results

BACKGROUND

Whether prostate cancer severity modifies patient-reported functional outcomes after radical prostatectomy (RP) or external beam radiotherapy (EBRT) for localized cancer is unknown.

OBJECTIVE

The purpose of this study was to determine whether differences in predicted function over time between RP and EBRT varied by risk group.

DESIGN, SETTING, AND PARTICIPANTS

The Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study is a prospective, population-based, observational study that enrolled men with localized prostate cancer in 2011-2012. Among 2117 CEASAR participants who underwent RP or EBRT, 817 had low-risk, 902 intermediate-risk, and 398 high-risk disease.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Patient-reported, disease-specific function was measured using the 26-item Expanded Prostate Index Composite (at baseline and 6, 12, and 36 mo). Predicted function was estimated using regression models and compared by disease risk.

RESULTS AND LIMITATIONS

Low-risk EBRT patients reported 3-yr sexual function scores 12 points higher than those of low-risk RP patients (RP, 39 points [95% confidence interval {CI}, 37-42] vs EBRT, 52 points [95% CI, 47-56]; p<0.001). The difference in 3-yr scores for high-risk patients was not clinically significant (RP, 32 points [95% CI, 28-35] vs EBRT, 38 points [95% CI, 33-42]; p=0.03). However, when using a commonly used binary definition of sexual function (erections firm enough for intercourse), no major differences were noted between RP and EBRT at 3 yr across low-, intermediate-, and high-risk disease strata. No clinically significant interactive effects between treatment and cancer severity were observed for incontinence, bowel, irritative voiding, and hormone domains. The primary limitation is the lack of firmly established thresholds for clinically significant differences in Expanded Prostate Index Composite domain scores.

CONCLUSIONS

For men with low-risk prostate cancer, EBRT was associated with higher sexual function scores at 3 yr than RP; however, for men with high-risk prostate cancer, no clinically significant difference was noted. Men with high-risk prostate cancer should be counseled that EBRT and RP carry similar sexual function outcomes at 3 yr.

PATIENT SUMMARY

In this report, we studied the urinary, sexual, bowel, and hormonal functions of patients 3 yr after undergoing prostate cancer surgery or radiation. We found that for patients with high-risk disease, sexual function was similar between surgery and radiation. We conclude that high-risk patients undergoing radiation therapy should be counseled that sexual function may not be as good as low-risk patients undergoing radiation.

Informed and patient-centered decision-making in the primary care visits of African Americans with depression

OBJECTIVE

We examined the prevalence and extent of informed decision-making (IDM) and patient-centered decision-making (PCDM) in primary care visits of African Americans with depression.

METHODS

We performed a cross-sectional analysis of audiotaped clinical encounters and post-visit surveys of 76 patients and their clinicians. We used RIAS to characterize patient-centeredness of visit dialogue. IDM entailed discussion of 3 components: the nature of the decision, alternatives, and pros/cons. PCDM entailed discussion of: lifestyle/coping strategies, knowledge/beliefs, or treatment concerns. We examined the association of IDM and PCDM with visit duration, overall patient-centeredness, and patient/clinician interpersonal ratings.

RESULTS

Approximately one-quarter of medication and counseling decisions included essential IDM elements and 40% included at least one PCDM element. In high patient-centered visits, IDM was associated with patients feeling respected in counseling and liking clinicians in medication decisions. IDM was not related to clinician ratings. In low patient-centered visits, PCDM in counseling decisions was positively associated with patients feeling respected and clinicians respecting patients.

CONCLUSIONS

The associations between IDM and PCDM with interpersonal ratings was moderated by overall patient-centeredness of the visit, which may be indicative of broader cross-cultural communication issues.

PRACTICE IMPLICATIONS

Strengthening partnerships between depressed African Americans and their clinicians may improve patient-engaged decision-making.

Factors associated with patient recall of key information in ambulatory specialty care visits: Results of an innovative methodology

While some studies have assessed patient recall of important information from ambulatory care visits, none has done so recently. Furthermore, little is known about features of clinical interactions which are associated with patient understanding and recall, without which shared decision making, a widely shared ideal for patient care, cannot occur. Our objective was to evaluate characteristics of patients and outpatient encounters associated with patient recall of information after one week, along with observation of elements of shared decision making. This was an observational study based on coded transcripts of 189 outpatient encounters, and post-visit interviews with patients 1 week later. Coding used three previously validated systems, adopted for this study. Forty-nine percent of decisions and recommendations were recalled accurately without prompting; 36% recalled with a prompt; 15% recalled erroneously or not at all. Provider behaviors hypothesized to be associated with patient recall, such as open-questioning and “teach back,” were rare. Patients with less than high school education recalled 38% of items freely and accurately, while patients with a college degree recalled 65% (p < .0001). In a multivariate model, the total number of items to be recalled per visit, and percentage of utterances in decision-making processes by the provider (“verbal dominance”), were significant predictors of poorer recall. The item count was associated with poorer recall for lower, but not higher, educated patients.