The influence of patient-practitioner agreement on outcome of care

Conceptualizing Symptom Invalidation as Experienced by Patients With Endometriosis

The aim of this paper is to provide foundational work to standardize the conceptual definition of what I refer to as symptom invalidation by using invalidating environments and illness representations as guiding conceptual frameworks. Mixed deductive-inductive thematic analysis was used to analyze survey responses to an open-ended question gauging an invalidating interaction patients experienced with a clinician among 1038 patients with endometriosis. Dissimilarity in illness representations between patients and clinicians, as perceived by patients, occurred with feelings of invalidation. Invalidation was experienced in relationship to all identified domains of illness representations including how clinicians communicated the diagnosis (identity label), the internal (internal cause) and/or external (external cause) nature of the cause, clinicians' understanding of the timeline (timeline) and consequences (consequences), and clinicians' understanding of control over the symptoms via the efficacy of patients (self-efficacy) and coping procedures (response efficacy). Inductive analysis revealed invalidation can also be related to how clinicians communicate judgments of whether patients are presenting with ulterior motives (secondary gains). Clinicians' actions appear to compound experiences of invalidation by not having symptoms investigated (investigative experiences). Invalidating environments and illness representations serve as effective conceptual frameworks for providing a conceptual definition of symptom invalidation.

Flares in IIMs and the timeline following COVID-19 vaccination: a combined analysis of the COVAD-1 and -2 surveys

OBJECTIVES

Disease flares in the post-coronavirus disease 2019 (COVID-19) vaccination period represent a prominent concern, though risk factors are poorly understood. We studied these flares among patients with idiopathic inflammatory myopathies (IIMs) and other autoimmune rheumatic diseases (AIRDs).

METHODS

The COVAD-1 and -2 global surveys were circulated in early 2021 and 2022, respectively, and we captured demographics, comorbidities, AIRDs details, COVID-19 infection history and vaccination details. Flares of IIMs were defined as (a) patient self-reported, (b) immunosuppression (IS) denoted, (c) clinical sign directed and (d) with >7.9-point minimal clinically significant improvement difference worsening of Patient-Reported Outcomes Measurement Information System (PROMIS) PROMISPF10a score. Risk factors of flares were analysed using regression models.

RESULTS

Of 15 165 total respondents, 1278 IIMs (age 63 years, 70.3% female, 80.8% Caucasians) and 3453 AIRDs were included. Flares of IIM were seen in 9.6%, 12.7%, 8.7% and 19.6% patients by definitions (a) to (d), respectively, with a median time to flare of 71.5 (10.7-235) days, similar to AIRDs. Patients with active IIMs pre-vaccination (OR 1.2; 95% CI 1.03, 1.6, P = 0.025) were prone to flares, while those receiving rituximab (OR 0.3; 95% CI 0.1, 0.7, P = 0.010) and AZA (OR 0.3, 95% CI 0.1, 0.8, P = 0.016) were at lower risk. Female gender and comorbidities predisposed to flares requiring changes in IS. Asthma (OR 1.62; 95% CI 1.05, 2.50, P = 0.028) and higher pain visual analogue score (OR 1.19; 95% CI 1.11, 1.27, P < 0.001) were associated with disparity between self-reported and IS-denoted flares.

CONCLUSION

A diagnosis of IIMs confers an equal risk of flares in the post-COVID-19 vaccination period to AIRDs, with active disease, female gender and comorbidities conferring a higher risk. Disparity between patient- and physician-reported outcomes represents a future avenue for exploration.

Feasibility of Goal Attainment Scaling as a patient-reported outcome measure for older patients in primary care

BACKGROUND

Goal Attainment Scaling (GAS) is an outcome measure that reflects the perspectives and experiences of patients, consistent with patient-centred care approaches and with the aims of patient-reported outcome measures (PROMs). GAS has been used in a variety of clinical settings, including in geriatric care, but research on its feasibility in primary care practice has been limited. The time required to complete GAS is a barrier to its use by busy primary care clinicians. In this study, we explored the feasibility of lay interviewers completing GAS with older primary care patients.

METHODS

Older adults were recruited from participants of a larger study in five primary care clinics in Alberta and Ontario, Canada. GAS guides were developed based on semi-structured telephone interviews completed by a non-clinician lay interviewer; goals were reviewed in a follow-up interview after six months.

RESULTS

Goal-setting interviews were conducted with 41 participants. GAS follow-up guides could be developed for 40 patients (mean of two goals/patient); follow-up interviews were completed with 29 patients. Mobility-focused goals were the most common goal areas identified.

CONCLUSIONS

Study results suggest that it is feasible for lay interviewers to conduct GAS over the telephone with older primary care patients. This study yielded an inventory of patient goal areas that could be used as a starting point for future goal-setting interviews in primary care. Recommendations are made for use of GAS and for future research in the primary care context.

"From Where I Stand": using multiple anchors yields different benchmarks for meaningful improvement and worsening in the rheumatoid arthritis flare questionnaire (RA-FQ)

PURPOSE

The Rheumatoid Arthritis Flare Questionnaire (RA-FQ) is a patient-reported measure of disease activity in RA. We estimated minimal and meaningful change from the perspective of RA patients, physicians, and using a disease activity index.

METHODS

Data were from 3- to 6-month visits of adults with early RA enrolled in the Canadian Early Arthritis Cohort. Participants completed the RA-FQ, the Patient Global Assessment of RA, and the Patient Global Change Impression at consecutive visits. Rheumatologists recorded joint counts and MD Global. Clinical Disease Activity Index (CDAI) scores were computed. We compared mean RA-FQ change across categories using patients, physicians, and CDAI anchors.

RESULTS

The 808 adults were mostly white (84%) women (71%) with a mean age of 55 and moderate-high disease activity (85%) at enrollment. At V2, 79% of patients classified their RA as changed; 59% were better and 20% were worse. Patients reporting they were a lot worse had a mean RA-FQ increase of 8.9 points, whereas those who were a lot better had a -6.0 decrease. Minimal worsening and improvement were associated with a mean 4.7 and - 1.8 change in RA-FQ, respectively, while patients rating their RA unchanged had stable scores. Physician and CDAI classified more patients as worse than patients, and minimal and meaningful RA-FQ thresholds differed by group.

CONCLUSION

Thresholds to identify meaningful change vary by anchor used. These data offer new evidence demonstrating robust psychometric properties of the RA-FQ and offer guidance about improvement or worsening, supporting its use in RA care, research, and decision-making.

Animal obesity: What insights can a one health approach offer when it comes to veterinarians 'making every contact count'?

There is an overweight/obesity crisis in both human and companion animal populations globally. Veterinarians have an ethical obligation to protect animal welfare and, therefore, have a duty to intervene by supporting their clients in changing care plans to mitigate and prevent pet overweight/obesity. Currently, there is limited evidence in veterinary contexts for when and how this can be done effectively. In contrast, a more comprehensive body of literature has been developed on how human healthcare practitioners 'make every contact count' (MECC). This review begins by briefly exploring the cross-species multifactorial causes of overweight/obesity, before considering the literature regarding whether veterinarians reliably address overweight/obesity and the obstacles they encounter. The review then explores the evidence from human healthcare contexts in terms of how person-centred and health 'coaching-style' MECC interventions have supported weight management in adult and child populations and the barriers practitioners face when implementing these interventions. The final section interprets this literature to provide a fresh 'lens' through which veterinarians' concerns can be understood. Recommendations are made for enhancing veterinarians' capacity to develop the knowledge and skills needed for successful outcomes when MECC. Opportunities for developing local multi-stakeholder/agency teams taking a 'one health' approach are considered.

Factors associated with variation in emergency diagnoses of cancer at general practice level in England

BACKGROUND

Cancer patients diagnosed following an emergency presentation have poorer outcomes. We explore whether practice characteristics are associated with differences in the proportion of emergency presentations.

METHODS

Univariable and multivariable logistic regression models were fitted to investigate the relationships between 2017-18 emergency cancer presentations at practice level in England and access and continuity in primary care, trust in healthcare professionals, 2-week-wait (2WW) referrals, quality and outcomes framework (QOF) achievements and socio-demographic factors (age, gender and deprivation).

RESULTS

Our analysis using comprehensive nationwide data found that the following practice level factors have significant associations with a lower proportion of emergency diagnosis of cancer: increased trust and confidence in the practice healthcare professionals; higher 2WW referral and conversion rate; higher total practice QOF score and higher satisfaction with appointment times or higher proportion able to see preferred GP. Our results also show that practices in more deprived areas are significantly associated with a higher proportion of emergency diagnoses of cancer.

CONCLUSIONS

Regional cancer networks should focus their efforts in increasing both the quantity and appropriateness of 2WW referrals from primary care. In addition, primary care clinicians should be supported to undertake high quality consultations, thus building trust with patients and ensuring continuity of care.

Association of Patient Mental Health Status With the Level of Agreement Between Patient and Physician Ratings of Psoriasis Severity

Importance

The emerging paradigm of treat-to-target in psoriasis requires accurate monitoring of treatment response. The commonly used physician global assessment tool does not capture the patient's perception of their disease. Patient assessments facilitate shared decision-making and foster patient-centered care; however, recent research reports a discordance between patient- and physician-reported psoriasis severity. Understanding the factors underlying this discordance may improve treatment satisfaction and disease outcomes.

Objectives

To evaluate the discordance between patient- and physician-reported measures of psoriasis severity and assess the association with patient mental health status.

Design, Setting, and Participants

A cohort study using repeated cross-sectional analysis of real-world longitudinal data was conducted at a large specialist psoriasis service serving London and Southeast England. A total of 502 patients attending the psoriasis service between May 12, 2016, and November 1, 2018, were included. Data analysis was conducted July 22 to October 22, 2019.

Main Outcomes and Measures

Psoriasis severity was assessed on each visit with identical 5-point physician and patient global assessment scales (clear/nearly clear, mild, moderate, severe, and very severe). Each patient completed validated self-report screens for depression and anxiety on each visit.

Results

Longitudinal data from 502 individuals with psoriasis (1985 total observations) were available. A total of 339 patients (68%) were men, 396 (79%) were White, mean (SD) age was 47 (13) years, and 197 patients (39%) had concurrent psoriatic arthritis, 43 (9%) screened positive for depression, and 49 (10%) screened positive for anxiety. There was discordance between physician and patient measures of disease severity in 768 of 1985 office appointments (39%); on 511 visits (26%) patients rated their psoriasis as less severe and on 257 visits (13%) patients rated their psoriasis as more severe compared with their physician. Individuals who screened positive for depression or anxiety were more likely to overestimate their psoriasis severity compared with their physician (relative risk ratio: depression, 2.7; 95% CI, 1.6-4.5; anxiety, 2.1; 95% CI, 1.3-3.4). These findings remained statistically significant after adjustment for age, ethnicity, sex, body mass index, smoking, number of comorbidities, treatment modality, and presence of psoriatic arthritis.

Conclusions and Relevance

The findings of this cohort study suggest that discordance between patient and physician assessments of psoriasis severity is associated with patients' mental health status. Recognition of anxiety and depression in individuals with psoriasis appears to be important when interpreting patient-reported outcome measures and informing appropriate treatment decisions.

Elements of Suffering in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: The Experience of Loss, Grief, Stigma, and Trauma in the Severely and Very Severely Affected

People who are severely and very severely affected by Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) experience profound suffering. This suffering comes from the myriad of losses these patients experience, the grief that comes from these losses, the ongoing stigma that is often experienced as a person with a poorly understood, controversial chronic illness, and the trauma that can result from how other people and the health care community respond to this illness. This review article examines the suffering of patients with ME/CFS through the lens of the Fennell Four-Phase Model of chronic illness. Using a systems approach, this phase framework illustrates the effects of suffering on the patient and can be utilized to help the clinician, patient, family, and caregivers understand and respond to the patient's experiences. We highlight the constructs of severity, uncertainty, ambiguity, and chronicity and their role in the suffering endured by patients with ME/CFS. A composite case example is used to illustrate the lives of severely and very severely affected patients. Recommendations for health care providers treating patients with ME/CFS are given and underscore the importance of providers understanding the intense suffering that the severely and very severely affected patients experience.

Predictors and Outcomes of Patient Knowledge of Plan of Care in Hospital Medicine: A Quality Improvement Study

BACKGROUND

Patient understanding of plan of care is associated with positive outcomes in ambulatory settings. In hospital medicine settings, patient-physician agreement on plan of care (concordance) has been limited and difficult to improve. This study examined the impact of adding a hospitalist to interdisciplinary rounds (IDR) on physician-patient-nurse concordance and the relationship between concordance and outcomes.

METHODS

IDR were conducted by core teams made up of unit-based nurses, a case manager, and a pharmacist. Over time, with cohorting, hospitalists were included in IDR (hospitalist IDR) for some patients assigned to unit-based hospitalists. In developing hospitalist IDR, the researchers emphasized using an IDR checklist, including a patient communication plan. Patient-nurse-physician interviews were used to assess concordance in the domains of diagnosis, tests and procedures, and expected discharge date. Using two-hospitalist review, agreement was rated as none, partial, or complete, and a total concordance score was calculated for each patient in both IDR groups. Multivariate analysis was used to examine the relationship between concordance, IDR type, patient factors, and utilization outcomes.

RESULTS

For 658 patients, the mean concordance score was 11.71 out of a possible 18. There was no difference in concordance between hospitalist and core IDR groups (11.68 vs. 11.84, p = 0.7). Higher total concordance score was associated with lower lengths of stay (p < 0.001) and readmission rates (p = 0.001). Total concordance had a negative association with patient age (p = 0.04).

CONCLUSION

Concordance did not change with IDR type. Higher concordance appears to be related to positive utilization outcomes. Future studies are needed to evaluate potential interventions to improve concordance.

Habilidades de comunicação clínica dos preceptores de medicina de família e comunidade em Florianópolis, Santa Catarina, Brasil

Objetivo: Este estudo investigou a autoavaliação dos preceptores (versão resumida do Guia Observacional Calgary-Cambridge) sobre quanto aplicam e ensinam HCC, bem como sobre oportunidades de ensino e qualidade do feedback. Métodos: Realizou-se um estudo transversal com 44 preceptores ativos do internato e da residência de medicina de família e comunidade de Florianópolis, Santa Catarina, Brasil. Resultados: Os preceptores se autoavaliaram positivamente em relação à aplicação e ao ensino de HCC, mas as oportunidades de ensino de HCC são escassas e a qualidade do feedback é mediana. Conclusão: É preciso melhorar a estrutura física e a educação permanente sobre feedback e métodos de ensino, incluindo videogravação de consulta, para ampliar as oportunidades de ensino de HCC.

Discordance between patient and physician global assessment of disease activity in Behçet's syndrome: a multicenter study cohort

BACKGROUND

To compare the patients' and physician's global assessment of disease activity in Behçet's syndrome (BS) and investigate the frequency, magnitude, and determinants of potential discordance.

METHODS

A total of 226 adult BS patients with a median (IQR) age of 46.9 (35.6-55.2) years were enrolled across Italy, Greece, Portugal, and Spain. Demographic, clinical, and therapeutic variables, as well as the patient reported outcomes, were collected at the recruitment visit. The physical (PCS) and mental (MCS) component summary scores of the Short Form Questionnaire 36 (SF-36) and the Behçet's syndrome Overall Damage Index (BODI) were calculated. Disease activity was assessed by the patients' (PtGA) and physician's global assessment (PGA) in a 10-cm visual analog scale, as well as the Behçet Disease Current Activity Form (BDCAF). Discordance (∆) was calculated by subtracting the PGA from the PtGA and defined as positive (PtGA>PGA) and negative (PtGA

RESULTS

Median PtGA and PGA scores were 2.0 (0.3-5.0) and 1.0 (0.0-3.0) cm, respectively. The discordance prevalence varied (from 29.6 to 55.3%) according to the cutoff applied, and the majority (> 80%) of disagreements were due to patients rating higher their disease activity. Higher values of BDCAF were associated to increased rate of positive discordance. When BDCAF = 0, the median (IQR) values of PtGA and PGA were 0.2 (0-2) and 0 (0-1), respectively. PCS (adjusted odds ratio (adjOR) 0.96 per unit, 95% CI 0.93-0.98, p = 0.006) and MCS (adjOR 0.96 per unit, 95% CI 0.93-0.99, p = 0.003) were independently associated with positive discordance using both cutoffs. Active ocular involvement emerged as a potential determinant of negative discordance (adjOR 5.88, 95% CI 1.48-23.30, p = 0.012).

CONCLUSIONS

PtGA and PGA should be considered as complementary measures in BS, as patients and physicians may be influenced by different factors when assessing active disease manifestations. Particularly, PtGA may be a useful tool in the assessment of BS disease activity, as it carries a low risk to misclassify an inactive disease, and may allow to capture aspects of the patient's health that negatively affect his well-being and the treatment.

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Key Words

• Behçet’s syndrome
• Disease activity
• Outcome measure
• Patients reported outcomes

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MESH Headings

• Adult
• Behcet Syndrome/diagnosis
• Behcet Syndrome/epidemiology
• Greece
• Humans
• Italy/epidemiology
• Middle Aged
• Physicians
• Severity of Illness Index
• Spain

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Grants

• Associazione Italiana Sindrome e Malattia di Behçet (SIMBA) - Onlus

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Affiliation(s)

Alberto Floris Rheumatology Unit, AOU University Clinic, Cagliari, Italy Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
Gerard Espinosa Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
Luisa Serpa Pinto Hospital Santo Antonio Centro Hospitalar do Porto, Unidade de Imunologia Clinica, Porto, Portugal
Nikolaos Kougkas Rheumatology, Clinical Immunology and Allergy Unit, University of Crete, Heraklion, Greece
Andrea Lo Monaco Rheumatology Unit, AOU S. Anna di Ferrara, University of Ferrara, Ferrara, Italy
Giuseppe Lopalco Rheumatology Unit, University of Bari, Bari, Italy
Ida Orlando Rheumatology Unit, University of Siena, Siena, Italy
George Bertsias Rheumatology, Clinical Immunology and Allergy Unit, University of Crete, Heraklion, Greece
Luca Cantarini Rheumatology Unit, University of Siena, Siena, Italy
Ricard Cervera Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
João Correia Hospital Santo Antonio Centro Hospitalar do Porto, Unidade de Imunologia Clinica, Porto, Portugal
Marcello Govoni Rheumatology Unit, AOU S. Anna di Ferrara, University of Ferrara, Ferrara, Italy
Florenzo Iannone Rheumatology Unit, University of Bari, Bari, Italy
Alessandro Mathieu Rheumatology Unit, AOU University Clinic, Cagliari, Italy Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
Piergiorgio Neri Ophthalmology Clinic, Università Politecnica delle Marche, Ancona, Italy Cleveland Clinic Abu Dhabi, Eye Institute, Abu Dhabi, United Arab Emirates
Ana Martins Silva Neurology Department, Centro Hospitalar do Porto/Hospital de Santo António, Porto, Portugal
Carlos Vasconcelos UMIB Abel Salazar Biomedical Sciences Institute, University of Porto, Porto, Portugal
Monica Muntoni Associazione Italiana Sindrome e Malattia di Behçet (SIMBA), Pontedera, Italy
Alberto Cauli Rheumatology Unit, AOU University Clinic, Cagliari, Italy Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
Matteo Piga Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy.

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Exploring the psychometric properties of the Working Alliance Inventory in general practice: a cross-sectional study

Background

The therapeutic alliance is a framework from psychology that describes three components: goals, tasks, and bond. The Working Alliance Inventory adapted for general practice (WAI-GP) measures the strength of the therapeutic alliance between the patient and the clinician, and it could be useful in both research and clinical settings.

Aim

To determine if the patient score on WAI-GP can delineate the three components (goals, tasks, and bond), and to test concurrent validity with the Consultation and Relational Empathy (CARE) measure and the Patient Perception of Patient-Centredness (PPPC) measure.

Design & setting

A cross-sectional study took place in 12 general practice waiting rooms in Australia.

Method

The research instruments included the 12-item WAI-GP (the patient version), the CARE and PPPC measures, plus a survey of demographics and reason for consultation. To perform a principal components factor analysis of the WAI-GP, this dataset was combined with an existing dataset. The Spearman rank correlation was used to determine concurrent validity between the WAI-GP and the CARE and PPPC measures.

Results

Participants (97–99%) reported a strong positive alliance after the consultation (average WAI-GP mean 4.27 ± 0.67 out of 5, n = 146). Factor analysis could not separate the three components (one factor, eigenvalue >1; Cronbach’s α = 0.957; n = 281). Concurrent validity was supported by moderate correlations with the other measures (PPPC ρ = –0.51, P<0.005, CARE ρ = 0.56, P<0.005).

Conclusion

Three components could not be identified, but the WAI-GP has a high internal consistency and concurrent validity with moderate correlations with the CARE and PPPC. A more diverse sample may better distinguish the three components leading to more specific feedback to clinicians on their consultation practices.

Agreement of physician and patient ratings of communication in medical encounters: A systematic review and meta-analysis of interrater agreement

OBJECTIVE

To determine the agreement of physician and patient ratings of communication in medical face-to-face consultations.

METHODS

A systematic search of twelve databases was conducted. Studies investigating agreement between physician and patient ratings of communication in medical face-to-face encounters and reporting interrater agreement were included. Methodological quality was assessed, and study characteristics and physician-patient agreement were narratively summarized. Meta-analysis was conducted for a subsample of the included studies investigating shared decision making.

RESULTS

Of the 17 included studies, ten studies did not demonstrate any correspondence between physician and patient ratings. The remaining seven studies revealed poor to fair absolute agreement (κ between .13 and .42; κ_w between .31 and .49; 95% CI 0.13 - 0.76) and poor to moderate consistency (r = .17 and .06; r_polyc between .39 and .63; p < .05). Meta-analysis of six studies yielded small association (r_polyc = .15).

CONCLUSION

Physicians and patients evaluate communication differently and at best, only slightly agree in their ratings, indicating that the construct of communication is not measurable in a stable manner.

PRACTICE IMPLICATIONS

Decision makers and researchers should be aware that they assess different aspects of communication, depending on the perspective examined. PROSPERO registration number: CRD42019120065.

Future Directions in Communication in Neurosurgery

Modern-day care of the neurosurgery patient has grown increasingly complex and typically involves a variety of medical team members. Proper communication and transmission of clinical data within the neurosurgery team is required for successful outcomes, especially within the operating room. Effective communication is also critical to the patient-physician relationship and can aid in improving rapport and possibly reducing malpractice lawsuit risk. In addition, interactions exist between practicing neurosurgeons and members of the administration, often focusing on reimbursement and quality issues. Although most physicians would agree that communication between all these stakeholders should improve, certain barriers are present, including the adoption of newer technologies and the lack of formal training. In this article, we review current and projected trends relating to the enhancement of neurosurgical communication at all levels.

Patient-Physician Agreement in Reporting and Prioritizing Existing Chronic Conditions

PURPOSE

In this study, we aimed to assess (1) the agreement between patient self-reports and general practitioner (GP) reports of the chronic conditions affecting the patients and (2) the agreement between patients and GPs on health priorities in a primary care setting.

METHOD

Patients were recruited in the Parisian area of France by a convenience sample of GPs; eligibility criteria required that the GP was the patient's listed primary care provider for at least 12 months. Participants were asked to report all the patient's current chronic conditions by using a previously developed list of 124 chronic conditions and write a list of up to 3 priority conditions.

RESULTS

From April to May 2017, 233 patients were recruited from 16 GP practices. Agreement between the number of conditions reported by patients and by GPs was moderate (intraclass correlation coefficient 0.59, 95% CI, 0.50 to 0.69). Agreement between patient self-reports and GP reports of each chronic condition ranged from very good (eg, κ = 0.85 for hypothyroidism) to poor (eg, κ = 0.12 for chronic anxiety disorder). Among the 153 patient-GP pairs for which both the patient and GP wrote a priority list, 45 (29.4%) of patients' first priorities did not appear anywhere on the corresponding GPs' lists, and 19 (12.4%) pairs had no matching priority condition.

CONCLUSIONS

Agreement between patients and their GPs varied widely depending on the diseases reported. Low agreement on health priorities suggests a need for improvement to ensure better alignment between patient and physician perspectives.

Perceptions among transgender women of factors associated with the access to HIV/AIDS-related health services in Yogyakarta, Indonesia

Access to HIV/AIDS-related health services among transgender women living with HIV is still a major public health issue in many developing countries, and Indonesia is not an exception. However, reportedly compared to other settings in the country, transgender women in Yogyakarta have a good access to the HIV-related health services. This study aimed to explore perceptions among transgender women living with HIV, locally known as waria, of factors supportive of their access to the services in Yogyakarta, Indonesia. A qualitative inquiry using in-depth interview method was conducted from December 2017 to February 2018 to collect the data from a selection of waria living with HIV (n = 29) recruited using both purposive and snowball sampling techniques. Data analysis employed a thematic approach which was guided by the framework analysis for qualitative data. The findings indicated several health service system-related determinants supportive of waria’s access to HIV/AIDS-related health services. These included the availability of the services, the simplicity and convenience of accessibility to the services and the comfort felt by the participants while accessing the services. Health professionals’ positive attitudes during healthcare provision, social relationships between waria and health professionals, proximity to healthcare facilities, free access to the services, and information sessions on HIV infection and prevention were also reported to enable participants’ access to the services. These findings call to efforts and strengthening of HIV health service system to support and provide equal access to HIV/AIDS-related services including to all Indonesians living with HIV, but more so for transgender women and other high-risk groups such as sex workers and their clients and men who have sex with men.

Attitudes about Care at the End of Life among Clinicians: A Quick, Reliable, and Valid Assessment Instrument

Several initiatives to improve care at the end of life involve educational programs to influence clinicians’ attitudes about care for patients with terminal illnesses. The objective of this research was to develop and test a short and easily administered instrument for measuring physicians’ and nurses’ attitudes towards care at the end of life. The instrument was tested using a cross-sectional study of 50 clinicians (25 physicians and 25 nurses) from general medicine, cardiology, oncology, and geriatric medicine. Both reliability and validity were assessed, and the instrument was found to have acceptable test-retest reliability and construct validity. Such an assessment instrument may be useful in evaluating the impact of initiatives to modify attitudes towards terminal care and in improving the quality of care at the end of life.

Impact of Symptom Reporting Agreement on Interdisciplinary Pain Program Participation

OBJECTIVE

To investigate whether physician-patient agreement of potential patient problem areas impacts subsequent patient enrollment in an interdisciplinary pain management program.

DESIGN

Retrospective chart review of 544 patients who underwent evaluation of their chronic pain. Physicians and their patients endorsed perceived patient problems during the evaluation. The potential problems included 7 clinical domains: pain, sleep, mood, physical functioning, ability to cope with pain, ability to manage pain flare-ups, and pain medication effectiveness.

RESULTS

Results indicated statistically significant levels of agreement among the physicians and their patients (free-marginal kappa range, 0.19 to 0.94, P's < 0.001). The highest agreement occurred for pain and the lowest for pain medication effectiveness. Patients who enrolled in a recommended program did not differ from those who did not enroll based on either levels of agreement or average number of physician-patient agreements for the 7 clinical domains (P's > 0.05). Patients recommended for higher-intensity programs were perceived by their evaluating physician to have a significantly greater number of problematic clinical domains than those recommended for less intense pain programs.

CONCLUSION

The level of physician-patient agreement regarding the patients' current difficulties did not appear to influence patients' decisions to participate in interdisciplinary pain management. Extraneous, nonclinical factors may have had a greater impact on participation in interdisciplinary pain management than physician-patient agreement. Future research should focus on identifying these factors and their impact. Also, studying the impact of physician-patient agreement beyond enrollment status (eg, on successful program completion) may be helpful in potentially enhancing patient outcomes.

Feasibility study of goal setting discussions between older adults and volunteers facilitated by an eHealth application: development of the Health TAPESTRY approach

BACKGROUND

In keeping with the changing needs of the Canadian population, primary care systems need to become more person-focused in providing quality care to older adults. As part of Health TAPESTRY, a complex intervention to strengthen primary care for older adults, a goal setting exercise was developed and tested in an initial feasibility study, intended to foster collaboration between patients and providers.

METHODS

Participants-clinic clients-were recruited from the McMaster Family Health Team in Hamilton, Ontario. Five participants took part in the goal setting feasibility study phase I, which tested the functionality of a technology-enabled goal setting exercise between older adults and volunteers. Based on observations and feedback from volunteers, interprofessional team members, and older adults, the exercise was refined to include a guided survey and goals report. The goal setting survey is a list of probing questions designed based on SMART (specific, measurable, attainable, relevant, timely) goal setting strategies and goal attainment scaling (GAS). This was used in phase II, carried out with 16 participants, where the feasibility of goal setting and goal attainment with support from volunteers and interprofessional teams was tested. Volunteers carried out the goal setting survey via a tablet computer, a report of client goals was generated and sent to interprofessional teams, and client goals were discussed during clinic huddles. At 6 months of follow-up, clients self-evaluated their progress using GAS.

RESULTS AND DISCUSSION

The goal setting exercise in phase I took an average of 24:45 (SD 11:42) minutes and yielded a diverse set of life and health goals. Goals identified by older adults were primarily focused on the maintenance of a certain level of activity or health state. Phase I work resulted in important changes to the goal setting process (e.g., asking about goal setting later in conversation, changing wording of questions) and development of a summary report of goals sent to the interprofessional team. In phase II, 44 goals were set by 16 participants during an average 7:23 (SD 4:26) minute discussion. Of these goals, 43.9% were characterized as health goals while 63.4% were characterized as life goals. Under the umbrella of Life goals, productivity featured most prominently at 22.9% of all goals. Goal attainment was not measured in phase I. In phase II, clients had an average weighted goal attainment score of 51.5. Considering client preferences for one goal over another, 68.8% of clients, on average, at least partially achieved the goals they had set.

CONCLUSION

Goal setting as part of the Health TAPESTRY approach was feasible and provided interprofessional teams with client narratives that helped improve care management for older adults. The overall intervention-including the refined goal setting component-is being scaled and evaluated in a pragmatic randomized controlled trial.

Pain, sleep and emotional well-being explain the lack of agreement between physician- and patient-perceived remission in early rheumatoid arthritis

BACKGROUND

Clinical response and remission are defined in multiple ways and measured with different instruments, resulting in substantial variation of the proportion of patients classified as being in remission. Therefore, the agreement between patient-perceived, physician-perceived remission and clinical response and remission definitions was determined in early rheumatoid arthritis (RA) patients. And secondly, differences in clinical and patient-reported outcomes, in patients in physician-perceived remission, between patients in and not in self-perceived remission were assessed.

METHODS

In 84 early RA patients, who received methotrexate and glucocorticoids, DAS44, ACR/EULAR Boolean-based remission, EULAR good and ACR70 response were determined after 12 weeks. Agreement between patient-perceived (phrased: "Would you say that, at this moment, your disease activity is as good as gone?"), physician-perceived remission (based on a visual analogue scale for global disease severity) and clinical response and remission definitions were calculated with the percentage of agreement and with kappa values (which corrects for change). In patients in physician-perceived remission, improvement in clinical and patient-reported outcomes (RAID) were compared between patients in and not in self-perceived remission.

RESULTS

Agreement between the assessed outcome measures differed enormously. The agreement between physician-perceived and patient-perceived remission was 64% (kappa 0.25, p < 0.01). Physician-perceived remission had the best agreement with EULAR good response (79%), and patient-perceived remission with EULAR good and ACR70 response (both 69%). Patients not in self-perceived remission improved less on RAID components, especially on pain, sleep and emotional well-being.

CONCLUSION

One-third of the early RA patients disagreed with the physician on being in remission. Those patients had less improvement on RAID components, especially on pain, sleep and emotional well-being. Together with the variability in clinical response and remission definitions, these results highlight the need to increase patient involvement in their own health care decisions.

Multimorbidity: can general practitioners identify the health conditions most important to their patients? Results from a national cross-sectional study in Switzerland

Background

Faced with patients suffering from more than one chronic condition, or multimorbidity, general practitioners (GPs) must establish diagnostic and treatment priorities. Patients also set their own priorities to handle the everyday burdens associated with their multimorbidity and these may be different from the priorities established by their GP. A shared patient–GP agenda, driven by knowledge of each other’s priorities, would seem central to managing patients with multimorbidity. We evaluated GPs’ ability to identify the health condition most important to their patients.

Methods

Data on 888 patients were collected as part of a cross-sectional Swiss study on multimorbidity in family medicine. For the main analyses on patients-GP agreement, data from 572 of these patients could be included. GPs were asked to identify the two conditions which their patient considered most important, and we tested whether either of them agreed with the condition mentioned as most important by the patient. In the main analysis, we studied the agreement rate between GPs and patients by grouping items medically-related into 46 groups of conditions. Socio-demographic and clinical variables were fitted into univariate and multivariate models.

Results

In 54.9% of cases, GPs were able to identify the health condition most important to the patient. In the multivariate model, the only variable significantly associated with patient–GP agreement was the number of chronic conditions: the higher the number of conditions, the less likely the agreement.

Conclusion

GPs were able to correctly identify the health condition most important to their patients in half of the cases. It therefore seems important that GPs learn how to better adapt treatment targets and priorities by taking patients’ perspectives into account.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0757-y) contains supplementary material, which is available to authorized users.

Psychological Distress and Quality of Life in Pediatric Crohn Disease: Impact of Pain and Disease State

OBJECTIVES

For patients with Crohn disease (CD), symptom reporting may not coincide with disease state; patients in remission may continue to report symptoms and pain, whereas other patients may be symptom-free despite a flare. This phenomenon has been documented in adults but only recently assessed in pediatric patients. The present study assessed the role of pain reporting and disease state in pediatric patients with CD in understanding psychological distress and quality of life.

METHODS

Participants included 116 children and adolescents ages 8 to 18 years with CD who completed self-report questionnaires assessing pain, disease symptoms, depression, anxiety, functional disability, and quality of life. Physicians completed the Pediatric Crohn's Disease Activity Index to assess disease activity (scores ≤10 = remission, scores >10 = flare).

RESULTS

Approximately two thirds of participants reported pain concordant with disease state. For patients in remission, those with pain experienced significantly increased disability and decreased quality of life compared to patients in remission without pain. For patients in a flare, those without pain experienced significantly decreased disability and depressive symptoms, and improved quality of life compared to patients in a flare with pain.

CONCLUSIONS

For pediatric patients with CD, report of pain, while in remission or a flare, is associated with increased disability and reduced quality of life. Although levels of depression did not differ by disease state, depressive symptoms did differ by pain report (presence or absence) for those in a flare. Pain reporting in CD appears to be associated with both physical and psychological state and should be assessed regardless of disease activity.

Agreement between electronic medical records and self-reported urologic domains in the National Spina Bifida Patient Registry (NSBPR): Implications for future research

BACKGROUND

Self-report (SR) is an efficient data collection method. However, SR data have been shown to be discrepant with medical record (MR) documentation, which raises questions about using SR to supplement retrospective chart review in research. In this study, pediatric spina bifida (SB) patients who completed SR interviews about continence status and personal bladder/bowel management were identified. We examined agreement between SR data and Urology provider notes in MRs.

OBJECTIVE

This study aimed to (1) identify demographic, medical, or methodological factors that might contribute to SR/MR disagreement; (2) postulate how these findings might be significant clinically; and (3) recommend improvements to SR data collection and MR documentation.

STUDY DESIGN

Our institution participates in the National Spina Bifida Patient Registry (NSBPR). NSBPR-enrolled subjects typically complete annual interviews about their urologic outcomes; we consider this to be a form of SR. After identifying patients who interviewed within 1 month of an encounter with a urology provider, we systematically reviewed and compared their SR responses to the MR. Overall SR/MR agreement (no. of agreeing data pairs/no. of complete data pairs) and strength of agreement (kappa, κ) were assessed. Agreement about daytime continence status was assessed for children ≥5 years or in younger children who were toilet trained. Analyses were also stratified by diagnosis, type of bladder management, and ethnicity.

RESULTS

Eleven urologic domains were analyzed for 176 patients. Overall SR/MR agreement was ≥90% for nine out of 11 domains (figure). Daytime urinary and stool incontinence (DUSI) domains demonstrated the lowest overall agreement, at 69% and 74% respectively. Patients with myelomeningocele (MM) and those on clean intermittent catheterization demonstrated twice as much SR/MR disagreement about DUSI than patients without MM and those who void. There was no significant difference in rates of SR/MR agreement about DUSI when analyzed by ethnicity, race, and ambulatory function status. Among cases of SR/MR disagreement about DUSI, the SR and MR had a roughly equal percentage of better outcomes reported for both UI and SI.

DISCUSSION

There was strong SR/MR agreement for the majority of urologic data we analyzed. Medically complex patients faced lower SR/MR agreement, which is consistent with findings in other patient populations. Biased reporting by patients/families or providers was not found.

CONCLUSION

Minimizing SR/MR disagreement through standardized data collection methods and tools, improved definitions of patient outcomes, and documentation of respondent identity will improve large, multisite studies that utilize SR and MR concurrently.

Exploring ways to manage healthcare professional-patient communication issues

Effective communication between clinicians and their patients has a positive impact not only on clinical outcomes but also on their experience of care. Communication skills are a core clinical skill, which can be taught by a number of methods. Understanding the impact of one's own communication skills has on a patient and their family can help hone a clinician's skills to improve both patient and clinician satisfaction.

Validation of the Norwegian version of MAPPIN'SDM, an observation-based instrument to measure shared decision-making in clinical encounters

OBJECTIVE

To validate the Norwegian version of MAPPIN'SDM observer scales with regard to reliability, accuracy and the extent to which the scales include the essentials of the shared decision-making concept.

METHODS

Three MAPPIN'SDM scales, focusing on the skills of doctor, patient and dyad, were applied to audiovisual records of 35 decision sequences. Inter-rater reliabilities were determined based on kappa coefficients. Sensitivities and specificities were calculated with regard to an expert reference standard. Convergent validities were calculated with the OPTION₅ scale. MAPPIN'SDM was qualitatively compared to OPTION5 using Makoul & Clayman's Integrative Model structure.

RESULTS

Inter-rater reliabilities were high on average over 11 items in each of three observer scales (MAPPIN_doctor=0.77, MAPPIN_patient=0.82, MAPPIN_dyad=0.77). Patient involvement was detected accurately (MAPPIN_dyad: mean sensitivity/specificity 93/91%). Comparison with OPTION₅ showed weak to moderate correlation (Spearman's ρ/p-value: MAPPIN_doctor:=0.44/0.009, MAPPIN_patient: 0.38/0.024, MAPPIN_dyad 0.40/0.016) and little content overlap.

CONCLUSION

MAPPIN'SDM_norge is capable of assessing SDM highly reliably and accurately. Divergence from OPTION₅ reflects explicit disagreement regarding the concept's assumptions.

PRACTICE IMPLICATIONS

MAPPIN'SDM_norge is ready for use in Norway. In-depth debate on the SDM concept's essentials is urgently needed.

Healthcare Providers versus Patients' Understanding of Health Beliefs and Values

OBJECTIVE

This study examined how well healthcare providers perceive and understand their patients' health beliefs and values compared to patients' actual beliefs, and to determine if communication relationships maybe improved as a result of healthcare providers' understanding of their patients' illness from their perspective.

METHODS

A total of 61 participants (7 healthcare providers and 54 patients) were enrolled in the study. Healthcare providers and patients individually completed survey instruments and each participated in a structured focus group.

RESULTS

Healthcare provider and patient differences revealed that patients perceived greater meaning of their illness (p = 0.038), and a greater preference for partnership (p = 0.026) compared to providers. The three qualitative themes most important for understanding patients' health beliefs and values as perceived by healthcare providers were education, trust, and culture. Educating patients was perceived as having the greatest impact and also the easiest method to implement to foster providers' understanding, with at least one patient focus group in agreement of same. Likewise, three themes were derived from patients' perspectives as relatively more important in understanding providers' beliefs and values; bidirectional communication, comprehensive treatment, and discipline. Overwhelmingly, bidirectional communication was perceived as a critical factor as having the greatest impact and may also be easiest to implement according to these patients.

CONCLUSION

When patients and healthcare providers listen and communicate with each other, they are likely to develop a shared understanding that may improve future decision making and quality of care patients receive.

Therapeutic alliance and obesity management in primary care - a cross-sectional pilot using the Working Alliance Inventory

Therapeutic alliance is a well-recognized predictor of patient outcomes within psychological therapy. It has not been applied to obesity interventions, and Bordin's theoretical framework shows particular relevance to the management of obesity in primary health care. This cross-sectional study of a weight management programme in general practice aimed to determine if therapeutic alliance was associated with patient outcomes. The Working Alliance Inventory short revised version (WAI-SR) was administered to 23 patients and 11 general practitioners (GPs) at the end of a 6-month weight management programme. Use of the WAI-SR indicated that the strength of therapeutic alliance varied between different patient-GP relationships in this pilot intervention. A robust therapeutic alliance was strongly associated with patient engagement in the weight management programme indicated by number of appointments. It was also associated with some general health and quality of life outcomes. These are promising results that require confirmation with larger studies in primary health care. The measurement of therapeutic alliance using the WAI-SR may predict patient attendance and outcomes in obesity interventions in primary healthcare settings.

How well do patients and providers agree on the severity of dyspnea?

BACKGROUND

Understanding the severity of patients' dyspnea is critical to avoid under- or overtreatment of patients with acute cardiopulmonary conditions.

OBJECTIVE

To evaluate the agreement between dyspnea assessment by patients and healthcare providers and to explore which factors contribute to discordance in assessment.

DESIGN, SETTINGS AND PARTICIPANTS

Prospective study of patients hospitalized for acute cardiopulmonary diseases at an urban teaching hospital.

INTERVENTION AND MEASUREMENTS

A numerical rating scale (0-10) was used to assess dyspnea severity as perceived by patients and assessed by providers. Agreement was defined as a score within ±1 between patient and healthcare provider; differences of ≥2 points were considered over- or underestimations. The relationship between patient self-perceived dyspnea severity and provider rating was assessed using a weighted kappa coefficient.

RESULTS

Of the 138 patients enrolled, 33% had a diagnosis of heart failure, 30% chronic obstructive pulmonary disease, and 13% pneumonia; median age was 72 years, and 57% were women. In all, 96 patient-physician and 138 patient-nurses pairs were included in the study. The kappa coefficient for agreement was 0.11 (95% confidence interval [CI]: 0.01 to 0.21) between patients and physicians and 0.18 (95% CI: 0.12 to 0.24) between patients and nurses. Physicians underestimated patients' dyspnea 37.9% of the time and overestimated it 25.8% of the time, whereas nurses underestimated it 43.5% of the time and overestimated it 12.4% of the time. Admitting diagnosis was the only patient factor associated with discordance.

CONCLUSIONS

Agreement between patient perception of dyspnea and healthcare providers' assessment is low. Future studies should prospectively test whether routine assessment of dyspnea results in better patient outcomes. Journal of Hospital Medicine 2016;11:701-707. © 2016 Society of Hospital Medicine.

The feasibility of implementing a communication skills training course in pediatric hematology/oncology fellowship

Communication skills are a competency highlighted by the Accreditation Council on Graduate Medical Education; yet, little is known about the frequency with which trainees receive formal training or what programs are willing to invest. We sought to answer this question and designed a program to address identified barriers. We surveyed pediatric fellowship program directors from all disciplines and, separately, pediatric hematology/oncology fellowship program directors to determine current use of formal communication skills training. At our institution, we piloted a standardized patient (SP)-based communication skills training program for pediatric hematology/oncology fellows. Twenty-seven pediatric hematology/oncology program directors and 44 pediatric program directors participated in the survey, of which 56% and 48%, respectively, reported having an established, formal communication skills training course. Multiple barriers to implementation of a communication skills course were identified, most notably time and cost. In the pilot program, 13 pediatric hematology/oncology fellows have participated, and 9 have completed all 3 years of training. Precourse assessment demonstrated fellows had limited comfort in various areas of communication. Following course completion, there was a significant increase in self-reported comfort and/or skill level in such areas of communication, including discussing a new diagnosis (p =.0004), telling a patient they are going to die (p =.005), discussing recurrent disease (p <.001), communicating a poor prognosis (p =.002), or responding to anger (p ≤.001). We have designed a concise communication skills training program, which addresses identified barriers and can feasibly be implemented in pediatric hematology/oncology fellowship.

Impact of the Ottawa Decision Support Framework on the Agreement and the Difference between Patients' and Physicians' Decisional Conflict

Background. The Ottawa Decision Support Framework (ODSF) provides a process that facilitates shared decision making. Objective. To assess the impact of implementing the ODSF on the agreement and the difference between patients' and physicians' decisional conflict scores. Design. In total, 120 physicians and 903 patients enrolled in this before-and-after study. Implementation of the ODSF was composed of an interactive workshop, feedback, and a reminder at the point of care. The Decisional Conflict Scale (DCS) was completed by physicians and patients after a clinical encounter. Results. The intraclass correlation coefficient was–0.205 ± 0.096 (95% confidence interval [CI]= – 0.224 to –0.186) before implementing the ODSF and– 0.013 ± 0.114 (95% CI = – 0.036 to 0.009) after. At the patient level, the following factors were significantly associated with the difference between the patients' and physicians' DCS: unemployed (P = 0.023), implementing the ODSF (P = 0.008), high school degree (P = 0.04), male (P = 0.03), and unilateral role in decision making (P = 0.03). At the physician level, provincial committee (P = 0.001), national committee (P = 0.045), clinical site (P = 0.016), reluctance to share uncertainty (P = 0.023), and anxiety due to uncertainty (P = 0.017) were significantly associated with this outcome. Conclusion. After implementing the ODSF, there was less dissimilarity between patients' and physicians' DSC than expected by chance than before. Implementing the ODSF was also found to be associated with the difference between patients' and physicians' DSC. The physician level explained a significant amount of the variance in this outcome, thus emphasizing the importance of an intervention at this level.

Discordance Between Drug Adherence as Reported by Patients and Drug Importance as Assessed by Physicians

PURPOSE

Among patients on long-term medical therapy, we compared (1) patient and physician assessments of drug adherence and of drug importance and (2) drug adherence reported by patients with drug importance as assessed by their physicians.

METHODS

We recruited to the study patients receiving at least 1 long-term drug treatment from both hospital and ambulatory settings in France. We compared drug adherence reported by patients and drug importance assessed by physicians using Spearman correlation coefficients. Reasons for nonadherence were collected with open-ended questions and classified as intentional or unintentional.

RESULTS

Between April and August 2014, we recruited 128 patients taking 498 drugs. Patients and physicians showed only weak agreement in their assessments of drug adherence (r = -0.25; 95% CI, -0.37 to -0.11) and drug importance (r = 0.07; 95% CI, 0.00 to 0.13). We did not find any correlation between physician-assessed drug importance and patient-reported drug adherence (r = -0.04; 95% CI, -0.14 to 0.06). In all, 94 (18.9%) of the drugs that physicians considered important were not correctly taken by patients. Patients intentionally did not adhere to 26 (48.1%) of the drugs for which they reported reasons for nonadherence.

CONCLUSIONS

We found substantial discordance between patient and physician evaluations of drug adherence and drug importance. Nearly 20% of drugs considered important by physicians were not correctly taken by patients. These findings highlight the need for better patient-physician collaboration in drug treatment.

Interventions in Physician-Elderly Patient Interactions

Currently, most research in the area of physician-elderly patient interactions relates to either outcome, context, or interaction styles. There are limited data in the area of intervention studies. The authors recognize five specific areas of interventional research to consider: communication during encounters, characteristics of older patients, physical impairments, physician attributes, and the team approach to health care. Also highlighted are recognition and evaluation of the special needs of elderly patients through geriatric assessment. The authors recognize the need for more intervention studies that attempt to change patient or physician behaviors and the applicability of the classic randomized controlled model of research. Overall, the authors contend that the formation of strong, meaningful relationships between elderly patients and their physicians is best achieved through effective medical communication and care, and thus should be the function of appropriate interventions.

Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms

PURPOSE

Patient participation in clinical decision making improves outcomes, including quality of life (QOL), but the typical problem-oriented approach may impede consideration of functional goals. We wondered if patients could encourage primary care physicians to pay attention to their QOL goals by writing them on pre-encounter forms.

METHODS

We conducted a randomized controlled trial comparing the impact of 2 different pre-visit questionnaires on the content of patient-physician encounters in a family medicine practice at an academic medical center. Using investigator-blinded block randomization, we arranged for 8 faculty and 8 resident physicians to participate in 2 intervention and 2 control videotaped encounters each for a total of 64 encounters. The intervention questionnaire included questions about QOL goals and concerns, while the control questionnaire asked about symptoms. Videotapes were reviewed to determine whether the patients' QOL goals were mentioned and whether they were used in decision making. We also scored encounters using Modified Flanders Interaction Analysis, which assesses and codifies patient and physician communication, and the Modified Carkhuff-Truax Scale, which measures empathy, attending, congruence, and positive regard.

RESULTS

Patients were able to record QOL goals and concerns, but QOL issues were mentioned in only 2 of the 64 encounters, once by a patient and once by a physician. In neither case was this information used in decision making. More empathy was expressed by physicians during control encounters (P = .03).

CONCLUSIONS

Patients were able to articulate their QOL goals on paper, but that did not prime them or their physicians to alter the process or content of the clinical encounters. In fact, providing QOL information was associated with reduced physician empathy.

Patient-physician discordance in global assessment in early spondyloarthritis and its change over time: the DESIR cohort

Objective

To assess patient-physician discordance in global assessment of disease activity in early axial spondyloarthritis (axSpA) over time and determinants of discordance.

Methods

DESIR (Devenir des Spondyloarthropathies Indifférenciées Récentes) is a French, multicentre, longitudinal cohort of patients with early inflammatory back pain suggestive of axSpA. Patient global assessment (PGA) and physician global assessment (PhGA) were rated with a 0–10 numerical rating scale, every 6 months during 2 years then at 3 years. Discordance was defined by the absolute difference |PGA–PhGA|≥3 (range 0–10) and was analysed at each visit. Determinants of (PGA−PhGA) were assessed at the visit level by a generalised linear mixed model.

Results

A total of 702 patients were analysed at baseline (401 with complete data over 3 years): mean age 33.8±8.6 years, 379 (54.0%) female, mean symptom duration 18.1±10.5 months. Mean PGA values were always higher than mean PhGA values with a mean absolute difference of 1.8 points. At baseline, 202 (28.8%) patients had discordance mainly by PGA>PhGA; over 3 years the frequency of discordance was stable (range 25.5–28.8%). Discordance was not stable at the patient level, 118 (29.4%) patients were discordant once and 88 (22.0%) twice, and only 92 (22.9%) more than twice. Determinants of (PGA−PhGA) were spine pain (β=0.24, p<0.001) and fatigue (β=0.13, p<0.001).

Conclusions

Discordance concerned a quarter of patients with early axSpA. Over 3 years of follow-up, discordance did not decrease (no ‘reference shift’). Discordance was not a stable trait, indicating discordance is not a patient characteristic.

Genetic Counselors' Judgments of Patient Concerns: Concordance and Consequences

The aims of this prospective study were to determine (a) the concordance between patient concerns and genetic counselors' judgments of these concerns, (b) the predictors of patient and counselor judgments, and (c) the relationship between concordance and patient outcomes. Patients' and counselors' views were sought before and after 131 routine genetic consultations. Before consultations, there was concordance about level of patient concern to within one point in 63% (82/131) of consultations and about type of patient concern in 60-84% of consultations. Lack of concordance in judging level and type of concern was associated with lower satisfaction with information and higher anxiety after the consultation. The biggest predictor of counselor judgment of concern was professional background: doctors judged patients to be more concerned than did nurses. Concordance of concern was predicted by counselors' experience in genetics: less experienced counselors overestimated patient concern. Future research needs to determine whether improving judgment of concern improves patient outcome.

Describing the factors that influence the process of making a shared-agenda in Japanese family physician consultations: a qualitative study

BACKGROUND

Patients cannot always share all necessary relevant information with doctors during medical consultations. Regardless, in order to ensure the best quality consultation and care, it is imperative that a doctor clearly understands each patient's agenda. The purpose of this study was to analyze the process of developing a shared-agenda during family physician consultations in Japan.

METHODS

We interviewed 15 first time patients visiting the outpatient clinic of the Department of Family Medicine in the hospital chosen for the investigation, and the 8 family physicians who examined them. In total we observed 16 consultations. We analyzed both patients' and doctors' narratives using a modified grounded theory approach.

RESULTS

For patients, we found four main factors that influenced the process of making a shared-agenda: past medical experiences, undisclosed but relevant information, relationship with the family physician, and the patient's own explanatory model. In addition, we found five factors that influenced the shared agenda making process for family physicians: understanding the patient's explanatory model, constructing the patient-doctor relationship, physical examination centered around the patient's explanatory model, discussion-styled explanation, and self-reflection on action.

CONCLUSIONS

The findings suggest that patient satisfaction would be increased if family physicians are proactive in considering these factors with respect to both the patient's agenda, and their own.

Effects of electronic health record use on the exam room communication skills of resident physicians: a randomized within-subjects study

Background The effects of electronic health records (EHRs) on doctor–patient communication are unclear.

Objective To evaluate the effects of EHR use compared with paper chart use, on novice physicians’ communication skills.

Design Within-subjects randomized controlled trial using observed structured clinical examination methods to assess the impact of use of an EHR on communication.

Setting A large academic internal medicine training program.

Population First-year internal medicine residents.

Intervention Residents interviewed, diagnosed, and initiated treatment of simulated patients using a paper chart or an EHR on a laptop computer. Video recordings of interviews were rated by three trained observers using the Four Habits scale.

Results Thirty-two residents completed the study and had data available for review (61.5% of those enrolled in the residency program). In most skill areas in the Four Habits model, residents performed at least as well using the EHR and were statistically better in six of 23 skills areas (p<0.05). The overall average communication score was better when using an EHR: mean difference 0.254 (95% CI 0.05 to 0.45), p = 0.012, Cohen's d of 0.47 (a moderate effect). Residents scoring poorly (>3 average score) with paper methods (n = 8) had clinically important improvement when using the EHR.

Limitations This study was conducted in first-year residents in a training environment using simulated patients at a single institution.

Conclusions Use of an EHR on a laptop computer appears to improve the ability of first-year residents to communicate with patients relative to using a paper chart.

The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To determine whether the patient-clinician relationship has a beneficial effect on either objective or validated subjective healthcare outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Electronic databases EMBASE and MEDLINE and the reference sections of previous reviews.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Included studies were randomized controlled trials (RCTs) in adult patients in which the patient-clinician relationship was systematically manipulated and healthcare outcomes were either objective (e.g., blood pressure) or validated subjective measures (e.g., pain scores). Studies were excluded if the encounter was a routine physical, or a mental health or substance abuse visit; if the outcome was an intermediate outcome such as patient satisfaction or adherence to treatment; if the patient-clinician relationship was manipulated solely by intervening with patients; or if the duration of the clinical encounter was unequal across conditions.

RESULTS

Thirteen RCTs met eligibility criteria. Observed effect sizes for the individual studies ranged from d = -.23 to .66. Using a random-effects model, the estimate of the overall effect size was small (d = .11), but statistically significant (p = .02).

CONCLUSIONS

This systematic review and meta-analysis of RCTs suggests that the patient-clinician relationship has a small, but statistically significant effect on healthcare outcomes. Given that relatively few RCTs met our eligibility criteria, and that the majority of these trials were not specifically designed to test the effect of the patient-clinician relationship on healthcare outcomes, we conclude with a call for more research on this important topic.

The impact of facecards on patients' knowledge, satisfaction, trust, and agreement with hospital physicians: a pilot study

BACKGROUND

Simple interventions such as facecards can improve patients' knowledge of names and roles of hospital physicians, but the effect on other aspects of the patient-physician relationship is not clear.

OBJECTIVE

To pilot an intervention to improve familiarity with physicians and assess its potential to improve patients' satisfaction, trust, and agreement with physicians.

DESIGN

Cluster randomized controlled trial assessing the impact of physician facecards. Physician facecards included pictures of physicians and descriptions of their roles. We performed structured interviews of randomly selected patients to assess outcomes.

SETTING

One of 2 similar hospitalist units and 1 of 2 teaching-service units in a large teaching hospital were randomly selected to implement the intervention.

MEASUREMENTS

Satisfaction with physician communication and overall hospital care was assessed using the Hospital Consumer Assessment of Healthcare Providers and Systems. Trust and agreement were each assessed through instruments used in prior research.

RESULTS

Overall, 138 patients completed interviews, with no differences in age, sex, or race between those receiving facecards and those not. More patients who received facecards correctly identified ≥1 hospital physician (89.1% vs 51.1%; P < 0.01) and their role (67.4% vs 16.3%; P < 0.01) than patients who had not received facecards. Patients had high baseline levels of satisfaction, trust, and agreement with hospital physicians, and we found no significant differences with the use of facecards.

CONCLUSIONS

Physician facecards improved patients' knowledge of the names and roles of hospital physicians. Larger studies are needed to assess the impact on satisfaction, trust, and agreement with physicians.

Supporting self-management of obesity using a novel game architecture

Obesity has commonly been addressed using a 'one size fits all' approach centred on a combination of diet and exercise. This has not succeeded in halting the obesity epidemic, as two-thirds of American adults are now obese or overweight. Practitioners are increasingly highlighting that one's weight is shaped by myriad factors, suggesting that interventions should be tailored to the specific needs of individuals. Health games have potential to provide such tailored approach. However, they currently tend to focus on communicating and/or reinforcing knowledge, in order to suscitate learning in the participants. We argue that it would be equally, if not more valuable, that games learn from participants using recommender systems. This would allow treatments to be comprehensive, as games can deduce from the participants' behaviour which factors seem to be most relevant to his or her weight and focus on them. We introduce a novel game architecture and discuss its implications on facilitating the self-management of obesity.

Triptan education and improving knowledge for optimal migraine treatment: an observational study

BACKGROUND

It is generally felt that patient education and patient knowledge regarding triptan use for acute migraine management are important for successful and safe treatment. It is unclear how knowledgeable triptan users are regarding their triptan, how much education occurs when triptans are prescribed, and the impact patient education has on actual patient knowledge regarding triptan use.

OBJECTIVE

The primary objective was to compare triptan users' self-perceived knowledge and actual knowledge about triptans in patients who report having received triptan education vs patients who report not having received triptan education.

METHODS

This was a multicenter prospective observational study of 207 migraine patients who were using triptans for abortive therapy and who were being evaluated as new patients at academic headache specialty clinics in the United States. Patients completed standardized questionnaires regarding their self-perceived knowledge about triptans, their actual knowledge regarding triptans, and the perceived education about the triptan that they had received at the time of prescription.

RESULTS

Although greater than 80% of the subjects reported receiving education about when to take the triptan and the number of doses they could take for headache, only 71.5% reported receiving education about triptan side effects, 64% for the number of triptan doses they could take each week/month, 64% for taking other medications with the triptan, and 49% for medical contraindications to triptan use. Compared with subjects who did not recall receiving education about when to take their triptan, subjects who recalled such education had a statistically significant greater actual knowledge for taking the triptan immediately after a headache begins (91% vs 77%, P = .049; confidence interval [CI]: 0.00-0.33), treating when pain is mild (75% vs 50%, P = .009; CI: 0.04-0.45), understanding that they do not need to fail treatment with over-the-counter medications before taking a triptan (74% vs 42%, P = .001; CI: 0.11-0.51), and recognizing that coronary artery disease is a contraindication to triptan use (40% vs 19%, P = .001; CI: 0.09-0.34).

CONCLUSION

This study provides evidence that patients who recall having received education at the time of triptan prescribing have greater knowledge regarding optimal triptan use. Triptan users who recalled having received this education had greater recognition of the importance of taking the triptan immediately at the onset of a headache, treating when pain is mild, not needing to fail treatment with over-the-counter medications before taking a triptan, and understanding that coronary artery disease is a contraindication to triptan use.

Physician communication behaviors from the perspective of adult HIV patients in Kenya

OBJECTIVE

We describe perceived physician communication behaviors and its association with adherence to care, among HIV patients in Kenya.

DESIGN

This cross-sectional study was conducted between July and August 2011.

SETTING

The study was conducted in three adult HIV clinics within the Academic Model Providing Healthcare program in western Kenya.

PARTICIPANTS

HIV adult patients.

MAIN OUTCOME MEASURES

Patient's predisposition to attend clinic, missed appointment and missed combined antiretroviral therapy (cART) medication.

RESULTS

A total of 400 patients were enrolled and participated in the study; the median age was 38 years (IQR = 33-44) and 56.5% were female. Patients perceived physicians engaged in a high number of communication behaviors (mean = 3.80, range 1-5). A higher perceived general health status (P = 0.01), shorter distance to the health facility (P = 0.03) and lesser time spent at the health facility (P = 0.02) were associated with a higher number of perceived physician communication behaviors. Physician-patient relationship factors were not associated with physician communication behaviors. In addition, a higher number of perceived physician communication behaviors was associated with a very high likelihood of patients' attending the next HIV clinic [adjusted odds ratio (AOR): 1.89, 95% confidence interval (CI): 1.49-2.40], a lower likelihood of patients' missing an appointment (AOR: 0.75, 95% CI: 0.61-0.92) and missing cART medication (AOR: 0.68, 95% CI: 0.52-0.87).

CONCLUSION

Patients' perception of physician communication behaviors was found to be associated with their adherence to HIV care.