1
|
Auschra C, Möller J, Berthod O, Mazheika Y, Borusiak P. [Communicating test results in a comprehensible manner: A randomized controlled trial of word usage in doctor-patient communication]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2020; 156-157:40-49. [PMID: 32900672 DOI: 10.1016/j.zefq.2020.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Doctor-patient communication is one of the hallmarks of good medical treatment. Mutual understanding is of foremost importance, in particular when communicating non-numerical test results. METHODS Using a two-step approach, this study analyses the influence of wording on the correct understanding of medical test results by people without a medical background. In a first step, a qualitative analysis of physicians' letters helped to identify adjectives that are frequently used to communicate test results. In a second step, a parallel randomised study was conducted to test the comprehensibility of particularly relevant adjectives, combining the written communication of test results with a subsequent survey. 1,131 participants, representing the population of Germany with regard to age, gender, and educational level, were recruited via an online platform. The participants read a scenario involving the communication of the results of a breath test, whereby non-numerical test results were described as being either "positive" vs. "negative" (n=566) or "abnormal" vs. "normal" (n=565). Participant assignment to one of these groups took place in a randomised way. The outcomes measured included the subjective and objective understanding of test results as well as the participants' subjective comprehension of the physician communicating with them. RESULTS People without a medical background can understand medical test results more readily when neutral, descriptive adjectives are used rather than adjectives considered as being judgmental in everyday language. 54 % of the participants who read test results using the adjectives "positive" vs. "negative" and 65 % of the participants who read test results using the adjectives "abnormal" vs. "normal", respectively, understood the results correctly. This relative difference of 20.4 % in the number of participants with a correct understanding is statistically significant (Chi square=13.061; p=0.001). There was also a considerable difference in the subjective understanding (means of 5.04 of "positive" vs. "negative" and 5.47 for "abnormal" vs. "normal" on a 7-point Likert scale; absolute mean difference 0.42 [95 % CI: 0.20; 0.64]) as well as in the subjective comprehension of the communicating physician (means of 4.49 for "positive" vs. "negative" and 4.95 for "abnormal" vs. "normal" on a 7-point Likert scale; absolute mean difference 0.45 [95% CI: 0.23; 0.67]). A higher level of comprehension for the words "abnormal" vs. "normal" was consistent across the overall sample. It is mainly people with no school-leaving certificate and a lower educational level who benefit from the changed wording. CONCLUSIONS In the process of communicating non-numerical medical test results, people without a medical background understand neutral, descriptive adjectives better than adjectives that are considered judgmental in everyday usage. A corresponding change of written and oral communication can easily be implemented by medical experts in their everyday practice and particularly supports a population group that already suffers disadvantages in the medical system.
Collapse
Affiliation(s)
- Carolin Auschra
- Freie Universität Berlin, Fachbereich Wirtschaftswissenschaft, Management-Department, Berlin, Deutschland
| | - Jana Möller
- Freie Universität Berlin, Fachbereich Wirtschaftswissenschaft, Marketing-Department, Berlin, Deutschland
| | - Olivier Berthod
- Jacobs University Bremen, Department of Business & Economics, Bremen, Deutschland
| | | | - Peter Borusiak
- Wagener-Stiftung für Sozialpädiatrie, Bremen, Deutschland; Universität Witten/Herdecke, Fakultät für Gesundheit, Department für Humanmedizin, Witten, Deutschland.
| |
Collapse
|
2
|
Holloway KL, Sajjad MA, Mohebbi M, Kotowicz MA, Livingston PM, Khasraw M, Hakkennes S, Dunning TL, Brumby S, Page RS, Pedler D, Sutherland A, Venkatesh S, Brennan-Olsen SL, Williams LJ, Pasco JA. The epidemiology of hip fractures across western Victoria, Australia. Bone 2018; 108:1-9. [PMID: 29229437 DOI: 10.1016/j.bone.2017.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 12/01/2017] [Accepted: 12/07/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hip fractures are associated with considerable morbidity and mortality. Hip fracture incidence varies across different levels of accessibility/remoteness and socioeconomic status (SES). As part of the Ageing, Chronic Disease and Injury Study, we aimed to map the pattern of hip fractures across the western region of the Australian state of Victoria, which contains a range of remoteness levels and SES. METHODS Data on hip fractures resulting in hospital admission were extracted from the Victorian Admitted Episodes Dataset (VAED) for men and women aged 40+years during 2010-2013 inclusive. An age-adjusted incidence rate (per 10,000population/year) was calculated for the entire region. Crude incidence rates and length of acute care hospital stay (excluding rehabilitation) were calculated for each Local Government Area (LGA). The impact of aggregated age, accessibility/remoteness index of Australia (ARIA) and SES on hip fracture rates aggregated across LGAs was determined using Poisson regression. RESULTS For men, the age-standardised rate of hospitalisations for hip fracture across the whole region was 19.2 per 10,000population/year (95%CI 18.0-20.4) and for women, 40.0 (95%CI 38.3-41.7). The highest incidence rates for both sexes occurred in the less accessible LGAs of Yarriambiack and Hindmarsh, as well as the LGA with the lowest SES, Central Goldfields. In both sexes, approximately two thirds of individuals were discharged from acute hospital care within 14days. Increasing age, higher remoteness and lower SES were all associated with higher hip fracture rates. CONCLUSION Crude incidence rates varied by location. Given that a high proportion of patients had acute hospital care of ≤14days, and accessibility and SES were associated with hip fracture rates, these results can inform policy and provide a model for other groups to conduct similar research in their local environment.
Collapse
Affiliation(s)
| | | | | | - Mark A Kotowicz
- Deakin University, School of Medicine, Geelong, Australia; Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia; University Hospital Geelong, Barwon Health, Geelong, Australia
| | | | | | | | | | - Susan Brumby
- Deakin University, School of Medicine, Geelong, Australia; National Centre for Farmer Health, Western District Health Service, Hamilton, Australia
| | - Richard S Page
- Deakin University, School of Medicine, Geelong, Australia; University Hospital Geelong, Barwon Health, Geelong, Australia; Barwon Centre of Orthopaedic Research and Education (B-CORE), St John of God Hospital and Barwon Health, Geelong, Australia
| | - Daryl Pedler
- Deakin University, School of Medicine, Geelong, Australia
| | - Alasdair Sutherland
- Deakin University, School of Medicine, Geelong, Australia; South West Healthcare, Warrnambool, Australia
| | | | - Sharon L Brennan-Olsen
- Deakin University, School of Medicine, Geelong, Australia; Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne, Australia; The Institute for Health and Ageing, Australian Catholic University, Melbourne, Australia
| | | | - Julie A Pasco
- Deakin University, School of Medicine, Geelong, Australia; Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia; University Hospital Geelong, Barwon Health, Geelong, Australia
| |
Collapse
|
3
|
Roblin DW, Cram P, Lou Y, Edmonds SW, Hall SF, Jones MP, Saag KG, Wright NC, Wolinsky FD. Diet and exercise changes following bone densitometry in the Patient Activation After DXA Result Notification (PAADRN) study. Arch Osteoporos 2018; 13:4. [PMID: 29307094 PMCID: PMC7409367 DOI: 10.1007/s11657-017-0402-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 11/13/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED Calcium and vitamin D intake and exercise are suboptimal among older adults. Following bone densitometry, a letter communicating individualized fracture risk accompanied by an educational brochure improved participants' lifestyle-but no more than existing communication strategies-over 52 weeks. Simple communication strategies are insufficient for achieving optimal levels of bone health behaviors. PURPOSE The Patient Activation After DXA Result Notification (PAADRN) study was designed to evaluate whether a letter with individualized fracture risk and an educational brochure mailed to patients soon after their DXA might improve bone health behaviors (daily calcium intake, vitamin D supplementation, and weekly exercise sessions) compared to slower, less individualized communication characterizing usual care. METHODS Participants ≥ 50 years were recruited, at three sites, following their DXA and randomized with 1:1 allocation to intervention and control (usual care only) groups. Data were collected at enrollment interview and by phone survey at 12 and 52 weeks thereafter. Intention-to-treat analyses were conducted on 7749 of the 20,397 eligible participants who enrolled. Changes in bone health behaviors were compared within and between study groups. Average treatment effects and heterogeneity of treatment effects were estimated with multivariable linear and logistic regression models. RESULTS In unadjusted analyses, calcium intake, vitamin D supplementation, and weekly exercise sessions increased significantly over 52 weeks within both the intervention and control groups (all p < 0.001). In unadjusted analyses and multivariable models, increases in each behavior did not significantly differ between the intervention and control groups. Intervention group participants with a > 20% 10-year fracture risk at enrollment did, however, have a significantly greater increase in calcium intake compared to other study participants (p = 0.031). CONCLUSIONS Bone health behaviors improved, on average, over 52 weeks among all participants following a DXA. Receipt of the PAADRN letter and educational brochure did not directly improve bone health behaviors compared to usual care. TRIAL REGISTRATION The Patient Activation after DXA Result Notification (PAADRN) Study is registered at ClinicalTrials.Gov: NCT01507662, https://clinicaltrials.gov/ct2/show/NCT01507662.
Collapse
Affiliation(s)
- Douglas W. Roblin
- Mid-Atlantic Permanente Research Institute, 2101 East Jefferson St., 3 West, Rockville, MD 20852, USA,Center for Clinical and Outcomes Research, Kaiser Permanente, Atlanta, GA, USA
| | - Peter Cram
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA,Faculty of Medicine, University of Toronto, Toronto, Canada,Division of General Internal Medicine and Geriatrics, Mt. Sinai/UHN Hospitals, Toronto, Canada
| | - Yiyue Lou
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Stephanie W. Edmonds
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA,College of Nursing, University of Iowa, Iowa City, IA, USA
| | - Sylvie F. Hall
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | - Michael P. Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Kenneth G. Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nicole C. Wright
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA,Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Fredric D. Wolinsky
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA,College of Nursing, University of Iowa, Iowa City, IA, USA,Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
| | | |
Collapse
|
4
|
Wolinsky FD, Hall SF, Lou Y, Edmonds SW, Saag KG, Roblin DW, Wright NC, Jones MP, Cram P, Curtis JR, Morgan SL, Schlechte JA, Williams JH, Zelman DJ. The cost of a patient activation intervention for achieving successful outcomes: results from the PAADRN randomized controlled trial. Osteoporos Int 2017. [PMID: 28620779 PMCID: PMC5670012 DOI: 10.1007/s00198-017-4113-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
UNLABELLED In a large, pragmatic clinical trial, we calculated the costs of achieving four successful patient-centered outcomes using a tailored patient activation DXA result letter accompanied by a bone health brochure. The cost to achieve one successful outcome (e.g., a 0.5 standard deviation improvement in care satisfaction) ranged from $127.41 to $222.75. INTRODUCTION Pragmatic randomized controlled trials (RCTs) should focus on patient-centered outcomes and report the costs for achieving those outcomes. We calculated per person incremental intervention costs, the number-needed-to-treat (NNT), and incremental per patient costs (cost per NNT) for four patient-centered outcomes in a direct-to-patient bone healthcare intervention. METHODS The Patient Activation after DXA Result Notification (PAADRN) pragmatic RCT enrolled 7749 patients presenting for DXA at three health centers between February 2012 and August 2014. Interviews occurred at baseline and 52 weeks post-DXA. Intervention subjects received an individually tailored DXA result letter accompanied by an educational bone health brochure 4 weeks post-DXA, while the usual care subjects did not. Outcomes focused on patients (a) correctly identifying their results, (b) contacting their providers, (c) discussing their results with their providers, and (d) satisfaction with their bone healthcare. NNTs were determined using intention-to-treat linear probability models, per person incremental intervention costs were calculated, and costs per NNT were computed. RESULTS Mean age was 66.6 years old, 83.8% were women, and 75.3% were non-Hispanic whites. The incremental per patient cost (costs per NNT) to increase the ability of a patient to (a) correctly identify their DXA result was $171.07; (b) contact their provider about their DXA result was $222.75; (c) discuss their DXA result with their provider was $193.55; and (d) achieve a 0.5 SD improvement in satisfaction with their bone healthcare was $127.41. CONCLUSION An individually tailored DXA result letter accompanied by an educational brochure can improve four patient-centered outcomes at a modest cost. TRIAL REGISTRATION clinicaltrials.gov identifier NCT01507662.
Collapse
Affiliation(s)
- F D Wolinsky
- Department of Health Management and Policy, University of Iowa, 145 North Riverside Drive, CPHB N211, Iowa City, IA, 52242, USA.
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
- College of Nursing, University of Iowa, Iowa City, IA, USA.
| | - S F Hall
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Y Lou
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - S W Edmonds
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
- CADRE, Iowa City VA Healthcare System, Iowa City, IA, USA
| | - K G Saag
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
| | - D W Roblin
- Kaiser Permanente, Atlanta, GA, USA
- Department of Health Management and Policy, Georgia State University, Atlanta, GA, USA
| | - N C Wright
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
- Department of Epidemiology, University of Alabama, Birmingham, AL, USA
| | - M P Jones
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - P Cram
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine and Geriatrics, Mt. Sinai/UHN Hospitals, Toronto, Canada
| | | | | | | | | | | | | |
Collapse
|
5
|
Wolinsky FD, Lou Y, Edmonds SW, Hall SF, Jones MP, Wright NC, Saag KG, Cram P, Roblin DW. Activating Patients With a Tailored Bone Density Test Results Letter and Educational Brochure: the PAADRN Randomized Controlled Trial. J Clin Densitom 2017; 20:464-471. [PMID: 27647261 PMCID: PMC5354993 DOI: 10.1016/j.jocd.2016.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/23/2016] [Indexed: 11/25/2022]
Abstract
In cross-sectional studies, patient activation has been associated with better health behaviors, health outcomes, and health-care experiences. Moreover, tailored interventions have led to clinically meaningful improvements in patient activation, as well as health outcomes over time. We tested whether a tailored patient-activation letter communicating bone mineral density (BMD) test results plus an educational brochure improved patient activation scores and levels at 12 and 52 wk post-baseline as the mechanism leading to enhanced bone healthcare. In a randomized, controlled, double-blinded, multicenter pragmatic clinical trial, we randomized 7749 patients ≥50 yr old and presenting for BMD testing at 3 medical centers in the United States between February 2012 and August 2014. The outcome measures were patient activation scores and levels based on 6 items taken from the Patient Activation Measure (PAM) that were administered at the baseline, 12-wk, and 52-wk follow-up interviews. Mean age was 66.6 yr, 83.8% were women, and 75.3% were Non-Hispanic-Whites. Overall, PAM activation scores improved from 58.1 at baseline to 76.4 by 12 wk (p < 0.001) and to 77.2 (p = 0.002) by 52 wk post-baseline. These improvements, however, were not significantly different between the intervention and usual care groups (18.7 vs 18.1, p = 0.176, at 12 wk) in intention-to-treat analyses. PAM activation scores and levels substantially improved at 12 wk and 52 wk, but no differences were observed in these improvements between the intervention and usual care groups. These null findings may have occurred because the tailoring focused on the patient's BMD and fracture risk results, rather than on the patient's BMD and fracture risk results as well as the patient's baseline PAM activation scores or levels.
Collapse
Affiliation(s)
- Fredric D Wolinsky
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA; Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; University of Iowa College of Nursing, Iowa City, IA, USA.
| | - Yiyue Lou
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Stephanie W Edmonds
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; University of Iowa College of Nursing, Iowa City, IA, USA
| | - Sylvie F Hall
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michael P Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Nicole C Wright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA; Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter Cram
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Department of Medicine, University of Toronto, Toronto, Canada; Division of General Internal Medicine, Mt. Sinai/UHN Hospitals, Toronto, Canada
| | - Douglas W Roblin
- Kaiser Permanente of Georgia, Atlanta, GA, USA; School of Public Health, Georgia State University, Atlanta, GA, USA
| |
Collapse
|
6
|
Wolinsky FD, Lou Y, Edmonds SW, Saag KG, Roblin DW, Wright NC, Jones MP, Cram P. The effects of a patient activation intervention on smoking and excessive drinking cessations: results from the PAADRN randomized controlled trial. Osteoporos Int 2017; 28:3055-3060. [PMID: 28573377 PMCID: PMC5670005 DOI: 10.1007/s00198-017-4101-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 05/21/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED Patients may exhibit risky bone health behaviors. In a large pragmatic clinical trial, we tested whether a tailored patient activation DXA result letter accompanied by a bone health brochure led to smoking and excessive drinking cessations. The intervention did not, however, alter these risky bone health behaviors. INTRODUCTION Besides dual-energy x-ray absorptiometry (DXA) screening and pharmacotherapy when indicated, beneficial bone health behaviors including proper calcium and vitamin D intake and weight-bearing and muscle-strengthening exercise should be encouraged. Similarly, risky bone health behaviors like smoking and excessive drinking should be discouraged. We examined whether a direct-to-patient activation intervention led to smoking and excessive drinking cessations. METHODS The Patient Activation after DXA Result Notification (PAADRN) pragmatic clinical trial enrolled 7749 patients between February 2012 and August 2014. Interviews occurred at baseline and 12 and 52 weeks later. Intervention subjects were mailed an individually tailored DXA results letter accompanied by a bone health educational brochure 4 weeks post-DXA. Usual care subjects were not sent these materials. Smoking and excessive drinking were assessed by self-report at each interview. Intention-to-treat linear probability models were used. RESULTS Mean age was 66.6 years, 83.8% were women, and 75.3% were Non-Hispanic-Whites. Smoking was reported at baseline by 7.6% of the intervention group vs. 7.7% of the usual care group (p = 0.873). Excessive drinking was reported at baseline by 6.5% of the intervention group vs. 6.5% of the usual care group (p = 0.968). Intention-to-treat analyses indicated no significant differences between the intervention vs. usual care groups at either 12 or 52 weeks post-DXA (all p values ≥ 0.346). CONCLUSION An individually tailored DXA result letter accompanied by an educational brochure did not lead to smoking or excessive drinking cessations in patients who received DXA. TRIAL REGISTRATION clinicaltrials.gov identifier NCT01507662.
Collapse
Affiliation(s)
- F D Wolinsky
- Department of Health Management and Policy, University of Iowa, 145 North Riverside Drive, CPHB N211, Iowa City, Iowa City, IA, 52242, USA.
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
- College of Nursing, University of Iowa, Iowa City, IA, USA.
| | - Y Lou
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - S W Edmonds
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
- CADRE, Iowa City VA Healthcare System, Iowa City, IA, USA
| | - K G Saag
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
| | - D W Roblin
- Kaiser Permanente, Atlanta, GA, USA
- Department of Health Management and Policy, Georgia State University, Atlanta, GA, USA
| | - N C Wright
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
- Department of Epidemiology, University of Alabama, Birmingham, AL, USA
| | - M P Jones
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - P Cram
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine and Geriatrics, Mt. Sinai/UHN Hospitals, Toronto, Canada
| | | |
Collapse
|
7
|
Roblin DW, Zelman D, Plummer S, Robinson BE, Lou Y, Edmonds SW, Wolinsky FD, Saag KG, Cram P. Evaluation of a "Just-in-Time" Nurse Consultation on Bone Health: A Pilot Randomized Controlled Trial. Perm J 2017; 21:16-112. [PMID: 28746019 DOI: 10.7812/tpp/16-112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Evidence is inconclusive whether a nurse consultation can improve osteoporosis-related patient outcomes. OBJECTIVE To evaluate whether a nurse consultation immediately after dual-energy x-ray absorptiometry (DXA) produced better osteoporosis-related outcomes than a simple intervention to activate adults in good bone health practices or usual care. DESIGN Pilot randomized controlled trial, conducted within the larger Patient Activation After DXA Result Notification (PAADRN) trial (NCT01507662). After DXA, consenting adults age 50 years or older were randomly assigned to 3 groups: nurse consultation, PAADRN intervention (mailed letter with individualized fracture risk and an educational brochure), or usual care (control). Nurse consultation included reviewing DXA results, counseling on bone health, and ordering needed follow-up tests or physician referrals. MAIN OUTCOME MEASURES Change from baseline to 52 weeks in participant-reported osteoporosis-related pharmacotherapy, lifestyle, activation and self-efficacy, and osteoporosis care satisfaction. RESULTS Nurse consultation participants (n = 104) reported 52-week improvements in strengthening and weight-bearing exercise (p = 0.09), calcium intake (p < 0.01), osteoporosis knowledge (p = 0.04), activation (p < 0.01), dietary self-efficacy (p = 0.06), and osteoporosis care satisfaction (p < 0.01). Compared with PAADRN intervention participants (n = 39), nurse consultation participants had improved dietary self-efficacy (p = 0.07) and osteoporosis care satisfaction (p = 0.05). No significant improvements in osteoporosis-related outcomes were achieved vs PAADRN controls (n = 70). CONCLUSION "Just-in-time" nurse consultation yielded a few improvements over 52 weeks in osteoporosis-related outcomes; however, most changes were not different from those obtained through the lower-cost PAADRN intervention or usual care.
Collapse
Affiliation(s)
- Douglas W Roblin
- Professor of Health Management and Policy at Georgia State University School of Public Health and a Consulting Senior Research Scientist at the Center for Clinical and Outcomes Research in Atlanta.
| | - David Zelman
- At the time of this study was a Rheumatologist with The Southeast Permanente Medical Group, Inc, in Atlanta, GA.
| | - Sally Plummer
- At the time of this study was a Consulting Nurse Educator at the Center for Clinical and Outcomes Research in Atlanta, GA.
| | - Brandi E Robinson
- Senior Project Manager at the Center for Clinical and Outcomes Research in Atlanta, GA.
| | - Yiyue Lou
- Biostatistician in the College of Public Health at the University of Iowa in Iowa City.
| | - Stephanie W Edmonds
- Graduate Research Assistant in Internal Medicine and a Doctoral Candidate in the College of Nursing at the University of Iowa in Iowa City.
| | - Fredric D Wolinsky
- The John W Colloton Chair in the College of Public Health at the University of Iowa in Iowa City.
| | - Kenneth G Saag
- Professor of Medicine in the Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham.
| | - Peter Cram
- Professor of Internal Medicine in the Division of General Internal Medicine at the University of Toronto and the Director of General Internal Medicine at the University Health Network and Mount Sinai Hospital in Ontario, Canada.
| |
Collapse
|
8
|
Cram P, Saag KG, Lou Y, Edmonds SW, Hall SF, Roblin DW, Wright NC, Jones MP, Wolinsky FD. Racial Differences and Disparities in Osteoporosis-related Bone Health: Results From the PAADRN Randomized Controlled Trial. Med Care 2017; 55:561-568. [PMID: 28288074 PMCID: PMC5432397 DOI: 10.1097/mlr.0000000000000718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Determining whether observed differences in health care can be called disparities requires persistence of differences after adjustment for relevant patient, provider, and health system factors. We examined whether providing dual-energy x-ray absorptiometry (DXA) test results directly to patients might reduce or eliminate racial differences in osteoporosis-related health care. DESIGN, SUBJECTS, AND MEASURES We analyzed data from 3484 white and 1041 black women who underwent DXA testing at 2 health systems participating in the Patient Activation after DXA Result Notification (PAADRN) pragmatic clinical trial (ClinicalTrials.gov NCT-01507662) between February 2012 and August 2014. We examined 7 outcomes related to bone health at 12 weeks and 52 weeks post-DXA: (1) whether the patient correctly identified their DXA baseline results; (2) whether the patient was on guideline-concordant osteoporosis pharmacotherapy; (3) osteoporosis-related satisfaction; (4) osteoporosis knowledge; (5 and 6) osteoporosis self-efficacy for exercise and for diet; and (7) patient activation. We examined whether unadjusted differences in outcomes between whites and blacks persisted after adjusting for patient, provider, and health system factors. RESULTS Mean age was 66.5 years and 29% were black. At baseline black women had less education, poorer health status, and were less likely to report a history of osteoporosis (P<0.001 for all). In unadjusted analyses black women were less likely to correctly identify their actual DXA results, more likely to be on guideline-concordant therapy, and had similar patient activation. After adjustment for patient demographics, baseline health status and other factors, black women were still less likely to know their actual DXA result and less likely to be on guideline-concordant therapy, but black women had greater patient activation. CONCLUSIONS Adjustment for patient and provider level factors can change how racial differences are viewed, unmasking new disparities, and providing explanations for others.
Collapse
Affiliation(s)
- Peter Cram
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine and Geriatrics, Mt. Sinai/UHN Hospitals, Toronto, Canada
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Kenneth G. Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - Yiyue Lou
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA
| | - Stephanie W. Edmonds
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
- University of Iowa College of Nursing, Iowa City, IA
- CADRE, Iowa City VA Healthcare System, Iowa City, IA
| | - Sylvie F. Hall
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
| | - Douglas W. Roblin
- Kaiser Permanente, Atlanta, GA
- School of Public Health, Georgia State University, Atlanta, GA
| | - Nicole C. Wright
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Michael P. Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA
| | - Fredric D. Wolinsky
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
- University of Iowa College of Nursing, Iowa City, IA
| |
Collapse
|
9
|
Danila MI, Outman RC, Rahn EJ, Mudano AS, Thomas TF, Redden DT, Allison JJ, Anderson FA, Anderson JP, Cram PM, Curtis JR, Fraenkel L, Greenspan SL, LaCroix AZ, Majumdar SR, Miller MJ, Nieves JW, Safford MM, Silverman SL, Siris ES, Solomon DH, Warriner AH, Watts NB, Yood RA, Saag KG. A multi-modal intervention for Activating Patients at Risk for Osteoporosis (APROPOS): Rationale, design, and uptake of online study intervention material. Contemp Clin Trials Commun 2016; 4:14-24. [PMID: 27453960 PMCID: PMC4955389 DOI: 10.1016/j.conctc.2016.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/09/2016] [Accepted: 06/22/2016] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To develop an innovative and effective educational intervention to inform patients about the need for osteoporosis treatment and to determine factors associated with its online uptake. METHODS Postmenopausal women with a prior fracture and not currently using osteoporosis therapy were eligible to be included in the Activating Patients at Risk for OsteoPOroSis (APROPOS). Four nominal groups with a total of 18 racially/ethnically diverse women identified osteoporosis treatment barriers. We used the Information, Motivation, Behavior Skills conceptual model to develop a direct-to-patient intervention to mitigate potentially modifiable barriers to osteoporosis therapy. The intervention included videos tailored by participants' race/ethnicity and their survey responses: ranked barriers to osteoporosis treatment, deduced barriers to treatment, readiness to behavior change, and osteoporosis treatment history. Videos consisted of "storytelling" narratives, based on osteoporosis patient experiences and portrayed by actresses of patient-identified race/ethnicity. We also delivered personalized brief phone calls followed by an interactive voice-response phone messages aimed to promote uptake of the videos. RESULTS To address the factors associated with online intervention uptake, we focused on participants assigned to the intervention arm (n = 1342). These participants were 92.9% Caucasian, with a mean (SD) age 74.9 (8.0) years and the majority (77.7%) had some college education. Preference for natural treatments was the barrier ranked #1 by most (n = 130; 27%), while concern about osteonecrosis of the jaw was the most frequently reported barrier (at any level; n = 322; 67%). Overall, 28.1% (n = 377) of participants in the intervention group accessed the videos online. After adjusting for relevant covariates, the participants who provided an email address had 6.07 (95% CI 4.53-8.14) higher adjusted odds of accessing their online videos compared to those who did not. CONCLUSION We developed and implemented a novel tailored multi-modal intervention to improve initiation of osteoporosis therapy. An email address provided on the survey was the most important factor independently associated with accessing the intervention online. The design and uptake of this intervention may have implications for future studies in osteoporosis or other chronic diseases.
Collapse
Affiliation(s)
| | - Ryan C. Outman
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Amy S. Mudano
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Jeroan J. Allison
- University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Fred A. Anderson
- University of Massachusetts Medical School, Worcester, MA 01655, USA
| | | | | | | | | | | | - Andrea Z. LaCroix
- Group Health Cooperative, Seattle, WA 98112, USA
- University of California San Diego, La Jolla, CA 92093, USA
| | | | - Michael J. Miller
- The University of Oklahoma Health Sciences Center, Tulsa, OK 74135, USA
| | | | - Monika M. Safford
- University of Alabama at Birmingham, Birmingham, AL, USA
- Weill Cornell Medical Center, New York, NY 10065, USA
| | | | - Ethel S. Siris
- Columbia University Medical Center, New York, NY 10032, USA
| | | | | | - Nelson B. Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH 45236, USA
| | | | | |
Collapse
|
10
|
Cram P, Wolinsky FD, Lou Y, Edmonds SW, Hall SF, Roblin DW, Wright NC, Jones MP, Saag KG. Patient-activation and guideline-concordant pharmacological treatment after bone density testing: the PAADRN randomized controlled trial. Osteoporos Int 2016; 27:3513-3524. [PMID: 27363400 PMCID: PMC5572571 DOI: 10.1007/s00198-016-3681-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 06/19/2016] [Indexed: 10/21/2022]
Abstract
Patients often do not know or understand their bone density test results, and pharmacological treatment rates are low. In a clinical trial of 7749 patients, we used a tailored patient-activation result letter accompanied by a bone health brochure to improve appropriate pharmacological treatment. Treatment rates, however, did not improve. INTRODUCTION Patients often do not know or understand their dual-energy x-ray absorptiometry (DXA) test results, which may lead to suboptimal care. We tested whether usual care augmented by a tailored patient-activation DXA result letter accompanied by an educational brochure would improve guideline-concordant pharmacological treatment compared to usual care only. METHODS We conducted a randomized, controlled, double-blinded, pragmatic clinical trial at three health care centers in the USA. We randomized 7749 patients ≥50 years old and presenting for DXA between February 2012 and August 2014. The primary clinical endpoint at 12 and 52 weeks post-DXA was receiving guideline-concordant pharmacological treatment. We also examined four of the steps along the pathway from DXA testing to that clinical endpoint, including (1) receiving and (2) understanding their DXA results and (3) having subsequent contact with their provider and (4) discussing their results and options. RESULTS Mean age was 66.6 years, 83.8 % were women, and 75.3 % were non-Hispanic whites. Intention-to-treat analyses revealed that guideline-concordant pharmacological treatment was not improved at either 12 weeks (65.1 vs. 64.3 %, p = 0.506) or 52 weeks (65.2 vs. 63.8 %, p = 0.250) post-DXA, even though patients in the intervention group were more likely (all p < 0.001) to recall receiving their DXA results letter at 12 weeks, correctly identify their results at 12 and 52 weeks, have contact with their provider at 52 weeks, and have discussed their results with their provider at 12 and 52 weeks. CONCLUSION A tailored DXA result letter and educational brochure failed to improve guideline-concordant care in patients who received DXA.
Collapse
Affiliation(s)
- P Cram
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine, Mt. Sinai/UHN Hospitals, Toronto, Canada
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - F D Wolinsky
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA.
- University of Iowa College of Nursing, Iowa City, IA, USA.
- The University of Iowa, 145 North Riverside Drive, CPHB N211, Iowa City, IA, 52242, USA.
| | - Y Lou
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - S W Edmonds
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- University of Iowa College of Nursing, Iowa City, IA, USA
| | - S F Hall
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - D W Roblin
- Kaiser Permanente, Atlanta, GA, 30305, USA
- School of Public Health, Georgia State University, Atlanta, GA, USA
| | - N C Wright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M P Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - K G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
11
|
Edmonds SW, Cram P, Lou Y, Jones MP, Roblin DW, Saag KG, Wright NC, Wolinsky FD. Effects of a DXA result letter on satisfaction, quality of life, and osteoporosis knowledge: a randomized controlled trial. BMC Musculoskelet Disord 2016; 17:369. [PMID: 27562713 PMCID: PMC5000520 DOI: 10.1186/s12891-016-1227-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 08/18/2016] [Indexed: 11/10/2022] Open
Abstract
Background Undiagnosed, or diagnosed and untreated osteoporosis (OP) increases the likelihood that falls result in hip fractures, decreased quality of life (QOL), and significant medical expenditures among older adults. We tested whether a tailored dual energy x-ray absorptiometry (DXA) test result letter and an accompanying educational bone-health brochure affected patient satisfaction, QOL, or OP knowledge. Methods The Patient Activation after DXA Result Notification (PAADRN) study was a double-blinded, pragmatic, randomized trial which enrolled patients from 2012 to 2014. We randomized 7,749 patients presenting for DXA at three health care institutions in the United States who were ≥ 50 years old and able to understand English. Intervention patients received a tailored letter four weeks after DXA containing their results, 10-year fracture risk, and a bone-health educational brochure. Control patients received the results of their DXA per the usual practices of their providers and institutions. Satisfaction with bone health care, QOL, and OP knowledge were assessed at baseline and 12- and 52-weeks after DXA. Intention-to-treat analyses used multiple imputation for missing data and random effects regression models to adjust for clustering within providers and covariates. Results At 12-weeks 6,728 (86.8 %) and at 52-weeks 6,103 participants (78.8 %) completed their follow-up interviews. The intervention group was more satisfied with their bone health care compared to the usual care group at both their 12- and 52-week follow-ups (standardized effect size = 0.28 at 12-weeks and 0.17 at 52-weeks, p < 0.001). There were no differences between the intervention and usual care groups in QOL or OP knowledge at either time point. Conclusions A tailored DXA result letter and bone-health educational brochure sent to patients improved patient satisfaction with bone-related health care. Trial registration Clinical Trials.gov Identifier: NCT01507662 First received: December 8, 2011.
Collapse
Affiliation(s)
- Stephanie W Edmonds
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, 5231 Westlawn, IA 52242, Iowa City, IA, USA. .,College of Nursing, University of Iowa, Iowa City, IA, USA.
| | - Peter Cram
- Department of Medicine, University of Toronto Division of General Internal Medicine, Toronto, ON, Canada.,University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Yiyue Lou
- College of Public Health, Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - Michael P Jones
- College of Public Health, Department of Biostatistics, University of Iowa, Iowa City, IA, USA.,Iowa City Veterans Affairs Health System, Iowa City, IA, USA
| | - Douglas W Roblin
- Kaiser Permanente, Atlanta, GA, USA.,School of Public Health, Department of Health Management and Policy, Georgia State University, Atlanta, GA, USA
| | - Kenneth G Saag
- Department of Internal Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nicole C Wright
- School of Public Health, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Fredric D Wolinsky
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, 5231 Westlawn, IA 52242, Iowa City, IA, USA.,College of Nursing, University of Iowa, Iowa City, IA, USA.,College of Public Health, Department of Health Management and Policy, University of Iowa, Iowa, IA, USA
| | | |
Collapse
|
12
|
Qu Y, Kang MY, Dong RP, Zhao JW. Correlations Between Abnormal Glucose Metabolism and Bone Mineral Density or Bone Metabolism. Med Sci Monit 2016; 22:824-32. [PMID: 26970713 PMCID: PMC4793637 DOI: 10.12659/msm.895387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background The aim of this meta-analysis was to explore the correlations of abnormal glucose metabolism (AGM) with bone mineral density (BMD) and bone metabolism. Material/Methods Relevant studies were identified using computerized and manual search strategies. The included studies were in strict accordance with inclusion and exclusion criteria. Statistical analyses were conducted with the Comprehensive Meta-analysis 2.0 (Biostat Inc., Englewood, NJ, USA). Results Our present meta-analysis initially searched 844 studies, and 7 studies were eventually incorporated in the present meta-analysis. These 7 cohort studies included 1123 subjects altogether (560 patients with AGM and 563 healthy controls). The results showed that bone mass index (BMI), insulin, and insulin resistance (IR) of patients with AGM were significantly higher than that of the population with normal glucose metabolism (BMI: SMD=1.658, 95% CI=0.663~2.654, P=0.001; insulin: SMD=0.544, 95% CI=0.030~1.058, P=0.038; IR: SMD=8.767, 95% CI=4.178~13.356, P<0.001). However, the results also indicated there was no obvious difference in osteocalcin (OC) and BMD in patients with AGM and the population with normal glucose metabolism (OC: SMD=0.293, 95% CI=−0.023~0.609, P=0.069; BMD: SMD=0.805, 95% CI=−0. 212~1.821, P=0.121). Conclusions Our meta-analysis results suggest that AGM might lead to increased BMI, insulin, and IR, while it has no significant correlation with BMD or bone metabolism.
Collapse
Affiliation(s)
- Yang Qu
- Department of Orthopedics, Second Hospital of Jilin University, Changchun, Jilin, China (mainland)
| | - Ming-Yang Kang
- Department of Orthopedics, Second Hospital of Jilin University, Changchun, Jilin, China (mainland)
| | - Rong-Peng Dong
- Department of Orthopedics, Second Hospital of Jilin University, Changchun, Jilin, China (mainland)
| | - Jian-Wu Zhao
- Department of Orthopedics, Second Hospital of Jilin University, Changchun, Jilin, China (mainland)
| |
Collapse
|