Congruence of health and treatment perceptions among older patients and providers of primary care

Incongruence between Health Perceptions and Health Problems

Subjective ratings of health are not always congruent with other health indices. The present study explored the congruence/incongruence between subjective overall health ratings and diseases/health problems as reported by elderly individuals. The goals were to consider the prevalence of health congruence/incongruence among seniors and to examine whether congruence/incongruence relates to mortality. Overall, it was found that incongruence was more likely to be in the form of more favorable, rather than less favorable, ratings (i.e., overestimates rather than underestimates). The relationship between congruence/incongruence and mortality was explored using three different follow-up periods and was examined separately among those who were well, ill, or neither well nor ill (i.e., typical elders). Although the findings differed depending on length of follow-up and health status, they generally suppported a link between overestimation of health and survival. Even among ill elders, those who overestimated their health were less likely to die than were those who did not.

Perceptions of medical interactions between healthcare providers and American Indian older adults

Cultural competence models assume that culture affects medical encounters, yet little research uses objective measures to examine how this may be true. Do providers and racial/ethnic minority patients interpret the same interactions similarly or differently? How might patterns of provider-patient concordance and discordance vary for patients with different cultural characteristics? We collected survey data from 115 medical visits with American Indian older adults at a clinic operated by the Cherokee Nation (in Northeastern Oklahoma, USA), asking providers and patients to evaluate nine affective and instrumental interactions. Examining data from the full sample, we found that provider and patient ratings were significantly discordant for all interactions (Wilcoxon signed-rank test p Collapse

Key Words

• cherokee nation
• doctor-patient communication
• cultural competence
• race
• american indians
• cultural identity, usa, older people

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MESH Headings

• Adult
• Aged
• Aged, 80 and over
• Attitude of Health Personnel
• Cultural Characteristics
• Female
• Health Personnel/psychology
• Humans
• Indians, North American/psychology
• Male
• Middle Aged
• Office Visits
• Patient Satisfaction
• Perception
• Professional-Patient Relations
• United States

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Grants

• K01 AG022434 NIA NIH HHS
• K01 AG022434-03 NIA NIH HHS
• 1K01AG022434-01A2 NIA NIH HHS

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Affiliation(s)

Eva Marie Garroutte Boston College Chestnut Hill, MA UNITED STATES [Proxy]
Natalia Sarkisian Boston College,
Jack Goldberg University of Washington,
Dedra Buchwald University of Washington,
Janette Beals University of Colorado at Denver Health Sciences Center,

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Cultural identities and perceptions of health among health care providers and older American Indians

BACKGROUND

Differences in provider-patient health perceptions have been associated with poor patient outcomes, but little is known about how patients' cultural identities may be related to discordant perceptions.

OBJECTIVE

To examine whether health care providers and American-Indian patients disagreed on patient health status ratings, and how differences related to these patients' strength of affiliation with American-Indian and white-American cultural identities.

DESIGN

Survey of patients and providers following primary care office visits.

PARTICIPANTS

One hundred and fifteen patients > or =50 years and 7 health care providers at a Cherokee Nation clinic. All patients were of American-Indian race, but varied in strength of affiliation with separate measures of American-Indian and white-American cultural identities.

MEASUREMENTS

Self-reported sociodemographic and cultural characteristics, and a 5-point rating of patient's health completed by both patients and providers. Fixed-effects regression modeling examined the relationships of patients' cultural identities with differences in provider-patient health rating.

RESULTS

In 40% of medical visits, providers and patients rated health differently, with providers typically judging patients healthier than patients' self-rating. Provider-patient differences were greater for patients affiliating weakly with white cultural identity than for those affiliating strongly (adjusted mean difference=0.70 vs 0.12, P=.01). Differences in ratings were not associated with the separate measure of affiliation with American-Indian identity.

CONCLUSIONS

American-Indian patients, especially those who affiliate weakly with white-American cultural identity, often perceive health status differently from their providers. Future research should explore sources of discordant perceptions.

Dietary pattern of self-care among Asian and Caucasian diabetic patients

Diabetes mellitus is a growing pandemic and its self-care management rests primarily with the individual. This qualitative case study investigated the self-care dietary pattern among a group of 25 Asians and 24 Caucasians diagnosed with type 1 or type 2 diabetes. Data collected from a semi-structured interview and a 7-day health diary explored the self-care activities undertaken by the participants to establish metabolic control. From an analytical perspective, the collective responses were placed on a continuum ranging from strict adherence, moderately flexible adherence to very flexible adherence. The findings suggest that most of the participants were located in the latter two categories of diet related to self-care. Implications for healthcare professionals in promoting self-care will be discussed.

The combined effects of participatory styles of elderly patients and their physicians on satisfaction

OBJECTIVES

To test whether concordance or discordance of patient participation between patients and physicians is associated with higher satisfaction, and to examine the effects of patients' and physicians' participatory styles on patients' satisfaction with their physicians.

DATA

Data collected in the Texas Tech 5000 Survey of elderly patients in West Texas were used. Patient satisfaction with their physicians was measured by a single item from the Consumer Assessment of Health Plans (CAHPS), representing patients' ratings of their physicians. Patient participation was measured by an index derived from a three-item instrument and physicians' participatory decision-making (PDM) style was measured by a three-item instrument developed by the Medical Outcomes Study.

METHODS

An ordered logit multivariate regression was used to investigate the effects of patients' and physicians' participatory styles on satisfaction with physicians. The interaction between patients' participation and physicians' participatory styles was also included to examine the dependency of the two variables.

RESULTS

Controlling for confounding factors, a higher PDM score was associated with a higher rating of patient satisfaction with physicians. A higher patient participation score was related to a lower physician satisfaction rating. The combined effect of patients' and physicians' participation styles indicated that for a low patient participation score, a high PDM score was not needed to produce high satisfaction. The greater the discordance in this direction, the higher the satisfaction. However, with a high patient participation score, only an extremely high PDM score would produce relatively high satisfaction.

CONCLUSIONS

The current study supports the discordance hypothesis. Participatory physicians and patient-physician communications concerning patient participation can promote higher satisfaction.

Physicians' and patients' perceptions of patients' communication competence in a primary care medical interview

Considerable research suggests that patients and physicians often perceive aspects of the medical interview quite differently. Despite extensive research into physician-patient communication, virtually no attention has been given to assessing patients' and physicians' perceptions of communication competence during the medical interview. The purpose of this research was to determine the extent of agreement between physicians and patients on what behaviors constitute competent patient communication. The results indicate that there is considerable agreement between physicians and patients on the categories of competent patient communication. However, there is little or no evidence for agreement at the dyadic level on the occurrence of competent patient communication. Moreover, there is little evidence that physicians' and patients' perceptions of competence correlate with patients' actual discourse. These results are discussed with respect to implications for future research on patient communication skills training interventions.

Implementation of consultative geriatric recommendations: the role of patient-primary care physician concordance

OBJECTIVES

To examine the effect on primary care physicians' implementation and their patients' adherence behaviors of patient-physician concordance about recommended geriatric health care.

DESIGN

Case-series, independent interviews of patients and their physicians about their perceptions of the patients' health and the comprehensive geriatric assessment (CGA).

SETTING

Community.

PARTICIPANTS

Community-dwelling older patients (n = 111) who received consultative outpatient CGA and their primary care physicians.

MEASUREMENTS

Concordance variables were generated using physician and patient responses to 10 questions on health- and CGA-related perceptions. An overall concordance score was generated by summing the total number of items on which patients and physicians agreed. Measures of the two dependent variables (physician implementation of and patient adherence to CGA recommendations) were by self-report.

RESULTS

In multiple logistic regression analyses, overall concordance between patient and physician proved to be a significant and powerful predictor of physician implementation of (adjusted odds ratio (OR) = 2.7, 95% confidence interval (CI) = 1.6-4.6, P <.001) and patient adherence to (OR = 2.7, 95% CI = 1.7-4.2, P <.001) CGA recommendations, controlling for patient and physician gender and age, patients' functional status, duration of the patient-physician relationship, and frequency of visits in the previous year. Further analysis revealed that mutual patient-physician concordance on health-related perceptions was a significant predictor of these outcomes, whereas individual patient or physician perceptions were not.

CONCLUSION

Concordance between older patients and their primary care physicians is a powerful predictor of physician implementation of and patient adherence to outpatient consultative CGA recommendations. Future research should focus on ways physicians can assess and negotiate patient-physician agreement on geriatric healthcare recommendations.

Determinants of health-promoting lifestyle behaviors in rural older women

The purpose of this study was to: (a) describe the health-promoting lifestyle behaviors and attempts at change among 102 community-dwelling rural women aged 65 and older, and (b) determine the extent to which personal influences (demographics, definition of health, and perceived health status) and contextual influences (sources of health information and provider counseling) explain health-promoting lifestyle behaviors and attempts at change among those women. They scored highest on frequency of nutrition behaviors and lowest on frequency of physical activity behaviors. They had attempted change in from zero to five areas of health-promoting lifestyle within the past year. Multiple regression analyses revealed that younger age, living with other(s), defining health as wellness, better perceived mental health, more sources of health information and provider counseling were significantly associated with health-promoting lifestyle behaviors. Only younger age and more sources of health information were significantly associated with attempts at change. These findings provide information that is relevant in designing interventions to enhance health-promoting lifestyle behaviors among rural older women.

The influence of older patient-physician communication on health and health-related outcomes

Effective patient-physician communication significantly influences health outcomes of older patients. For example, concordance between patient and physician expectations and patient participation in the decision-making process affects older patients. Communication is also linked to patient recall, adherence, and satisfaction. Furthermore, communication impacts emotional and physical outcomes of older patients, although evidence of improved physical outcomes remains under-investigated in this population. Dimensions of communication, such as continuity of relationship, seem to be important in decreasing hospitalization of older patients. This article explores the link between communication and health care outcomes in the older population.

Patients' explanatory models for heart failure and COPD exacerbations

Although there is extensive information on the disease aspect of heart failure (HF) and chronic obstructive pulmonary disease (COPD), the illness aspect of these diseases has received limited attention. This limitation in our knowledge is of concern because these diseases are increasing in incidence and prevalence and contributing to the premature morbidity and mortality of thousands of persons. This naturalistic inquiry study was undertaken to describe the explanatory models (EMs) of persons hospitalized for HF (n = 30) or COPD (n = 30) exacerbations. In semistructured interviews, participants offered descriptions of the etiology, cause, and effects of their disease exacerbations and identified interventions that they believed would have helped prevent their hospitalizations or helped them to live better at home. The findings provide a basis for understanding the EMs of persons with HF or COPD as an initial step in making health care more relevant.

Effects of a physician communication intervention on patient care outcomes

OBJECTIVE

To determine whether an intervention designed to improve patient-physician communication increases the frequency with which physicians elicit patients' concerns, changes other communication behaviors, and improves health care outcomes.

DESIGN

Pretest-posttest design with random assignment of physicians to intervention or control groups.

SETTING

General medicine clinics of a university-affiliated Veterans Affairs Hospital.

PATIENTS/PARTICIPANTS

Forty-two physicians and 348 continuity care patients taking prescription medications for chronic medical conditions.

INTERVENTIONS

Intervention group physicians received 4.5 hours of training on eliciting and responding to patients' concerns and requests, and their patients filled out the Patient Requests for Services Questionnaire prior to a subsequent clinic visit. Control group physicians received 4.5 hours of training in medical decision-making.

MEASUREMENTS AND MAIN RESULTS

The frequency with which physicians elicited all of a patient's concerns increased in the intervention group as compared with the control group (p = .032). Patients perceptions of the amount of information received from the physician did increase significantly (p < .05), but the actual magnitude of change was small. A measure of patient satisfaction with the physicians was high at baseline and also showed no significant change after the intervention. Likewise, the intervention was not associated with changes in patient compliance with medications or appointments, nor were there any effects on outpatient utilization.

CONCLUSIONS

A low-intensity intervention changed physician behavior but had no effect on patient outcomes such as satisfaction, compliance, or utilization. Interventions may need to focus on physicians and patients to have the greatest effect.

Self-management of the health care regimen: a comparison of nurses' and cardiac patients' perceptions

This study compared perceptions of 129 elderly cardiac patients regarding their health status and self-management skills with corresponding assessments by outpatient nursing staff members. Nurse-patient perceptions were most congruent on general questions regarding the heart condition. Differences were most apparent regarding how aware patients were of being asked to follow a regimen for managing their heart problems; what specific components comprised the regimens the patients were to follow; and how much confidence patients had in their ability to comply with specific components of the regimen. Congruence in perceptions of nurses and patients varied by the sex of the patient. Findings suggest that careful and continuous assessment of patients' perceptions about their condition and ongoing instruction regarding specifics of the therapeutic regimen are key elements in efforts to enhance elderly patients' self-management skills.

Self care: Japan and the U.S. compared

Experience of common symptoms and subsequent self care behaviors among older adults are compared between Japan and the United States, two industrial countries with different cultural backgrounds and health insurance systems. Based on a modification of the Health Belief Model, perceived susceptibility to illness and belief in the efficacy of physician care were selected as major explanatory concepts for the decision to use self care for a complaint. Among 900 respondents in Japan and 728 in the United States, in three communities of varying size, self evaluations of good health, an indicator of low susceptibility, were very similar. Although Japanese respondents claimed fewer experiences of physician error, they still expressed lower preference for physician care than did those in the U.S. In addition, the Japanese reported far fewer symptoms than their U.S. counterparts during a three month period, and were more likely to use self care, even for symptoms they considered more serious. Disparate effects of such variables as good health behaviors, presence of a chronic condition and desire for autonomy are discussed in terms of cultural differences in the two countries.