Survey of infections due to Staphylococcus species: frequency of occurrence and antimicrobial susceptibility of isolates collected in the United States, Canada, Latin America, Europe, and the Western Pacific region for the SENTRY Antimicrobial Surveillance Program, 1997-1999

Between January 1997 and December 1999, bloodstream isolates from 15,439 patients infected with Staphylococcus aureus and 6350 patients infected with coagulase-negative Staphylococcus species (CoNS) were referred by SENTRY-participating hospitals in the United States, Canada, Latin America, Europe, and the Western Pacific region. S. aureus was found to be the most prevalent cause of bloodstream infection, skin and soft-tissue infection, and pneumonia in almost all geographic areas. A notable increase in methicillin (oxacillin) resistance among community-onset and hospital-acquired S. aureus strains was observed in the US centers. The prevalence of methicillin (oxacillin)-resistant S. aureus varied greatly by region, site of infection, and whether the infection was nosocomial or community onset. Rates of methicillin resistance were extremely high among S. aureus isolates from centers in Hong Kong and Japan. Uniformly high levels of methicillin resistance were observed among CoNS isolates. Given the increasing multidrug resistance among staphylococci and the possible emergence of vancomycin-resistant strains, global strategies are needed to control emergence and spread of multiply resistant staphylococci.

Cultural competence: a systematic review of health care provider educational interventions

OBJECTIVE

We sought to synthesize the findings of studies evaluating interventions to improve the cultural competence of health professionals.

DESIGN

This was a systematic literature review and analysis.

METHODS

We performed electronic and hand searches from 1980 through June 2003 to identify studies that evaluated interventions designed to improve the cultural competence of health professionals. We abstracted and synthesized data from studies that had both a before- and an after-intervention evaluation or had a control group for comparison and graded the strength of the evidence as excellent, good, fair, or poor using predetermined criteria.

MAIN OUTCOME MEASURES

We sought evidence of the effectiveness and costs of cultural competence training of health professionals.

RESULTS

Thirty-four studies were included in our review. There is excellent evidence that cultural competence training improves the knowledge of health professionals (17 of 19 studies demonstrated a beneficial effect), and good evidence that cultural competence training improves the attitudes and skills of health professionals (21 of 25 studies evaluating attitudes demonstrated a beneficial effect and 14 of 14 studies evaluating skills demonstrated a beneficial effect). There is good evidence that cultural competence training impacts patient satisfaction (3 of 3 studies demonstrated a beneficial effect), poor evidence that cultural competence training impacts patient adherence (although the one study designed to do this demonstrated a beneficial effect), and no studies that have evaluated patient health status outcomes. There is poor evidence to determine the costs of cultural competence training (5 studies included incomplete estimates of costs).

CONCLUSIONS

Cultural competence training shows promise as a strategy for improving the knowledge, attitudes, and skills of health professionals. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of services across racial and ethnic groups is lacking. Future research should focus on these outcomes and should determine which teaching methods and content are most effective.

The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care

OBJECTIVES

We examined the associations of clinicians' implicit attitudes about race with visit communication and patient ratings of care.

METHODS

In a cross-sectional study of 40 primary care clinicians and 269 patients in urban community-based practices, we measured clinicians' implicit general race bias and race and compliance stereotyping with 2 implicit association tests and related them to audiotape measures of visit communication and patient ratings.

RESULTS

Among Black patients, general race bias was associated with more clinician verbal dominance, lower patient positive affect, and poorer ratings of interpersonal care; race and compliance stereotyping was associated with longer visits, slower speech, less patient centeredness, and poorer ratings of interpersonal care. Among White patients, bias was associated with more verbal dominance and better ratings of interpersonal care; race and compliance stereotyping was associated with less verbal dominance, shorter visits, faster speech, more patient centeredness, higher clinician positive affect, and lower ratings of some aspects of interpersonal care.

CONCLUSIONS

Clinician implicit race bias and race and compliance stereotyping are associated with markers of poor visit communication and poor ratings of care, particularly among Black patients.

Calcium supplements for the prevention of colorectal adenomas. Calcium Polyp Prevention Study Group

BACKGROUND AND METHODS

Laboratory, clinical, and epidemiologic evidence suggests that calcium may help prevent colorectal adenomas. We conducted a randomized, double-blind trial of the effect of supplementation with calcium carbonate on the recurrence of colorectal adenomas. We randomly assigned 930 subjects (mean age, 61 years; 72 percent men) with a recent history of colorectal adenomas to receive either calcium carbonate (3 g [1200 mg of elemental calcium] daily) or placebo, with follow-up colonoscopies one and four years after the qualifying examination. The primary end point was the proportion of subjects in whom at least one adenoma was detected after the first follow-up endoscopy but up to (and including) the second follow-up examination. Risk ratios for the recurrence of adenomas were adjusted for age, sex, lifetime number of adenomas before the study, clinical center, and length of the surveillance period.

RESULTS

The subjects in the calcium group had a lower risk of recurrent adenomas. Among the 913 subjects who underwent at least one study colonoscopy, the adjusted risk ratio for any recurrence of adenoma with calcium as compared with placebo was 0.85 (95 percent confidence interval, 0.74 to 0.98; P=0.03). The main analysis was based on the 832 subjects (409 in the calcium group and 423 in the placebo group) who completed both follow-up examinations. At least one adenoma was diagnosed between the first and second follow-up endoscopies in 127 subjects in the calcium group (31 percent) and 159 subjects in the placebo group (38 percent); the adjusted risk ratio was 0.81 (95 percent confidence interval, 0.67 to 0.99; P=0.04). The adjusted ratio of the average number of adenomas in the calcium group to that in the placebo group was 0.76 (95 percent confidence interval, 0.60 to 0.96; P=0.02). The effect of calcium was independent of initial dietary fat and calcium intake.

CONCLUSIONS

Calcium supplementation is associated with a significant - though moderate - reduction in the risk of recurrent colorectal adenomas.

Relationship-centered care. A constructive reframing

All illness, care, and healing processes occur in relationship--relationships of an individual with self and with others. Relationship-centered care (RCC) is an important framework for conceptualizing health care, recognizing that the nature and the quality of relationships are central to health care and the broader health care delivery system. RCC can be defined as care in which all participants appreciate the importance of their relationships with one another. RCC is founded upon 4 principles: (1) that relationships in health care ought to include the personhood of the participants, (2) that affect and emotion are important components of these relationships, (3) that all health care relationships occur in the context of reciprocal influence, and (4) that the formation and maintenance of genuine relationships in health care is morally valuable. In RCC, relationships between patients and clinicians remain central, although the relationships of clinicians with themselves, with each other and with community are also emphasized.

Patient centeredness, cultural competence and healthcare quality

Cultural competence and patient centeredness are approaches to improving healthcare quality that have been promoted extensively in recent years. In this paper, we explore the historical evolution of both cultural competence and patient centeredness. In doing so, we demonstrate that early conceptual models of cultural competence and patient centeredness focused on how healthcare providers and patients might interact at the interpersonal level and that later conceptual models were expanded to consider how patients might be treated by the healthcare system as a whole. We then compare conceptual models for both cultural competence and patient centeredness at both the interpersonal and healthcare system levels to demonstrate similarities and differences. We conclude that, although the concepts have had different histories and foci, many of the core features of cultural competence and patient centeredness are the same. Each approach holds promise for improving the quality of healthcare for individual patients, communities and populations.

Is the quality of the patient-provider relationship associated with better adherence and health outcomes for patients with HIV?

PURPOSE

Patient-centeredness, originally defined as understanding each patient as a unique person, is widely considered the standard for high-quality interpersonal care. The purpose of our study was to examine the association between patient perception of being "known as a person" and receipt of highly active antiretroviral therapy (HAART), adherence to HAART, and health outcomes among patients with HIV.

STUDY DESIGN

Cross-sectional analysis.

SUBJECTS

One thousand seven hundred and forty-three patients with HIV.

MEASUREMENTS

Patient reports that their HIV provider "knows me as a person" and 3 outcomes: receipt of HAART, adherence to HAART, and undetectable serum HIV RNA.

RESULTS

Patients who reported that their provider knows them "as a person" were more likely to receive HAART (60% vs 47%, P<.001), be adherent to HAART (76% vs 67%, P=.007), and have undetectable serum HIV RNA (49% vs 39%, P<.001). Patients who reported their provider knows them "as a person" were also older (mean 38.0 vs 36.6 years, P<.001), reported higher quality-of-life (mean LASA score 71.1 vs 64.8, P<.001), had been followed in clinic longer (mean 64.4 vs 61.7 months, P=.008), missed fewer appointments (mean proportion missed appointments 0.124 vs 0.144, P<.001), reported more positive beliefs about HAART therapy (39% vs 28% strongly believed HIV medications could help them live longer, P<.008), reported less social stress (50% vs 62% did not eat regular meals, P<.001) and were less likely to use illicit drugs or alcohol (22% vs 33% used drugs, P<.001; 42% vs 53% used alcohol, P<.001). Controlling for patient age, sex, race/ethnicity, quality-of-life, length of time in clinic, missed appointments, health beliefs, social stress, and illicit drug and alcohol use, patients who reported their provider knows them "as a person" had higher odds of receiving HAART (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.19 to 1.65), adhering to HAART (OR 1.33, 95% CI 1.02 to 1.72), and having undetectable serum HIV RNA (1.20, 95% CI 1.02 to 1.41).

CONCLUSIONS

We found that a single item measuring the essence of patient-centeredness-the patients' perception of being "known as a person"-is significantly and independently associated with receiving HAART, adhering to HAART, and having undetectable serum HIV RNA. These results support the hypothesis that the quality of patient-physician relationship is directly related to the health of patients.

Racial and ethnic differences in patient perceptions of bias and cultural competence in health care

OBJECTIVES

To determine: 1) whether racial and ethnic differences exist in patients' perceptions of primary care provider (PCP) and general health care system-related bias and cultural competence; and 2) whether these differences are explained by patient demographics, source of care, or patient-provider communication variables.

DESIGN

Cross-sectional telephone survey.

SETTING

The Commonwealth Fund 2001 Health Care Quality Survey.

SUBJECTS

A total of 6,299 white, African-American, Hispanic, and Asian adults.

MEASUREMENTS AND MAIN RESULTS

Interviews were conducted using random-digit dialing; oversampling respondents from communities with high racial/ethnic minority concentrations; and yielding a 54.3% response rate. Main outcomes address respondents' perceptions of their PCPs' and health care system-related bias and cultural competence; adjusted probabilities (Pr) are reported for each ethnic group. Most racial/ethnic differences in perceptions of PCP bias and cultural competence were explained by demographics, source of care, and patient-physician communication variables. In contrast, racial/ethnic differences in patient perceptions of health care system-wide bias and cultural competence persisted even after controlling for confounders: African Americans, Hispanics, and Asians remained more likely than whites (P <.001) to perceive that: 1) they would have received better medical care if they belonged to a different race/ethnic group (Pr 0.13, Pr 0.08, Pr 0.08, and Pr 0.01, respectively); and 2) medical staff judged them unfairly or treated them with disrespect based on race/ethnicity (Pr 0.06, Pr 0.04, Pr 0.06, and Pr 0.01, respectively) and how well they speak English (Pr 0.09, Pr 0.06, Pr 0.06, and Pr 0.03, respectively).

CONCLUSION

While demographics, source of care, and patient-physician communication explain most racial and ethnic differences in patient perceptions of PCP cultural competence, differences in perceptions of health care system-wide bias and cultural competence are not fully explained by such factors. Future research should include closer examination of the sources of cultural bias in the US medical system.

Do Words Matter? Stigmatizing Language and the Transmission of Bias in the Medical Record

BACKGROUND

Clinician bias contributes to healthcare disparities, and the language used to describe a patient may reflect that bias. Although medical records are an integral method of communicating about patients, no studies have evaluated patient records as a means of transmitting bias from one clinician to another.

OBJECTIVE

To assess whether stigmatizing language written in a patient medical record is associated with a subsequent physician-in-training's attitudes towards the patient and clinical decision-making.

DESIGN

Randomized vignette study of two chart notes employing stigmatizing versus neutral language to describe the same hypothetical patient, a 28-year-old man with sickle cell disease.

PARTICIPANTS

A total of 413 physicians-in-training: medical students and residents in internal and emergency medicine programs at an urban academic medical center (54% response rate).

MAIN MEASURES

Attitudes towards the hypothetical patient using the previously validated Positive Attitudes towards Sickle Cell Patients Scale (range 7-35) and pain management decisions (residents only) using two multiple-choice questions (composite range 2-7 representing intensity of pain treatment).

KEY RESULTS

Exposure to the stigmatizing language note was associated with more negative attitudes towards the patient (20.6 stigmatizing vs. 25.6 neutral, p < 0.001). Furthermore, reading the stigmatizing language note was associated with less aggressive management of the patient's pain (5.56 stigmatizing vs. 6.22 neutral, p = 0.003).

CONCLUSIONS

Stigmatizing language used in medical records to describe patients can influence subsequent physicians-in-training in terms of their attitudes towards the patient and their medication prescribing behavior. This is an important and overlooked pathway by which bias can be propagated from one clinician to another. Attention to the language used in medical records may help to promote patient-centered care and to reduce healthcare disparities for stigmatized populations.

A Research Agenda for Communication Between Health Care Professionals and Patients Living With Serious Illness

IMPORTANCE

Poor communication by health care professionals contributes to physical and psychological suffering in patients living with serious illness. Patients may not fully understand their illness, prognosis, and treatment options or may not receive medical care consistent with their goals. Despite considerable research exploring the role of communication in this setting, many questions remain, and a clear agenda for communication research is lacking.

OBSERVATIONS

Through a consensus conference and subsequent activities, we reviewed the state of the science, identified key evidence gaps in understanding the impact of communication on patient outcomes, and created an agenda for future research. We considered 7 broad topics: shared decision making, advance care planning, communication training, measuring communication, communication about prognosis, emotion and serious illness communication, and cultural issues. We identified 5 areas in which further research could substantially move the field forward and help enhance patient care: measurement and methodology, including how to determine communication quality; mechanisms of communication, such as identifying the specific clinician behaviors that patients experience as both honest and compassionate, or the role of bias in the clinical encounter; alternative approaches to advance care planning that focus on the quality of serious illness communication and not simply completion of forms; teaching and disseminating communication skills; and approaches, such as economic incentives and other clinician motivators, to change communication behavior.

CONCLUSIONS

Our findings highlight the urgent need to improve quality of communication between health care professionals and patients living with serious illness through a broad range of research that covers communication skills, tools, patient education, and models of care.

Consequences of intravascular catheter sepsis

Intravascular (IV) catheter sepsis is a widely recognized complication of IV therapy or monitoring, but little emphasis has been placed on the morbidity and cost associated with this infection. To assess the consequences of IV catheter sepsis, we examined the medical records of 94 patients with 102 episodes of IV catheter sepsis due to percutaneously inserted catheters. Major complications occurred in 33 (32%) of the episodes and included septic shock (12 episodes), sustained sepsis (12), suppurative thrombophlebitis (7), metastatic infection (5), endocarditis (2), and arteritis (2). One patient died due to sepsis, and hospital stay was clearly prolonged in 15 episodes. The risk of major complications was highest in episodes of IV catheter sepsis caused by Candida, Pseudomonas aeruginosa, Staphylococcus aureus, or multiple pathogens, and the most severe complications were usually caused by S. aureus. The hospital cost of IV catheter sepsis was assessed by reviewing medical and billing records to identify extra medical care and then multiplying charges for that care by the appropriate cost-to-charge ratio. The average cost per episode, adjusted to 1991 dollars, was $3,707 for all episodes and $6,064 for episodes caused by S. aureus. The morbidity and cost associated with IV catheter sepsis warrant substantial efforts to minimize the incidence of this complication and especially to prevent cases due to S. aureus.

Systematic review: Hydroxyurea for the treatment of adults with sickle cell disease

BACKGROUND

Hydroxyurea is the only approved drug for treatment of sickle cell disease.

OBJECTIVE

To synthesize the published literature on the efficacy, effectiveness, and toxicity of hydroxyurea when used in adults with sickle cell disease.

DATA SOURCES

MEDLINE, EMBASE, TOXLine, and CINAHL were searched through 30 June 2007.

STUDY SELECTION

Randomized trials, observational studies, and case reports evaluating efficacy and toxicity of hydroxyurea in adults with sickle cell disease, and toxicity studies of hydroxyurea in other conditions that were published in English.

DATA EXTRACTION

Paired reviewers abstracted data on study design, patient characteristics, and outcomes sequentially and did quality assessments independently.

DATA SYNTHESIS

In the single randomized trial, the hemoglobin level was higher in hydroxyurea recipients than placebo recipients after 2 years (difference, 6 g/L), as was fetal hemoglobin (absolute difference, 3.2%). The median number of painful crises was 44% lower than in the placebo group. The 12 observational studies that enrolled adults reported a relative increase in fetal hemoglobin of 4% to 20% and a relative reduction in crisis rates by 68% to 84%. Hospital admissions declined by 18% to 32%. The evidence suggests that hydroxyurea may impair spermatogenesis. Limited evidence indicates that hydroxyurea treatment in adults with sickle cell disease is not associated with leukemia. Likewise, limited evidence suggests that hydroxyurea and leg ulcers are not associated in patients with sickle cell disease, and evidence is insufficient to estimate the risk for skin neoplasms, although these outcomes can be attributed to hydroxyurea in other conditions.

LIMITATION

Only English-language articles were included, and some studies were of lower quality.

CONCLUSION

Hydroxyurea has demonstrated efficacy in adults with sickle cell disease. The paucity of long-term studies limits conclusions about toxicity.

Survey of bloodstream infections due to gram-negative bacilli: frequency of occurrence and antimicrobial susceptibility of isolates collected in the United States, Canada, and Latin America for the SENTRY Antimicrobial Surveillance Program, 1997

During 1997, a total of 4,267 nosocomial and community-acquired bloodstream infections due to gram-negative organisms were reported from SENTRY hospitals in Canada (8 sites), the United States (30 sites), and Latin America (10 sites). Escherichia coli was the most common isolate (41% of all gram-negative isolates), followed by Klebsiella species (17.9%), Pseudomonas aeruginosa (10.6%), and Enterobacter species (9.4%). For all gram-negative isolates combined, the most active antimicrobials tested were meropenem, imipenem, and cefepime. The quinolones levofloxacin (MIC90, 2 microg/mL), ciprofloxacin (MIC90, 1 microg/mL), gatifloxacin (MIC90, 2 microg/mL), sparfloxacin (MIC90, 2 microg/mL), and trovafloxacin (MIC90, 2 microg/mL) were also active against most isolates. Bloodstream infection isolates from Latin America were uniformly more resistant to all classes of antimicrobial agents tested than were isolates from Canada or the United States. Resistance phenotypes consistent with extended-spectrum beta-lactamase production were also most common among E. coli and Klebsiella species from Latin America. Further investigation of the reasons for regional differences in resistance patterns is needed, as is ongoing surveillance to detect resistance trends and to guide antimicrobial use.

The effect of do-not-resuscitate orders on physician decision-making

The effect of do-not-resuscitate (DNR) orders on physicians' decisions to provide life-prolonging treatments other than cardiopulmonary resuscitation (CPR) for patients near the end of life was explored using a cross-sectional mailed survey. Each survey presented three patient scenarios followed by 10 treatment decisions. Participants were residents and attending physicians who were randomly assigned surveys in which all patient scenarios included or did not include a DNR order. Response to three case scenarios when a DNR order was present or absent were measured. Response from 241 of 463 physicians (52%) was received. Physicians agreed or strongly agreed to initiate fewer interventions when a DNR order was present versus absent (4.2 vs 5.0 (P =.008) in the first scenario; 6.5 vs 7.1 (P =.004) in the second scenario; and 5.7 vs 6.2 (P =.037) in the third scenario). In all three scenarios, patients with DNR orders were significantly less likely to be transferred to an intensive care unit, to be intubated, or to receive CPR. In some scenarios, the presence of a DNR order was associated with a decreased willingness to draw blood cultures (91% vs 98%, P =.038), central line placement (68% vs 80%, P =.030), or blood transfusion (75% vs 87%, P =.015). The presence of a DNR order may affect physicians' willingness to order a variety of treatments not related to CPR. Patients with DNR orders may choose to forgo other life-prolonging treatments, but physicians should elicit additional information about patients' treatment goals to inform these decisions.

Do patients treated with dignity report higher satisfaction, adherence, and receipt of preventive care?

PURPOSE

Although involving patients in their own health care is known to be associated with improved outcomes, this study was conducted to determine whether respecting persons more broadly, such as treating them with dignity, has additional positive effects.

METHODS

Using data from the Commonwealth Fund 2001 Health Care Quality Survey of 6,722 adults living in the United States, we performed survey-weighted logistic regression analysis to evaluate independent associations between 2 measures of respect (involvement in decisions and treatment with dignity) and patient outcomes (satisfaction, adherence, and receipt of optimal preventive care). Then we calculated adjusted probabilities of these outcomes and performed stratified analyses to examine results across racial/ethnic groups.

RESULTS

After adjustment for respondents' demographic characteristics, the probability of reporting a high level of satisfaction was higher for those treated with dignity vs not treated with dignity (0.70 vs 0.38, P < .001) and for those involved in, versus not involved in, decisions (0.70 vs 0.39, P < .001). These associations were consistent across all racial/ethnic groups. Being involved in decisions was significantly associated with adherence for whites, whereas being treated with dignity was significantly associated with adherence for racial/ethnic minorities. The probability of receiving optimal preventive care was marginally greater for those treated with dignity (0.68 vs 0.63, P = .054), but did not differ with respect to involvement in decisions (0.67 vs 0.67, P = .95).

CONCLUSIONS

Being treated with dignity and being involved in decisions are independently associated with positive outcomes. Although involving patients in decisions is an important part of respecting patient autonomy, it is also important to respect patients more broadly by treating them with dignity.

Are physicians' attitudes of respect accurately perceived by patients and associated with more positive communication behaviors?

OBJECTIVE

To explore the domain of physician-reported respect for individual patients by investigating the following questions: How variable is physician-reported respect for patients? What patient characteristics are associated with greater physician-reported respect? Do patients accurately perceive levels of physician respect? Are there specific communication behaviors associated with physician-reported respect for patients?

METHODS

We audiotaped 215 patient-physician encounters with 30 different physicians in primary care. After each encounter, the physician rated the level of respect that s/he had for that patient using the following item: "Compared to other patients, I have a great deal of respect for this patient" on a five-point scale between strongly agree and strongly disagree. Patients completed a post-visit questionnaire that included a parallel respect item: "This doctor has a great deal of respect for me." Audiotapes of the patient visits were analyzed using the Roter Interaction Analysis System (RIAS) to characterize communication behaviors. Outcome variables included four physician communication behaviors: information-giving, rapport-building, global affect, and verbal dominance. A linear mixed effects modeling approach that accounts for clustering of patients within physicians was used to compare varying levels of physician-reported respect for patients with physician communication behaviors and patient perceptions of being respected.

RESULTS

: Physician-reported respect varied across patients. Physicians strongly agreed that they had a great deal of respect for 73 patients (34%), agreed for 96 patients (45%) and were either neutral or disagreed for 46 patients (21%). Physicians reported higher levels of respect for older patients and for patients they knew well. The level of respect that physicians reported for individual patients was not significantly associated with that patient's gender, race, education, or health status; was not associated with the physician's gender, race, or number of years in practice; and was not associated with race concordance between patient and physician. While 45% of patients overestimated physician respect, 38% reported respect precisely as rated by the physician, and 16% underestimated physician respect (r=0.18, p=0.007). Those who were the least respected by their physician were the least likely to perceive themselves as being highly respected; only 36% of the least respected patients compared to 59% and 61% of the highly and moderately respected patients perceived themselves to be highly respected (p=0.012). Compared with the least-respected patients, physicians were more affectively positive with highly respected patients (p=0.034) and provided more information to highly and moderately respected patients (p=0.018).

CONCLUSION

Physicians' ratings of respect vary across patients and are primarily associated with familiarity rather than sociodemographic characteristics. Patients are able to perceive when they are respected by their physicians, although when they are not accurate, they tend to overestimate physician respect. Physicians who are more respectful towards particular patients provide more information and express more positive affect in visits with those patients.

PRACTICE IMPLICATIONS

Physician respectful attitudes may be important to target in improving communication with patients.

Delving below the surface. Understanding how race and ethnicity influence relationships in health care

There is increasing evidence that racial and ethnic minority patients receive lower quality interpersonal care than white patients. Therapeutic relationships constitute the interpersonal milieu in which patients are diagnosed, given treatment recommendations, and referred for tests, procedures, or care by consultants in the health care system. This paper provides a review and perspective on the literature that explores the role of relationships and social interactions across racial and ethnic differences in health care. First, we examine the social and historical context for examining differences in interpersonal treatment in health care along racial and ethnic lines. Second, we discuss selected studies that examine how race and ethnicity influence clinician-patient relationships. While less is known about how race and ethnicity influence clinician-community, clinician-clinician, and clinician-self relationships, we briefly examine the potential roles of these relationships in overcoming disparities in health care. Finally, we suggest directions for future research on racial and ethnic health care disparities that uses a relationship-centered paradigm.

Hydroxyurea for sickle cell disease: a systematic review for efficacy and toxicity in children

CONTEXT

Hydroxyurea is the only approved medication for the treatment of sickle cell disease in adults; there are no approved drugs for children.

OBJECTIVE

Our goal was to synthesize the published literature on the efficacy, effectiveness, and toxicity of hydroxyurea in children with sickle cell disease.

METHODS

Medline, Embase, TOXLine, and the Cumulative Index to Nursing and Allied Health Literature through June 2007 were used as data sources. We selected randomized trials, observational studies, and case reports (English language only) that evaluated the efficacy and toxicity of hydroxyurea in children with sickle cell disease. Two reviewers abstracted data sequentially on study design, patient characteristics, and outcomes and assessed study quality independently.

RESULTS

We included 26 articles describing 1 randomized, controlled trial, 22 observational studies (11 with overlapping participants), and 3 case reports. Almost all study participants had sickle cell anemia. Fetal hemoglobin levels increased from 5%-10% to 15%-20% on hydroxyurea. Hemoglobin concentration increased modestly (approximately 1 g/L) but significantly across studies. The rate of hospitalization decreased in the single randomized, controlled trial and 5 observational studies by 56% to 87%, whereas the frequency of pain crisis decreased in 3 of 4 pediatric studies. New and recurrent neurologic events were decreased in 3 observational studies of hydroxyurea compared with historical controls. Common adverse events were reversible mild-to-moderate neutropenia, mild thrombocytopenia, severe anemia, rash or nail changes (10%), and headache (5%). Severe adverse events were rare and not clearly attributable to hydroxyurea.

CONCLUSIONS

Hydroxyurea reduces hospitalization and increases total and fetal hemoglobin levels in children with severe sickle cell anemia. There was inadequate evidence to assess the efficacy of hydroxyurea in other groups. The small number of children in long-term studies limits conclusions about late toxicities.

A multicenter study of physician mindfulness and health care quality

PURPOSE

Mindfulness (ie, purposeful and nonjudgmental attentiveness to one's own experience, thoughts, and feelings) is associated with physician well-being. We sought to assess whether clinician self-rated mindfulness is associated with the quality of patient care.

METHODS

We conducted an observational study of 45 clinicians (34 physicians, 8 nurse practitioners, and 3 physician assistants) caring for patients infected with the human immunodeficiency virus (HIV) who completed the Mindful Attention Awareness Scale and 437 HIV-infected patients at 4 HIV specialty clinic sites across the United States. We measured patient-clinician communication quality with audio-recorded encounters coded using the Roter Interaction Analysis System (RIAS) and patient ratings of care.

RESULTS

In adjusted analyses comparing clinicians with highest and lowest tertile mindfulness scores, patient visits with high-mindfulness clinicians were more likely to be characterized by a patient-centered pattern of communication (adjusted odds ratio of a patient-centered visit was 4.14; 95% CI, 1.58-10.86), in which both patients and clinicians engaged in more rapport building and discussion of psychosocial issues. Clinicians with high-mindfulness scores also displayed more positive emotional tone with patients (adjusted β = 1.17; 95% CI, 0.46-1.9). Patients were more likely to give high ratings on clinician communication (adjusted prevalence ratio [APR] = 1.48; 95% CI, 1.17-1.86) and to report high overall satisfaction (APR = 1.45; 95 CI, 1.15-1.84) with high-mindfulness clinicians. There was no association between clinician mindfulness and the amount of conversation about biomedical issues.

CONCLUSIONS

Clinicians rating themselves as more mindful engage in more patient-centered communication and have more satisfied patients. Interventions should determine whether improving clinician mindfulness can also improve patient health outcomes.

Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions

BACKGROUND

Despite awareness of inequities in health care quality, little is known about strategies that could improve the quality of healthcare for ethnic minority populations. We conducted a systematic literature review and analysis to synthesize the findings of controlled studies evaluating interventions targeted at health care providers to improve health care quality or reduce disparities in care for racial/ethnic minorities.

METHODS

We performed electronic and hand searches from 1980 through June 2003 to identify randomized controlled trials or concurrent controlled trials. Reviewers abstracted data from studies to determine study characteristics, results, and quality. We graded the strength of the evidence as excellent, good, fair or poor using predetermined criteria. The main outcome measures were evidence of effectiveness and cost of strategies to improve health care quality or reduce disparities in care for racial/ethnic minorities.

RESULTS

Twenty-seven studies met criteria for review. Almost all (n = 26) took place in the primary care setting, and most (n = 19) focused on improving provision of preventive services. Only two studies were designed specifically to meet the needs of racial/ethnic minority patients. All 10 studies that used a provider reminder system for provision of standardized services (mostly preventive) reported favorable outcomes. The following quality improvement strategies demonstrated favorable results but were used in a small number of studies: bypassing the physician to offer preventive services directly to patients (2 of 2 studies favorable), provider education alone (2 of 2 studies favorable), use of a structured questionnaire to assess adolescent health behaviors (1 of 1 study favorable), and use of remote simultaneous translation (1 of 1 study favorable). Interventions employing more than one main strategy were used in 9 studies with inconsistent results. There were limited data on the costs of these strategies, as only one study reported cost data.

CONCLUSION

There are several promising strategies that may improve health care quality for racial/ethnic minorities, but a lack of studies specifically targeting disease areas and processes of care for which disparities have been previously documented. Further research and funding is needed to evaluate strategies designed to reduce disparities in health care quality for racial/ethnic minorities.

Effect of immune globulin on the prevention of experimental hepatitis C virus infection

The efficacy of postexposure prophylaxis for the prevention of hepatitis C virus (HCV) infection was studied in experimentally infected chimpanzees. Three chimpanzees were inoculated with HCV: Two were treated 1 h later with anti-HCV--negative intravenous immune globulin (IGIV) or hepatitis C immune globulin (HCIG), and a third animal was not treated. HCV infection was detected in all 3 animals within a few days of inoculation. Once passively transferred anti-HCV declined in the HCIG-treated animal, there was an increase of HCV antigen (Ag)--positive hepatocytes followed by reappearance of anti-HCV; HCV Ag disappeared concordant with the development of acute hepatitis. Acute hepatitis C developed in both the IGIV-treated and untreated chimpanzees, with peak liver enzyme activity on day 59, but was delayed in the HCIG-treated animal until day 146. Postexposure HCIG treatment markedly prolonged the incubation period of acute hepatitis C but did not prevent or delay HCV infection. IGIV had no effect on the course of HCV infection.

Shared decision-making as an existential journey: Aiming for restored autonomous capacity

OBJECTIVE

We describe the different ways in which illness represents an existential problem, and its implications for shared decision-making.

METHODS

We explore core concepts of shared decision-making in medical encounters (uncertainty, vulnerability, dependency, autonomy, power, trust, responsibility) to interpret and explain existing results and propose a broader understanding of shared-decision making for future studies.

RESULTS

Existential aspects of being are physical, social, psychological, and spiritual. Uncertainty and vulnerability caused by illness expose these aspects and may lead to dependency on the provider, which underscores that autonomy is not just an individual status, but also a varying capacity, relational of nature. In shared decision-making, power and trust are important factors that may increase as well as decrease the patient's dependency, particularly as information overload may increase uncertainty.

CONCLUSION

The fundamental uncertainty, state of vulnerability, and lack of power of the ill patient, imbue shared decision-making with a deeper existential significance and call for greater attention to the emotional and relational dimensions of care. Hence, we propose that the aim of shared decision-making should be restoration of the patient's autonomous capacity.

PRACTICE IMPLICATIONS

In doing shared decision-making, care is needed to encompass existential aspects; informing and exploring preferences is not enough.

Challenges in systematic reviews of educational intervention studies

Educators have recognized the need to apply evidence-based approaches to medical training. To do so, medical educators must have access to reliable evidence on the impact of educational interventions. This paper describes 5 methodologic challenges to performing systematic reviews of educational interventions for health care professionals: finding reports of medical education interventions, assessing quality of study designs, assessing the scope of interventions, assessing the evaluation of interventions, and synthesizing the results of educational interventions. We offer suggestions for addressing these challenges and make recommendations for reporting, reviewing, and appraising interventions in medical education.

Physician Use of Stigmatizing Language in Patient Medical Records

IMPORTANCE

Negative attitudes toward patients can adversely impact health care quality and contribute to health disparities. Stigmatizing language written in a patient's medical record can perpetuate negative attitudes and influence decision-making of clinicians subsequently caring for that patient.

OBJECTIVE

To identify and describe physician language in patient health records that may reflect, or engender in others, negative and positive attitudes toward the patient.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study analyzed randomly selected encounter notes from electronic medical records in the ambulatory internal medicine setting at an urban academic medical center. The 600 encounter notes were written by 138 physicians in 2017. Data were analyzed in 2019.

MAIN OUTCOMES AND MEASURES

Common linguistic characteristics reflecting an overall positive or negative attitude toward the patient.

RESULTS

A total of 138 clinicians wrote encounter notes about 507 patients. Of these patients, 350 (69%) were identified as female, 406 (80%) were identified as Black/African American, and 76 (15%) were identified as White. Of 600 encounter notes included in this study, there were 5 major themes representing negative language and 6 themes representing positive language. The majority of negative language was not explicit and generally fell into one or more of the following categories: (1) questioning patient credibility, (2) expressing disapproval of patient reasoning or self-care, (3) stereotyping by race or social class, (4) portraying the patient as difficult, and (5) emphasizing physician authority over the patient. Positive language was more often more explicit and included (1) direct compliments, (2) expressions of approval, (3) self-disclosure of the physician's own positive feelings toward the patient, (4) minimization of blame, (5) personalization, and (6) highlighting patient authority for their own decisions.

CONCLUSIONS AND RELEVANCE

This qualitative study found that physicians express negative and positive attitudes toward patients when documenting in the medical record. Although often not explicit, this language could potentially transmit bias and affect the quality of care that patients subsequently receive. These findings suggest that increased physician awareness when writing and reading medical records is needed to prevent the perpetuation of negative bias in medical care.

Physician respect for patients with obesity

INTRODUCTION

Obesity stigma is common in our society, and a general stigma towards obesity has also been documented in physicians. We hypothesized that physician respect for patients would be lower in patients with higher body mass index (BMI).

METHODS

We analyzed data from the baseline visit of 40 physicians and 238 patients enrolled in a randomized controlled trial of patient-physician communication. The independent variable was BMI, and the outcome was physician respect for the patient. We performed Poisson regression analyses with robust variance estimates, accounting for clustering of patients within physicians, to examine the association between BMI and physician ratings of respect for particular patients.

RESULTS

The mean (SD) BMI of the patients was 32.9(8.1) kg/m(2). Physicians had low respect for 39% of the participants. Higher BMI was significantly and negatively associated with respect [prevalence ratio (PrR) 0.83, 95% CI: 0.73-0.95; p = 0.006; per 10 kg/m(2) increase in BMI]. BMI remained significantly associated with respect after adjustment for patient age and gender (PrR 0.86, 95%CI: 0.74-1.00; p = 0.049).

CONCLUSION

We found that higher patient BMI was associated with lower physician respect. Further research is needed to understand if lower physician respect for patients with higher BMI adversely affects the quality of care.