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1.  Association of Race Consciousness With the Patient–Physician Relationship, Medication Adherence, and Blood Pressure in Urban Primary Care Patients 
American Journal of Hypertension  2013;26(11):1346-1352.
BACKGROUND
Race consciousness (the frequency with which one thinks about his or her own race) is a measure that may be useful in assessing whether racial discrimination negatively impacts blood pressure (BP). However, the relation between race consciousness and BP has yet to be empirically tested, especially within the context of the patient–physician relationship and medication adherence.
METHODS
Race-stratified generalized estimating equations were used to assess the relationship of race consciousness on BP, measures of the patient–physician relationship, and self-reported medication adherence, controlling for patients being nested within physicians and for patient age and sex.
RESULTS
The mean age of the patients was 61.3 years, 62% were black, and 65% were women. Black patients were more likely to ever think about race than were white patients (49% vs. 21%; P < 0.001). Race-conscious blacks had significantly higher diastolic BP (79.4 vs. 74.5mm Hg; P = 0.004) and somewhat higher systolic BP (138.8 vs. 134.7mm Hg; P = 0.13) than blacks who were not race conscious. Race-conscious whites were more likely to perceive respect from their physician (57.1% vs. 25.8%; P = 0.01) but had lower medication adherence (62.4% vs. 82.9%; P = 0.05) than whites who were not race-conscious.
CONCLUSIONS
Among blacks, race consciousness was associated with higher diastolic BP. In contrast, among whites, there was no association between race consciousness and BP, but race consciousness was associated with poor ratings of adherence, despite more favorable ratings of the patient–physician relationship. Future work should explore disparities in race consciousness and its impact on health and health-care disparities.
doi:10.1093/ajh/hpt116
PMCID: PMC3790452  PMID: 23864583
adherence; blood pressure; blood pressure discrimination; disparities; hypertension; perceived quality of care; race; racism.
2.  The Impact of Health Literacy on Desire for Participation in Healthcare, Medical Visit Communication, and Patient Reported Outcomes among Patients with Hypertension 
Journal of General Internal Medicine  2013;28(11):1469-1476.
ABSTRACT
BACKGROUND
Low health literacy (HL) is associated with poor healthcare outcomes; mechanisms for these associations remain unclear.
OBJECTIVE
To elucidate how HL influences patients’ interest in participating in healthcare, medical visit communication, and patient reported visit outcomes.
DESIGN, SETTING, AND PATIENTS
Cross-sectional study of enrollment data from a randomized controlled trial of interventions to improve patient adherence to hypertension treatments. Participants were 41 primary care physicians and 275 of their patients. Prior to the enrollment visit, physicians received a minimal intervention or communication skills training and patients received a minimal intervention or a pre-visit coaching session. This resulted in four intervention groups (minimal patient/minimal physician; minimal patient/intensive physician; intensive patient/minimal physician; and intensive patient/intensive physician).
MEASUREMENTS
Rapid Estimate of Adult Literacy in Medicine; patients’ desire for involvement in decision making; communication behaviors; patient ratings of participatory decision making (PDM), trust, and satisfaction.
RESULTS
A lower percentage of patients with low versus adequate literacy had controlled blood pressure. Both groups were similarly interested in participating in medical decision making. Communication behaviors did not differ based on HL except for medical question asking by patients, which was lower among low literacy patients. This was particularly true in the intensive patient /intensive physician group (3.85 vs. 6.42 questions; p = 0.002). Overall, ratings of care didn’t differ based on HL; however, in analyses stratified by intervention assignment, patients with low literacy in minimal physician intervention groups reported significantly lower PDM scores than adequate literacy patients.
CONCLUSIONS
Patients with low and adequate literacy were similarly interested in participating in medical decision making. However, low literacy patients were less likely to experience PDM in their visits. Low literacy patients in the intensive physician intervention groups asked fewer medical questions. Patients with low literacy may be less able to respond to physicians’ use of patient-centered communication approaches than adequate literacy patients.
doi:10.1007/s11606-013-2466-5
PMCID: PMC3797328  PMID: 23690237
health literacy;  participatory decision making; patient–physician relationship; communication
3.  Anthracobunids from the Middle Eocene of India and Pakistan Are Stem Perissodactyls 
PLoS ONE  2014;9(10):e109232.
Anthracobunidae is an Eocene family of large mammals from south Asia that is commonly considered to be part of the radiation that gave rise to elephants (proboscideans) and sea cows (sirenians). We describe a new collection of anthracobunid fossils from Middle Eocene rocks of Indo-Pakistan that more than doubles the number of known anthracobunid fossils and challenges their putative relationships, instead implying that they are stem perissodactyls. Cranial, dental, and postcranial elements allow a revision of species and the recognition of a new anthracobunid genus. Analyses of stable isotopes and long bone geometry together suggest that most anthracobunids fed on land, but spent a considerable amount of time near water. This new evidence expands our understanding of stem perissodactyl diversity and sheds new light on perissodactyl origins.
doi:10.1371/journal.pone.0109232
PMCID: PMC4189980  PMID: 25295875
4.  Racial Patterns of Cardiovascular Disease Risk Factors in Serious Mental Illness and the Overall U.S. Population 
Schizophrenia research  2013;150(1):10.1016/j.schres.2013.07.022.
Background
Serious mental illness (SMI) and minority race are each associated with elevated cardiovascular disease (CVD) mortality. However, little is known about racial variation in CVD risk factors in individuals with SMI. This study aimed to determine racial patterns of CVD risk factors in individuals with SMI and to compare these patterns to those of the general population.
Methods
Overweight/obese adults with SMI (163 whites; 111 African Americans) examined from 2008 to 2011 during a weight loss trial were compared at study baseline to overweight/obese adults (1103 whites; 550 African Americans) of similar age, sex, and race in the 2007 to 2010 National Health and Nutrition Examination Survey.
Results
All CVD risk factors except cholesterol were higher in SMI than the overall U.S. population. After adjusting for age and sex, both racial groups with SMI had similarly high risks of smoking, obesity, diabetes, and hypertension, while African Americans with SMI had lower risks of high cholesterol (RR 0.73; 95% CI 0.57–0.94) and metabolic syndrome (RR 0.75; 95% CI 0.63–0.91) than whites with SMI. In the U.S. population sample, African Americans compared to whites had higher risks of obesity (RR 1.23; 95% CI 1.14–1.34), diabetes (RR 1.68; 95% CI 1.21–2.34), and hypertension (RR 1.44; 95% CI 1.31–1.60) but no significant difference in smoking, high cholesterol, and metabolic syndrome.
Conclusions
Compared to the general population, the greater burden and dissimilar racial pattern of CVD risk factors in SMI underscore the need for CVD prevention programs targeting the SMI population.
doi:10.1016/j.schres.2013.07.022
PMCID: PMC3821976  PMID: 23916188
cardiovascular disease risk factors; serious mental illness; racial disparities; obesity; diabetes; hypertension
6.  The impact of depressive symptoms on patient–provider communication in HIV care 
AIDS care  2013;25(9):1185-1192.
Persons with HIV who develop depression have worse medical adherence and outcomes. Poor patient–provider communication may play a role in these outcomes. This cross-sectional study evaluated the influence of patient depression on the quality of patient–provider communication. Patient–provider visits (n = 406) at four HIV care sites were audio-recorded and coded with the Roter Interaction Analysis System (RIAS). Negative binomial and linear regressions using generalized estimating equations tested the association of depressive symptoms, as measured by the Center for Epidemiology Studies Depression scale (CES-D), with RIAS measures and postvisit patient-rated quality of care and provider-reported regard for his or her patient. The patients, averaged 45 years of age (range = 20–77), were predominately male (n = 286, 68.5%), of black race (n = 250, 60%), and on antiretroviral medications (n = 334, 80%). Women had greater mean CES-D depression scores (12.0) than men (10.6; p = 0.03). There were no age, race, or education differences in depression scores. Visits with patients reporting severe depressive symptoms compared to those reporting none/mild depressive symptoms were longer and speech speed was slower. Patients with severe depressive symptoms did more emotional rapport building but less social rapport building, and their providers did more data gathering/counseling (ps < 0.05). In postvisit questionnaires, providers reported lower levels of positive regard for, and rated more negatively patients reporting more depressive symptoms (p < 0.01). In turn, patients reporting more depressive symptoms felt less respected and were less likely to report that their provider knows them as a person than none/mild depressive symptoms patients (ps < 0.05). Greater psychosocial needs of patients presenting with depressive symptoms and limited time/resources to address these needs may partially contribute to providers’ negative attitudes regarding their patients with depressive symptoms. These negative attitudes may ultimately serve to adversely impact patient–provider communication and quality of HIV care.
doi:10.1080/09540121.2012.752788
PMCID: PMC4090599  PMID: 23320529
depression; communication; quality of health care; patient satisfaction; HIV
7.  In vitro reconstitution of the radical SAM enzyme MqnC involved in the biosynthesis of futalosine-derived menaquinone 
Biochemistry  2013;52(27):10.1021/bi400498d.
The radical S-adenosylmethionine (SAM) enzyme MqnC catalyzes conversion of dehypoxanthine futalosine (DHFL) to the unique spiro-compound cyclic DHFL in the futalosine pathway for menaquinone biosynthesis. This study describes the in vitro reconstitution of [4Fe-4S]-cluster-dependent MqnC activity and identifies the site of hydrogen atom abstraction from DHFL by the adenosyl radical.
doi:10.1021/bi400498d
PMCID: PMC3855634  PMID: 23763543
Menaquinone; futalosine; radical SAM enzyme
9.  Reversal of Substrate Specificity of CMP N-glycosidase to dCMP†,‡ 
Biochemistry  2013;52(23):4037-4047.
MilB is a CMP hydrolase involved in the early steps of biosynthesis of the antifungal compound mildiomycin. An enzyme from the bacimethrin biosynthetic pathway, BcmB, is closely related in both sequence and function to MilB. These two enzymes belong to the nucleoside 2′-deoxyribosyltransferase (NDT) superfamily. NDTs catalyze N-glycosidic bond cleavage of 2′-deoxynucleosides via a covalent 2-deoxyribosyl-enzyme intermediate. Conservation of key active site residues suggests that members of the NDT superfamily share a common mechanism; however, the enzymes differ in their substrate preferences. Substrates vary in the type of nucleobase, the presence or absence of a 2′-hydroxyl group, and the presence or absence of a 5′-phosphate group. We have determined the structures of MilB and BcmB and compared them to previously determined structures of NDT superfamily members. The comparisons reveal how these enzymes differentiate between ribosyl and deoxyribosyl nucleotides or nucleosides, and among different nucleobases. The 1.6 Å structure of the MilB-CMP complex reveals an active site feature that is not obvious from sequence comparisons alone. MilB and BcmB that prefer substrates containing 2′-ribosyl groups have a phenylalanine positioned in the active site whereas NDT family members with preference for 2′-deoxyribosyl groups have a tyrosine residue. Further studies show that the phenylalanine is critical for MilB and BcmB specificity towards CMP, and mutation of this phenylalanine residue to tyrosine results in a 1000-fold reversal of substrate specificity from CMP to dCMP.
doi:10.1021/bi400316p
PMCID: PMC3750073  PMID: 23659472
10.  Disparities in trauma care and outcomes in the United States: A systematic review and meta-analysis 
Background
Race and socioeconomic disparities are pervasive and persist throughout our health care system. Inequities have also been identified in outcomes after trauma despite its immediate nature and the perceived equal access to emergent care.
Objectives
Our objective was to systematically evaluate the current literature on the association between trauma mortality and race, insurance status, and socioeconomic status. Our secondary objective was to assess data investigating potential mechanisms underlying these outcome disparities.
Methods
We performed a systematic review and random effects meta-analysis to examine the relationship between trauma and race, insurance, and socioeconomic disparities published between April 1990 and October 2011. The Cochrane Review Handbook and the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) statement were used as guides.
Results
Thirty-five studies were included in the final review. The current body of literature indicates that uninsured status is an independent negative predictor of trauma outcomes. Our meta-analysis corroborated this by demonstrating that uninsured patients were more likely to die than privately insured patients (OR 2.17 95% CI 1.51–3.11). Racial disparities in trauma outcomes are shown to be present and independent for black patients compared to whites. Our meta-analysis demonstrated that black race was associated with higher odds of death when compared with white race (OR 1.19 95% CI 1.09 – 1.31). Studies comparing Hispanic and white non-Hispanic patients’ post-trauma mortality outcomes, however, have provided conflicting results. Our meta-analysis found no significant difference in mortality comparing Hispanic patients with white patients (OR 1.08 95% CI 0.99–1.18)
Conclusions
Both race/ethnicity and insurance are clearly associated with disparate outcomes following trauma. These disparities are likely due to myriad factors across the trauma continuum of care: host factors, prehospital factors, hospital/provider factors, and factors associated with postacute care and rehabilitation. While there are many proposed mechanisms, we believe that there are several interventions that could be particularly effective in combatting trauma disparities. These include trauma prevention programs targeting vulnerable populations, expansion of healthcare coverage, relocation of trauma centers to better provide for vulnerable populations, and restructuring clinical training to address implicit biases. While much work still remains to fully elucidate the mechanisms underlying trauma disparities, we can and should now act to begin to reduce or eliminate these disparities that still plague our healthcare system.
Level of Evidence
Two.
doi:10.1097/TA.0b013e31828c331d
PMCID: PMC3641534  PMID: 23609267
11.  Insurance Coverage for Weight Loss 
Background
Given the prevalence of obesity and associated chronic conditions among U.S. adults, wellness benefits are an increasingly popular approach to promoting weight loss.
Purpose
The goal of the study was to assess overweight and obese adults’ beliefs about the helpfulness of insurance coverage of weight loss–related benefits, their willingness to pay for such benefits, and whether these opinions differ by individuals’ weight or health insurance type.
Methods
A national survey was fielded in 2012 am ong non-pregnant, overweight and obese adults who had seen a primary care provider in the past year (n=600). Descriptive statistics summarized beliefs about which weight loss–related benefits would be helpful, willingness to pay for such benefits, and agreement about whether health insurers should be able to charge more to obese individuals. Multivariable logistic regression was employed to determine whether beliefs differed by weight category or health insurance type. Analyses were conducted in July 2012.
Results
The majority (83%) of respondents cited a specific benefit as helpful. Those with private health insurance had a higher probability (89%, 95% CI=86%, 93%) of endorsing any benefit as helpful relative to those with other types of health insurance. Being obese relative to overweight was associated with greater support (57% vs 39%, p<0.05) for preventing health insurers from charging higher premiums to obese individuals.
Conclusions
In this sample of overweight adults, a large proportion endorsed the value of weight loss–related benefits offered by health plans. However, only about one third were willing to pay extra for them, and half disagreed with the notion that health plans should charge more to obese individuals. Given evidence of their effectiveness, wellness benefits should be offered to all individuals.
doi:10.1016/j.amepre.2013.01.021
PMCID: PMC3671931  PMID: 23597807
12.  Physicians build less rapport with obese patients 
Obesity (Silver Spring, Md.)  2013;21(10):2146-2152.
Objective
Physicians’ negative attitudes towards patients with obesity are well documented. Whether or how these beliefs may affect patient-physician communication is unknown. We aimed to describe the relationship between patient BMI and physician communication behaviors (biomedical, psychosocial/lifestyle, and rapport building) during typical outpatient primary care visits.
Design and Methods
Using audio-recorded outpatient encounters from 39 urban PCPs and 208 of their patients, we examined the frequency of communication behaviors using the Roter Interaction Analysis System. The independent variable was measured patient BMI and dependent variables were communication behaviors by the PCP within the biomedical, psychosocial/lifestyle, and rapport building domains. We performed a cross-sectional analysis using multilevel Poisson regression models to evaluate the association between BMI and physician communication.
Results
PCPs demonstrated less emotional rapport with overweight and obese patients (IRR 0.65, 95%CI 0.48–0.88, p=0.01; IRR 0.69, 95%CI 0.58–0.82, p<0.01, respectively) than for normal weight patients. We found no differences in PCPs’ biomedical or psychosocial/lifestyle communication by patient BMI.
Conclusions
Our findings raise the concern that low levels of emotional rapport in primary care visits with overweight and obese patients may weaken the patient-physician relationship, diminish patients’ adherence to recommendations, and decrease the effectiveness of behavior change counseling.
doi:10.1002/oby.20384
PMCID: PMC3694993  PMID: 23512862
Obesity; patient-provider; primary care; psychosocial research
13.  Physician Communication Behaviors and Trust among Black and White Patients with Hypertension 
Medical care  2013;51(2):151-157.
Background
Racial differences in patient trust have been observed, but it is unclear which physician communication behaviors are related to trust, and whether the relationship of communication and trust differs among black and white patients.
Objective
We sought to determine whether there were associations between physician communication behaviors, visit process measures and patient trust, particularly within racial groups.
Methods
Study participants included 39 primary care physicians and 227 black and white hypertensive patients from community-based practices in Baltimore, Maryland. Physician informational and affective communication behaviors and visit process measures were coded from visit audiotapes using the Roter Interaction Analysis System. Patient trust was measured using items from the Trust in Physician Scale, and dichotomized (high/low). Logistic regression analysis using generalized estimating equations was used to assess the association of each physician communication behavior and visit process measure with patient trust, among the entire sample and then stratified by patient race.
Results
Positive physician affect and longer visits were significantly associated with high patient trust in unadjusted analyses. After adjustment for covariates, positive physician affect remained a significant predictor of high patient trust in the overall sample (OR 1.26; 95%CI 1.08, 1.48; p=0.004) and after stratification by race, among black patients (OR 1.35; 95%CI 1.09, 1.67; p=0.006).
Conclusion
Physician communication behaviors may have a varying effect on patient trust, depending on patient race. Communication skills training programs targeting emotion-handling and rapport-building behaviors are promising strategies to reduce disparities in healthcare and to enhance trust among ethnic minority patients.
doi:10.1097/MLR.0b013e31827632a2
PMCID: PMC3552122  PMID: 23132201
patient-physician communication; trust; African Americans
14.  Patient Trust in Physicians and Adoption of Lifestyle Behaviors to Control High Blood Pressure 
Objective
To assess the relationship between patients’ trust in their physician and self-reported adoption of lifestyle modification behaviors and medication adherence for control of hypertension.
Methods
Longitudinal analysis of data from a randomized controlled trial of interventions to enhance hypertensive patients’ adherence to medications and recommended lifestyle modifications. Two hundred patients were seen by 41 physicians at 14 urban primary care practices in Baltimore, Maryland, and followed for 12 months.
Results
Seventy percent of patients reported complete trust in their physician. In adjusted analyses, patients with complete trust had higher odds of reporting that they were trying to lose weight (OR=2.27, 95% CI=1.38–3.74) than did patients with less than complete trust in their physician. Though not statistically significant, the odds of reporting trying to cut back on salt and engaging in regular exercise were greater in patients with complete trust. We observed no association for reports of medication adherence.
Conclusion
Trust in one’s physician predicts attempts to lose weight among patients with hypertension, and may contribute to attempts to reduce salt and increase exercise.
Practice Implications
Strengthening patient-physician relationships through efforts to enhance trust may be a promising strategy to enhance patients’ engagement in healthy lifestyle behaviors for hypertension.
doi:10.1016/j.pec.2012.06.003
PMCID: PMC3462260  PMID: 22770676
adherence; African-Americans; blood pressure control; hypertension; lifestyle modification; trust
15.  Impact of Patient–Doctor Race Concordance on Rates of Weight-Related Counseling in Visits by Black and White Obese Individuals 
Obesity (Silver Spring, Md.)  2011;20(3):562-570.
The objective of this study was to assess the impact of patient-provider race concordance on weight-related counseling among visits by obese patients. We hypothesized that race concordance would be positively associated with weight-related counseling. We used clinical encounter data obtained from the 2005–2007 National Ambulatory Medical Care Surveys (NAMCS). The sample size included 2,231 visits of black and white obese individuals (ages 20 and older) to their black and white physicians from the specialties of general/family practice and general internal medicine. Three outcome measures of weight-related counseling were explored: weight reduction, diet/nutrition, and exercise. Logistic regression was used to model the outcome variables of interest. Wald tests were used to statistically compare whether physicians of each race provided counseling at different rates for obese patients of different races. We did not observe a positive association between patient–physician race concordance and weight-related counseling. We found that visits by black obese patients to white doctors had a lower odds of exercise counseling as compared to visits by white obese patients to white doctors (odds ratio (OR) = 0.54; 95% confidence interval (CI): 0.31, 0.95), and visits by black obese patients to black physicians had lower odds of receiving weight-reduction counseling than visits among white obese patients seeing black physicians (OR = 0.34; 95% CI: 0.13, 0.90). Black obese patients receive less exercise counseling than white obese patients in visits to white physicians and may be less likely than white obese patients to receive weight-reduction counseling in visits to black physicians.
doi:10.1038/oby.2010.330
PMCID: PMC3786341  PMID: 21233803
16.  Do physician beliefs about causes of obesity translate into actionable issues on which physicians counsel their patients? 
Preventive medicine  2013;56(5):326-328.
Objective
To describe the relationship between primary care physicians’ (PCPs’) beliefs about the causes of obesity with the frequency of nutritional counseling.
Methods
We analyzed a national cross-sectional internet-based survey of 500 US PCPs collected between February and March 2011.
Results
PCPs that identified overconsumption of food as a very important cause of obesity had significantly greater odds of counseling patients to reduce portion sizes (OR 3.40; 95%CI: 1.73–6.68) and to avoid high calorie ingredients when cooking (OR 2.16; 95%CI: 1.07–4.33). Physicians who believed that restaurant/fast food eating was a very important cause of obesity had significantly greater odds of counseling patients to avoid high calorie menu items outside the home (OR 1.93; 95%CI: 1.20–3.11). Physicians who reported that sugar-sweetened beverages were a very important cause of obesity had significantly greater odds of counseling their obese patients to reduce consumption (OR 5.99; 95%CI: 3.53–10.17).
Conclusions
PCP beliefs about the diet-related causes of obesity may translate into actionable nutritional counseling topics for physicians to use with their patients.
doi:10.1016/j.ypmed.2013.01.012
PMCID: PMC3745015  PMID: 23399006
Obesity; Physician beliefs; Nutrition counseling
17.  How does physician BMI impact patient trust and perceived stigma? 
Preventive medicine  2013;57(2):120-124.
Objective
The objective is to evaluate whether physician body mass index (BMI) impacts their patients’ trust or perceptions of weight-related stigma.
Methods
We used a national cross-sectional survey of 600 non-pregnant overweight and obese patients conducted between April 5 and April 13, 2012. The outcome variables were patient trust (overall and by type of advice) and patient perceptions of weight-related stigma. The independent variable of interest was primary care physician (PCP) BMI. We conducted multivariate regression analyses to determine whether trust or perceived stigma differed by physician BMI, adjusting for covariates.
Results
Patients reported high levels of trust in their PCPs, regardless of the PCPs body weight (normal BMI = 8.6; overweight = 8.3; obese = 8.2; where 10 is the highest). Trust in diet advice was significantly higher among patients seeing overweight PCPs as compared to normal BMI PCPs (87% vs. 77%, p = 0.04). Reports of feeling judged by their PCP were significantly higher among patients seeing obese PCPs (32%; 95% confidence interval (CI): 23–41) as compared to patients seeing normal BMI PCPs (14%; 95% CI: 7–20).
Conclusion
Overweight and obese patients generally trust their PCP, but they more strongly trust diet advice from overweight PCPs as compared to normal BMI PCPs.
doi:10.1016/j.ypmed.2013.05.005
PMCID: PMC3745018  PMID: 23743418
Physician BMI; Patient trust; Weight stigma; Weight-related advice
18.  Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members 
Introduction
We aimed to inform the design of behavioral interventions by identifying patients’ and their family members’ perceived facilitators and barriers to hypertension self-management.
Materials and methods
We conducted focus groups of African American patients with hypertension and their family members to elicit their views about factors influencing patients’ hypertension self-management. We recruited African American patients with hypertension (n = 18) and their family members (n = 12) from an urban, community-based clinical practice in Baltimore, Maryland. We conducted four separate 90-minute focus groups among patients with controlled (one group) and uncontrolled (one group) hypertension, as well as their family members (two groups). Trained moderators used open-ended questions to assess participants’ perceptions regarding patient, family, clinic, and community-level factors influencing patients’ effective hypertension self-management.
Results
Patient participants identified several facilitators (including family members’ support and positive relationships with doctors) and barriers (including competing health priorities, lack of knowledge about hypertension, and poor access to community resources) that influence their hypertension self-management. Family members also identified several facilitators (including their participation in patients’ doctor’s visits and discussions with patients’ doctors outside of visits) and barriers (including their own limited health knowledge and patients’ lack of motivation to sustain hypertension self-management behaviors) that affect their efforts to support patients’ hypertension self-management.
Conclusion
African American patients with hypertension and their family members reported numerous patient, family, clinic, and community-level facilitators and barriers to patients’ hypertension self-management. Patients’ and their family members’ views may help guide efforts to tailor behavioral interventions designed to improve hypertension self-management behaviors and hypertension control in minority populations.
doi:10.2147/PPA.S46517
PMCID: PMC3743518  PMID: 23966772
hypertension; patient perspective; qualitative research; health disparities
19.  Obese patients overestimate physicians’ attitudes of respect 
Objective
To evaluate whether obese patients overestimate or underestimate the level of respect that their physicians hold towards them.
Methods
We performed a cross-sectional analysis of data from questionnaires and audio-recordings of visits between primary care physicians and their patients. Using multilevel logistic regression, we evaluated the association between patient BMI and accurate estimation of physician respect. Physician respectfulness was also rated independently by assessing the visit audiotapes.
Results
Thirty-nine primary care physicians and 199 of their patients were included in the analysis. The mean patient BMI was 32.8 kg/m2 (SD 8.2). For each 5 kg/m2 increase in BMI, the odds of overestimating physician respect significantly increased [OR 1.32, 95%CI 1.04–1.68, p=0.02]. Few patients underestimated physician respect. There were no differences in ratings of physician respectfulness by independent evaluators of the audiotapes.
Conclusion
We consider our results preliminary. Patients were significantly more likely to overestimate physician respect as BMI increased, which was not accounted for by increased respectful treatment by the physician.
Practice Implications
Among patients who overestimate physician respect, the authenticity of the patient-physician relationship should be questioned.
doi:10.1016/j.pec.2011.12.010
PMCID: PMC3340528  PMID: 22240006
Obesity; patient-provider; respect
20.  Association of Unconscious Race and Social Class Bias With Vignette-Based Clinical Assessments by Medical Students 
Context
Studies involving physicians suggest that unconscious bias may be related to clinical decision making and may predict poor patient-physician interaction. The presence of unconscious race and social class bias and its association with clinical assessments or decision making among medical students is unknown.
Objective
To estimate unconscious race and social class bias among first-year medical students and investigate its relationship with assessments made during clinical vignettes.
Design, Setting, and Participants
A secure Web-based survey was administered to 211 medical students entering classes at Johns Hopkins School of Medicine, Baltimore, Maryland, in August 2009 and August 2010. The survey included the Implicit Association Test (IAT) to assess unconscious preferences, direct questions regarding students’ explicit race and social class preferences, and 8 clinical assessment vignettes focused on pain assessment, informed consent, patient reliability, and patient trust. Adjusting for student demographics, multiple logistic regression was used to determine whether responses to the vignettes were associated with unconscious race or social class preferences.
Main Outcome Measures
Association of scores on an established IAT for race and a novel IAT for social class with vignette responses.
Results
Among the 202 students who completed the survey, IAT responses were consistent with an implicit preference toward white persons among 140 students (69%, 95% CI, 61%–75%). Responses were consistent with a preference toward those in the upper class among 174 students (86%, 95% CI, 80%–90%). Assessments generally did not vary by patient race or occupation, and multivariable analyses for all vignettes found no significant relationship between implicit biases and clinical assessments. Regression coefficient for the association between pain assessment and race IAT scores was −0.49 (95% CI, −1.00 to 0.03) and for social class, the coefficient was −0.04 (95% CI, −0.50 to 0.41). Adjusted odds ratios for other vignettes ranged from 0.69 to 3.03 per unit change in IAT score, but none were statistically significant. Analysis stratified by vignette patient race or class status yielded similarly negative results. Tests for interactions between patient race or class status and student IAT D scores in predicting clinical assessments were not statistically significant.
Conclusions
The majority of first-year medical students at a single school had IAT scores consistent with implicit preference for white persons and possibly for those in the upper class. However, overall vignette-based clinical assessments were not associated with patient race or occupation, and no association existed between implicit preferences and the assessments.
doi:10.1001/jama.2011.1248
PMCID: PMC3684149  PMID: 21900134
21.  Association Between Hospitals Caring for a Disproportionately High Percentage of Minority Trauma Patients and Increased Mortality 
Objective
To determine whether there is an increased odds of mortality among trauma patients treated at hospitals with higher proportions of minority patients (ie, black and Hispanic patients combined).
Design
Hospitals were categorized on the basis of the percentage of minority patients admitted with trauma. The adjusted odds of in-hospital mortality were compared between hospitals with less than 25% of patients who were minorities (the reference group) and hospitals with 25% to 50% of patients who were minorities and hospitals with more than 50% of patients who were minorities. Multivariate logistic regression (with generalized linear modeling and a cluster-correlated robust estimate of variance) was used to control for multiple patient and injury severity characteristics.
Setting
A total of 434 hospitals in the National Trauma Data Bank.
Participants
Patients aged 18 to 64 years whose medical records were included in the National Trauma Data Bank for the years 2007 and 2008 with an Injury Severity Score of 9 or greater and who were white, black, or Hispanic.
Main Outcome Measures
Crude mortality and adjusted odds of in-hospital mortality.
Results
A total of 311 568 patients were examined. Hospitals in which the percentage of minority patients was more than 50% also had younger patients, fewer female patients, more patients with penetrating trauma, and the highest crude mortality. After adjustment for potential confounders, patients treated at hospitals in which the percentage of minority patients was 25% to 50% and at hospitals in which the percentage of minority patients was more than 50% demonstrated increased odds of death (adjusted odds ratio, 1.16 [95% confidence interval, 1.01–1.34] and adjusted odds ratio, 1.37 [95% confidence interval, 1.16–1.61], respectively), compared with the reference group. This disparity increased further on subset analysis of patients with a blunt injury. Uninsured patients had significantly increased odds of mortality within all 3 hospital groups.
Conclusions
Patients treated at hospitals with higher proportions of minority trauma patients have increased odds of dying, even after adjusting for potential confounders. Differences in outcomes between trauma hospitals may partly explain racial disparities.
doi:10.1001/archsurg.2011.254
PMCID: PMC3684151  PMID: 21930976
22.  Patient–Physician Gender Concordance and Weight-Related Counseling of Obese Patients 
Background
Obesity affects approximately one third of Americans. Patient and provider characteristics such as gender may influence obesity care. Gender concordance has been associated with clinical practice patterns in chronic conditions such as hypertension and diabetes, but its role in obesity care is unknown.
Purpose
The purpose of this study was to investigate the association of patient–physician gender concordance with weight-related counseling among obese adults.
Methods
A cross-sectional study using the 2005–2007 National Ambulatory Medical Care Survey was conducted in 2010. Postvisit data from the clinical encounters of 5667 obese individuals and their physicians were analyzed to determine the association between patient– physician gender concordance (categorized using patient gender as the reference point as female gender-concordant, male gender-concordant, male gender-discordant and female gender-discordant) and three types of weight-related counseling (diet/nutrition, exercise, and weight reduction).
Results
Diet/nutrition, exercise, and weight reduction counseling was provided to 30%, 23%, and 20% of obese patients, respectively. Patients in male gender-concordant patient–physician pairs had significantly higher adjusted odds of receiving diet/nutrition (OR 1.58; 95% CI: 1.05, 2.40) and exercise counseling (1.76; 95% CI: 1.13, 2.74) than female gender-concordant pairs. There were no significant differences in any form of weight-related counseling between female gender-concordant and gender-discordant pairs.
Conclusions
The findings of this study suggest that male patient–physician gender concordance is positively associated with diet/nutrition and exercise counseling.
doi:10.1016/j.amepre.2011.02.020
PMCID: PMC3675445  PMID: 21565652
23.  A multi-level system quality improvement intervention to reduce racial disparities in hypertension care and control: study protocol 
Background
Racial disparities in blood pressure control have been well documented in the United States. Research suggests that many factors contribute to this disparity, including barriers to care at patient, clinician, healthcare system, and community levels. To date, few interventions aimed at reducing hypertension disparities have addressed factors at all of these levels. This paper describes the design of Project ReD CHiP (Reducing Disparities and Controlling Hypertension in Primary Care), a multi-level system quality improvement project. By intervening on multiple levels, this project aims to reduce disparities in blood pressure control and improve guideline concordant hypertension care.
Methods
Using a pragmatic trial design, we are implementing three complementary multi-level interventions designed to improve blood pressure measurement, provide patient care management services and offer expanded provider education resources in six primary care clinics in Baltimore, Maryland. We are staggering the introduction of the interventions and will use Statistical Process Control (SPC) charting to determine if there are changes in outcomes at each clinic after implementation of each intervention. The main hypothesis is that each intervention will have an additive effect on improvements in guideline concordant care and reductions in hypertension disparities, but the combination of all three interventions will result in the greatest impact, followed by blood pressure measurement with care management support, blood pressure measurement with provider education, and blood pressure measurement only. This study also examines how organizational functioning and cultural competence affect the success of the interventions.
Discussion
As a quality improvement project, Project ReD CHiP employs a novel study design that specifically targets multi-level factors known to contribute to hypertension disparities. To facilitate its implementation and improve its sustainability, we have incorporated stakeholder input and tailored components of the interventions to meet the specific needs of the involved clinics and communities. Results from this study will provide knowledge about how integrated multi-level interventions can improve hypertension care and reduce disparities.
Trial Registration
ClinicalTrials.gov NCT01566864
doi:10.1186/1748-5908-8-60
PMCID: PMC3680084  PMID: 23734703
Quality improvement; Hypertension; Health disparities; Pragmatic trial; Organizational culture; Community-based participatory research; Study design
24.  National survey of US primary care physicians’ perspectives about causes of obesity and solutions to improve care 
BMJ Open  2012;2(6):e001871.
Objective
To describe physician perspectives on the causes of and solutions to obesity care and identify differences in these perspectives by number of years since completion of medical school.
Design
National cross-sectional online survey from 9 February to 1 March 2011.
Setting
USA.
Participants
500 primary care physicians.
Main Measures
We evaluated physician perspectives on: (1) causes of obesity, (2) competence in treating obese patients, (3) perspectives on the health professional most qualified to help obese patients lose or maintain weight and (4) solutions for improving obesity care.
Results
Primary care physicians overwhelmingly supported additional training (such as nutrition counselling) and practice-based changes (such as having scales report body mass index) to help them improve their obesity care. They also identified nutritionists/dietitians as the most qualified providers to care for obese patients. Physicians with fewer than 20 years since completion of medical school were more likely to identify lack of information about good eating habits and lack of access to healthy food as important causes of obesity. They also reported feeling relatively more successful helping obese patients lose weight. The response rate for the survey was 25.6%.
Conclusions
Our results indicate a perceived need for improved medical education related to obesity care.
doi:10.1136/bmjopen-2012-001871
PMCID: PMC3533040  PMID: 23257776
Medical Education & Training; Internal Medicine
25.  Patient-Physician Social Concordance, Medical Visit Communication and Patients’ Perceptions of Health Care Quality 
Patient education and counseling  2011;85(3):e201-e208.
Social characteristics (e.g. race, gender, age, education) are associated with health care disparities. We introduce social concordance, a composite measure of shared social characteristics between patients and physicians.
Objective
To determine whether social concordance predicts differences in medical visit communication and patients’ perceptions of care.
Methods
Regression analyses were used to determine the association of patient-provider social concordance with medical visit communication and patients’ perceptions of care using data from two observational studies involving 64 primary care physicians and 489 of their patients from the Baltimore, MD /Washington, DC/Northern Virginia area.
Results
Lower patient-physician social concordance was associated with less positive patient perceptions of care and lower positive patient affect. Patient-physician dyads with low vs. high social concordance reported lower ratings of global satisfaction with office visits (OR=0.64 vs. OR=1.37, p=0.036) and were less likely to recommend their physician to a friend (OR=0.61vs. OR=1.37, p=0.035). A graded-response was observed for social concordance with patient positive affect and patient perceptions of care.
Conclusion
Patient-physician concordance across multiple social characteristics may have cumulative effects on patient-physician communication and perceptions of care.
Practice Implications
Research should move beyond one-dimensional measures of patient-physician concordance to understand how multiple social characteristics influence health care quality.
doi:10.1016/j.pec.2011.07.015
PMCID: PMC3217162  PMID: 21840150
patient-provider communication; health care disparities; patient-provider concordance

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