To assess the reliability, applicability, and validity of a refined system (taxonomy of requests by patients [TORP]) for characterizing patient requests and physician responses in office practice.
Data were obtained from visits to six general internists practicing in North-Central California in 1994 and eight cardiologists practicing in the same region in 1998.
This was an observational study of patient requests and physician responses in two practice settings. Patients were surveyed before and after the visit. Physicians were surveyed immediately after the visit, and all visits were audio recorded for future study.
Data Collection/Extraction Methods
TORP was refined using input from a multidisciplinary panel. Audiotape recordings of 131 visits (71 in internal medicine and 60 in cardiology) were rated independently by two coders. Estimates of classifying reliability (intercoder agreement on the sorting of requests into categories) and unitizing reliability (intercoder agreement on the labeling of elements of discourse as “requests” and subsequent classification into categories) were calculated. Validity was assessed by testing three specific hypotheses concerning the antecedents and consequences of patient requests and request fulfillment.
The overall unitizing kappa for identifying patients' requests was 0.64, and the classification kappa was 0.73, indicating substantial agreement beyond chance. The average patient made 4.19 requests for information and 0.88 requests for physician action; there were few differences in the spectrum of requests between internal medicine and cardiology. Approximately 15 percent of visits included a direct request for completion of paperwork. Patients who were very or extremely worried about their health made more requests than those who were not (6.06 vs. 3.89, p < 0.05). Visits involving more patient requests took longer (p < 0.05) and were perceived as more demanding by the treating physician (p = 0.025). The vast majority of requests were fulfilled.
The refined TORP shows evidence of both unitizing and classification reliability and should be a useful tool for understanding the clinical negotiation. In addition the system appears applicable to both generalist and specialist practices. More experience with the system is necessary to appraise TORP's ability to predict important clinical outcomes.
This study examined the effect of a theoretically grounded, tailored education-coaching intervention to help patients more effectively discuss their pain-related questions, concerns, and preferences with physicians.
Grounded in social-cognitive and communication theory, a tailored education coaching (TEC) intervention was developed to help patients learn pain management and communication skills. In a RCT, 148 cancer patients agreed to have their consultations audio-recorded and were assigned to the intervention or a control group. The recordings were used to code for patients’ questions, acts of assertiveness, and expressed concerns and to rate the quality of physicians’ communication.
Patients in the TEC group discussed their pain concerns more than did patients in the control group. More active patients also had more baseline pain and interacted with physicians using participatory decision-making. Ratings of physicians’ information about pain were higher when patients talked more about their pain concerns.
The study demonstrates the efficacy of a theoretically grounded, coaching intervention to help cancer patients talk about pain control.
Coaching interventions can be effective resources for helping cancer patients communicate about their pain concerns if they are theoretically grounded, can be integrated within clinical routines, and lead to improve health outcomes.
Physician-patient communication; cancer; pain; patient participation
Cancer-related pain is common and under-treated. This article describes a study designed to test the effectiveness of a theory-driven, patient-centered coaching intervention to improve cancer pain processes and outcomes.
The Cancer Health Empowerment for Living without Pain (Ca-HELP) Study is an American Cancer Society sponsored randomized trial conducted in Sacramento, California. A total of 265 cancer patients with at least moderate pain severity (Worst Pain Numerical Analog Score >=4 out of 10) or pain-related impairment (Likert score >= 3 out of 5) were randomly assigned to receive tailored education and coaching (TEC) or educationally-enhanced usual care (EUC); 258 received at least one follow-up assessment. The TEC intervention is based on social-cognitive theory and consists of 6 components (assess, correct, teach, prepare, rehearse, portray). Both interventions were delivered over approximately 30 minutes just prior to a scheduled oncology visit. The majority of visits (56%) were audio-recorded for later communication coding. Follow-up data including outcomes related to pain severity and impairment, self-efficacy for pain control and for patient-physician communication, functional status and well-being, and anxiety were collected at 2, 6, and 12 weeks.
Building on social cognitive theory and pilot work, this study aims to test the hypothesis that a brief, tailored patient activation intervention will promote better cancer pain care and outcomes. Analyses will focus on the effects of the experimental intervention on pain severity and impairment (primary outcomes); self-efficacy and quality of life (secondary outcomes); and relationships among processes and outcomes of cancer pain care. If this model of coaching by lay health educators proves successful, it could potentially be implemented widely at modest cost.
[Clinical Trials Identifier: NCT00283166]
Effective communication is a critical component of quality health care, and to improve it we must understand its dynamics. This investigation examined the extent to which physicians' and patients' preferences for control in their relationship (e.g., shared control vs doctor control) were related to their communications styles and adaptations (i.e., how they responded to the communication of the other participant).
Stratified case-controlled study.
Twenty family medicine and internal medicine physicians and 135 patients.
Based on scores from the Patient-Practitioner Orientation Scale, 10 patient-centered physicians (5 male, 5 female) and 10 doctor-centered physicians (5 male, 5 female) each interacted with 5 to 8 patients, roughly half of whom preferred shared control and the other half of whom were oriented toward doctor control. Audiotapes of 135 consultations were coded for behaviors indicative of physician partnership building and active patient participation.
Patients who preferred shared control were more active participants (i.e., expressed more opinions, concerns, and questions) than were patients oriented toward doctor control. Physicians' beliefs about control were not related to their use of partnership building. However, physicians did use more partnership building with male patients. Not only were active patient participation and physician partnership building mutually predictive of each other, but also approximately 14% of patient participation was prompted by physician partnership building and 33% of physician partnership building was in response to active patient participation.
Communication in medical encounters is influenced by the physician's and patient's beliefs about control in their relationship as well as by one another's behavior. The relationship between physicians' partnership building and active patient participation is one of mutual influence such that increases in one often lead to increases in the other.
physician-patient communication; patient participation; control; gender
Commercial advertising and patient education have separate theoretical underpinnings, approaches, and practitioners. This paper aims to describe a collaboration between academic researchers and a marketing firm working to produce demographically targeted public service anouncements (PSAs) designed to enhance depression care-seeking in primary care.
An interdisciplinary group of academic researcherss contracted with a marketing firm in Rochester, NY to produce PSAs that would help patients with depressive symptoms engage more effectively with their primary care physicians (PCPs). The researchers brought perspectives derived from clinical experience and the social sciences and conducted empirical research using focus groups, conjoint analysis, and a population-based survey. Results were shared with the marketing firm, which produced four PSA variants targeted to gender and socioeconomic position.
There was no simple, one-to-one relationship between research results and the form, content, or style of the PSAs. Instead, empirical findings served as a springboard for discussion and kept the creative process tethered to the experiences, attitudes, and opinions of actual patients. Reflecting research findings highlighting patients’ struggles to recognize, label, and disclose depressive symptoms, the marketing firm generated communication objectives that emphasized: a) educating the patient to consider and investigate the possibility of depression; b) creating the belief that the PCP is interested in discussing depression and capable of offering helpful treatment; and c) modelling different ways of communicating with physicians about depression. Before production, PSA prototypes were vetted with additional focus groups.
The winning prototype, “Faces,” involved a multi-ethnic montage of formerly depressed persons talking about how depression affected them and how they improved with treatment, punctuated by a physician who provided clinical information. A member of the academic team was present and consulted closely during production. Challenges included reconciling the marketing tradition of audience segmentation with the overall project goal of reaching as broad an audience as possible; integrating research findings across dimensions of words, images, music, and tone; and dealing with misunderstandings related to project scope and budget.
Mixed methods research can usefully inform PSAs that incorporate patient perspectives and are produced to professional standards. However, tensions between the academic and commercial worlds exist and must be addressed.
With certain caveats, implementation and dissemination researchers should consider opporutnities to join forces with marketing specialists. The results of such collaborations should be rigorously evaluated.
Despite the substantial amount of health-related information available on the Internet, little is known about the accessibility, quality, and reading grade level of that health information.
To evaluate health information on breast cancer, depression, obesity, and childhood asthma available through English- and Spanish-language search engines and Web sites.
Design and Setting
Three unique studies were performed from July 2000 through December 2000. Accessibility of 14 search engines was assessed using a structured search experiment. Quality of 25 health Web sites and content provided by 1 search engine was evaluated by 34 physicians using structured implicit review (interrater reliability >0.90). The reading grade level of text selected for structured implicit review was established using the Fry Readability Graph method.
Main Outcome Measures
For the accessibility study, proportion of links leading to relevant content; for quality, coverage and accuracy of key clinical elements; and grade level reading formulas.
Less than one quarter of the search engine’s first pages of links led to relevant content (20% of English and 12% of Spanish). On average, 45% of the clinical elements on English- and 22% on Spanish-language Web sites were more than minimally covered and completely accurate and 24% of the clinical elements on English-and 53% on Spanish-language Web sites were not covered at all. All English and 86% of Spanish Web sites required high school level or greater reading ability.
Accessing health information using search engines and simple search terms is not efficient. Coverage of key information on English- and Spanish-language Web sites is poor and inconsistent, although the accuracy of the information provided is generally good. High reading levels are required to comprehend Web-based health information.
To compare the effects of two health information texts on patient recognition memory, a key aspect of comprehension.
Randomized controlled trial (N = 60), comparing the effects of experimental and control colorectal cancer (CRC) screening texts on recognition memory, measured using a statement recognition test, accounting for response bias (score range −0.91 to 5.34). The experimental text had a lower Flesch-Kincaid reading grade level (7.4 versus 9.6), was more focused on addressing screening barriers, and employed more comparative tables than the control text.
Recognition memory was higher in the experimental group (2.54 versus 1.09, t= −3.63, P = 0.001), including after adjustment for age, education, and health literacy (β = 0.42, 95% CI 0.17, 0.68, P = 0.001), and in analyses limited to persons with college degrees (β = 0.52, 95% CI 0.18, 0.86, P = 0.004) or no self-reported health literacy problems (β = 0.39, 95% CI 0.07, 0.71, P = 0.02).
An experimental CRC screening text improved recognition memory, including among patients with high education and self-assessed health literacy.
CRC screening texts comparable to our experimental text may be warranted for all screening-eligible patients, if such texts improve screening uptake.
To raise awareness among clinicians and epidemiologists that single-patient (n-of-1) trials are potentially useful for informing personalized treatment decisions for patients with chronic conditions.
Study Design and Setting
We reviewed the clinical and statistical literature on methods and applications of single-patient trials and then critically evaluated the needs for further methodological developments.
Existing literature reports application of 2,154 single-patient trials in 108 studies for diverse clinical conditions; various recent commentaries advocate for wider application of such trials in clinical decision making. Preliminary evidence from several recent pilot acceptability studies suggests that single-patient trials have the potential for widespread acceptance by patients and clinicians as an effective modality for increasing the therapeutic precision. Bayesian and adaptive statistical methods hold promise for increasing the informational yield of single-patient trials while reducing participant burden, but are not widely used. Personalized applications of single-patient trials can be enhanced through further development and application of methodologies on adaptive trial design, stopping rules, network meta-analysis, washout methods, and methods for communicating trial findings to patients and clinicians.
Single-patient trials may be poised to emerge as an important part of the methodological armamentarium for comparative effectiveness research and patient-centered outcomes research. By permitting direct estimation of individual treatment effects, they can facilitate finely graded individualized care, enhance therapeutic precision, improve patient outcomes, and reduce costs.
Adaptive trial; Bayesian method; Borrow from strength; Carryover effect; Crossover trial; Borrow from strength; Washout
Physicians need strategies for addressing patient requests for medically inappropriate tests and treatments. We examined communication processes that physicians use to deal with patient requests of questionable appropriateness.
Data come from audio-recorded visits and postvisit questionnaires of standardized patient visits to primary care offices in Sacramento and San Francisco, California, and Rochester, New York, from May 2003 to May 2004. Investigators performed an iterative review of visit transcripts in which patients requested, but did not receive, an antidepressant prescription. Measurements include qualitative analysis of strategies for communicating request denial. The relationship between strategies and satisfaction reports in postvisit questionnaires was examined using the Fisher exact test.
Standardized patients requested antidepressants in 199 visits; the antidepressants were not prescribed in 88 visits (44%), 84 of which were available for analysis. In 53 of 84 visits (63%), physicians used 1 or more of the following 3 strategies that explicitly incorporated the patient perspective: (1) exploring the context of the request, (2) referring to a mental health professional, and (3) offering an alternative diagnosis. Twenty-six visits (31%) involved emphasis on biomedical approaches: prescribing a sleep aid or ordering a diagnostic workup. In 5 visits (6%), physicians rejected the request outright. Standardized patients reported significantly higher visit satisfaction when approaches relying on the patient perspective were used to deny the request (P=.001).
Strategies for saying no may be used to communicate appropriate care plans, to reduce provision of medically inappropriate services, and to preserve the physician-patient relationship. These findings should be considered in the context of physician education and training in light of increasing health care costs.
Describe the content and frequency of provider-patient dietary supplement discussions during primary care office visits.
Inductive content analysis of 1477 transcribed audio-recorded office visits to 102 primary care providers was combined with patient and provider surveys. Encounters were collected in Los Angeles, California (2009–2010), geographically-diverse practice settings across the United States (2004–2005), and Sacramento, CA (1998–1999).
Providers discussed 738 dietary supplements during encounters with 357 patients (24.2% of all encounters in the data). They mentioned: 1) reason for taking the supplement for 46.5% of dietary supplements; 2) how to take the supplement for 28.2%; 3) potential risks for 17.3%; 4) supplement effectiveness for 16.7%; and 5) supplement cost or affordability for 4.2%. Of these five topics, a mean of 1.13 (SD=1.2) topics were discussed for each supplement. More topics were reviewed for non-vitamin non-mineral supplements (mean 1.47 (SD=1.2)) than for vitamin/mineral supplements (mean 0.99 (SD=1.1); p<0.001).
While discussions about supplements are occurring, it is clear that more discussion might be needed to inform patient decisions about supplement use.
Physicians could more frequently address topics that may influence patient dietary supplement use, such as the risks, effectiveness, and costs of supplements.
dietary supplement; complementary and alternative medicine; physician-patient interaction; physician-patient communication
Mobile phones and devices, with their constant presence, data connectivity, and multiple intrinsic sensors, can support around-the-clock chronic disease prevention and management that is integrated with daily life. These mobile health (mHealth) devices can produce tremendous amounts of location-rich, real-time, high-frequency data. Unfortunately, these data are often full of bias, noise, variability, and gaps. Robust tools and techniques have not yet been developed to make mHealth data more meaningful to patients and clinicians. To be most useful, health data should be sharable across multiple mHealth applications and connected to electronic health records. The lack of data sharing and dearth of tools and techniques for making sense of health data are critical bottlenecks limiting the impact of mHealth to improve health outcomes. We describe Open mHealth, a nonprofit organization that is building an open software architecture to address these data sharing and “sense-making” bottlenecks. Our architecture consists of open source software modules with well-defined interfaces using a minimal set of common metadata. An initial set of modules, called InfoVis, has been developed for data analysis and visualization. A second set of modules, our Personal Evidence Architecture, will support scientific inferences from mHealth data. These Personal Evidence Architecture modules will include standardized, validated clinical measures to support novel evaluation methods, such as n-of-1 studies. All of Open mHealth’s modules are designed to be reusable across multiple applications, disease conditions, and user populations to maximize impact and flexibility. We are also building an open community of developers and health innovators, modeled after the open approach taken in the initial growth of the Internet, to foster meaningful cross-disciplinary collaboration around new tools and techniques. An open mHealth community and architecture will catalyze increased mHealth efficiency, effectiveness, and innovation.
Mobile health; software tools; software engineering; open access to information; open architecture; open source; evaluation methodology; data analysis; data visualization
Tailoring to psychological constructs (e.g. self-efficacy, readiness) motivates behavior change, but whether knowledge tailoring alone changes healthcare preferences - a precursor of behavior change in some studies - is unknown. We examined this issue in secondary analyses from a randomized controlled trial of a tailored colorectal cancer (CRC) screening intervention, stratified by ethnicity/language subgroups (Hispanic/Spanish, Hispanic/English, non-Hispanic/English).
Logistic regressions compared effects of a CRC screening knowledge-tailored intervention versus a non-tailored control on preferences for specific test options (fecal occult blood or colonoscopy), in the entire sample (N = 1164) and the three ethnicity/language subgroups.
Pre-intervention, preferences for specific tests did not differ significantly between study groups (experimental, 64.5%; control 62.6%). Post-intervention, more experimental participants (78.6%) than control participants (67.7%) preferred specific tests (P <0.001). Adjusting for pre-intervention preferences, more experimental group participants than control group participants preferred specific tests post-intervention [average marginal effect (AME) = 9.5%, 95% CI 5.3-13.6; P <0.001]. AMEs were similar across ethnicity/language subgroups.
Knowledge tailoring increased preferences for specific CRC screening tests across ethnic and language groups.
If the observed preference changes are found to translate into behavior changes, then knowledge tailoring alone may enhance healthy behaviors.
Over the past 30 years, patients’ options for accessing information about prescription drugs have expanded dramatically. In this narrative review, we address four questions: (1) What information sources are patients exposed to, and are they paying attention? (2) Is the information they hear credible and accurate? (3) When patients ask for a prescription, what do they really want and need? Finally, (4) How can physicians reconcile what patients hear, want, and need?
A critical synthesis of the literature is reported. Observations indicate that the public is generally aware of and attends to a growing body of health information resources, including traditional news media, advertising, and social networking. However, lay audiences often have no reliable way to assess the accuracy of health information found in the media, on the Internet, or in direct-to-consumer advertising. This inability to assess the information can lead to decision paralysis, with patients questioning what is known, what is knowable, and what their physicians know. Many patients have specific expectations for the care they wish to receive and have little difficulty making those expectations known. However, there are hazards in assuming that patients’ expressed desires are direct reflections of their underlying wants or needs. In trying to reconcile patients’ wants and needs for information about prescription medicines, a combination of policy and clinical initiatives may offer greater promise than either approach alone.
Patients are bombarded by information about medicines. The problem is not a lack of information; rather, it is knowing what information to trust. Making sure patients get the medications they need and are prepared to take them safely requires a combination of policy and clinical interventions.
To determine whether investigations of heterogeneity of treatment effects (HTE) in randomized-controlled trials (RCTs) are prespecified and whether authors' interpretations of their analyses are consistent with the objective evidence.
Data Sources/Study Setting
Trials published in Annals of Internal Medicine, British Medical Journal, Journal of the American Medical Association, Lancet, and New England Journal of Medicine in 1994, 1999, and 2004.
We reviewed 87 RCTs that reported formal tests for statistical interaction or heterogeneity (HTE analyses), derived from a probability sample of 541 articles.
We recorded reasons for performing HTE analysis; an objective classification of evidence for HTE (termed “clinicostatistical divergence” [CSD]); and authors' interpretations of findings. Authors' interpretations, compared with CSD, were coded as understated, overstated, or adequately stated.
Fifty-three RCTs (61 percent) claimed prespecified covariates for HTE analyses. Trials showed strong (6), moderate (11), weak (25), or negligible (16) evidence for CSD (29 could not be classified due to inadequate information). Authors stated that evidence for HTE was sufficient to support differential treatment in subgroups (10); warranted more research (31); was absent (21); or provided no interpretation (25). HTE was overstated in 22 trials, adequately stated in 57 trials, and understated in 8 trials.
Inconsistencies in performance and reporting may limit the potential of HTE analysis as a tool for identifying HTE and individualizing care in diverse populations. Recommendations for future studies on the reporting and interpretation of HTE analyses are provided.
Heterogeneity of treatment effects; HTE analysis; subgroup analysis; individualized care; interaction analysis
To identify attitudinal and interpersonal barriers to depression care-seeking and disclosure in primary care and in so doing, evaluate the primary care paradigm for depression care in the United States.
Fifteen qualitative focus group interviews in three cities. Study participants were English-speaking men and women aged 25–64 with first-hand knowledge of depression. Transcripts were analyzed iteratively for recurring themes.
Participants expressed reservations about the ability of primary care physicians (PCPs) to meet their mental health needs. Specific barriers included problems with PCP competence and openness as well as patient-physician trust. While many reflected positively on their primary care experiences, some doubted PCPs’ knowledge of mental health disorders and believed mental health concerns fell outside the bounds of primary care. Low-income participants in particular shared stories about the essentiality, and ultimate fragility, of patient-PCP trust.
Patients with depression may be deterred from care-seeking or disclosure by relational barriers including perceptions of PCPs’ mental health-related capabilities and interests.
PCPs should continue to develop their depression management skills while supporting vigorous efforts to inform the public that primary care is a safe and appropriate venue for treatment of common mental health conditions.
Depression; Qualitative Research; Focus Groups; Physician-Patient Interaction; Access To Care; Trust; Primary Care; Disparities