Showing papers in "Journal of General Internal Medicine in 2012"
TL;DR: A model of how to do shared decision making that is based on choice, option and decision talk is proposed that is practical, easy to remember, and can act as a guide to skill development.
Abstract: The principles of shared decision making are well documented but there is a lack of guidance about how to accomplish the approach in routine clinical practice. Our aim here is to translate existing conceptual descriptions into a three-step model that is practical, easy to remember, and can act as a guide to skill development. Achieving shared decision making depends on building a good relationship in the clinical encounter so that information is shared and patients are supported to deliberate and express their preferences and views during the decision making process. To accomplish these tasks, we propose a model of how to do shared decision making that is based on choice, option and decision talk. The model has three steps: a) introducing choice, b) describing options, often by integrating the use of patient decision support, and c) helping patients explore preferences and make decisions. This model rests on supporting a process of deliberation, and on understanding that decisions should be influenced by exploring and respecting “what matters most” to patients as individuals, and that this exploration in turn depends on them developing informed preferences.
2,596 citations
TL;DR: This cross sectional study finds that patient activation is strongly related to a broad range of health-related outcomes, which suggests improving activation has great potential.
Abstract: Background
There is a growing awareness that patients should be more active and effective managers of their health and health care. Recent studies have found patient activation—or having the knowledge, skills, and confidence to manage one’s health, to be related to health-related outcomes. These studies have often relied on self-reported outcomes and often have used small samples.
802 citations
TL;DR: Relative to the full MBI, single-item measures of emotional exhaustion and depersonalization exhibit strong and consistent associations with key outcomes in medical students, internal medicine residents, and practicing surgeons.
Abstract: BACKGROUND
Burnout is a common problem among physicians and physicians-in-training. The Maslach Burnout Inventory (MBI) is the gold standard for burnout assessment, but the length of this well-validated 22-item instrument can limit its feasibility for survey research.
377 citations
TL;DR: A brief intervention grounded in the neurobiology of empathy significantly improved physician empathy as rated by patients, suggesting that the quality of care in medicine could be improved by integrating the neuroscience of empathy into medical education.
Abstract: Background
Physician empathy is an essential attribute of the patient–physician relationship and is associated with better outcomes, greater patient safety and fewer malpractice claims.
315 citations
TL;DR: A flexible taxonomy is introduced called the 7Ps of Stakeholder Engagement and Six Stages of Research for identifying stakeholders and developing engagement strategies across the full spectrum of research activities.
Abstract: Despite widespread agreement that stakeholder engagement is needed in patient-centered outcomes research (PCOR), no taxonomy exists to guide researchers and policy makers on how to address this need. We followed an iterative process, including several stages of stakeholder review, to address three questions: (1) Who are the stakeholders in PCOR? (2) What roles and responsibilities can stakeholders have in PCOR? (3) How can researchers start engaging stakeholders? We introduce a flexible taxonomy called the 7Ps of Stakeholder Engagement and Six Stages of Research for identifying stakeholders and developing engagement strategies across the full spectrum of research activities. The path toward engagement will not be uniform across every research program, but this taxonomy offers a common starting point and a flexible approach.
314 citations
TL;DR: A roadmap for reducing racial and ethnic disparities in care is presented and shows that promising interventions frequently are culturally tailored to meet patients’ needs, employ multidisciplinary teams of care providers, and target multiple leverage points along a patient’s pathway of care.
Abstract: Over the past decade, researchers have shifted their focus from documenting health care disparities to identifying solutions to close the gap in care Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation, is charged with identifying promising interventions to reduce disparities Based on our work conducting systematic reviews of the literature, evaluating promising practices, and providing technical assistance to health care organizations, we present a roadmap for reducing racial and ethnic disparities in care The roadmap outlines a dynamic process in which individual interventions are just one part It highlights that organizations and providers need to take responsibility for reducing disparities, establish a general infrastructure and culture to improve quality, and integrate targeted disparities interventions into quality improvement efforts Additionally, we summarize the major lessons learned through the Finding Answers program We share best practices for implementing disparities interventions and synthesize cross-cutting themes from 12 systematic reviews of the literature Our research shows that promising interventions frequently are culturally tailored to meet patients’ needs, employ multidisciplinary teams of care providers, and target multiple leverage points along a patient’s pathway of care Health education that uses interactive techniques to deliver skills training appears to be more effective than traditional didactic approaches Furthermore, patient navigation and engaging family and community members in the health care process may improve outcomes for minority patients We anticipate that the roadmap and best practices will be useful for organizations, policymakers, and researchers striving to provide high-quality equitable care
Electronic supplementary material
The online version of this article (doi:101007/s11606-012-2082-9) contains supplementary material, which is available to authorized users
239 citations
TL;DR: Utilization rates for HCC surveillance are low, although they are significantly higher among patients followed in subspecialty clinics, and non-Caucasians and patients of low socioeconomic status had lower surveillance rates than their counterparts.
Abstract: BACKGROUND
Although surveillance for hepatocellular carcinoma (HCC) is recommended in high-risk patients, several studies have suggested it is being underutilized in clinical practice. The aim of our study was to quantify utilization rates for HCC surveillance among patients with cirrhosis and summarize patterns of association between utilization rates and patient socio-demographic characteristics.
237 citations
TL;DR: It is reaffirmed that the care encounter extends beyond the patient–physician dyad; staff, access, and convenience all affect patient’s reviews of physicians.
Abstract: Doctor rating websites are a burgeoning trend, yet little is known about their content. To explore the content of Internet reviews about primary care physicians. Qualitative content analysis of 712 online reviews from two rating websites. We purposively sampled reviews of 445 primary care doctors (internists and family practitioners) from four geographically dispersed U.S. urban locations. We report the major themes, and because this is a large sample, the frequencies of domains within our coding scheme. Most reviews (63%) were positive, recommending the physician. We found a major distinction between global reviews, “Dr. B is a great doctor.” vs. specific descriptions which included interpersonal manner, “She always listens to what I have to say and answers all my questions.”; technical competence “No matter who she has recommended re: MD specialists, this MD has done everything right.”; and/or systems issues such as appointment and telephone access. Among specific reviews, interpersonal manner “Dr. A is so compassionate.” and technical competence “He is knowledgeable, will research your case before giving you advice.” comments tended to be more positive (69% and 80%, respectively), whereas systems-issues comments “Staff is so-so, less professional than should be…” were more mixed (60% positive, 40% negative). The majority of Internet reviews of primary care physicians are positive in nature. Our findings reaffirm that the care encounter extends beyond the patient–physician dyad; staff, access, and convenience all affect patient’s reviews of physicians. In addition, negative interpersonal reviews underscore the importance of well-perceived bedside manner for a successful patient–physician interaction.
215 citations
TL;DR: Geriatric syndromes that are potentially amenable to treatment are common in older homeless adults, and are experienced at higher rates than in the general older population.
Abstract: BACKGROUND
The average age of the US homeless population is increasing. Little is known about the prevalence of geriatric syndromes in older homeless adults.
199 citations
TL;DR: Evidence quantifying the extent of failure to follow-up test results and the impact for ambulatory patients is systematically reviewed to establish an important safety concern which requires urgent attention.
Abstract: Serious lapses in patient care result from failure to follow-up test results. To systematically review evidence quantifying the extent of failure to follow-up test results and the impact for ambulatory patients. Medline, CINAHL, Embase, Inspec and the Cochrane Database were searched for English-language literature from 1995 to 2010. Studies which provided documented quantitative evidence of the number of tests not followed up for patients attending ambulatory settings including: outpatient clinics, academic medical or community health centres, or primary care practices. Four reviewers independently screened 768 articles. Nineteen studies met the inclusion criteria and reported wide variation in the extent of tests not followed-up: 6.8% (79/1163) to 62% (125/202) for laboratory tests; 1.0% (4/395) to 35.7% (45/126) for radiology. The impact on patient outcomes included missed cancer diagnoses. Test management practices varied between settings with many individuals involved in the process. There were few guidelines regarding responsibility for patient notification and follow-up. Quantitative evidence of the effectiveness of electronic test management systems was limited although there was a general trend towards improved test follow-up when electronic systems were used. Most studies used medical record reviews; hence evidence of follow-up action relied upon documentation in the medical record. All studies were conducted in the US so care should be taken in generalising findings to other countries. Failure to follow-up test results is an important safety concern which requires urgent attention. Solutions should be multifaceted and include: policies relating to responsibility, timing and process of notification; integrated information and communication technologies facilitating communication; and consideration of the multidisciplinary nature of the process and the role of the patient. It is essential that evaluations of interventions are undertaken and solutions integrated into the work and context of ambulatory care delivery.
195 citations
TL;DR: The length of a hospital stay for LEP patients was significantly longer when professional interpreters were not used at admission or both admission/discharge and when the rate of interpretation at admission and/or discharge was analyzed.
Abstract: Background
The population of persons seeking medical care is linguistically diverse in the United States. Language barriers can adversely affect a patient’s ability to explain their symptoms. Among hospitalized patients, these barriers may lead to higher readmission rates and longer hospitalizations. Trained interpreters help overcome communication barriers; however, interpreter usage among patients is suboptimal.
TL;DR: An interdisciplinary approach to care directed toward mitigating the long-term health impacts of combat is recommended in light of relationships between physical, psychological and psychosocial concerns in this population of veterans.
Abstract: Since September 11, 2001, 2.4 million military personnel have deployed to Iraq and Afghanistan. To date, roughly 1.44 million have separated from the military and approximately 772,000 of these veterans have used VA health care. Combat deployments impact the physical, psychological, and social health of veterans. Given that many veterans are receiving care from non-VA providers, it is important that all community health care workers be familiar with the unique health care needs of this patient population, which include injuries associated with blast exposures (including mild traumatic brain injury), as well as a variety of mental health conditions, such as post-traumatic stress disorder. Other important health concerns are chronic musculoskeletal pain, medically unexplained symptoms, sequelae of environmental exposures, depression, suicide, substance abuse, sleep disturbances, and impairments in family, occupational and social functioning. Elevated rates of hypertension and tobacco use remind us that deployment may result not only in immediate impacts on health, but also increase risk for chronic disease, contributing to a growing public health burden. This paper provides a comprehensive review of these health concerns and offers practical management guidelines for primary care providers. In light of relationships between physical, psychological and psychosocial concerns in this population, we recommend an interdisciplinary approach to care directed toward mitigating the long-term health impacts of combat.
TL;DR: The most common measures used in health literacy studies are detecting individual differences in cognitive abilities, which may predict one’s capacity to engage in self-care and achieve desirable health outcomes.
Abstract: BACKGROUND
Emerging evidence suggests the relationship between health literacy and health outcomes could be explained by cognitive abilities.
TL;DR: The majority of PEMS available through the NLM and a popular EHR were written at reading levels considerably higher than that of the average US adult.
Abstract: Background
Many patient education materials (PEMs) available on the internet are written at high school or college reading levels, rendering them inaccessible to the average US resident, who reads at or below an 8th grade level. Currently, electronic health record (EHR) providers partner with companies that produce PEMs, allowing clinicians to access PEMs at the point of care.
TL;DR: SSurrogates’ struggle to reconcile personal and family emotional needs with their loved ones’ wishes, and utilize common coping strategies to combat intrapersonal tensions are suggested.
Abstract: BACKGROUND
Although numerous studies have addressed external factors associated with difficulty in surrogate decision making, intrapersonal sources of tension are an important element of decision making that have received little attention
TL;DR: Seniors with adequate health literacy are more inclined to purposefully not adhere to their discharge instructions, and this results may explain why previous studies have shown a lack of association between health literacy and overall medication discrepancies.
Abstract: BACKGROUND
Inadequate health literacy is prevalent among seniors and is associated with poor health outcomes. At hospital discharge, medications are frequently changed and patients are informed of these changes via their discharge instructions.
TL;DR: Tailored patient education combined with patient navigation services, and physician training in communicating with patients of low health literacy, can modestly improve adherence to CRC screening.
Abstract: Objective
To systematically review the literature to identify interventions that improve minority health related to colorectal cancer care.
TL;DR: More rigorous surveys are clearly needed to quantify physician OSN use at the national level, and the paper by Bosslet and colleagues suggests interesting domains to include in future investigations.
Abstract: The Editors Reply—We appreciate the thoughtful and valid critique of this study by Dr. Campbell and colleagues.
The low response rate of the survey was indeed the primary critique of this study during peer review. However, this critique was balanced by the novelty of the topic and relative lack of published data. Reviewers, therefore, suggested focusing the discussion of results on survey questions related to the ethics of online social network use (OSN). These questions are presumed to be less susceptible to bias than questions related to prevalence of OSN use.
The published manuscript reflects these suggestions and we believe is appropriately cautious about the clear and important limitations of this study. More rigorous surveys are clearly needed to quantify physician OSN use at the national level. But the paper by Bosslet and colleagues suggests interesting domains to include in future investigations.
TL;DR: PHR use, but not intensity of use, was associated with improved diabetes quality measure profiles, and it is likely that better diabetes profiles among PHR users is due to higher level of engagement with their health among those registered for the PHR rather than PHR use itself.
Abstract: Background
Electronic personal health records (PHRs) have the potential to empower patients in self-management of chronic diseases, which should lead to improved outcomes.
TL;DR: Although TTG was associated with fewer post-hospitalization health-related events, larger, multi-centered studies are needed to evaluate the durability and clinical outcomes associated with this hospital-based education.
Abstract: BACKGROUND
Hospitalized patients frequently misuse their respiratory inhalers, yet it is unclear what the most effective hospital-based educational intervention is for this population.
TL;DR: Medication reconciliation and patient understanding are inadequate in older patients post-discharge, and errors and misunderstandings are particularly common in medications unrelated to the primary diagnosis.
Abstract: BACKGROUND
Adverse drug events after hospital discharge are common and often serious. These events may result from provider errors or patient misunderstanding.
TL;DR: Mong community-dwelling older adults, early hospital readmission is a marker for notably increased risk of one-year mortality, and providers, patients, and families all might respond profitably to an early readmission by reviewing treatment plans and goals of care.
Abstract: BACKGROUND
Hospital readmission within thirty days is common among Medicare beneficiaries, but the relationship between rehospitalization and subsequent mortality in older adults is not known.
TL;DR: SDaily diet soft drink consumption was associated with several vascular risk factors and with an increased risk for vascular events, and this persisted after controlling for the metabolic syndrome, peripheral vascular disease, diabetes, cardiac disease, hypertension, and hypercholesterolemia.
Abstract: BACKGROUND
Diet and regular soft drinks have been associated with diabetes and the metabolic syndrome, and regular soft drinks with coronary heart disease.
TL;DR: SSSBs and ASBs are independently associated with an increased risk of incident hypertension after controlling for multiple potential confounders, and these associations may be mediated by factors common to both SSBs and AsBs.
Abstract: BACKGROUND
Consumption of sugar-sweetened beverages (SSBs) is associated with an increased risk of hypertension in cross-sectional studies. However, prospective data are limited.
TL;DR: This study aims to use database information from an integrated system to compare patient, prescriber, and payment characteristics of patients with primary non-adherence and patients with ongoing dispensings of newly initiated medications for hypertension, diabetes, and/or hyperlipidemia.
Abstract: BACKGROUND
Information comparing characteristics of patients who do and do not pick up their prescriptions is sparse, in part because adherence measured using pharmacy claims databases does not include information on patients who never pick up their first prescription, that is, patients with primary non-adherence. Electronic health record medication order entry enhances the potential to identify patients with primary non-adherence, and in organizations with medication order entry and pharmacy information systems, orders can be linked to dispensings to identify primarily non-adherent patients.
TL;DR: A meta-analysis revealed that analogue patients’ evaluations of practitioners’ communication are not subject to ceiling effects, implying that analog patients can be included as proxies for clinical patients in studies on communication, taken some described precautions into account.
Abstract: When studying the patient perspective on communication, some studies rely on analogue patients (patients and healthy subjects) who rate videotaped medical consultations while putting themselves in the shoes of the video-patient. To describe the rationales, methodology, and outcomes of studies using video-vignette designs in which videotaped medical consultations are watched and judged by analogue patients. Pubmed, Embase, Psychinfo and CINAHL databases were systematically searched up to February 2012. Data was extracted on: study characteristics and quality, design, rationales, internal and external validity, limitations and analogue patients’ perceptions of studied communication. A meta-analysis was conducted on the distribution of analogue patients’ evaluations of communication. Thirty-four studies were included, comprising both scripted and clinical studies, of average-to-superior quality. Studies provided unspecific, ethical as well as methodological rationales for conducting video-vignette studies with analogue patients. Scripted studies provided the most specific methodological rationales and tried the most to increase and test internal validity (e.g. by performing manipulation checks) and external validity (e.g. by determining identification with video-patient). Analogue patients’ perceptions of communication largely overlap with clinical patients’ perceptions. The meta-analysis revealed that analogue patients’ evaluations of practitioners’ communication are not subject to ceiling effects. Analogue patients’ evaluations of communication equaled clinical patients’ perceptions, while overcoming ceiling effects. This implies that analogue patients can be included as proxies for clinical patients in studies on communication, taken some described precautions into account. Insights from this review may ease decisions about including analogue patients in video-vignette studies, improve the quality of these studies and increase knowledge on communication from the patient perspective.
TL;DR: Misunderstanding of the active ingredient and proper instructions for over-the-counter medications containing acetaminophen is common and the potential for errors and adverse events associated with unintentional misuse of these products is substantial, particularly among heavy users of acetamophen and those with limited literacy.
Abstract: Background
There is increasing concern over the risk of consumer unintentional misuse of non-prescription (a.k.a. ‘over-the-counter’) medications containing acetaminophen, which could lead to acute liver failure.
TL;DR: Most patients in this diverse sample of disabled elders were interested in discussing prognosis, while a substantial minority was not, and many said that prognostic information would be important as they made difficult medical and personal decisions in late-life.
Abstract: BACKGROUND
Prognosis is critical in individualizing care for older adults with late life disability. Evidence suggests that preferences for prognostic information may be culturally determined. Yet little is known about the preferences of diverse elders for discussing prognosis.
TL;DR: Healthcare providers should consider encouraging their patients with significant depressive symptoms or depression histories to seek smoking cessation services that include NRT and behavioral mood management, as several promising interventions exist.
Abstract: We conducted a systematic literature review of smoking cessation interventions for patients with histories of depressive disorders or current significant depressive symptoms. We examined the comparative effectiveness of smoking cessation strategies on abstinence rates, differential effects of cessation strategies by depression status (i.e., history positive vs. current depression), and differential effects by gender. Peer-reviewed literature in MEDLINE, Embase, PsycINFO, and Cochrane Library. Randomized controlled trials or secondary analysis of RCT data comparing two or more smoking cessation interventions or intervention to control, and reporting cessation outcomes in adults with depression. Two trained researchers screened articles for inclusion. When possible, we estimated pooled risk ratios with 95% confidence intervals by using a random effects model with the Mantel–Haenszel method. We synthesized other studies qualitatively. We classified each intervention as antidepressants, nicotine replacement therapy (NRT), brief smoking cessation counseling, smoking cessation behavioral counseling, or behavioral mood management. We identified 16 unique RCTs, of which, only three trials recruited participants with current depression. Meta-analysis demonstrated a small, positive effect of adding behavioral mood management (RR = 1.41, 95% CI 1.01–1.96). All included antidepressant trials showed small, positive effects, but risk ratio summary was not significant (RR = 1.31, 95% CI 0.73–2.34). Three NRT trials demonstrated small, positive effects on smoking cessation rates. We found insufficient evidence to examine gender and depression status moderator effects. Few RCTs exist that test smoking cessation interventions among adults with depression. To make meaningful comparisons, we created broad intervention categories that contained heterogeneity. Few trials enrolled smokers with current depression. Most of data identified were from subgroup analyses of patients history-positive for depression. However, several promising interventions exist. Healthcare providers should consider encouraging their patients with significant depressive symptoms or depression histories to seek smoking cessation services that include NRT and behavioral mood management.
TL;DR: Providing patients with HM reminders via a PHR may be effective in improving some elements of preventive care, and significant increases in mammography and influenza vaccination were observed.
Abstract: BACKGROUND
Provider and patient reminders can be effective in increasing rates of preventive screenings and vaccinations. However, the effect of patient-directed electronic reminders is understudied.