Patients' attitudes towards cost feedback to doctors to prevent unnecessary testing: a qualitative focus group study.

OBJECTIVES: There is a need to improve efficiency in healthcare delivery without compromising quality of care. One approach is the development and evaluation of behavioural strategies to reduce unnecessary use of common tests. However, there is an absence of evidence on patient attitudes to the use of such approaches in the delivery of care. Our objective was to explore patient acceptability of a nudge-type intervention that aimed to modify blood test requests by hospital doctors. STUDY DESIGN: Single-centre qualitative study. METHODS: The financial costs of common blood tests were presented to hospital doctors on results reports for 1 year at a hospital. Focus group discussions were conducted with recent inpatients at the hospital using a semi-structured question schedule. Discussions were transcribed and analysed using qualitative content analysis to identify and prioritise common themes explaining attitudes to the intervention approach. RESULTS: Three focus groups involving 17 participants were conducted. Patients were generally apprehensive about the provision of blood test cost feedback to doctors. Attitudes were organised around themes representing beliefs about blood tests, the impact on doctors and their autonomy, and beliefs about unnecessary testing. Patients thought that blood tests were important, powerful and inexpensive, and cost information could place doctors under additional pressure. CONCLUSION: The findings identify predominantly positive beliefs about testing and negative attitudes to the use of financial costs in the decision-making of hospital doctors. Public discussion and education about the possible overuse of common tests may allow more resources to be allocated to evidence-based healthcare, by reducing the perception that such strategies to improve healthcare efficiency negatively impact on quality of care.

Primary care clinicians' attitudes towards point-of-care blood testing: a systematic review of qualitative studies.

BACKGROUND: Point-of-care blood tests are becoming increasingly available and could replace current venipuncture and laboratory testing for many commonly used tests. However, at present very few have been implemented in most primary care settings. Understanding the attitudes of primary care clinicians towards these tests may help to identify the barriers and facilitators to their wider adoption. We aimed to systematically review qualitative studies of primary care clinicians' attitudes to point-of-care blood tests. METHODS: We systematically searched Medline, Embase, ISI Web of Knowledge, PsycINFO and CINAHL for qualitative studies of primary care clinicians' attitudes towards point-of-care blood tests in high income countries. We conducted a thematic synthesis of included studies. RESULTS: Our search identified seven studies, including around two hundred participants from Europe and Australia. The synthesis generated three main themes: the impact of point-of-care testing on decision-making, diagnosis and treatment; impact on clinical practice more broadly; and impact on patient-clinician relationships and perceived patient experience. Primary care clinicians believed point-of-care testing improved diagnostic certainty, targeting of treatment, self-management of chronic conditions, and clinician-patient communication and relationships. There were concerns about test accuracy, over-reliance on tests, undermining of clinical skills, cost, and limited usefulness. CONCLUSIONS: We identified several perceived benefits and barriers regarding point-of-care tests in primary care. These imply that if point-of-care tests are to become more widely adopted, primary care clinicians require evidence of their accuracy, rigorous testing of the impact of introduction on patient pathways and clinical practice, and consideration of test funding.

Influence of watchful waiting on satisfaction and anxiety among patients seeking care for unexplained complaints.

PURPOSE: We undertook a study to determine whether test-ordering strategy and other consultation-related factors influence satisfaction with and anxiety after a consultation among patients seeking care for unexplained complaints. METHODS: A cluster-randomized clinical trial was conducted in family medicine practices in the Netherlands. Participants were 498 patients with unexplained complaints seen by 63 primary care physicians. Physicians either immediately ordered a blood test for patients or followed a 4-week watchful waiting approach. Physicians and patients completed questionnaires asking about their characteristics, satisfaction with care, and anxiety, and aspects of the consultation. The main outcomes were patient satisfaction and anxiety. Data were analyzed by multilevel logistic regression analysis. RESULTS: Patients were generally satisfied with their consultation and had moderately low anxiety afterward (mean scores on 11-point scales, 7.3 and 3.1, respectively), with no difference between the immediate testing and watchful waiting groups (chi(2) = 2.4 and 0.3, respectively). The factors associated with higher odds of satisfaction were mainly related to physician-patient communication: patients' satisfaction with their physician generally, feeling taken seriously, and knowing the seriousness of complaints afterward; physicians' discussing testing and not considering complaints bearable; and older physician age. The same was true for factors associated with higher odds of anxiety: patients expecting testing or referral, patients not knowing the seriousness of their complaints afterward, and physicians not seeing a cause for alarm. CONCLUSIONS: Test-ordering strategy does not influence patients' satisfaction with and anxiety after a consultation. Instead, specific aspects of physician-patient communication are important. Apparently, primary care physicians underestimate how much they can contribute to the well-being of their patients by discussing their worries.

Evaluation of Digital Face Recognition Technology for Pain Assessment in Young Children.

OBJECTIVES: Accurate assessment of pain in young children is challenging. An Emotion Application Programing Interface (API) can analyze and report 8 emotions from facial images. Each emotion ranges between 0 (no correlation) to 1 (greatest correlation). We evaluated correlation between the Emotion API with the FLACC scale (face, lets, activity, cry, and consolability) among children younger than 6 years old during blood sampling. METHODS: Prospective pilot exploratory study in children during blood sampling. Pictures with facial expressions were uploaded to Emotion API program. Primary outcome was the correlation coefficient between FLACC scale and emotions. Secondary outcomes included maximal correlation of each emotion for 3 pictures-before, during and after needle penetration; and the average of each emotion for 9 pictures-4 before, 1 during and 4 after needle penetration to the skin. RESULTS: A total of 77 children were included. During needle penetration, SADNESS was significantly correlated (0.887, P<0.05), and NEUTRAL was negative correlated with the FLACC scale (-0.841; P<0.05). The maximal correlation of each emotion showed increase in SADNESS and decrease in NEUTRAL emotions during, compared to before, needle penetration. Similar findings were observed when the average of each emotion was compared during to before needle penetration. DISCUSSION: During a blood test procedure, young children show higher SADNESS and lower NEUTRAL emotions as reported by the Emotion API. This software program may be useful in reporting emotions related to pain in young children, and more research is needed to compare its validity, reliability and real-time application compared to the FLACC scale.

Blood Draw Barriers for Treatment with Clozapine and Development of a Point-of-Care Monitoring Device.

BACKGROUND: While clozapine (CLZ) is the most effective antipsychotic drug for schizophrenia treatment, it remains underused. In order to understand the barriers of frequent blood draws for white blood cell counts (WBCs) and clozapine levels, we developed a psychiatrist survey and began an integrative approach of designing a point-of-care device that could eventually have real-time monitoring with immediate results. METHODS: We ascertained barriers related to CLZ management and the acceptance of possible solutions by sending an anonymous survey to physicians in psychiatric practice (n=860). In parallel, we tested CLZ sensing using a prototype point-of-care monitoring device. RESULTS: 255 responses were included in the survey results. The two barriers receiving mean scores with the highest agreement as being a significant barrier were patient nonadherence to blood work and blood work's burden on the patient (out of 28). Among nine solutions, the ability to obtain lab results in the physician's office or pharmacy was top ranked (mean±sd Likert scale [4.0±1.0]). Physicians responded that a point-of-care device to measure blood levels and WBCs would improve care and increase CLZ use. Residents ranked point-of-care devices higher than older physicians (4.07±0.87 vs. 3.47±1.08, p<0.0001). Also, the prototype device was able to detect CLZ reliably in 1.6, 8.2, and 16.3 µg/mL buffered solutions. DISCUSSION: Survey results demonstrate physicians' desire for point-of-care monitoring technology, particularly among younger prescribers. Prototype sensor results identify that CLZ can be detected and integrated for future device development. Future development will also include integration of WBCs for a complete detection device.

Interactive music as a treatment for pain and stress in children during venipuncture: a randomized prospective study.

OBJECTIVE: The experience of venipuncture is seen by children as one of the most fearful experiences during hospitalization. Children experience anxiety both before and during the procedure. Therefore, any intervention aiming to prevent or reduce distress should focus on the entire experience of the procedure, including waiting, actual preparation, and conclusion. This study was designed to determine whether the presence of musicians, who had attended specific training to work in medical settings, could reduce distress and pain in children undergoing blood tests. METHODS: Our sample population was composed of 108 unpremedicated children (4-13 years of age) undergoing blood tests. They were randomly assigned to a music group (n=54), in which the child underwent the procedure while interacting with the musicians in the presence of a parent or to a control group (n=54), in which only the parent provided support to the child during the procedure. The distress experienced by the child before, during and after the blood test was assessed with the Amended Form of the Observation Scale of Behavioral Distress, and pain experience with FACES scale (Wong Baker Scale) only after the venipuncture. RESULTS: Our results show that distress and pain intensity was significantly lower (p<.001; p<.05) in the music group compared with the control group before, during, and after blood sampling. CONCLUSIONS: This controlled study demonstrates that songs and music, performed by "professional" musicians, have a beneficial effect in reducing distress before, during, and after blood tests. This study shows, moreover, that the presence of musicians has a minor, but yet significant, effect on pain due to needle insertion.

'It's only a blood test': what people know and think about venepuncture and blood.

Medicine finds human blood infinitely useful. It is a source of important and sometimes controversial information about individuals, their relatives and the general public. Blood also has economic value, carries a heavy cultural freight, and can transmit dangerous diseases. Yet there is precious little sociological analysis of how these radically different applications, potentials and significations are managed in health care settings where, it is no exaggeration to claim, everyday a vast quantity of blood is produced by venepuncture. This paper focuses on blood produced in hospitals for tests. The data were derived from 19 focus groups of patients, health care professionals, and members of the public, held between 2002 and 2003, in and around the obstetrics and gynaecology department of a large London teaching hospital. Not surprisingly, all the participants had had a blood test at some time or other. Yet their responses suggest no template exists for talking about them. No-one--lay or professional--had a full picture of how blood produced for tests circulates around the hospital. Lay people tended to envisage it as remaining in a liquid form whereas health care professionals saw it as materially and substantially transformed. Participants deployed a variety of ritual and rhetorical devices that devalue blood produced for tests. Nonetheless, blood left over from tests emerged as a significant anomaly, simultaneously an excess (waste), a challenge (to use wisely), or a potential crime (illegitimate research).

Why do patients want to have their blood tested? A qualitative study of patient expectations in general practice.

BACKGROUND: General practitioners often take their impression of patients' expectations into account in their decision to have blood tests done. It is commonly recommended to involve patients in decision-making during consultations. The study aimed to obtain detailed information on patients' expectations about blood tests. METHODS: Qualitative study among patients in waiting rooms of general practices. Each patient was presented with a short questionnaire about their preferences in terms of diagnostics. Patients who would like blood tests to be done were interviewed. RESULTS: Fifty-seven (26%) of the 224 respondents wanted blood tests. Twenty-two were interviewed. Patients overestimated the qualities of blood tests. Favourable test results were regarded as proof of good health. Patients regarded blood tests as a useful instrument to screen for serious disorders, and were confirmed in this belief by people in their social environment and by the media. Many patients expected their GP to take an active test ordering approach, though some indicated that they might be convinced if their GP proposed a wait-and-see policy. CONCLUSIONS: GPs' perceptions about patient expectations seem justified: patients appear to have high hopes for testing as a diagnostic tool. They expect diagnostic certainty without mistakes and a proof of good health. The question is whether it would be desirable to remove patients' misconceptions, allowing them to participate in policy decisions on the basis of sound information, or whether it would be better to leave the misconceptions uncontested, in order to retain the 'magic' of additional tests and reassure patients. We expect that clarifying the precise nature of patients' expectations by the GP may be helpful in creating a diagnostic strategy that satisfies both patients and GPs. GPs will have to balance the benefits of reassuring their patients by means of blood tests which may be unnecessary against the benefits of avoiding unnecessary tests. Further research is needed into the effects of different types of patient information and the effects of testing on satisfaction and anxiety.

Getting results for hematology patients through access to the electronic health record.

PURPOSE: To conduct a needs assessment to identify patient and provider perceptions about providing patients with access to their electronic health record in order to develop an online system that is appropriate for all stakeholders. METHODS: Malignant hematology patients were surveyed and health care providers were interviewed to identify issues and validate concerns reported in the literature. Based on the analysed data, a prototype will be designed to examine the feasibility and efficacy of providing patients with access to their electronic health record and tailored information. RESULTS: 61% of patients reported using the internet to find health information; 89% were interested in accessing their electronic health record and 79% stated they would benefit from educational material along with the results. Staff members viewed patient online access to the record favourably, but expressed the importance of providing the necessary patient support and education. A Web-based prototype was developed for patients to review their registration data and blood results. CONCLUSIONS: Hematology oncology patients are more interested in using the internet to monitor their clinical information than to find health information. Using the constructed prototype, the feasibility of this project is currently being tested.

Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives.

BACKGROUND: The testing and result communication process in primary care is complex. Its successful completion relies on the coordinated efforts of a range of staff in primary care and external settings working together with patients. Despite the importance of diagnostic testing in provision of care, this complexity renders the process vulnerable in the face of increasing demand, stretched resources and a lack of supporting guidance. METHODS: We conducted a series of focus groups with patients and staff across four primary care practices using process-improvement strategies to identify and understand areas where either unnecessary delay is introduced, or the process may fail entirely. We then worked with both patients and staff to arrive at practical strategies to improve the current system. RESULTS: A total of six areas across the process were identified where improvements could be introduced. These were: (1) delay in phlebotomy, (2) lack of a fail-safe to ensure blood tests are returned to practices and patients, (3) difficulties in accessing results by telephone, (4) role of non-clinical staff in communicating results, (5) routine communication of normal results and (6) lack of a protocol for result communication. CONCLUSIONS: A number of potential failures in testing and communicating results to patients were identified, and some specific ideas for improving existing systems emerged. These included same-day phlebotomy sessions, use of modern technology methods to proactively communicate routine results and targeted training for receptionists handling sensitive data. There remains an urgent need for further work to test these and other potential solutions.

A prospective survey of reactions to blood tests by children and adolescents.

A sample of 171 children and adolescents aged 3-17 years requiring venepuncture for blood sampling were asked to report on their pain and anxiety and were observed immediately before and during blood drawing. Depending on the measures used, 36-64% of children from 3 to 6 years old experienced moderate to severe distress from blood drawing. Multiple regression analysis revealed that age and the parents' prediction of how upset the child would feel before the blood test was a significant predictor of the observed distress and the self-report of pain. Experience with previous needle procedures did not add significantly to the prediction of distress. Identification of children at high risk to respond poorly to painful medical procedures is discussed.

Hospitalization stress in children: sensitizer and repressor coping styles.

To examine the effects of individual sensitizer/repressor coping styles on responses to hospital procedures, 56 children (mean age = 6.5 years) were observed during hospitalization for minor surgery. Although the sensitizer children, as classified by their mothers, did not differ from the repressor children on baseline measures including hospital preparation, they were more talkative, expressive, and active during hospital play observations. During blood tests and preoperative injections, the sensitizers, compared with the repressors, were reported by their mothers to observe the procedures, to seek additional information about the procedures, and to show more protest behaviors. Finally, the sensitizer children required fewer hours of intensive care.

SMART START: an option for adolescents to delay the pelvic examination and blood work in family planning clinics.

PURPOSE: The goal was to encourage earlier use of family planning services and effective birth control for teens. METHOD: In three federally-funded family planning clinics, the SMART START service model was offered to non-pregnant teens under 18. Teens making their first family planning visit to the clinics for family planning services had the option to delay the requisite pelvic examination and blood work following a careful medical and social history for up to 6 months while obtaining oral contraceptives and/or other non-prescriptive contraceptives. Each teen also received individualized counseling and follow-up telephone contacts. Survey and medical chart data were collected during the project period to evaluate the effects of SMART START on 151 teens. RESULTS: Of the 151 teens, 26% delayed the pelvic examination and 40% delayed the blood work. The delay of medical services did not result in negative health outcomes. Teens who elected to delay the pelvic examination returned to the clinic as frequently for revisits, they reported using condoms more consistently, they had fewer pregnancies and had similar STD rates compared with those not delaying. SMART START also found that ethnic factors correlated with deferring the blood work. CONCLUSIONS: SMART START offered teens options over how and when they receive reproductive health care services without withholding effective contraceptive methods. No serious complications of STDs resulted from the delay procedures. Expansion of the SMART START model to include both teen and adult populations is encouraged.

A questionnaire on factors influencing children's assent and dissent to non-therapeutic research.

BACKGROUND: Knowledge about assent or dissent of children to non-therapeutic research is poor. OBJECTIVES: To assess sociodemographic characteristics in healthy children and adolescents who were invited to participate in non-therapeutic research, to evaluate their motives for assent or dissent and their understanding of the information given. METHODS: A total of 1281 healthy children and adolescents six to sixteen years of age were invited to participate in a non-therapeutic study and a questionnaire. RESULTS: Assenting children were motivated by a desire to help sick children (n = 638, 98%) and to gain experience with participating in a research study (n = 503, 82%). Dissenting children made their decision because of worries about having a blood (n = 193, 46%) or a urine sample (n = 94, 26%) taken or because of worries about a doctor's examination (n = 136, 33%). Fewer children in the assent group (n = 166, 25%) than in the dissent group (136, 33%) worried about the doctor's examination (p = 0.01). In the assent and dissent group, 568 (86%) and 343 (85%) children, respectively, said they were able to understand some or all of the written information (p = 0.42), and 650 (97%) and 330 (98%), respectively, were able to understand some or all of the verbal information (p = 0.07). CONCLUSIONS: Sociodemographic characteristics may not influence healthy children's decision to volunteer for non-therapeutic research. Assenting children have altruistic and educational motives, whereas worries about procedures may cause children to dissent. A great majority of school children and adolescents feel capable of understanding and giving assent or dissent to non-therapeutic research.

Community response to intermittent preventive treatment delivered to infants (IPTi) through the EPI system in Manhiça, Mozambique.

OBJECTIVE: To describe attitudes to the expanded programme on immunization (EPI) and intermittent preventive treatment in infants (IPTi), and perceptions of the relationship between them. In particular, whether the introduction of IPTi negatively affects community attitudes to, or use of, EPI; or, conversely, whether and if so how, the concurrent delivery of IPTi and immunization influences perceptions of IPTi. METHODS: Anthropological study carried out in the context of a trial of IPTi with sulphadoxine-pyrimethamine delivered alongside routine EPI vaccinations. We used open in-depth interviews, semi-structured interviews and participant observation, conducted in both community and clinic settings. RESULTS: IPTi was generally acceptable, in spite of initial resistance. Perceived negative aspects of IPTi did not affect perceptions of EPI, and IPTi was not misinterpreted as immunization against malaria, leading to a reduction of other preventive measures or delay in treatment seeking. Initial resistance was related more to the trial than to IPTi per se, but both rejection and acceptance were embedded in a complex constellation of local and wider contextual factors. CONCLUSIONS: IPTi delivered together with EPI was generally accepted after initial rejection. The factors that led to this rejection were largely local and trial related, but they did resonate with much wider cultural themes (rumours about research and health interventions, gender inequality and health-related decision making). The prior acceptance and routine administration of EPI played a key role in the acceptance of IPTi in this community. However, more studies, in different social and cultural settings and using different drugs and regimens, are needed before generalizations can be made. Although trial settings are different from actual implementation, it is necessary to study acceptability before implementation in order to anticipate problems and design information campaigns to ensure maximum community acceptance.

Colorectal cancer: a survey of community beliefs and behaviours in Victoria.

OBJECTIVE: To document self-reported beliefs and behaviours in relation to colorectal cancer (CRC) and screening for CRC. DATA COLLECTION: A stratified random sample was selected from the telephone directory, and structured telephone interviews were conducted using a computer-assisted telephone interviewing system. PARTICIPANTS: 500 men and 500 women aged 40-60 years, 70% randomly selected from the Melbourne metropolitan area and 30% from rural Victoria. The response rate to the initial telephone invitation of 1569 eligible people was 63.7%. OUTCOME MEASURES: Awareness of and experience with CRC; knowledge of CRC risk, risk reduction behaviour, and screening tests for CRC; willingness to have screening tests for CRC; and test preferences. RESULTS: The people surveyed were relatively unaware of their personal risk of CRC, despite 61% (95% CI, 57%-65%) knowing someone who had CRC. Although 51% (95% CI, 48%-54%) could not name any CRC screening test, 68% (95% CI, 65%-71%) knew of the value of a high fibre diet in prevention. However, 67% (95% CI, 64%-70%) thought it was unlikely they would have a screening test for CRC in the next two years, but 64% (95% CI, 61%-67%) considered that some person could influence their decision to have a test, 60% (95% CI, 56%-64%) stating that they would be influenced by a doctor. Faecal occult blood testing and sigmoidoscopy were equally acceptable. In general, women were more knowledgeable than men. There were no systematic age or urban/rural differences. CONCLUSIONS: There is a variable understanding of CRC in the community. Although prevention is well understood, this is not true of screening. General practitioners are likely to be influential in the uptake of any screening programs.

Community response to intermittent preventive treatment delivered to infants (IPTi) through the EPI system in Manhiça, Mozambique

Objective: To describe attitudes to the expanded programme on immunization (EPI) and intermittent preventive treatment in infants (IPTi), and perceptions of the relationship between them. In particular, whether the introduction of IPTi negatively affects community attitudes to, or use of, EPI; or, conversely, whether and if so how, the concurrent delivery of IPTi and immunization influences perceptions of IPTi. Methods: Anthropological study carried out in the context of a trial of IPTi with sulphadoxine-pyrimethamine delivered alongside routine EPI vaccinations. We used open in-depth interviews, semi-structured interviews and participant observation, conducted in both community and clinic settings. Results: IPTi was generally acceptable, in spite of initial resistance. Perceived negative aspects of IPTi did not affect perceptions of EPI, and IPTi was not misinterpreted as immunization against malaria, leading to a reduction of other preventive measures or delay in treatment seeking. Initial resistance was related more to the trial than to IPTi per se, but both rejection and acceptance were embedded in a complex constellation of local and wider contextual factors. Conclusions: IPTi delivered together with EPI was generally accepted after initial rejection. The factors that led to this rejection were largely local and trial related, but they did resonate with much wider cultural themes (rumours about research and health interventions, gender inequality and health-related decision making). The prior acceptance and routine administration of EPI played a key role in the acceptance of IPTi in this community. However, more studies, in different social and cultural settings and using different drugs and regimens, are needed before generalizations can be made. Although trial settings are different from actual implementation, it is necessary to study acceptability before implementation in order to anticipate problems and design information campaigns to ensure maximum community acceptance.