What do doctors say when prescribing medications?: an examination of medical recommendations from a communication perspective.

We described physician usage of persuasive strategies pertaining to four dimensions of medical recommendations given during naturally occurring clinical visits-problem seriousness, treatment effectiveness, patient's self-efficacy, and potential limitations with the recommended treatment. We then examined the impact of these strategies on patient satisfaction and intention to follow physicians' medical advice. An analysis was conducted of 187 transcripts of audio-recorded outpatient visits during which a new medication was prescribed, augmented with patient and physician surveys. Two-hundred forty-two cases of new medication prescription were identified, and each case was coded into categories describing physicians' prescription-giving behaviors. In most cases, physicians addressed only one or two of the four dimensions of medical recommendations when they were prescribing new medications to their patients. In about one-third of visits, none of the four dimensions was addressed. However, physician use of persuasive strategies pertaining to the four dimensions did not appear to have any significant impact on patients' satisfaction with the visit or intention to follow their doctor's advice. The implications of the findings are discussed in light of the study's limitations and directions for future research.

Factors associated with Hispanic/non-Hispanic white colorectal cancer screening disparities.

BACKGROUND: In the United States, Hispanics are less likely to undergo colorectal cancer (CRC) screening than non-Hispanic whites (whites). OBJECTIVE: To examine factors associated with disparities in CRC screening between whites and Hispanic national origin subgroups. DESIGN: Cross-sectional analysis of 1999-2005 Medical Expenditure Panel Survey data. PARTICIPANTS: Respondents aged >50 years self-identifying as non-Hispanic white (18,733) or Hispanic (3686)-the latter of Mexican (2779), Cuban (336), Puerto Rican (376), or Dominican (195) origin. MEASUREMENTS: Dependent variable: self-report of up to date CRC screening, defined as fecal occult blood testing within 2 years and/or lower endoscopy at any time. INDEPENDENT VARIABLES: ethnicity/race, country of origin, interview language, socio-demographics, and access to care. RESULTS: Unadjusted CRC screening rates were highest in whites [mean (standard error), 55.9 (0.6) %], and lowest in Dominicans [28.5 (4.2) %]. After demographic adjustment, CRC screening was significantly lower for Mexicans [adjusted odds ratio (95% confidence interval), 0.46 (0.40, 0.53), p < 0.001)], Puerto Ricans [0.65 (0.47, 0.91), p = 0.01], and Dominicans [0.30 (0.19, 0.45), p < 0.001] versus whites. With further adjustment for language, socioeconomic factors, and access, Hispanic/white disparities were not significant, while among Hispanics, Cubans were more likely to be screened [1.57 (1.15, 2.14), p = 0.01]. CONCLUSIONS: Factors associated with CRC screening disparities between Hispanics and non-Hispanic whites appear similar among Hispanic sub-groups. However, the relative contribution of these factors to disparities varies by Hispanic national origin group, suggesting a need for differing approaches to increasing screening for each group.

Telemonitoring for patients with chronic heart failure: a systematic review.

BACKGROUND: Telemonitoring, the use of communication technology to remotely monitor health status, is an appealing strategy for improving disease management. METHODS AND RESULTS: We searched Medline databases, bibliographies, and spoke with experts to review the evidence on telemonitoring in heart failure patients. Interventions included: telephone-based symptom monitoring (n = 5), automated monitoring of signs and symptoms (n = 1), and automated physiologic monitoring (n = 1). Two studies directly compared effectiveness of 2 or more forms of telemonitoring. Study quality and intervention type varied considerably. Six studies suggested reduction in all-cause and heart failure hospitalizations (14% to 55% and 29% to 43%, respectively) or mortality (40% to 56%) with telemonitoring. Of the 3 negative studies, 2 enrolled low-risk patients and patients with access to high quality care, whereas 1 enrolled a very high-risk Hispanic population. Studies comparing forms of telemonitoring demonstrated similar effectiveness. However, intervention costs were higher with more complex programs (8383 dollars per patient per year) versus less complex programs (1695 dollars per patient per year). CONCLUSION: The evidence base for telemonitoring in heart failure is currently quite limited. Based on the available data, telemonitoring may be an effective strategy for disease management in high-risk heart failure patients.

Cigarette prices, smoking, and the poor: implications of recent trends.

OBJECTIVE: We examined the relationship between smoking participation and cigarette pack price by income group and time period to determine role of cigarette prices in income-related disparities in smoking in the United States. METHODS: We used data from the 1984-2004 Behavioral Risk Factor Surveillance System surveys linked to information on cigarette prices to examine the adjusted prevalence of smoking participation and smoking participation-cigarette pack price elasticity (change in percentage of persons smoking relative to a 1% change in cigarette price) by income group (lowest income quartile [lower] vs all other quartiles [higher]) and time period (before vs after the Master Settlement Agreement [MSA]). RESULTS: Increased real cigarette-pack price over time was associated with a marked decline in smoking among higher-income but not among lower-income persons. Although the pre-MSA association between cigarette pack price and smoking revealed a larger elasticity in the lower- versus higher-income persons (-0.45 vs -0.22), the post-MSA association was not statistically significant (P>.2) for either income group. CONCLUSIONS: Despite cigarette price increases after the MSA, income-related smoking disparities have increased. Increasing cigarette prices may no longer be an effective policy tool and may impose a disproportionate burden on poor smokers.

The Palliative Care in Assisted Living (PCAL) pilot study: successes, shortfalls, and methodological implications.

Troubling deficits exist in palliative care (PC) of older adults under the prevailing "terminal care"-oriented model. We previously described a PC model--TLC--that provides a blueprint for remedying these shortfalls. In this model, PC is envisioned as Timely and Team-oriented, Longitudinal, and Collaborative and Comprehensive. We present results of the Palliative Care in Assisted Living pilot, comparing two TLC model-based, facility delivered interventions for improving the PC of elderly assisted living residents in Sacramento, California, a growing and under-researched population. The less intensive intervention involved one assessment followed by a PC improvement recommendation letter to the resident, family member, primary provider, and facility staff, while the more intensive intervention involved assessments and letters every three months. Primary outcomes were SF-36 Physical (PCS) and Mental (MCS) Component scores and recommendation adherence. Eighty-one subjects enrolled (mean age 85), 58 in the more and 23 in the less intensive group. A loved one attended 56% of baseline assessments. Most subjects expressed a preference for maintaining current quality of life over prolonging life at reduced quality. None were eligible for hospice care. A total of 418 recommendations (mean 5.1 per subject) were generated concerning symptoms, mood, functional impairments, and advance directives. We found no significant differences in recommendation adherence between more (42%) and less (44%) intensive groups, and no significant changes in PCS and MCS scores within or between groups. However, a loved one's attendance of the baseline assessment was associated with improved PCS scores (p=0.04). Our pilot study had methodological limitations that could account for the lack of significant outcome effects. In this context, and given the myriad unmet PC needs we detected, interventions based on the TLC model might allow delivery of timely PC to assisted living residents not eligible for hospice care. Further studies exploring the TLC model appear warranted.

Studying physician effects on patient outcomes: physician interactional style and performance on quality of care indicators.

Many prior studies which suggest a relationship between physician interactional style and patient outcomes may have been confounded by relying solely on patient reports, examining very few patients per physician, or not demonstrating evidence of a physician effect on the outcomes. We examined whether physician interactional style, measured both by patient report and objective encounter ratings, is related to performance on quality of care indicators. We also tested for the presence of physician effects on the performance indicators. Using data on 100 US primary care physician (PCP) claims data on 1,21,606 of their managed care patients, survey data on 4746 of their visiting patients, and audiotaped encounters of 2 standardized patients with each physician, we examined the relationships between claims-based quality of care indicators and both survey-derived patient perceptions of their physicians and objective ratings of interactional style in the audiotaped standardized patient encounters. Multi-level models examined whether physician effects (variance components) on care indicators were mediated by patient perceptions or objective ratings of interactional style. We found significant physician effects associated with glycohemoglobin and cholesterol testing. There was also a clinically significant association between better patient perceptions of their physicians and more glycohemoglobin testing. Multi-level analyses revealed, however, that the physician effect on glycohemoglobin testing was not mediated by patient perceived physician interaction style. In conclusion, similar to prior studies, we found evidence of an apparent relationship between patient perceptions of their physician and patient outcomes. However, the apparent relationships found in this study between patient perceptions of their physicians and patient care processes do not reflect physician style, but presumably reflect unmeasured patient confounding. Multi-level modeling may contribute to better understanding of the relationships between physician style and patient outcomes.

Reducing Medical School Admissions Disparities in an Era of Legal Restrictions: Adjusting for Applicant Socioeconomic Disadvantage.

A diverse physician workforce is needed to increase access to care for underserved populations, particularly as the Affordable Care Act expands insurance coverage. Yet legal restrictions constrain the extent to which medical schools may use race/ethnicity in admissions decisions. We conducted simulations using academic metrics and socioeconomic data from applicants to a California public medical school from 2011 to 2013. The simulations systematically adjusted medical school applicants' academic metrics for socioeconomic disadvantage. We found that socioeconomic and under-represented minority disparities in admissions could be eliminated while maintaining academic readiness. Adjusting applicant academic metrics using socioeconomic information on medical school applications may be a race-neutral means of increasing the socioeconomic and racial/ethnic diversity of the physician workforce.

Are patients' ratings of their physicians related to health outcomes?

PURPOSE: Observational studies using patient reports suggest associations between physician interpersonal styles and patient outcomes. Possible confounding of these associations has not been carefully examined. METHODS: Approximately 4,700 patients of 96 physicians completed a survey instrument that included reported health status changes during the previous year, perceptions of their physician (satisfaction, trust, knowledge of patient, and autonomy support), and sociodemographic and clinical covariates. We examined the adjusted relationship between patient perceptions of their physicians and reported health status changes. Using multilevel analyses, we then explored differences among physicians in patient perceptions of their physicians and whether these differences were explained by the relationship between patient perceptions and reported health status changes. RESULTS: There were significant adjusted relationships between patient perceptions of their physician and reported health status changes: better perceptions were associated with a smaller risk of health status decline (adjusted odds ratio = 1.14; 95% confidence interval [CI], 1.05-1.24; P <.01). Multilevel analysis showed significant differences between physicians in patient perceptions of their physicians (rho = 0.10; 95% CI, 0.07-0.13; P <.01), but these physician differences were unrelated to reported health status decline (rho = 0; P >.99). CONCLUSIONS: Using methods similar to those of previous studies, we found a relationship between patient perceptions of their physicians and reported health status declines. Multilevel analysis, however, suggested that this relationship is not a physician effect; it may reflect unmeasured patient confounding. Multilevel analyses may help to examine the relationships between physician styles and outcomes.

Patients' perceived barriers to active self-management of chronic conditions.

Few studies have elicited barriers to patient self-management of chronic conditions, and only one concerned people with two or more conditions. To inform development of Homing in on Health (HioH), a home delivery variant of the Chronic Disease Self-Management Program (CDSMP), we conducted 10 focus groups involving 54 chronically ill people, 46 (85%) of whom had multiple conditions. The goals were to elicit perceived barriers to active self-management and to accessing self-management support resources. Depression, weight problems, difficulty exercising, fatigue, poor physician communication, low family support, pain, and financial problems were the most frequently noted barriers to active self-management. The most common barriers to accessing self-management support resources were lack of awareness, physical symptoms, transportation problems, and cost/lack of insurance coverage. Our findings provided initial support for the Homing in on Health approach, since many of the barriers identified may be more amenable to home-based intervention than to centralized, facility-based programs.

A national study of obesity prevalence and trends by type of rural county.

CONTEXT: Obesity is epidemic in the United States, but information on this trend by type of rural locale is limited. PURPOSE: To estimate the prevalence of and recent trends in obesity among US adults residing in rural locations. METHODS: Analysis of data from the Behavioral Risk Factor Surveillance System (BRFSS) for the years 1994-1996 (n = 342,055) and 2000-2001 (n = 385,384). The main outcome measure was obesity (body mass index [BMI] > or = 30), as determined by calculating BMI from respondents' self-reported height and weight. RESULTS: In 2000-2001, the prevalence of obesity was 23.0% (95% confidence interval [CI] 22.6%-23.4%) for rural adults and 20.5% (95% CI 20.2%-20.7%) for their urban counterparts, representing increases of 4.8% (95% CI 4.2%-5.3%) and 5.5% (95% CI 5.1%-5.9%), respectively, since 1994-1996. The highest obesity prevalence occurred in rural counties in Louisiana, Mississippi, and Texas; obesity prevalence increased for rural residents in all states but Florida over the study period. African Americans had the highest obesity prevalence of any group, up to 31.4% (95% CI 29.1%-33.6) in rural counties adjacent to urban counties. The largest difference in obesity prevalence between those with a college education compared with those without a high school diploma occurred in urban areas (18.4% [95% CI 17.9%-18.9%] vs 23.5% [95% CI 22.5%-24.5%], respectively); the smallest difference occurred in small, remote rural counties (20.3% [95% CI 18.7%-21.9%] versus 22.3% [95% CI 20.7%-24.0%], respectively). CONCLUSIONS: The prevalence of obesity is higher in rural counties than in urban counties; obesity affects some residents of rural counties disproportionately.

Walk a mile in my shoes: a chronic illness care workshop for first-year students.

BACKGROUND AND OBJECTIVES: A number of educators and recent medical school graduates have suggested a need to expand predoctoral training in chronic illness care. We developed a workshop to enhance first-year students' self-awareness regarding attitudes toward chronic illness care and to help them communicate effectively around patient self-care. METHODS: Students participated in a two-part workshop incorporating lectures, patient-centered interviewing role-plays, and an assignment requiring students to "have" a chronic illness and perform self-care tasks for 2 weeks. We assessed impact on chronic care knowledge by comparing pre- and post-workshop quiz scores. We also reviewed student evaluations of the experience. RESULTS: Of 96 students, 86 (90%) attended Session 1, and 91 (95%) attended Session 2. The mean (standard deviation) knowledge score improved from 6.4 (1.5) before the workshop to 8.4 (1.2) after the workshop (10 points possible). Of 53 students (55%) who completed an evaluation, most perceived the value of the workshop, including the self-care assignment and role-plays. Some felt more positively about chronic illness care following the workshop, and many indicated additional chronic care training in the clinical years would be welcome. CONCLUSIONS: An introductory workshop for first-year students led to increased knowledge of and improved attitudes toward chronic illness care. Longitudinal training in chronic illness care should be considered in predoctoral education.

Primary Care Attributes Associated with Receipt of Preventive Care Services: A National Study.

BACKGROUND: Primary care attributes (PCAs) encompassed by patient-centered medical homes may increase receipt of preventive care, though national studies are lacking. METHODS: We performed cross-sectional adjusted analyses of self-report data from adults in the 2007 to 2010 US Medical Expenditure Panel Surveys (N = 50,457). PCAs were considered individually and as a total score for each respondent and included comprehensiveness (a usual source of care for new and ongoing problems, preventive care, and referrals); patient-centeredness (shared decision making); and enhanced access (night and weekend hours). Preventive care measures included mammography, influenza vaccination, annual exams, colorectal cancer screening, and Papanicolaou, prostate-specific antigen, and cholesterol testing. RESULTS: The total PCA score was positively associated with increased receipt of each preventive care measure. Colorectal cancer screening (18.5%) and prostate-specific antigen testing (20.7%) showed the largest increases across PCA score quartiles. Individual primary care attributes except enhanced access were positively associated with each preventive care measure. Enhanced access was negatively associated with annual examination (adjusted odds ratio, 0.83; 95% confidence interval, 0.77-0.91). CONCLUSION: In a nationally representative sample, greater reported exposure to key primary care attributes, with the exception of enhanced access, was associated with increased preventive care. These findings may inform best practices for maximizing preventive care delivery.

Validity of scores generated by a web-based multimedia simulated patient case software: a pilot study.

PURPOSE: The value of multimedia simulated patient cases (MSPCs) in medical education remains unclear. The authors conducted a pilot study to assess the validity of automated scores of diagnostic reasoning ability provided by DxR Clinician, a widely available Web-based MSPC software. METHOD: In 2002-03, all 89 students enrolled in a required third-year primary care clerkship at the University of California, Davis, School of Medicine were assigned to complete four MSPCs. The authors determined the degree of correlation between the Clinical Reasoning Score (CRS) and Level of Diagnostic Performance (LDP) generated by the MSPC software and subscale scores from a validated measure of diagnostic reasoning sophistication, the Diagnostic Thinking Inventory (DTI). RESULTS: Of 356 completed case events, instructor override of automated scoring was required in 206 (58%) to obtain an accurate LDP and CRS. Mean DTI subscale scores improved significantly from the beginning to the end of the year (p <.0001, Wilcoxon signed rank test). However, there were no significant correlations between CRS or LDP scores on any of the four cases and either of the two DTI subscale scores. CONCLUSION: Automated diagnostic reasoning scores generated by one widely available MSPC software appear to lack criterion validity. The validity of automated diagnostic reasoning scores generated by MSPCs should be established before such cases can be confidently employed as educational tools.

Increases in resident and faculty computing skills between 1998 and 2001.

BACKGROUND AND OBJECTIVES: Following a 1998 survey, we hypothesized that family practice residents would soon demand more advanced informatics and computer training than faculty could provide. We repeated the survey in 2001 to test our hypothesis. METHODS: We surveyed 97 first-year medical students, 46 family practice residents, and 18 family medicine faculty at our institution. We compared responses among groups and within groups since 1998. RESULTS: Significantly more respondents owned a computer in 2001 than in 1998. E-mail and Internet use increased dramatically for all groups. Students and faculty had significantly greater confidence in their general computer abilities than residents did in 2001, but third-year residents' confidence had increased significantly since 1998. Respondents cited inadequate computer resources as the most important barrier to effective computer use. CONCLUSIONS: Resident and faculty self-assessed computer skills have increased substantially at our program since 1998. These increases appear due to the current ubiquity of computers in society and improvements in device functionality and ease of use rather than curricular activities. Few residents and faculty need the basic computer training recommended in curricular guidelines. Residency programs should maintain up-to-date computer resources and consider providing selective advanced computer skills training.

Influence of elective versus emergent hospital admission on patient satisfaction.

BACKGROUND: Patient satisfaction is increasingly used as a health care quality metric, although satisfaction has been associated with more intense health care, including hospitalization. Whether the increased hospitalization associated with satisfaction is limited to elective (often discretionary) hospitalization is unknown. METHODS: We conducted a prospective cohort study of adult respondents to the 2000 to 2010 US National Medical Expenditure Panel Survey (N = 50,978), including 2 years of panel data for each subject. Patient sociodemographics, health status, and hospital use were assessed in year 1, with hospital use categorized as elective or emergent hospitalization (based on whether it was preceded by an emergency visit). Year 2 patient satisfaction with health care providers was assessed using 5 items from the Consumer Assessment of Health Plans Survey. We used ordinal logistic regression to estimate adjusted associations between year 1 hospitalization and year 2 patient satisfaction quartile. RESULTS: Adjusting for sociodemographics, insurance status, availability of a usual source of care, chronic disease burden, health status, and year 1 office and prescription drug utilization, having ≥ 1 elective hospitalizations in year 1 was associated with higher year 2 satisfaction quartile (adjusted odds ratio [OR], 1.21; 95% confidence interval [CI], 1.11-1.32). Emergent hospitalizations in year 1 were not associated with satisfaction quartile in year 2 (adjusted OR, 1.01; 95% CI, 0.91-1.12). CONCLUSION: In a nationally representative sample, elective (but not emergent) hospitalizations were associated with subsequently higher overall satisfaction with health care providers, suggesting a nexus between discretionary hospital use and patient satisfaction.

The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality.

BACKGROUND: Patient satisfaction is a widely used health care quality metric. However, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes remains ill defined. METHODS: We conducted a prospective cohort study of adult respondents (N = 51,946) to the 2000 through 2007 national Medical Expenditure Panel Survey, including 2 years of panel data for each patient and mortality follow-up data through December 31, 2006, for the 2000 through 2005 subsample (n = 36,428). Year 1 patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. We estimated the adjusted associations between year 1 patient satisfaction and year 2 health care utilization (any emergency department visits and any inpatient admissions), year 2 health care expenditures (total and for prescription drugs), and mortality during a mean follow-up duration of 3.9 years. RESULTS: Adjusting for sociodemographics, insurance status, availability of a usual source of care, chronic disease burden, health status, and year 1 utilization and expenditures, respondents in the highest patient satisfaction quartile (relative to the lowest patient satisfaction quartile) had lower odds of any emergency department visit (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.00), higher odds of any inpatient admission (aOR, 1.12; 95% CI, 1.02-1.23), 8.8% (95% CI, 1.6%-16.6%) greater total expenditures, 9.1% (95% CI, 2.3%-16.4%) greater prescription drug expenditures, and higher mortality (adjusted hazard ratio, 1.26; 95% CI, 1.05-1.53). CONCLUSION: In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.

Personality and risk for Alzheimer's disease in adults 72 years of age and older: a 6-year follow-up.

[Correction Notice: An erratum for this article was reported in Vol 26(2) of Psychology and Aging (see record 2011-05802-001). This article contains an error in the Discussion, under the Implications, Caveats, Future Directions heading. The third paragraph includes the sentences that should have been removed. The corrected paragraph appears in the correction.] We conducted secondary analyses to determine the relationship between longstanding personality traits and risk for Alzheimer's disease (AD) among 767 participants 72 years of age or older who were followed for more than 6 years. Personality was assessed with the NEO-FFI. We hypothesized that elevated Neuroticism, lower Openness, and lower Conscientiousness would be independently associated with risk of AD. Hypotheses were supported. The finding that AD risk is associated with elevated Neuroticism and lower Conscientiousness can be added to the accumulating literature documenting the pathogenic effects of these two traits. The link between lower Openness and AD risk is consistent with recent findings on cognitive activity and AD risk. Findings have implications for prevention research and for the conceptualization of the etiology of AD.

Physician counseling for colorectal cancer screening: impact on patient attitudes, beliefs, and behavior.

PURPOSE: To determine how often primary care physicians address patient-level health behavioral constructs that are associated with colorectal cancer (CRC) screening and whether physician counseling addressing constructs is associated with favorable changes in patients' attitudes, beliefs, intentions, and subsequent screening. METHODS: We conducted a prospective cohort study of patients eligible for CRC screening and attending routine appointments within two academic primary care clinics (50 patients, 20 primary care clinicians). Patients completed validated measures of behavioral constructs associated with CRC screening (benefits, barriers, susceptibility, self-efficacy, intention, and stage of readiness) before and after their visits. Audio-recorded discussions of CRC screening were coded for conversation addressing constructs. Bivariate and regression analyses estimated associations between discussions that did and did not address constructs and, after the visit, measures of perceived benefits, barriers, susceptibility, self-efficacy, intention, and completion of CRC screening within 6 months. RESULTS: Physicians discussed CRC screening during 38 encounters (76%) and addressed behavioral constructs during 26 (52%). Relative to visits without CRC screening discussion, visits with discussion were associated with increased perceived susceptibility (ß = 0.39; 95% CI, 0.09-0.68) and screening intention (ß = 0.42; 95% CI, 0.11-0.73) after the visit but no significant change in perceived benefits, barriers, or self-efficacy. Within 6 months, 17 of 38 patients (45%) who discussed screening completed screening compared with 0 of 12 patients who did not discuss screening (P = .001). Associations between discussions and outcomes were similar whether or not counseling addressed behavioral constructs. CONCLUSIONS: These findings suggest that physician counseling is associated with increased patient perception of CRC susceptibility, greater screening intention, and completion of screening regardless of whether counseling addresses behavioral constructs.