Self-reported physician attitudes and behaviours towards incarcerated patients.

Physicians anecdotally report inquiring about incarcerated patients' crimes and their length of sentence, which has potential implications for the quality of care these patients receive. However, there is minimal research on how a physician's awareness of their patient's crimes/length of sentence impacts physician behaviours and attitudes. We performed regression modelling on a 27-question survey to analyse physician attitudes and behaviours towards incarcerated patients. We found that, although most physicians did not usually try to learn of their patients' crimes, they often became aware of them. We observed associations between awareness of a patient's crime and poor physician disposition towards their patients and between physicians' poor dispositions and lower reported quality of care. These associations suggest that awareness of a patient's crime may reduce quality of care by negatively impacting physicians' dispositions towards their patients. Future quantitative and qualitative studies, for example, involving physician interviews and direct patient outcome assessments, are needed to confirm these findings and further uncover and address hurdles incarcerated patients face in seeking medical care.

An Electronic Tool to Support Patient-Centered Broad Consent: A Multi-Arm Randomized Clinical Trial in Family Medicine.

PURPOSE: Patients are frequently asked to share their personal health information. The objective of this study was to compare the effects on patient experiences of 3 electronic consent (e-consent) versions asking patients to share their health records for research. METHODS: A multi-arm randomized controlled trial was conducted from November 2017 through November 2018. Adult patients (n = 734) were recruited from 4 family medicine clinics in Florida. Using a tablet computer, participants were randomized to (1) a standard e-consent (standard), (2) an e-consent containing standard information plus hyperlinks to additional interactive details (interactive), or (3) an e-consent containing standard information, interactive hyperlinks, and factual messages about data protections and researcher training (trust-enhanced). Satisfaction (1 to 5), subjective understanding (0 to 100), and other outcomes were measured immediately, at 1 week, and at 6 months. RESULTS: A majority of participants (94%) consented to future uses of their health record information for research. No differences in study outcomes between versions were observed at immediate or 1-week follow-up. At 6-month follow-up, compared with the standard e-consent, participants who used the interactive e-consent reported greater satisfaction (B = 0.43; SE = 0.09; P <.001) and subjective understanding (B = 18.04; SE = 2.58; P <.001). At 6-month follow-up, compared with the interactive e-consent, participants who used the trust-enhanced e-consent reported greater satisfaction (B = 0.9; SE = 1.0; P <.001) and subjective understanding (B = 32.2; SE = 2.6, P <.001). CONCLUSIONS: Patients who used e-consents with interactive research details and trust-enhancing messages reported higher satisfaction and understanding at 6-month follow-up. Research institutions should consider developing and further validating e-consents that interactively deliver information beyond that required by federal regulations, including facts that may enhance patient trust in research.

Comparison of Factors Identified by Patients and Physicians Associated with Hospital Readmission (COMPARE2).

OBJECTIVE: Factors contributing to hospital readmission have rarely been sought from the patient perspective. Furthermore, it is unclear how patients and physicians compare in identifying factors contributing to readmission. The objective of the study was to identify and compare factors contributing to hospital readmission identified by patients and physicians by surveying participants upon hospital readmission to a teaching medicine service. METHODS: Patients 18 years and older who were discharged and readmitted to the same service within 30 days and the physicians caring for these patients were surveyed to identify factors contributing to readmission. Secondary outcomes included comparing responses between groups and determining level of agreement. Patients could be surveyed multiple times on subsequent readmissions; physicians could be surveyed for multiple patients. RESULTS: A total of 131 patients and 37 physicians were consented. The mean patient age was 60.1 years (standard deviation 16.8 years) and 55.6% were female; 56.4% were white, and 42.1% were black/African American. In total, 179 patient surveys identified "multiple medical problems" (48.6%), "trouble completing daily activities" (45.8%), and "discharged too soon" (43.6%) most frequently as contributing factors; 231 physician surveys identified "multiple medical problems" (45.0%) and "medical condition too difficult to care for at home" (35.6%) most frequently as contributing factors. Paired survey results were available for 135 readmissions and showed fair agreement for only 1 factor but no agreement for 5 factors. CONCLUSIONS: Patients identified previously unknown factors contributing to readmission. Little agreement existed between patients and physicians. Additional research is needed to determine how best to address patient-identified factors contributing to readmission.

Perception of Risk of Developing Diabetes Among Patients With Undiagnosed Prediabetes: The Impact of Health Care Provider Advice.

IN BRIEF Patient awareness of prediabetes and an increased diabetes risk is crucial to diabetes prevention. This article reports on a study investigating perceptions of diabetes risk among U.S. adults with prediabetes and the role of physician communication about risks in influencing patient perceptions. This study demonstrates that few patients with undiagnosed prediabetes are even told that they are at high risk for diabetes. This study provides further evidence that diabetes prevention requires improved patient-centered care, which likely begins with the delivery of adequate information to patients.

Daily self-regulation with biofeedback to improve stress and job satisfaction in a primary care clinic.

BACKGROUND: Burnout in healthcare professions is higher than other careers. An undesirable work-life balance has resulted in declining job satisfaction among primary care physicians. Biofeedback devices teach self-regulation techniques, which reduce stress and increase resilience. OBJECTIVES: We assessed whether self-regulation with biofeedback is effective at decreasing stress and improving job satisfaction among primary care clinicians and nurses. METHODS: Two naturally occurring cohorts of clinicians and nurses were followed over 12 weeks. The treatment group (N = 9) completed 12 weeks of self-regulation with optional clinic-based biofeedback and received peer support for the first half. The control group (N = 9) started a delayed intervention after 6 weeks without peer support. Descriptive and bivariate analyses were conducted. RESULTS: The treatment group averaged one biofeedback session weekly for 6 min and the control group two sessions for 11 min. Adherence differed by age. Subjects also reported using self-regulation techniques without biofeedback. Perceived stress initially increased in both groups with intervention implementation, more so in the treatment group (P = 0.03) whose stress then decreased but was not significant. Overall and extrinsic job satisfaction similarly increased but were not significance. CONCLUSION: The initial increase in perceived stress was related to daily biofeedback adherence and clinic responsibilities. Treatment group stress then decreased with self-regulation but was difficult to quantify in a small cohort. Larger studies could increase daily self-regulation adherence by improving biofeedback accessibility for leisurely use. Using self-regulation with biofeedback may be an innovative approach to reduce stress and improve job satisfaction in primary care.

Impact of Match Violations on Applicants' Perceptions and Rankings of Residency Programs.

Introduction The National Resident Matching Program (NRMP) requires all Match participants to adhere to a strict code of conduct known as the Match Participation Agreement, yet Match violations continue to occur. We sought to determine how interview experiences, including Match violations, impact applicants' perceptions and rankings of residency programs. Methods An electronic survey was sent to all accredited medical school Deans of Student Affairs and Association of American Medical Colleges Student Representatives for distribution to fourth-year medical students. Questions assessed pressures that residency programs placed on applicants during interview season and their impact on applicants. Both quantitative and qualitative data were collected. Results Of the 433 included respondents, 31.2% (n = 135) reported breaches of the NRMP Match Participation Agreement. Of those, 63% (n = 85) had a negative perception of the violating programs, and 37.8% (n = 51) were less likely to rank those programs highly. Violations included asking applicants about the locations of their other interviews (60.3%, n = 261), pressuring applicants to reveal their ranking (24.0%, n = 104), explicitly requesting applicants to reveal their ranking (6.5%, n = 28), asking applicants to provide a commitment before Match day (3.9%, n = 17), and other behavior that was felt to ignore the spirit of the Match (16.4%, n = 71). Implying that applicants would match into a program if they ranked it highly (37.2%, n = 161) was received positively by 65.2% (n = 105) of applicants experiencing this breach, with 42.2% (n = 68) ranking the program more highly. Three major themes impacting applicants' impressions of residency programs emerged from the qualitative data: interview experience, professionalism, and post-interview communication (PIC). Respondents overwhelmingly agreed that PIC should either be eliminated or that programs should set clear expectations for PIC. Conclusions Match violations continue to occur, despite the NRMP Match Participation Agreement. With the notable exception of communication implying that applicants would match into a program, applicants overwhelmingly view programs that commit these violations negatively and often rank these programs lower as a result.

Systematic Analysis of Extracting Data on Advance Directives from Patient Electronic Health Records (EHR) in Terminal Oncology Patients.

BACKGROUND: Advance directives are legal documents that include living wills and durable health care power of attorney documents. They are critical components of care for seriously ill patients which are designed to be implemented when a patient is terminally ill and incapacitated. We sought to evaluate potential reasons for why advance directives were not appropriately implemented, by reviewing the electronic health record (EHR) in patients with terminal cancer. METHODS: A retrospective analysis of the EHR of 500 cancer patients from 1/1/2013 to 12/31/2016 was performed. Data points were manually collected and entered in a central database. RESULTS: Of the 500 patients, 160 (32%) had an advance directive (AD). The most common clinical terminology used by physicians indicating a terminal diagnosis was progressive (36.6%) and palliative (31%). The most common clinical terminology indicating incapacity was altered mental status (25.6%), and not oriented (14%). 34 (6.8%) patients met all criteria of having a terminal diagnosis, a documented AD, and were deemed incapacitated. Of these patients who met all of these data points, their ADs were implemented on average 1.7 days (SD: 4.4 days) after which they should have been. This resulted in a total of 58 days of additional care provided. DISCUSSION: This study provided insight on to how ADs are managed in day to day practice in the hospital. From our analysis it appears that physicians are able to identify when a patient is terminal, however, it is typically later than it should have been recognized. Further studies should be performed focusing on harnessing the power of the EHR and providing physicians formative and evaluative feedback of practice patterns to ensure that ADs are honored when appropriate.

Effect of Sedentary Lifestyle on Cardiovascular Disease Risk Among Healthy Adults With Body Mass Indexes 18.5 to 29.9 kg/m2.

A substantial proportion of adults at healthy body mass index (BMI) are potentially at high risk for cardiovascular disease (CVD). The objective of this study is to determine if sedentary lifestyle characteristics in healthy weight adults increase their likelihood of being at high CVD risk to that of individuals who are overweight. Adults aged 40 to 79 years in the 2011 to 2016 National Health and Nutrition Examination Survey at a healthy BMI (18.5 to 24.9) and overweight BMI (25 to 29.9; unweighted n = 4,572; weighted n = 43,919,354) were analyzed. The American College of Cardiology/American Heart Association atherosclerotic CVD risk score was used to assess CVD risk. For individuals with a BMI 18.5 to 24.9, 29.6% had increased risk of a CVD event. In logistic regressions adjusted for age, race, gender, education, poverty/income ratio, insurance status, and number of visits to a healthcare provider in the past year, individuals with unhealthy sagittal abdominal diameter (odds ratio [OR] 2.44; 95% confidence interval [CI], 0.97 to 6.14), shortness of breath upon exertion (OR 1.35; 95% CI, 0.65 to 2.79), unhealthy waist circumference (OR 0.99; 95% CI, 0.60 to 1.61), and less than recommended levels of physical activity (OR 0.73; 95% CI, 0.43 to 1.23) were not significantly different than overweight adults in being at high risk for CVD events. Individuals with healthy characteristics and a BMI 18.5 to 24.9 were significantly less likely than overweight adults to be at high risk for CVD. In conclusion, the findings suggest that in individuals at a BMI 18.5 to 24.9, characteristics of a sedentary lifestyle increase the likelihood of being at high risk for CVD to that of overweight individuals.

Does an interactive trust-enhanced electronic consent improve patient experiences when asked to share their health records for research? A randomized trial.

OBJECTIVE: In the context of patient broad consent for future research uses of their identifiable health record data, we compare the effectiveness of interactive trust-enhanced e-consent, interactive-only e-consent, and standard e-consent (no interactivity, no trust enhancement). MATERIALS AND METHODS: A randomized trial was conducted involving adult participants making a scheduled primary care visit. Participants were randomized into 1 of the 3 e-consent conditions. Primary outcomes were patient-reported satisfaction with and subjective understanding of the e-consent. Secondary outcomes were objective knowledge, perceived voluntariness, trust in medical researchers, consent decision, and time spent using the application. Outcomes were assessed immediately after use of the e-consent and at 1-week follow-up. RESULTS: Across all conditions, participants (N = 734) reported moderate-to-high satisfaction with consent (mean 4.3 of 5) and subjective understanding (79.1 of 100). Over 94% agreed to share their health record data. No statistically significant differences in outcomes were observed between conditions. Irrespective of condition, black participants and those with lower education reported lower satisfaction, subjective understanding, knowledge, perceived voluntariness, and trust in medical researchers, as well as spent more time consenting. CONCLUSIONS: A large majority of patients were willing to share their identifiable health records for research, and they reported positive consent experiences. However, incorporating optional additional information and messages designed to enhance trust in the research process did not improve consent experiences. To improve poorer consent experiences of racial and ethnic minority participants and those with lower education, other novel consent technologies and processes may be valuable. (An Interactive Patient-Centered Consent for Research Using Medical Records; NCT03063268).

Professional Identity, Job Satisfaction, and Commitment of Nonphysician Faculty in Academic Family Medicine.

BACKGROUND AND OBJECTIVES: Nonphysician faculty are common in academic family medicine departments and residencies. The objective of this study was to examine whether these nonphysician faculty have adopted a professional identity of family medicine and how that relates to job satisfaction and organizational commitment. METHODS: In 2017, a survey of nonphysician members of the Council of Academic Family Medicine organizations in the United States and Canada was conducted. The overall response rate for the survey was 52.6% (526/1,001). The current analysis was conducted on the individuals who met all of the inclusion criteria and had complete data on all investigated scales (n=360). Scales on professional identity, job satisfaction, and organizational commitment were examined along with age, gender, race, and professional characteristics. RESULTS: The respondents indicated a professional identity with family medicine, commitment to their organization, and high job satisfaction. There was a lack of association with gender for these primary variables. Professional identity had a moderately positive relationship with years in family medicine (r=0.23). Professional identity had a moderately strong positive relationship with both commitment to the organization (r=0.41), and job satisfaction (r=0.43). In multivariate regressions, race/ethnicity was associated with both professional identity (P<.05) and job satisfaction (P<.05), with nonwhites having lower professional identity and job satisfaction. CONCLUSIONS: The results of this survey of nonphysician faculty in family medicine indicated a high professional identity to family medicine, high job satisfaction, and commitment to their organization. Strategies including cultural competency training may serve as important tools to avoid dissatisfaction or turnover among this key workforce element in academic family medicine.

Patient preferences toward an interactive e-consent application for research using electronic health records.

OBJECTIVE: The purpose of this study was to assess patient perceptions of using an interactive electronic consent (e-consent) application when deciding whether or not to grant broad consent for research use of their identifiable electronic health record (EHR) information. MATERIALS AND METHODS: For this qualitative study, we conducted a series of 42 think-aloud interviews with 32 adults. Interview transcripts were coded and analyzed using a modified grounded theory approach. RESULTS: We identified themes related to patient preferences, reservations, and mixed attitudes toward consenting electronically; low- and high-information-seeking behavior; and an emphasis on reassuring information, such as data protections and prohibitions against sharing data with pharmaceutical companies. Participants expressed interest in the types of information contained in their EHRs, safeguards protecting EHR data, and specifics on studies that might use their EHR data. DISCUSSION: This study supports the potential value of interactive e-consent applications that allow patients to customize their consent experience. This study also highlights that some people have concerns about e-consent platforms and desire more detailed information about administrative processes and safeguards that protect EHR data used in research. CONCLUSION: This study contributes new insights on how e-consent applications could be designed to ensure that patients' information needs are met when seeking consent for research use of health record information. Also, this study offers a potential electronic approach to meeting the new Common Rule requirement that consent documents contain a "concise and focused" presentation of key information followed by more details.