Patients' experiences with navigation for cancer care.

OBJECTIVE: We examined how navigation, defined as the assessment and alleviation of barriers to adequate health care, influences patients' perspectives on the quality of their cancer care. METHODS: We conducted post-study patient interviews from a randomized controlled trial (usual care vs. patient navigation services) from cancer diagnosis through treatment completion. Patients were recruited from 11 primary care, hospital and community oncology practices in New York. We interviewed patients about their expectations and experience of patient navigation or, for non-navigated patients, other sources of assistance. RESULTS: Thirty-five patients newly diagnosed with breast or colorectal cancer. Valued aspects of navigation included emotional support, assistance with information needs and problem-solving, and logistical coordination of cancer care. Unmet cancer care needs expressed by patients randomized to usual care consisted of lack of assistance or support with childcare, household responsibilities, coordination of care, and emotional support. CONCLUSION: Cancer patients value navigation. Instrumental benefits were the most important expectations for navigation from navigated and non-navigated patients. Navigated patients received emotional support and assistance with information needs, problem-solving, and logistical aspects of cancer care coordination. PRACTICE IMPLICATIONS: Navigation services may help improve cancer care outcomes important to patients by addressing fragmented, confusing, uncoordinated, or inefficient care.

Reliability of the Lifetime Inventory of Drug Use Consequences (INDUC) in methadone maintenance patients.

One hundred twenty one opiate-dependent individuals in methadone maintenance treatment at an urban university medical center in the U.S. were administered the Inventory of Drug Use Consequences (InDUC), and 68 subjects provided follow-up assessments at two to six weeks. The sample included 61 (50.4%) women; 86 (71.1%) of the subjects reported that they were White, 29 (24.0%) Black, and six (5.0%) other race. The mean age was 41.9 (SD = 9.7) years. Ninety-nine (81.8%) of participants had used opiates intravenously. INDUC total scores and a short form showed high internal consistency (alpha) and test-retest reliability (ICC) across gender, race, ethnicity, and education, supporting their use as global measures of drug use consequences. The interpersonal scale was also reliable across strata whereas the physical and intrapersonal scales were not reliable. The impulse control and social responsibility scales were stable but not internally consistent.

Dimensions of psychopathy in relation to suicidal and self-injurious behavior.

Externalizing psychopathology is associated with an increased risk for suicidal behavior. Within the externalizing domain, psychopathy may be an important construct for the understanding of which individuals are at particularly high risk. However, prior studies of psychopathy and suicidal behavior have not distinguished between suicide attempts and nonsuicidal self-injurious behavior (NSIB). The present study used data on 810 civil psychiatric patients from the MacArthur Violence Risk Assessment Project to examine the relationships between scores on the four dimensions of the Psychopathy Checklist: Screening Version (PCL: SV) and suicide attempts and nonsuicidal self-injurious behavior (NSIB). Results indicate that only the antisocial dimension of psychopathy is associated with suicide attempts. With regard to NSIB, an interaction was found such that, among African-Americans, NSIB was more prevalent at higher levels of antisociality. Present findings refine previous results from studies using the two-factor PCL:SV model and have important implications for the assessment of suicide risk.

Further challenges in measuring communication skills: accounting for actor effects in standardised patient assessments.

CONTEXT: Subjective rating scales for communication skills may yield more personally meaningful responses than more standardised rating schemes. It is unclear, however, whether such evaluations may be overly biased by respondents' rating styles, which may lead to unreliable measurement of examinees' communication skills. METHODS: Our study involved 212 students from the classes of 2005 and 2006 at the University of Rochester School of Medicine and Dentistry. All students were rated by actors depicting standardised patients (SPs) on the same seven cases using the 19-item Rochester Communication Rating Scale (RCRS). Different students were assigned to different actors playing the same SP. We assessed the extent to which actors' personal rating styles influenced the scores they assigned to students. Main outcome measures were: between-actor variability in responses; the degree to which actors' response styles contribute to overall scores, and improvements in reliability achieved by standardising actors' ratings. RESULTS: There were statistically significant differences between actors in their mean assigned scores. Scores aggregated over 18 separate SP cases have an expected generalisability coefficient of 0.79. If raw RCRS scores are used, a total of 27 replications of the RCRS are required to achieve a Cronbach's alpha of 0.8; standardisation reduces this number to 18. CONCLUSIONS: Although actors are variable in their use of a standardised subjective scale of communication, such differences contribute to an acceptably small proportion of the total variance if scores are combined across a large number of cases. Reliability can be markedly improved by standardising scores across raters.

Clinician-patient communication about physical activity in an underserved population.

BACKGROUND: The 5A (Ask, Advise, Agree, Assist, Arrange) model, used to promote patient behavior changes in primary care, can also be applied to physical activity. Our goal was to assess primary care physicians' use of the 5A model in discussions with underserved populations about physical activity. METHODS: We analyzed 51 audio-recorded, transcribed office visits on randomly selected patient care days and after-visit patient surveys with adults in 2 community health centers in Rochester, New York. RESULTS: The patient sample was 51% African-American and predominantly female (70%), with the majority having a high school-level education or less (66%) and an annual household income < dollars 39,000 (57%). Physical activity was discussed during 19 of the 51 visits, which included 16 (84%) visits with "Ask"; 10 (53%) with "Advise"; 4 (21%) with "Agree"; 5 (26%) with "Assist"; and 0 with "Arrange" statements. Most discussions of physical activity contained several Ask or Advise statements but few Agree, Assist, or Arrange statements. CONCLUSION: Communication about physical activity that included Agree, Arrange, and Assist statements of the 5A model was infrequent. Health promotion interventions in underserved populations should target these steps and prompt patients to initiate communication to improve physical activity.

"Could this be something serious?" Reassurance, uncertainty, and empathy in response to patients' expressions of worry.

BACKGROUND: Previous work suggests that exploration and validation of patients' concerns is associated with greater patient trust, lower health care costs, improved counseling, and more guideline-concordant care. OBJECTIVE: To describe physicians' responses to patients' worries, how their responses varied according to clinical context (straightforward versus medically unexplained symptoms [MUS]) and associations between their responses and patients' ratings of interpersonal aspects of care. DESIGN: Multimethod study. For each physician, we surveyed 50 current patients and covertly audiorecorded 2 unannounced standardized patient (SP) visits. SPs expressed worry about "something serious" in 2 scenarios: straightforward gastroesophageal reflux or poorly characterized chest pain with MUS. PARTICIPANTS: One hundred primary care physicians and 4,746 patients. MEASUREMENTS: Patient surveys measuring interpersonal aspects of care (trust, physician knowledge of the patient, satisfaction, and patient activation). Qualitative coding of 189 transcripts followed by descriptive, multivariate, and lag-sequential analyses. RESULTS: Physicians offered a mean of 3.1 responses to each of 613 SP prompts. Biomedical inquiry and explanations, action, nonspecific acknowledgment, and reassurance were common, whereas empathy, expressions of uncertainty, and exploration of psychosocial factors and emotions were uncommon. Empathy expressed during SP visits was associated with higher patient ratings of interpersonal aspects of care. After adjusting for demographics and comorbidities, the association was only statistically significant for the MUS role. Empathy was most likely to occur if expressed at the beginning of the conversational sequence. CONCLUSIONS: Empathy is associated with higher patient ratings of interpersonal care, especially when expressed in situations involving ambiguity. Empathy should be expressed early after patient expressions of worry.

Transitions to, and correlates of, suicidal ideation, plans, and unplanned and planned suicide attempts among 3,729 men and women with alcohol dependence.

OBJECTIVE: Using a heuristic model of suicidal ideation and behavior, the two objectives were to identify correlates of (1) unique suicide-related outcomes (ideation, planning, planned attempt, unplanned attempt) and (2) specific transitions from one suicide-related category to the next. METHOD: Analyses were conducted with data from the Collaborative Study on the Genetics of Alcoholism (COGA), a six-site family pedigree study of individuals in treatment for alcoholism, their relatives, and control families. There were 3,729 subjects in the analysis; all were age 18 years or older with a diagnosis of current alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Lifetime suicidal ideation, planning, and attempts were analyzed retrospectively. Correlates of each lifetime transition were analyzed using a series of multivariate logistic regressions. Multivariate multinomial regression analysis was used to examine correlates of each lifetime outcome. RESULTS: Female gender is uniquely associated with transitions to unplanned and planned attempts. Independent depression and substance-induced depression are associated with transitions to ideation and planning, whereas alcohol-related aggression is correlated with transitions to unplanned attempts. Analyses of suicide-related outcomes show that women are at higher risk for unplanned and planned attempts. Substance use and impairment are related to suicidal plans and attempts but not ideation. Independent and substance-induced depressions are associated with each suicide-related outcome, whereas alcohol-related aggression is uniquely related to unplanned attempts. CONCLUSIONS: Data underscore the heterogeneity of suicidal ideation and behavior among alcoholics and indicate the need to make clear distinctions between types of suicidal ideation and behavior in research and prevention efforts.

Predictors of low-intent and high-intent suicide attempts in rural China.

OBJECTIVES: Acts of suicide are heterogeneous with respect to level of intent. Data on correlates of intent are overwhelmingly from Western samples. We sought to identify correlates of low-intent and high-intent suicide attempts in China. METHODS: We compared 277 adult case patients who presented to the emergency department in a rural hospital because of attempted suicide to 277 community control individuals, pair-matched for age, gender, and location of residence. Attempted suicides were stratified into 3 levels of suicide intent: low, intermediate, and high. Paired logistic regression analyses were used to analyze the data. RESULTS: High-intent acts of suicide were associated with major depression, chronic stress, and a relative or associate who had a history of suicidal behavior. These correlates were not associated with low-intent acts of suicide. CONCLUSIONS: High-intent acts of suicide in China are the culmination of longstanding difficulties or symptoms including depression, chronic stress, and previous exposure to suicidal behavior. Prevention of high-intent acts of suicide should include a focus on these domains.

Exploring and validating patient concerns: relation to prescribing for depression.

PURPOSE: This study examined moderating effects of physician communication behaviors on relationships between patient requests for antidepressant medications and subsequent prescribing. METHODS: We conducted a secondary analysis of a randomized trial. Primary care physicians (N = 152) each had 1 or 2 unannounced visits from standardized patients portraying the role of major depression or adjustment disorder. Each standardized patient made brand-specific, general, or no requests for antidepressants. We coded covert visit audio recordings for physicians' exploration and validation of patient concerns (EVC). Effects of communication on prescribing (the main outcome) were evaluated using logistic regression analysis, accounting for clustering and for site, physician, and visit characteristics, and stratified by request type and standardized patient role. RESULTS: In the absence of requests, high-EVC visits were associated with higher rates of prescribing of antidepressants for major depression. In low-EVC visits, prescribing was driven by patient requests (adjusted odds ratio [AOR] for request vs no request = 43.54, 95% confidence interval [CI], 1.69-1,120.87; P < or = .005), not clinical indications (AOR for depression vs adjustment disorder = 1.82; 95% CI, 0.33-9.89; P = NS). In contrast, in high-EVC visits, prescribing was driven equally by requests (AOR = 4.02; 95% CI, 1.67-9.68; P < or = .005) and clinical indications (AOR = 4.70; 95% CI, 2.18-10.16; P < or = .005). More thorough history taking of depression symptoms did not mediate these results. CONCLUSIONS: Quality of care for depression is improved when patients participate more actively in the encounter and when physicians explore and validate patient concerns. Communication interventions to improve quality of care should target both physician and patient communication behaviors. Cognitive mechanisms that link patient requests and EVC to quality of care warrant further study.

Physicians' responses to patients' medically unexplained symptoms.

OBJECTIVE: To understand how physicians communicate may contribute to the mistrust and poor clinical outcomes observed in patients who present with medically unexplained symptoms (MUS). METHODS: After providing informed consent, 100 primary care physicians in greater Rochester, New York, were visited by two unannounced covert standardized patients (actors, or SPs) portraying two chest pain roles: classic symptoms of gastroesophageal reflux disease (GERD) with nausea and insomnia (the GERD role) and poorly characterized chest pain with fatigue and dizziness (the MUS role). The visits were surreptitiously audiorecorded and analyzed using the Measure of Patient-Centered Communication (MPCC), which scores physicians on their exploration of the patients' experience of illness (component 1) and psychosocial context (component 2), and their attempts to find common ground on diagnosis and treatment (component 3). RESULTS: In multivariate analyses, MUS visits yielded significantly lower scores on MPCC component 1 (p = .01). Subanalysis of component 1 scores showed that patients' symptoms were not explored as fully and that validation was less likely to be used in response to patient concerns in the MUS than in the GERD visits. Component 2 and component 3 were unchanged. CONCLUSION: Physicians' inquiry into and validation of symptoms in patients with MUS was less common compared with more medically straightforward patient presentations. Further research should study the relationship between communication variables and poor clinical outcomes, misunderstandings, mutual distrust, and inappropriate healthcare utilization in this population, and test interventions to address this problem.

Patient-centered communication and diagnostic testing.

PURPOSE: Although patient-centered communication is associated with improved health and patient trust, information about the impact of patient-centered communication on health care costs is limited. We studied the relationship between patient-centered communication and diagnostic testing expenditures. METHODS: We undertook an observational cross-sectional study using covert standardized patient visits to study physician interaction style and its relationship to diagnostic testing costs. Participants were 100 primary care physicians in the Rochester, NY, area participating in a large managed care organization (MCO). Audio recordings of 2 standardized patient encounters for each physician were rated using the Measure of Patient-Centered Communication (MPCC). Standardized diagnostic testing and other expenditures, adjusted for patient demographics and case-mix, were derived from the MCO claims database. Analyses were adjusted for demographics and standardized patient detection. RESULTS: Compared with other physicians, those who had MPCC scores in the lowest tercile had greater standardized diagnostic testing expenditures (11.0% higher, 95% confidence interval [CI], 4.5%-17.8%) and greater total standardized expenditures (3.5% higher, 95% CI, 1.0%-6.1%). Whereas lower MPCC scores were associated with shorter visits, adjustment for visit length and standardized patient detection did not affect the relationship with expenditures. Total (testing, ambulatory and hospital care) expenditures were also greater for physicians who had lower MPCC scores, an effect primarily associated with the effect on testing expenditures. CONCLUSIONS: Patient-centered communication is associated with fewer diagnostic testing expenditures but also with increased visit length. Because costs and visit length may affect physicians' and health systems' willingness to endorse and practice a patient-centered approach, these results should be confirmed in future randomized trials.

Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues.

The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.

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.

Pilot educational outreach project on partner violence.

BACKGROUND: To assess the impact of a multimodal educational outreach on physician screening and documentation of intimate partner violence (IPV) in primary care. METHODS: Pre- and post-intervention assessment of physician screening and chart documentation of IPV. Physician screening was assessed by post-visit survey of patients and documentation was assessed by medical record review. SETTING: Three medical offices in an urban community of approximately 1 million. PARTICIPANTS: Three primary care physicians (one internist, one obstetrician, and one family physician) and 100 patients from each of these practices. INTERVENTIONS: Multimodal educational outreach to physicians and their office staff regarding appropriate screening and management of IPV. A trained IPV educator made periodic office visits in 2002 to educate the physician and office staff regarding appropriate screening and management of IPV. RESULTS: Before the intervention, 36/150 (24%) of sample patients reported having been previously asked about IPV and 24/150 (16%) reported being asked in a written format. After the intervention, 100/149 (67%) and 41/108(28%) reported being asked verbally or in writing, respectively. CONCLUSIONS: This pilot study of three physicians suggests educational outreach represents a promising and feasible means of improving physician screening and documentation of IPV in primary care.

Comprehensive assessment of professional competence: the Rochester experiment.

BACKGROUND: A required 2-week comprehensive assessment (CA) for 2nd-year medical students that integrates basic science, clinical skills, information management, and professionalism was implemented. DESCRIPTION: The CA links standardized patients (SPs) with computer-based exercises, a teamwork exercise, and peer assessments; and culminates in student-generated learning plans. EVALUATION: Scores assigned by SPs showed acceptable interrater reliability. Factor analyses defined meaningful subscales of the peer assessment and communication rating scales. Ratings of communication skills were correlated with information gathering, patient counseling, and peer assessments; these, in turn, were strongly correlated with the written exercises. Students found the CA fair, with some variability in opinion of the peer and written exercises. Useful learning plans and positive curricular changes were undertaken in response to the CA results. CONCLUSION: A CA that integrates multiple domains of professional competence is feasible, useful to students, and fosters reflection and change. Preliminary data suggest that this format is reliable and valid.