Chronic Illness with Complexity: Association With Self-Perceived Burden and Advance Care Planning.

The present study examines how different chronic illnesses and mental illness comorbidity (chronic illness with complexity [CIC]) associate with components of advance care planning (ACP). We also explore the role self-perceived burden plays in the relationship between illness and ACP. Data were gathered from a cross-sectional survey of 305 elderly participants from the New Jersey End-of-Life study. Participants with diabetes and those with cardiovascular disease (CVD) are less likely, while participants with CIC are more likely, to plan for the end-of-life. Participants with diabetes are less likely to make formal plans, whereas those with CVD are less likely to hold informal discussions. CIC is associated with increased odds of having an advance directive, but no other form of ACP. Self-perceived burden did not appear to be the gateway by which illness groups differentially engaged in ACP. Future research should investigate what aspects of illnesses drive ACP.

Default clinic appointments promote influenza vaccination uptake without a displacement effect.

The majority of U.S. adults do not receive an annual influenza vaccination. Behavioral economics tools can be harnessed to encourage health behaviors. Specifically, scheduling patients by default for a flu shot appointment leads to higher vaccination rates at a medical practice than does merely encouraging flu shot appointments. It is not known, however, whether default appointments actually increase net vaccination or merely displace vaccinations from other venues. In the current field experiment, we examined the use of default appointments in a large medical practice and established that automatically scheduled appointments increased the total vaccination rate by 10 percentage points within the practice without displacing vaccinations that patients would otherwise have received in other settings. This increased vaccination rate came at the cost of a high no-show rate. These findings point to an effective way to increase vaccination rates and may offer a cost-saving measure in the scope of accountable care organizations.

Decision-making Processes among Prostate Cancer Survivors with Rising PSA Levels: Results from a Qualitative Analysis.

BACKGROUND: Prostate cancer survivors with a rising prostate-specific antigen (PSA) level have few treatment options, experience a heightened state of uncertainty about their disease trajectory that might include the possibility of cancer metastasis and death, and often experience elevated levels of distress as they have to deal with a disease they thought they had conquered. Guided by self-regulation theory, the present study examined the cognitive and affective processes involved in shared decision making between physicians and patients who experience a rising PSA after definitive treatment for prostate cancer. METHODS: In-depth interviews were conducted with 34 prostate cancer survivors who had been diagnosed with a rising PSA (i.e., biochemical failure) within the past 12 months. Survivors were asked about their experiences and affective responses after being diagnosed with a rising PSA and while weighing potential treatment options. In addition, patients were asked about their decision-making process for the initial prostate cancer treatment. RESULTS: Compared with the initial diagnosis, survivors with a rising PSA reported increased negative affect following their diagnosis, concern about the treatability of their disease, increased planning and health behavior change, heightened levels of worry preceding doctor appointments (especially prior to the discussion of PSA testing results), and a strong reliance on physicians' treatment recommendations. CONCLUSIONS: Prostate cancer survivors' decision-making processes for the treatment of a rising PSA are markedly different from those of the initial diagnosis of prostate cancer. Because patients experience heightened distress and rely more heavily on their physicians' recommendations with a rising PSA, interactions with the health care provider provide an excellent opportunity to address and assist patients with managing the uncertainty and distress inherent with rising PSA levels.

Using the common sense model of self-regulation to understand the relationship between symptom reporting and trait negative affect.

BACKGROUND/PURPOSE: Based on the Common Sense Model of Self-Regulation, we examined if the relationship of trait NA to physical symptom reporting was moderated by life events and illness representations. METHODS: This relationship was examined using a cross-sectional dataset of 554 elderly adults. RESULTS: A significant three-way interaction demonstrated that individuals who reported the greatest severity of physical symptoms were higher in trait NA, and reported more life events and a chronic illness history. CONCLUSIONS: The results of this study are consistent with the hypothesis that individual high on trait NA who have a history of a chronic illness have illness representations with both disease specific physical symptoms and symptoms from other causes, such as emotional distress. This may complicate the care of medical conditions for these patients.

Using the Common Sense Model of Self-regulation to review the effects of self-monitoring of blood glucose on glycemic control for non-insulin-treated adults with type 2 diabetes.

PURPOSE: This systematic review examined the relationship between self-monitoring of blood glucose (SMBG) and glycemic control in patients with type 2 diabetes. The Common Sense Model of Self-Regulation (CSM) served as a theoretical framework for examining how, when (mediators), and for whom (moderators) SMBG improved glycemic control. DATA SOURCES: Five databases were searched: Medline, PsychInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing & Allied Health Literature. STUDY SELECTION: Included studies had cross-sectional, longitudinal, or randomized controlled trial designs; were published between 2007 and 2011; and included patients with type 2 diabetes at least some of whom were not taking insulin; 1318 studies were screened, 119 were reviewed in detail, and 26 were included. DATA EXTRACTION: Data were collected on the relationship between SMBG and glycemic control, study design, mediators, moderators, participant characteristics, the CSM, and limitations. DATA SYNTHESIS: Twenty-six studies met criteria for inclusion: 11 cross-sectional, 4 longitudinal, and 11 randomized controlled trials. The results of the cross-sectional studies were inconclusive. Results from the longitudinal studies and randomized control trials suggested that SMBG may improve glycemic control. The few studies investigating mediators or moderators reported mixed results. Few studies effectively measured the CSM. CONCLUSION: Data suggested that SMBG may help improve glycemic control. Future trials must be designed to test hypotheses and improve our understanding of when, how, and for whom SMBG can enhance glycemic control. Rigorously controlled repetitions of current 2-arm trials will yield little new knowledge of theoretical or practical value.

Assessing theoretical predictors of long-term medication adherence: patients' treatment-related beliefs, experiential feedback and habit development.

Patient non-adherence to medication is a pervasive problem that contributes to poor patient health and high healthcare costs. Basic research and interventions have focused thus far on behaviour initiation factors, such as patients' illness and treatment beliefs. This paper proposes two processes that occur after behaviour initiation that are theorised to contribute to prediction of long-term medication adherence: 'coherence' of patients' beliefs from experiences with treatment and habit development. Seventy-one hypertensive patients reported their treatment-related beliefs, experiences related to treatment efficacy and medication-taking habit strength in a baseline interview. Patients then used an electronic monitoring pill bottle for approximately one month. Patients' medication habit-strength was the strongest predictor of all adherence measures, explaining 6-27% incremental variance in adherence to that explained by patients' treatment-related beliefs. Patients' beliefs and experiences did not predict overall adherence, even for patients with 'weaker' habits. However, patients' experiences were found to predict intentional non-adherence and habit strength was found to predict unintentional adherence. Practitioners may assess patients' medication-taking habits to get an initial view of their likely adherence to long-term medications. Future research should assess the current theoretical predictions in a hypertension inception sample and in populations with symptomatic conditions.

Why do comparative assessments predict health? The role of self-assessed health in the formation of comparative health judgments.

OBJECTIVE: Research has shown that self-assessments of health are strong predictors of morbidity and mortality regardless of format (i.e., self or comparative). In this study, the authors examined the relationship between 2 of these health assessments, self-assessed health (SAH) and comparative health (CH). On the basis of social psychological theory, they hypothesized that CH is predictive of health outcomes because it is based on SAH. Additionally, the authors examined whether motivational and dispositional factors influenced CH and whether these factors were able to account for the differences between CH and SAH. METHOD: Data were obtained from 851 community-dwelling older adults (M = 73 years). Participants responded to questionnaires assessing personality characteristics (e.g., trait affectivity, dispositional optimism and pessimism), and health status (e.g., functional limitations). All-cause mortality was tracked for a 10-year period. RESULTS: Correlation and agreement analyses revealed that both judgments had a high degree of similarity. As expected, survival analysis showed that CH predicted mortality but only until SAH was added into the model. Analysis examining the factors that influence CH showed that after controlling for SAH, high levels of trait positive affectivity, low levels of functional limitations, and low levels of fatigue-lack of energy were associated with high CH ratings. Examination of CH-SAH difference scores showed that only participants' age accounted for differences between these 2 judgments. CONCLUSIONS: These data revealed that CH judgments were, to a great extent, based on SAH. Results showed that motivational factors influence CH judgments but do not explain the differences between SAH and CH.

The perceived sensitivity to medicines (PSM) scale: an evaluation of validity and reliability.

OBJECTIVES: We report on the development and psychometric properties of a scale to measure perceived sensitivity to medicines (PSM). Design. The internal consistency, test-retest reliability, criterion-related, and predictive validity of the PSM Scale were evaluated using data collected as part of four previously published studies and one unpublished data set. METHODS: Participants (n= 1,166) included patients receiving treatment for HIV infection and hypertension, individuals receiving a travel vaccination, and undergraduate students. Criterion-related validity was assessed by examining associations between the PSM and beliefs about medicines (Beliefs about Medicines Questionnaire), anxiety and depression (Hospital Anxiety and Depression Scale). Predictive validity was assessed by examining associations between the PSM and medication adherence and with symptom reports following vaccination. Test-retest reliability was assessed in an undergraduate sample who completed the PSM on two occasions, 2 weeks apart. RESULTS: Test-retest reliability was high (r= .89, p < .001). Cronbach's alpha ranged from 0.79-0.94. Consistent with expectations, high PSM scores were associated with negative beliefs about medicines in general, strong concerns about potential adverse effects of prescribed medicines, and doubts about the necessity for treatment. High PSM scores predicted non-adherence to anti-retroviral therapy and a higher incidence of symptoms following vaccination. CONCLUSION: The findings present preliminary evidence that the PSM is a valid and reliable measure of perceived sensitivity to medication. While further work is needed to develop and evaluate the scale, the findings support its use as a research tool in studies of the use and effects of medicines. STATEMENT OF CONTRIBUTION: What is already known on this subject? It is now well understood that beliefs about medicines have an important influence on whether patients start and continue with treatment. Research spanning a range of long-term conditions and across different countries has shown that treatment uptake and adherence are consistently related to specific beliefs about prescribed medicines, such as how patients judge their personal need relative to concerns about potential adverse effects as well as more general beliefs about medicines as a class of treatment. What does this study add? The paper reports on the development and psychometric properties of a new scale to measure patients' perceptions of their sensitivity to medicines. In five studies involving different groups of individuals we found the Perceived Sensitivity to Medicines (PSM) Scale to be a reliable and valid measure. The PSM may be useful for researchers and clinicians in explaining treatment decisions, adherence and reported side-effects.

Heterogeneity in depression symptoms and health status among older adults.

OBJECTIVES: We assessed whether distinct classes of depression symptoms could be identified. In addition, we determined how these classes differed in terms of health status. METHODS: Data were analyzed with latent profile analysis. MANOVA tests were used to compare the health status of the various classes. RESULTS: A four-class model had the best fit. Classes were labeled according to participants' responses to the Center for Epidemiologic Studies-Depression Scale (CES-D) items and their overall score: low depression symptoms, high depression symptoms, subthreshold with anhedonia, and subthreshold with anhedonia and negative interpersonal feelings. Cross-sectional and longitudinal analyses showed that health status differed across classes. CONCLUSIONS: The results provide support for the idea that there is heterogeneity in the presentation of depression symptoms among older adults. These data showed that about a third of our sample of older adults reported increased levels of anhedonia and that negative interpersonal feelings were uncommon.

Physicians' communication of the common-sense self-regulation model results in greater reported adherence than physicians' use of interpersonal skills.

OBJECTIVES: Interventions that address patients' illness and treatment representations have improved patient adherence and outcomes when administered by psychologists and/or health educators and focused on a single chronic illness. The current study assesses the potential feasibility/effectiveness of an intervention based on the common-sense self-regulation model (CS-SRM) when administered by providers in a primary care setting. DESIGN: We designed a prospective, correlational study in order to optimize patients' and providers' time and to gain initial evidence of the CS-SRM-approach's feasibility/effectiveness. METHODS: Patients (n= 243) were recruited from a primary care waiting room and reported on objective behaviours of their providers (providers' CS-SRM-related behaviours and interpersonal skills) and other theoretically related measures directly after the medical encounter and reported on adherence, presenting problem resolution, and emergency care usage 1 month later. RESULTS: The more providers gave their patients an adaptive understanding of their presenting problem/treatment (the greater the number of CS-SRM-related behaviours they engaged in), the more adherent were patients in the month following the encounter and the better was their problem resolution 1 month later. The CS-SRM-related behaviours were more predictive of these outcomes and emergency care usage than were the providers' interpersonal skills. CONCLUSIONS: In the time-limited encounter, interventions may have to prioritize theoretical approaches for attaining patient adherence. The current study, although correlational, indicates that addressing the patients' illness/treatment representations is more important than the providers' interpersonal skills for attaining patient adherence and provides preliminary evidence that a CSM-based intervention in the primary care setting may be both feasible and effective.

Factors associated with the accuracy of physicians' predictions of patient adherence.

OBJECTIVE: Physicians are inaccurate in predicting non-adherence in patients, a problem that interferes with physicians': (1) appropriate prescribing decisions and (2) effective prevention/intervention of non-adherence. The purpose of the current study is to investigate potential reasons for the poor accuracy of physicians' adherence-predictions and conditions under which their predictions may be more accurate. METHODS: After the medical encounter, predictions of patient-adherence and other ratings from primary-care physicians (n=24) regarding patient-factors that may have influenced their predictions were collected. Patients (n=288) rated their agreement regarding the prescribed treatment after the encounter and reported adherence 1 month later. RESULTS: Several factors were related to physicians' adherence-predictions, including physicians' perceptions of patient-agreement regarding treatment. However, some factors were not related to adherence and agreement-perceptions were inaccurate overall, potentially contributing to the poor accuracy of adherence-predictions. The degree to which physicians discussed treatment-specifics with the patient moderated agreement-perception accuracy but not adherence-prediction accuracy. CONCLUSIONS: Training providers to discuss certain treatment-specifics with patients may improve their ability to perceive patient-agreement regarding treatment and may directly improve patient-adherence. PRACTICE IMPLICATIONS: Discussing treatment-specifics with patients may directly improve adherence, but providers should not rely on these discussions to give them accurate estimates of the patients' likely adherence.

Cognitive science speaks to the "common-sense" of chronic illness management.

We describe the parallels between findings from cognitive science and neuroscience and Common-Sense Models in four areas: (1) Activation of illness representations by the automatic linkage of symptoms and functional changes with concepts (an integration of declarative and perceptual and procedural knowledge); (2) Action plans for the management of symptoms and disease; (3) Cognitive and behavioral heuristics (executive functions parallel to recent findings in cognitive science) involved in monitoring and modifying automatic control processes; (4) Perceiving and communicating to "other minds" during medical visits to address the declarative and non-declarative (perceptual and procedural) knowledge that comprise a patient's representations of illness and treatment (the transparency of other minds).

End-of-life planning and its relevance for patients' and oncologists' decisions in choosing cancer therapy.

The goal of end-of-life (EoL) planning is to provide individuals with tools to control their financial and healthcare decisions when they are incapacitated. When an elderly patient is diagnosed with advanced cancer, the possible treatment options are palliative care with curative intent or prolongation of life or palliative care only. Treatment of cancer in elderly patients creates a significant array of monetary and symptom burdens. The question is whether advance care planning, part of EoL planning, allows patients' families and communities to control and reduce these burdens. Although the number of patients completing advance directives has increased in recent years, there are multiple barriers to the implementation of patients' wishes, such as limited knowledge of patient wishes by proxy and physician and inadequate communication regarding prognosis. In this article, the authors propose that improvements in patient decision making and clinical practice can reduce the burden of symptoms for patients if clinicians gain a better understanding of patients' models and expectations respecting the longer term consequences of diagnosis and treatment. This understanding can arise from improved information exchange and constant updating of the information as the disease and treatment evolves. Clinicians also need better prognostication tools and better training in effective communication skills to elicit patient goals and to make appropriate recommendations.

Psychological factors influencing self-assessments of health: toward an understanding of the mechanisms underlying how people rate their own health.

BACKGROUND: Research in the past 20 years has shown that self-assessed health (SAH) is a consistent and reliable predictor of health outcomes. However, it is still unclear what factors are responsible for the association of SAH with mortality and other objective health indicators. PURPOSE: This study examined the impact of trait positive affect, trait negative affect, and functional limitations (FL) on SAH cross-sectionally and longitudinally. We hypothesized that changes in SAH ratings would be mainly influenced by FL, whereas affective information would have a biasing effect on SAH ratings cross-sectionally. METHODS: We analyzed longitudinal data obtained from five successive annual interviews conducted with over 800 elderly respondents (mean age = 73 years) using latent growth curve modeling. RESULTS: Results revealed that SAH judgments were related to FL and to trait affects in each of the five waves (cross-sectional data), but only changes in FL were related to changes in SAH over time. These data also showed that changes in SAH were predictive of mortality above and beyond its initial levels. CONCLUSIONS: The results suggest that the temporal trajectory of FL is a source of information that allows an individual's SAH to predict objective health measures of both morbidity and mortality.

Integrating co-morbid depression and chronic physical disease management: identifying and resolving failures in self-regulation.

Research suggests that treatments for depression among individuals with chronic physical disease do not improve disease outcomes significantly, and chronic disease management programs do not necessarily improve mood. For individuals experiencing co-morbid depression and chronic physical disease, demands on the self-regulation system are compounded, leading to a rapid depletion of self-regulatory resources. Because disease and depression management are not integrated, patients lack the understanding needed to prioritize self-regulatory goals in a way that makes disease and depression management synergistic. A framework in which the management of co-morbidity is considered alongside the management of either condition alone offers benefits to researchers and practitioners and may help improve clinical outcomes.

Commonsense illness beliefs, adherence behaviors, and hypertension control among African Americans.

Hypertension, particularly among African Americans, has been increasing in importance in the past 10 years. One aspect of this problem is poor disease management. This study examined illness beliefs, behaviors, and hypertension control among 102 African American outpatients. Participants were interviewed about their commonsense beliefs concerning hypertension and its management in accordance with Leventhal's commonsense model of self-regulation (CSM). Also assessed were medication adherence, stress-reducing behaviors, and lifestyle behaviors recommended for blood pressure control. Blood pressure was measured at about the time of interviewing. Results indicated that endorsement of a medical belief model of hypertension (i.e., caused and controlled by factors such as diet, age, and weight) was cross-sectionally associated with lower systolic blood pressure, a relationship that was statistically mediated by lifestyle behaviors (e.g., cut down salt, exercise). Endorsement of a stress belief model (i.e., stress is the main factor in hypertension cause and control) was associated with engagement in stress-related behaviors but not with blood pressure. These results further support the utility of the CSM for understanding patients' disease management behaviors.

Using the common sense model to design interventions for the prevention and management of chronic illness threats: from description to process.

In this article, we discuss how one might use the common sense model of self-regulation (CSM) for developing interventions for improving chronic illness management. We argue that features of that CSM such as its dynamic, self-regulative (feedback) control feature and its system structure provide an important basis for patient-centered interventions. We describe two separate, ongoing interventions with patients with diabetes and asthma to demonstrate the adaptability of the CSM. Finally, we discuss three additional factors that need to be addressed before planning and implementing interventions: (1) the use of top-down versus bottom-up intervention strategies; (2) health care interventions involving multidisciplinary teams; and (3) fidelity of implementation for tailored interventions.

Health Psychology: the Search for Pathways between Behavior and Health.

This review of the current status of theoretically based behavioral research for chronic illness management makes the following points: (a) Behavioral interventions have demonstrated effectiveness for improving health outcomes using biomedical indicators, (b) current interventions are too costly and time consuming to be used in clinical and community settings, (c) translation of the conceptual models generated from studies of the problem-solving processes underlying self-management and the relationship of these processes to the self system and cultural and institutional contexts suggest new avenues for developing effective and efficient cognitive-behavioral interventions, and (d) it is proposed that integration of the conceptual developments in self-management with new approaches to the design of clinical trials can generate tailored, behavioral interventions that will improve quality of care.

Lessons from white coat hypertension: comment on Spruill et al. "The impact of perceived hypertension status on anxiety and the white coat effect".

The Implications of White Coat Hypertension by Spruill et al. (2007) are multiple and extend well beyond the domain of hypertension and cardiovascular risk. First, their excellent study indicates that theory and research need to treat emotional reactions as situation-specific events. Although traits such as Anxiety can be easily and reliably measured, their assessment may not detect the situation-specific mechanisms that link emotional responses to health risks. Second, patients' self perceptions, whether they label themselves as having a chronic disease, give meaning to the situational cues that elicit emotional reactions. Third, as Spruill et al. indicate, health behavioral research needs to examine how the clinical setting and social and cultural frameworks affect self-labeling. We add to their clinical concerns by questioning whether a clinician's words, i.e., whether they suggest a condition is related to stress, can in our contemporary culture, lead patients to treat a condition as acute rather than chronic, and how the clinicians' behavior, e.g., attention to specific areas of the body during a clinical examination, may shape the perceived cause of symptoms. The implications of this excellent study extend well beyond its focus on white coat hypertension.

The influence of default options on the expression of end-of-life treatment preferences in advance directives.

BACKGROUND: Advance directives promise to preserve patient autonomy, but research indicates that end-of-life preferences can be influenced by the way in which questions are posed. OBJECTIVE: To determine whether preferences expressed by geriatric patients on advance directives are influenced by the default response inherent in the question. DESIGN: Mailed survey containing 1 of 3 versions of an advance directive. SETTING: General internal medicine outpatient medical practice. PARTICIPANTS: Outpatients aged 65 or older (n = 106, response rate = 27%). INTERVENTIONS: In the "withhold" version of the survey, participants indicated situations where they would want treatments withheld (i.e., the default preference was in favor of treatment). In the "provide" version, participants indicated situations where they would want treatment provided (i.e., the default preference was against treatment). In the forced-choice control version, participants made an explicit decision to withhold or provide treatment for each situation. MAIN OUTCOME MEASURE: Participants' treatment preferences. RESULTS: Preferences differed by condition, F(2, 103) = 3.61, MSE = 0.09, eta2 = .07, p = .03. Participants tended to express the default preference, and thus, were more likely to favor treatment in the "withhold" condition than in the "provide" condition. Preferences in the forced-choice control condition were intermediate. CONCLUSIONS: The default inherent in a question can impact preferences for medical treatment. This default effect limits the utility of advance directives.