Understanding Physicians' Perceptions of Patient-Identified Barriers to Osteoporosis Medication Initiation: A Cognitive Mapping Approach.

Objective: Interventions to initiate medication and increase adherence for postmenopausal women who have had a fragility fracture were not always successful. The purpose of this study was to derive an empirical framework for patient-identified barriers to osteoporosis medication initiation and adherence from physician experts. Methods: A cognitive mapping approach involving nominal group technique (NGT) meetings and a card sorting and rating task were used to obtain formative data. We first conducted four NGT meetings with 18 women patients who were not on osteoporosis treatment to identify barriers to osteoporosis medication, then invited 27 osteoporosis physicians to sort and rate 25 patients identified barriers. Descriptive analysis, multidimensional scaling analysis, and hierarchical cluster analysis were applied for data analysis. Results: A two-dimensional five-cluster cognitive map was derived to provide an organizational framework for understanding patients perceived barriers to medication initiation and adherence. The five clusters were concerns about side effects, experience of side effects, lifestyle changes, medication access and complexity, and patient uncertainty about treatment and trust in the provider. The two dimensions were interpreted as internal to patients (X-axis) and external to patients (Y-axis). Conclusions/Implications: Views of patients solicited in a structured format provided directions to help in designing interventions to improve osteoporosis medication initiation and adherence.

Identifying Patient Profiles for Developing Tailored Diabetes Self-Management Interventions: A Latent Class Cluster Analysis.

Purpose: Interventions that are tailored to the specific psychosocial needs of people with diabetes may be more effective than a "one size fits all" approach. The purpose of this study is to identify patient profiles with distinct characteristics to inform the development of tailored interventions. Methods: A latent class cluster analysis was conducted with data from the ENCOURAGE trial based on participant responses to 6 baseline psychosocial measures, including trust in physicians, perceived discrimination, perceived efficacy in patient-physician interactions, social support, patient activation, and diabetes distress. The trial's primary outcomes were hemoglobin A1c, body mass index, systolic blood pressure, low-density lipoprotein cholesterol, and quality of life; secondary outcomes were diabetes distress and patient engagement. Results: Three classes of participants were identified: Class 1 (n = 72) had high trust, activation, perceived efficacy and social support; low diabetes distress; and good glycemic control (7.1 ± 1.3%). Class 2 (n = 178) had moderate values in all measures with higher baseline A1c (8.1 ± 2.1%). Class 3 (n = 155) had high diabetes distress; low trust, patient engagement, and perceived efficacy; with similar baseline A1c (8.2 ± 2.1%) as Class 2. Intervention effects differed for these 3 classes. Conclusion: Three distinct subpopulations, which exhibited different responses to the ENCOURAGE intervention, were identified based on baseline characteristics. These groups could be used as intervention targets. Future studies can determine whether these approaches can be used to target scarce resources efficiently and effectively in real-world settings to maximize the impact of interventions on population health, especially in impoverished communities.

Promoting Physical Activity in Rural Settings: Effectiveness and Potential Strategies.

PURPOSE: Implementing efficacious physical activity interventions in real-world rural settings is needed because rural cancer survivors are more physically inactive and experience poorer health. To address this gap, this study evaluated effectiveness of an evidenced-based physical activity program (Better Exercise Adherence after Treatment for Cancer [BEAT Cancer]) for rural women cancer survivors when implemented by community-based, non-research staff. METHODS: 16 rural women cancer survivors received BEAT Cancer implemented by a rural, community organization and non-research staff; physical activity, patient-reported outcomes, and social cognitive constructs were measured at baseline and post-program. Cancer survivors and interventionists completed program evaluations post-program. RESULTS: Cancer survivor mean age was 58±12 years; 62% were White. Mean months since diagnosis was 54±72; 69% had breast cancer. Significant improvements from pre- to post-program occurred for self-report weekly minutes of moderate-to-vigorous physical activity (mean change [M] = 146±186, p = 0.009), anxiety (M = -1.3±1.8, p = 0.016), depression (M = -2.1±2.0, p = 0.001), self-efficacy (M = 20.9±30.5, p = 0.019), barriers interference (M = -15.0±14.1, p = 0.001), and social support (M = 5.0±7.4, p = 0.02). Cancer survivors ranked the program highly, identified strategies that were helpful (e.g., group activities, personalized exercise plan, etc.), and suggested additional implementation strategies (e.g., guide for home-based phase, etc.). Interventionists identified strategies (e.g., logistics, staff training and certification, cost, etc.) for enhancing organizational readiness for program delivery. CONCLUSION: Evidence-based physical activity programs can be effective when implemented by non-research staff in rural settings. Further research testing strategies that improve implementation is needed. PRACTICAL IMPLICATIONS: Effectiveness and identified strategies supporting delivery when implemented by a rural organization can improve physical activity promotion for rural, at-risk populations.

Cognitive mapping as an approach to facilitate organ donation among African Americans.

Making up 13.4% of the United States population, African Americans (AAs) account for 28.7% of candidates who are currently waiting for an organ donation. AAs are disproportionately affected by end-organ disease, particularly kidney disease, therefore, the need for transplantation among this population is high, and the high need is also observed for other solid organ transplantation. To this end, we worked with the AA community to derive an empirical framework of organ donation strategies that may facilitate AA decision-making. We used a cognitive mapping approach involving two distinct phases of primary data collection and a sequence of data analytic procedures to elicit and systematically organize strategies for facilitating organ donation. AA adults (n = 89) sorted 27 strategies identified from nominal group technique meetings in phase 1 based on their perceived similarities. Sorting data were aggregated and analyzed using Multidimensional scaling and hierarchical cluster analyses. Among 89 AA participants, 68.2% were female, 65.5% obtained > high school education, 69.5% reported annual household income ≤ $50,000. The average age was 47.4 years (SD = 14.5). Derived empirical framework consisted of five distinct clusters: fundamental knowledge, psychosocial support, community awareness, community engagement, and system accountability; and two dimensions: Approach, Donor-related Information. The derived empirical framework reflects an organization scheme that may facilitate AA decision-making about organ donation and suggests that targeted dissemination of donor-related information at both the individual-donor and community levels may be critical for increasing donation rates among AAs.

Determining patient needs to enhance exercise program implementation and uptake in rural settings for women after a cancer diagnosis.

PURPOSE: To qualitatively explore exercise barriers and facilitators experienced by rural female cancer survivors from the program interventionist and recipient perspective for the purpose of enhancing exercise program implementation and uptake in rural settings. METHODS: A descriptive qualitative study design was utilized. Focus groups were conducted prior to implementation of an evidence-based exercise program by a rural non-research cancer clinical site. Nineteen rural female cancer survivors (mean age = 61.7 ± 10.9 years) and 11 potential interventionists (mean age = 42.3 ± 15.3 years) completed focus groups (stratified by participant role). Focus groups were audio recorded, transcribed, coded, and analyzed using inductive thematic analysis with NVivo 11. RESULTS: Cancer survivors identified 12 barrier themes (cancer specific adverse effects, lack of support, lack of knowledge, perceived negative aspects of exercise, cost, lack of resources, motivation, inconvenience, lack of program flexibility, time, weather, safety) and eight facilitator themes (knowledge, ease of access, resources, awareness, cost, options, organized, fun) related to exercise. Interventionists identified seven barrier themes (cost, transportation, lack of cancer survivor and interventionist knowledge, fear, motivation, lack of support, lack of resources) and four facilitator themes (resources, support, knowledge, motivation). Narratives revealed differing role-specific perspectives on shared themes between survivors and interventionists as well as potential implementation strategies for enhancing exercise participation and exercise program uptake among rural female cancer survivors. CONCLUSION: Exploring multi-level stakeholder perspectives on cancer survivors' exercise needs and related strategies yields important information for organizations to consider when implementing exercise programs in rural contexts.

Factors associated with the provision of inpatient care in hospices.

BACKGROUND: Hospices provide end-of-life care to patients who have complex health care needs and whose symptoms are difficult to control. Understanding why some hospices offer inpatient hospice care to patients could bring more evidence for policy makers and researchers to focus on the role of inpatient care in hospice. PURPOSE: The purpose of this study was to examine market and organizational factors that are associated with the provision of hospice inpatient care. METHODOLOGY: This study used a retrospective, longitudinal design (2009-2013). The study sample was drawn from three data resources: the Area Health Resources Files, the Provider of Services files, and Hospice Cost Reports from Centers for Medicare & Medicaid Services. The sample size was 2,391 hospices or 10,999 hospice observations over 5 years. A generalized linear mixed-effects model was used to examine the association between market and organizational factors and hospice inpatient services offering. RESULTS: On average, 94.59% of hospices offer inpatient services to patients. Proportion of adults who were over 65 years old (OR = 1.12) and Medicare-managed care penetration (OR = 1.02) were positively associated with the provision of hospice inpatient services. The number of hospitals with hospice program was negatively related to hospice inpatient services offering (OR = .95). Other factors such as nursing skill mix, volunteer dependence, and census region were also associated with inpatient services offering. PRACTICE IMPLICATIONS: The age demand of hospice care and Medicare-managed care penetration are related to hospice inpatient services offering. Hospices located in the market with more competition from hospitals that offer hospice program are less likely to offer inpatient care.

Hospice inpatient services provision, utilization, and financial performance.

BACKGROUND: Hospice performance is an overlooked area in the health care field due to the difficulty of measuring quality of care and the infrequent quality inspection. Based on the daily reimbursement mechanism for different levels of hospice care, inpatient services provision could influence both hospice-level length of stay (LOS) and financial performance. PURPOSE: The objective of this study was to explore the relationship between hospice inpatient services provision and hospice utilization and financial performance. METHODOLOGY/APPROACH: A longitudinal secondary data set (2009-2013) was merged from three sources: (a) Hospice Cost Reports from the Centers for Medicare & Medicaid Services, (b) the Provider of Services files, and (c) the Area Health Resources Files. The dependent variable in this study was hospice average LOS and financial performance measured by total operating margin (TOM) and return on assets. The independent variable was hospice inpatient services' offering. Mixed-effects regression models were used in the multivariate regression analyses. RESULTS: When comparing to hospices not providing inpatient services, offering inpatient services by staff was negatively related to average LOS (b = -0.063, p < .05) and TOM (b = -0.022, p < .05). The combination method with providing inpatient services by staff and under arrangement was negatively associated with return on assets (b = -0.073, p < .05). CONCLUSION: Hospice inpatient services provision was associated with average LOS and financial performance. PRACTICE IMPLICATIONS: Offering the inpatient services to patients by staff decreased average LOS and TOM. Hospice agencies may seek strategies to maintain their financial sustainability through outsourcing.

Systematic review of the hospice performance literature.

BACKGROUND: Hospice is the key provider of end-of-life care to patients. As the number of U.S. hospice agencies has rapidly increased, the performance has been scrutinized more deeply. PURPOSE: To foster understanding of how hospice performance is measured and what factors are associated with performance, we conducted a systematic review of empirical research on hospice performance in the United States. METHODS: Both structure-process-outcome and structure-conduct-performance frameworks were applied to categorize and summarize the hospice performance literature. A total of 36 studies were included in the systematic review. RESULTS: Hospice agencies adopted different strategies (e.g., service provision strategy and staffing strategy) to improve performance. Two strategic approaches (innovation and volunteer usage) were associated with better outcomes. Hospice organizational factors, market environment, and patient characteristics were related to hospice strategic conduct and performance. Majority of hospice performance studies have examined the relationship between hospice structure and strategic conduct/process, with fewer studies focusing on structure performance and even fewer concentrating on strategy performance. PRACTICE IMPLICATIONS: Patient, organizational, and market factors are associated with hospice strategic conduct and performance. The majority of the literature considered the impact of hospice organizational characteristics, whereas only a few studies included patient and market factors. The summarization of factors that may influence hospice performance provides insight to different stakeholders.

Mapping Perceptions of Lupus Medication Decision-Making Facilitators: The Importance of Patient Context.

OBJECTIVE: Numerous factors can impede or facilitate patients' medication decision-making and adherence to physicians' recommendations. Little is known about how patients and physicians jointly view issues that affect the decision-making process. Our objective was to derive an empirical framework of patient-identified facilitators to lupus medication decision-making from key stakeholders (including 15 physicians, 5 patients/patient advocates, and 8 medical professionals) using a patient-centered cognitive mapping approach. METHODS: We used nominal group patient panels to identify facilitators to lupus treatment decision-making. Stakeholders independently sorted the identified facilitators (n = 98) based on their similarities and rated the importance of each facilitator in patient decision-making. Data were analyzed using multidimensional scaling and hierarchical cluster analysis. RESULTS: A cognitive map was derived that represents an empirical framework of facilitators for lupus treatment decisions from multiple stakeholders' perspectives. The facilitator clusters were 1) hope for a normal/healthy life, 2) understand benefits and effectiveness of taking medications, 3) desire to minimize side effects, 4) medication-related data, 5) medication effectiveness for "me," 6) family focus, 7) confidence in physician, 8) medication research, 9) reassurance about medication, and 10) medication economics. CONCLUSION: Consideration of how different stakeholders perceive the relative importance of lupus medication decision-making clusters is an important step toward improving patient-physician communication and effective shared decision-making. The empirically derived framework of medication decision-making facilitators can be used as a guide to develop a lupus decision aid that focuses on improving physician-patient communication.

Barriers to Medication Decision Making in Women with Lupus Nephritis: A Formative Study using Nominal Group Technique.

OBJECTIVE: To assess the perspectives of women with lupus nephritis on barriers to medication decision making. METHODS: We used the nominal group technique (NGT), a structured process to elicit ideas from participants, for a formative assessment. Eight NGT meetings were conducted in English and moderated by an expert NGT researcher at 2 medical centers. Participants responded to the question: "What sorts of things make it hard for people to decide to take the medicines that doctors prescribe for treating their lupus kidney disease?" Patients nominated, discussed, and prioritized barriers to decisional processes involving medications for treating lupus nephritis. RESULTS: Fifty-one women with lupus nephritis with a mean age of 40.6 ± 13.3 years and disease duration of 11.8 ± 8.3 years participated in 8 NGT meetings: 26 African Americans (4 panels), 13 Hispanics (2 panels), and 12 whites (2 panels). Of the participants, 36.5% had obtained at least a college degree and 55.8% needed some help in reading health materials. Of the 248 responses generated (range 19-37 responses/panel), 100 responses (40%) were perceived by patients as having relatively greater importance than other barriers in their own decision-making processes. The most salient perceived barriers, as indicated by percent-weighted votes assigned, were known/anticipated side effects (15.6%), medication expense/ability to afford medications (8.2%), and the fear that the medication could cause other diseases (7.8%). CONCLUSION: Women with lupus nephritis identified specific barriers to decisions related to medications. Information relevant to known/anticipated medication side effects and medication cost will form the basis of a patient guide for women with systemic lupus erythematosus, currently under development.

Patient assessment of primary care physician communication: segmentation approach.

PURPOSE: The purpose of this paper is to examine how patient assessment of primary care physician (PCP) communication is related to patient satisfaction with the PCP, patient perception of PCP professional competence, patient assessment of the relationship with the doctor and patient demographic characteristics using a segmentation approach. DESIGN/METHODOLOGY/APPROACH: The authors surveyed 514 adult patients waiting for appointments with their PCPs in two US primary care clinics. A latent class analysis was used to identify mutually exclusive unobserved homogeneous classes of patients. FINDINGS: The authors identified three distinct classes/groups with regard to patient assessment of physician communication and the physician-patient relationship. The largest group (53 percent of the sample) assessed their PCP communication and other doctor-patient relationship aspects as excellent. However, 37 percent provided mostly negative assessments, expressed high general dissatisfaction with the physician and disagreed with the statement that their PCP was well qualified to manage their health problems. These patients were on average more educated and affluent and the group included more males. About 10 percent of patients expressed generally lower satisfaction with the PCP, though their dissatisfaction was not as extreme as in the highly dissatisfied group. RESEARCH LIMITATIONS/IMPLICATIONS: Further studies are needed to help physicians develop skills to communicate with different patients. ORIGINALITY/VALUE: Patient segmentation can be an important tool for healthcare quality improvement particularly for emerging approaches to primary care such as patient-centered care.

Resilience in the initial year of caregiving for a family member with a traumatic spinal cord injury.

OBJECTIVE: Individuals who assume caregiving duties for a family member disabled in a traumatic injury often exhibit considerable distress, yet few studies have examined characteristics of those who may be resilient in the initial year of caregiving. Reasoning from the influential Pearlin model of caregiving (Pearlin & Aneshensel, 1994) and the resilience process model (Bonanno, 2005), we expected a significant minority of caregivers would be chronically distressed and another group would be resilient throughout the inaugural year of caregiving for a person with a traumatic spinal cord injury (SCI), and these groups would differ significantly in primary and secondary stress and in personal resources and mediators. METHOD: Twenty men and 108 women who identified as caregivers for a family member who incurred a traumatic SCI consented to complete measures during the inpatient rehabilitation and at 1 month, 6 months, and 12 months postdischarge. RESULTS: Latent growth mixture modeling of depression symptoms over time revealed 3 groups of caregivers: chronic (24%), recovery (24%) and resilient (48%). The chronic group reported more anxiety, negative affect, and ill health than the other 2 groups throughout the year. The resilient group was best characterized by their enduring levels of positive affect and supportive social networks. CONCLUSIONS: A large percentage of individuals are resilient in the initial year of caregiving, and those who have problems adapting exhibit significant distress soon following the traumatic event. Early detection of and psychological interventions for individuals who have difficulty adjusting are indicated, as their distress is unlikely to abate untreated over the year.

Frictions as barriers to perioperative alignment: results from a latent class analysis.

The quality of the relationship between the sterile processing department (SPD) and the operating room (OR) is an important determinant of OR safety and performance. In this article, the concept of "friction" refers to the SPD behaviors and attributes that can negatively affect OR performance. Panels of SPD professionals initially were asked to identify and operationally define different ways in which behaviors of a hospital's SPD could compromise OR performance. A national convenience sample of OR nurses (N=291) rated 14 frictions in terms of their agreement or disagreement that each had a negative effect on OR performance in their hospital. Overall, more than 50% of the entire sample agreed that 2 frictions, "SPD does not communicate effectively with the OR" (55%) and "SPD inventories are insufficient for surgical volume" (52%), had negative effect on OR performance. However, a latent class analysis revealed 3 distinct classes of nurses who varied with respect to their level of agreement that SPD-OR frictions negatively affected OR performance. The observed heterogeneity in how different groups of nurses viewed different frictions suggests that effective efforts aimed at reducing performance-limiting frictions should be customized so that resources can be used where they are most needed.

Teaching behaviors that define highest rated attending physicians: a study of the resident perspective.

BACKGROUND: Better understanding teaching behaviors of highly rated clinical teachers could improve training for teaching. We examined teaching behaviors demonstrated by higher rated attending physicians. METHODS: Qualitative and quantitative group consensus using the nominal group technique (NGT) among internal medicine residents and students on hospital services (2004-2005); participants voted on the three most important teaching behaviors (weight of 3 = top rated, 1 = lowest rated). Teaching behaviors were organized into domains of successful rounding characteristics. We used teaching evaluations to sort attending physicians into tertiles of overall teaching effectiveness. RESULTS: Participants evaluated 23 faculty in 17 NGT sessions. Participants identified 66 distinct teaching behaviors (total sum of weights [sw] = 502). Nineteen items had sw ≥ 10, and these were categorized into the following domains: Teaching Process (n = 8; sw = 215, 42.8%), Learning Atmosphere (n = 5; sw = 145, 28.9%), Role Modeling (n = 3; sw = 74, 14.7%) and Team Management (n = 3; sw = 65, 12.9%). Attendings in the highest tertile received a larger number of votes for characteristics within the Teaching Process domain (56% compared to 39% in lowest tertile). CONCLUSIONS: The most effective teaching behaviors fell into two broad domains: Teaching Process and Learning Atmosphere. Highest rated attending physicians are most recognized for characteristics in the Teaching Process domain.

Health care providers' recommendations for physical activity and adherence to physical activity guidelines among adults with arthritis.

INTRODUCTION: Physical activity is beneficial for reducing pain and improving health-related quality of life among people with arthritis. However, physical inactivity is prevalent among people with arthritis. Health care providers' recommendations act as a catalyst for changes in health behavior. However, information about the effectiveness of such recommendations is limited in the arthritis literature. We examined the association between providers' recommendations for physical activity and adherence to physical activity guidelines for adults with arthritis and whether adults' age influenced this association. METHODS: We used combined data of adult respondents aged 45 years or older with provider-diagnosed arthritis (N = 10,892) from the 2011 Behavioral Risk Factor Surveillance System to conduct a retrospective, cross-sectional study. We used a multivariable logistic regression model to examine the association between health care providers' recommendations and adherence to physical activity guidelines among adults with arthritis. RESULTS: Adults with arthritis who received health care providers' recommendations for physical activity were more likely (odds ratio, 1.22; 95% confidence interval, 1.12-1.32) to adhere to physical activity guidelines than those who did not, after controlling for relevant covariates. Adults' age did not influence the association between providers' recommendations and adherence to physical activity (odds ratio, 1.00; 95% confidence interval, 0.99-1.00), after controlling for covariates. CONCLUSION: Health care providers' recommendations are associated with adherence to physical activity guidelines among adults with arthritis. Providers should recommend physical activity to adults with arthritis.

What Hispanic parents do to encourage and discourage 3-5 year old children to be active: a qualitative study using nominal group technique.

PURPOSE: Hispanic preschoolers are less active than their non-Hispanic peers. As part of a feasibility study to assess environmental and parenting influences on preschooler physical activity (PA) (Niños Activos), the aim of this study was to identify what parents do to encourage or discourage PA among Hispanic 3-5 year old children to inform the development of a new PA parenting practice instrument and future interventions to increase PA among Hispanic youth. METHODS: Nominal Group Technique (NGT), a structured multi-step group procedure, was used to elicit and prioritize responses from 10 groups of Hispanic parents regarding what parents do to encourage (5 groups) or discourage (5 groups) preschool aged children to be active. Five groups consisted of parents with low education (less than high school) and 5 with high education (high school or greater) distributed between the two NGT questions. RESULTS: Ten NGT groups (n = 74, range 4-11/group) generated 20-46 and 42-69 responses/group for practices that encourage or discourage PA respectively. Eight to 18 responses/group were elected as the most likely to encourage or discourage PA. Parental engagement in child activities, modeling PA, and feeding the child well were identified as parenting practices that encourage child PA. Allowing TV and videogame use, psychological control, physical or emotional abuse, and lack of parental engagement emerged as parenting practices that discourage children from being active. There were few differences in the pattern of responses by education level. CONCLUSIONS: Parents identified ways they encourage and discourage 3-5 year-olds from PA, suggesting both are important targets for interventions. These will inform the development of a new PA parenting practice scale to be further evaluated. Further research should explore the role parents play in discouraging child PA, especially in using psychological control or submitting children to abuse, which were new findings in this study.

Feeding style differences in food parenting practices associated with fruit and vegetable intake in children from low-income families.

OBJECTIVE: To examine the moderating effects of feeding styles on the relationship between food parenting practices and fruit and vegetable (F & V) intake in low-income families with preschool-aged children. DESIGN: Focus group meetings with Head Start parents were conducted by using the nominal group technique. Parents completed information on food parenting practices and feeding styles. Three dietary recalls were collected on each child. SETTING: Parents completed measures in Head Start centers and/or over the telephone. PARTICIPANTS: 667 parents of preschool-aged children participated. OUTCOMES: Food parenting practices and F & V intake. ANALYSIS: Mean differences in the food parenting practices across the 4 feeding styles were established through multivariate general linear modeling using MANOVA. Moderated multiple regression analysis was conducted to examine the moderating role of feeding style on food parenting practices and child F & V intake. RESULTS: The indulgent feeding style moderated the relationship between food parenting practices and child F & V intake. CONCLUSIONS AND IMPLICATIONS: This study indicates that parents' feeding styles have a moderating effect on the relationship between the food parenting practices and children's F & V intake. This finding can facilitate the development of interventions aimed at reducing childhood overweight.

Age bias in physicians' recommendations for physical activity: a behavioral model of healthcare utilization for adults with arthritis.

OBJECTIVE: To examine whether age bias exists in physicians' recommendations for physical activity among individuals with arthritis. METHODS: A cross-sectional sample with 33,071 U.S. adults, 45 years or older with physician-diagnosed arthritis was obtained from 2007 Behavioral Risk Factor Surveillance System Survey. We used logistic regression to examine physicians' recommendations for physical activity as a function of age controlling for gender, race, education, marital status, employment, income, health insurance, personal physician, emotional support, body mass index, activity limitations, health status, and comorbidities. RESULTS: Majority of individuals were females (65%), White (85%), had annual household income < $50,000 (67%), and with comorbidities (86%). Respondents were approximately equal across age groups: middle-aged group (53%) and older group (47%). About 36% were obese and 44% had activity limitations, and 44% did not receive any physicians' recommendations for physical activity. Results from logistic regression indicated older adults (≥ 65 years old) were less likely (OR = 0.87; 95% CI, 0.82-0.92) to receive physicians' recommendations for physical activity compared with the middle-aged group (45-64 years old). CONCLUSIONS: This study indicates that although the benefits associated with the physical activity is well recognized, there is age bias in physicians' recommendations for physical activity.

Using cognitive mapping to define key domains for successful attending rounds.

BACKGROUND: Ward attending rounds are an integral part of internal medicine education. Being a good teacher is necessary, but not sufficient for successful rounds. Understanding perceptions of successful attending rounds (AR) may help define key areas of focus for enhancing learning, teaching and patient care. OBJECTIVE: We sought to expand the conceptual framework of 30 previously identified attributes contributing to successful AR by: 1) identifying the most important attributes, 2) grouping similar attributes, and 3) creating a cognitive map to define dimensions and domains contributing to successful rounds. DESIGN: Multi-institutional, cross-sectional study design. PARTICIPANTS: We recruited residents and medical students from a university-based internal medicine residency program and a community-based family medicine residency program. Faculty attending a regional general medicine conference, affiliated with multiple institutions, also participated. MAIN MEASURES: Participants performed an unforced card-sorting exercise, grouping attributes based on perceived similarity, then rated the importance of attributes on a 5-point Likert scale. We translated our data into a cognitive map through multi-dimensional scaling and hierarchical cluster analysis. KEY RESULTS: Thirty-six faculty, 49 residents and 40 students participated. The highest rated attributes (mean rating) were "Teach by example (bedside manner)" (4.50), "Sharing of attending's thought processes" (4.46), "Be approachable-not intimidating" (4.45), "Insist on respect for all team members" (4.43), "Conduct rounds in an organized, efficient & timely fashion" (4.39), and "State expectations for residents/students" (4.37). Attributes were plotted on a two-dimensional cognitive map, and adequate convergence was achieved. We identified five distinct domains of related attributes: 1) Learning Atmosphere, 2) Clinical Teaching, 3) Teaching Style, 4) Communicating Expectations, and 5) Team Management. CONCLUSIONS: We identified five domains of related attributes essential to the success of ward attending rounds.