Intervention to promote adolescents' communication and engagement in diabetes clinic encounters: A pilot randomized controlled trial.

AIM: To conduct a pilot randomized trial of an intervention to improve adolescent question-asking and provider education during paediatric diabetes visits. METHODS: Adolescents aged 11 to 17 with type 1 diabetes and their parents were enrolled from two urban tertiary paediatric clinics. Adolescents were randomised to the intervention group or control group. Adolescent consultations were audio-recorded, their HbA1c level was recorded, and they completed surveys after three clinic appointments. The intervention group completed a question prompt list and watched a video on a tablet with their parents before meeting their doctor and completed a short evaluation after each visit. RESULTS: Six consultant endocrinologists and ninety-nine adolescents and their parents participated. The intervention increased adolescents' question asking and provider education in diabetes encounters. Total patient question-asking across the 3 consultations and a higher baseline HbA1c at time one was significantly associated with HbA1c at time three. CONCLUSIONS: Question prompt lists and an educational video are useful tools to increase adolescents' question-asking and communication between adolescents and their providers. PRACTICE IMPLICATIONS: Interventions that encourage adolescents' question-asking in healthcare encounters may lead to more meaningful providers-adolescents' communication and tailored education. Interventions to improve professionals' listening, communication and educational skills are also required.

Applying the resources and supports in self-management framework to examine ophthalmologist-patient communication and glaucoma medication adherence.

Little is known about how ophthalmologist-patient communication over time is associated with glaucoma patient long-term adherence. The purpose of our study was to examine the association between provider use of components of the resources and supports in self-management model when communicating with patients and adherence to glaucoma medications measured electronically over an 8-month period. In this longitudinal prospective cohort study, the main variables studied were ophthalmologist communication-individualized assessment, collaborative goal setting and skills enhancement. Patients with glaucoma who were newly prescribed or on glaucoma medications were recruited from six ophthalmology clinics. Patients' baseline and next follow-up visits were videotape-recorded. Patients were interviewed after their visits. Patients used medication event monitoring systems (MEMS) for 8 months after enrollment into the study, and adherence was measured electronically using MEMS for 240 days after their visits. Two hundred and seventy-nine patients participated. Patient race and regimen complexity were negatively associated with glaucoma medication adherence over an 8-month period. Provider communication behaviors, including providing education and positive reinforcement, can improve patient adherence to glaucoma medications over an 8-month period.

Development of an instrument to measure glaucoma medication self-efficacy and outcome expectations.

PURPOSE: The purpose of this study was to develop and evaluate the psychometric properties of (a) a glaucoma medication self-efficacy scale and (b) a glaucoma outcome expectations scale. PATIENTS AND METHODS: Two instruments were developed: a glaucoma medication self-efficacy scale and a glaucoma outcome expectations scale. Packets containing (a) the instruments and patient demographic questions and (b) a letter explaining the study were distributed to 225 glaucoma patients from three ophthalmology practices between August and December 2007. The instrument was completed by 191 patients for a response rate of 85%. Principal components factor analysis with a varimax rotation and Cronbach's alpha reliability were used to analyse the data. To assess discriminant validity, we administered the scales and two self-reported measures of adherence in a separate sample of 43 glaucoma patients who were currently using at least one glaucoma medication. RESULTS: Our results yielded a 21-item self-efficacy in overcoming barriers that might interfere with the use of glaucoma medications scale, a 14-item self-efficacy in carrying out specific tasks required to use eye drops correctly scale, and a four-item glaucoma outcome expectations scale. Results of the Cronbach's alpha reliability indicated that the scales are internally consistent. The self-efficacy scales were both significantly associated with two patient self-reported measures of glaucoma medication adherence, which show discriminant validity. CONCLUSIONS: Eye care providers and researchers can use these scales to identify patients with low self-efficacy in using their glaucoma medications and patients who do not believe that following their eye care providers' advice can help their vision.

Ethnicity and physician-older patient communication about alternative therapies.

OBJECTIVES: The purpose of this study was to describe ethnic differences in physician-patient communication about alternative therapies, using a data set comprised of audiotapes and transcripts of primary care medical visits. METHODS: The data set was collected during 1995 at the family practice and general medicine clinics at the University of New Mexico Health Sciences Center, Albuquerque, NM. Twenty-seven (27) resident physicians and 205 of their Hispanic and non-Hispanic white patients age 50 and over participated. RESULTS: Almost 18 percent of patients reported using one or more alternative therapies during the preceding month. Herbal medicine was the most widely used therapy. Eighty-three percent (83%) of patients who reported using an alternative therapy in the previous month did not tell their physicians. Physicians asked one or more questions about alternative therapies during only 3.4% of encounters. Only 2% of patients asked their physicians one or more questions about alternative therapies. There were no ethnic differences in physician-older patient communication about alternative therapies. DISCUSSION: Physician-patient communication could be improved to enhance physician understanding of the spectrum of interventions patients pursue to improve their health.

Physician-patient communication about over-the-counter medications.

The purpose of this study was to describe physician-patient communication about over-the-counter medications using a data set comprised of audio-tapes and transcripts of 414 primary care medical visits. The data set was collected during 1995 at the family practice and general medicine clinics at the University of New Mexico Health Sciences Center. Twenty-seven resident physicians and 414 of their adult patients participated. Fifty-seven percent of patients reported using one or more OTC medications during the past month. Analgesics, cold or allergy products, and antacids were the most commonly used OTC medications. White patients were significantly more likely to have reported using an analgesic in the past month than non-white patients. Female, white, and younger patients were more likely to have reported using a cold or allergy product in the past month than male, non-white, and older patients. Approximately 58% of patients discussed OTC medications with their physicians. Older patients and female patients as well as patients who reported using an antacid in the past month were significantly more likely to have discussed OTC medications with their physicians. Physicians asked questions about OTC medications during only 37% of encounters. Patients asked questions about OTC medications during 11% of encounters. Patient ethnicity did not influence physician or patient question-asking and information-giving about OTC medications. Male physicians were more likely to state information and ask questions about OTC medications than female physicians. Patients were more likely to ask male physicians questions about OTC medications. Physicians were more likely to state OTC information to and ask OTC questions of female and older patients. Physicians were more likely to ask less educated patients questions about OTC medications. Less educated patients were more likely to ask physicians questions about OTC medications. Despite the fact that more than half of all patients reported using OTC medications, physicians asked questions about OTC use during only approximately one-third of encounters. Of patients who reported using an OTC medication in the past month, 58% did not tell their physicians, yet only 14% of patients believed that it was not important for the physician to know about their OTC use. Physician-patient communication about OTC medications should be encouraged so that the patient becomes a collaborative partner in medication management.

Resident physician management of Hispanic and non-Hispanic white patients on antidepressants.

OBJECTIVE: The purpose of this study was to examine how well resident physicians monitored Hispanic and non-Hispanic white patients who were prescribed antidepressant medication. METHOD: Retrospective and prospective review of patients' medical records. SETTING: Family practice and internal medicine clinics at the University of New Mexico Health Sciences Center. PARTICIPANTS: Twenty-six resident physicians and 109 of their Hispanic and non-Hispanic white patients who were prescribed antidepressant medication when recruited into the study between March and December 1995. MAIN OUTCOME MEASURES: (i) Whether a physician recorded an appropriate diagnosis in the patient's chart, scheduled a follow-up visit and saw the patient for a follow-up visit within four weeks of the antidepressant being prescribed, and (ii) whether a physician recorded an adequate treatment plan, a discussion of side-effects and a discussion of how well the medication was working on the date the patient was enrolled in the study. RESULTS: Twenty-seven percent of patients were prescribed antidepressant medication. Less than half of the patients who were prescribed an antidepressant had a follow-up visit scheduled and only about one-third of patients were seen by their physician within one month of the antidepressant being prescribed. Physicians documented an adequate treatment plan in the charts of 51.1% of patients, a discussion of side-effects in 11.1% of charts and an assessment of how well the medication was working in 33.3% of charts. Younger patients and patients in better emotional health were more likely to have an adequate treatment plan documented in their chart. Patients in poorer physical health were more likely to have an adequate treatment plan documented in their chart along with a description of the effectiveness of the medication. Hispanic and non-Hispanic white patients who were prescribed antidepressants were monitored equally well by their primary care physicians. CONCLUSION: Primary care resident physicians need further training on the importance of monitoring patients on antidepressant medication.

Physician gender and hormone replacement therapy discussion.

Hormone replacement therapy (HRT) is a major issue confronting millions of women today, and general internal medicine and family practice physicians are an important source of information and counseling on this issue. Previous studies have suggested that HRT discussion and prescribing are more frequent with female than with male physicians, but others have suggested age and practice setting may be the reason for observed differences. We attempted to determine if physician gender influenced HRT discussion frequency between physicians and their patients using cross-sectional, secondary analysis of data collected at general internal medicine and family practice clinics at the University of New Mexico Health Sciences Center. Twenty-seven family practice and internal medicine resident physicians (15 female, 12 male) participated. There were 127 female patients age 45 and older. Audio-taped observations of patient-physician visits collected during 1995 for a study on patient-physician communication and patient satisfaction were used. There was less frequent discussion with female than male physicians (OR = 0.42, p = 0.0014). HRT was discussed during 51 visits. Patients initiated HRT discussion in 39.2% of visits in which it was discussed. Patients with diabetes were less likely to discuss HRT (OR = 0.25, p = 0.0122). Increasing year of physician residency was associated with decreased discussion of HRT (OR = 0.51, p < 0.0001). In this health sciences center, with physicians similar in age and training, male physicians discussed HRT significantly more often than did female physicians.

Antidepressant prescribing to Hispanic and non-Hispanic white patients in primary care.

OBJECTIVE: To examine whether there was a difference in the prescribing of selective serotonin-reuptake inhibitors (SSRIs) and non-SSRI antidepressants to Hispanic and non-Hispanic white patients in primary care. METHODS: Twenty-seven family practice and internal medicine resident physicians and 407 of their Hispanic and non-Hispanic white patients who were fluent in English or Spanish participated in the study The medical records of all patients were reviewed and information about patient diagnoses and antidepressant prescriptions was abstracted. Logistic regression was used to examine whether Hispanic ethnicity influenced physician prescribing of SSRI and non-SSRI antidepressants while controlling for other patient characteristics and diagnoses. For patients with a diagnosis of depression, logistic regression was used to examine whether Hispanic ethnicity influenced whether patients received antidepressant treatment while controlling for other patient characteristics RESULTS: Twenty-seven percent of patients received a prescription for one or more antidepressants. Hispanic and non-Hispanic white patients were equally likely to be prescribed SSRI and non-SSRI antidepressant medications. Having a diagnosis of depression and having a diagnosis of chronic pain was significantly correlated with the prescribing of a non-SSRI antidepressant (p < 0.001, p < 0.01, respectively). Having a diagnosis of depression was significantly correlated with the prescribing of an SSRI antidepressant (p < 0.001). Hispanic and non-Hispanic white patients with a diagnosis of depression were equally likely to be prescribed antidepressant treatment. Patients with a diagnosis of depression in the general medicine clinic were significantly less likely to receive antidepressant therapy than patients in the family practice clinic. CONCLUSIONS: Hispanic ethnicity did not influence antidepressant prescribing. Future research in other settings is needed to further determine whether Hispanic ethnicity influences antidepressant prescribing.

Consumer participation in health policy decisions: empowerment or puffery?

Many consumers in today's society have increased access to information about health and medical care through books, videotapes, audiotapes, the Internet, and television programming. However, consumers often are excluded from involvement in health policy decision making because it is believed that they do not have the necessary expertise. In this paper, the following will be discussed: (1) the historic role of consumer involvement in health policy decision making, (2) an overview of major barriers that consumers have encountered in health policy decision making, and (3) strategies for overcoming these barriers so that consumer empowerment can be enhanced when they serve on health policy panels.

Relationship between selected personality traits and citation for violating pharmacy board regulations.

The relationship between certain personality traits and citation for pharmacy board violations was studied. The Gordon Personal Profile-Inventory (GPP-I) was mailed to three samples of pharmacists licensed in North Carolina (95 pharmacist leaders, 199 pharmacists who had been cited for violating one or more board of pharmacy regulations, and a random sample of 494 pharmacists licensed in the state). The pharmacists were asked to provide demographic information and to complete the 38-item GPP-I, which measures eight different personality traits (ascendancy, responsibility, emotional stability, sociability, cautiousness, original thinking, personal relations, and vigor). The response rates for the three samples were 78.9%, 23.6%, and 58.3%, respectively. Pharmacists who had been cited for one or more board of pharmacy violations had significantly lower scores on the GPP-I for the personality trait vigor than general pharmacists. They also had lower scores on the GPP-I traits of ascendancy, original thinking, and vigor than pharmacy leaders. They were less likely to have advanced degrees or belong to any pharmacy organizations. They tended to be male, older, and out of school longer than those pharmacists who had never been cited for violating one or more board of pharmacy regulations. Significant differences in personality traits were found between pharmacists who had been cited for violating board of pharmacy regulations and general pharmacists and pharmacy leaders.

Physician expression of empathy and positiveness to Hispanic and non-Hispanic white patients during medical encounters.

BACKGROUND: This study examined the extent to which physicians expressed empathy and positiveness to Hispanic and non-Hispanic white patients during primary care visits. METHODS: Twenty-seven family practice and internal medicine resident physicians at the University of New Mexico Health Sciences Center were audiotaped in 1995 with 427 adult patients who were fluent in English or Spanish. The tapes were reviewed and organized to measure how frequently physicians expressed empathy and positiveness to patients. RESULTS: Physicians expressed empathy at equal rates to Hispanic and non-Hispanic white patients. When examining only Hispanic patients, physicians were significantly more likely to express empathy to patients who they knew better. Physicians expressed positiveness to non-Hispanic white patients more often than to Hispanic patients. When examining only Hispanic patients, physicians were more likely to express positiveness to patients who they knew better, who rated their health better, and who were more educated. When examining only non-Hispanic white patients, physicians were more likely to express positiveness to older and male patients than to younger and female patients. Also, female and younger physicians were significantly more likely to express positiveness to non-Hispanic white patients than male and older physicians were. CONCLUSIONS: Our findings illustrate that the resident physicians expressed empathy equally well to Hispanic and non-Hispanic white patients but that resident physicians need further training on how to express positiveness to patients from different ethnic backgrounds, especially Hispanic patients.

Asking questions about medication: analysis of physician-patient interactions and physician perceptions.

OBJECTIVES: The purpose of this research was to examine physicians' and patients' question-asking about medications during medical encounters. METHODS: A dataset of 467 audiotapes and transcripts of outpatient visits, as well as postvisit interviews with chronic disease patients and their primary care physicians, was analyzed. RESULTS: All patients took at least one prescribed medication and were using an average of 3.9 continued medications. Physicians and patients spent an average of 3.94 minutes, or 20% of each medical visit, discussing medications. Physicians asked patients an average of 9.3 questions about medications during each medical visit. Physicians asked significantly more questions of non-white patients, lower-income patients, and patients using more continued medications. Almost half (47%) of the patients observed did not ask any medication questions at all even though they were currently taking at least one medication; for those patients who did ask questions, the average number asked was 2.4. Starting a new medication doubled a patient's likelihood of question-asking. Physicians perceive question-asking in a positive light; patients who asked questions about medication were rated by their physicians as more interested and assertive than patients who did not ask questions, but not any more irritated or angry. CONCLUSIONS: The findings of the study illustrate the importance of improving physicians' and patients' question-asking about medications in primary care settings so that potential problems with medications can be detected and avoided and patient compliance can be improved.

Using feedback letters to influence the use of antiulcer agents in a Medicaid program.

OBJECTIVE: To determine the impact of printed patient-specific feedback regarding potential misprescribing of antiulcer agents (AUAs). Measures of impact included improvements in patients' dispensing profiles, assessed according to predetermined criteria, and decreases in cost and quantity of AUAs dispensed. DESIGN: Controlled study. After evaluation for compliance with predetermined criteria, prescribers identified as having one or two patient profiles with potential errors were assigned alternatively to control or experimental groups. An intervention was mailed to the experimental group. SETTING: Outpatient setting in the New Mexico Medicaid population. PARTICIPANTS: Patients and prescribers identified as having potential misprescribing of AUAs. INTERVENTION: The intervention consisted of a cover letter describing the purpose of the drug utilization review program, an educational fact sheet regarding prescribing AUAs, patient profiles with potential misprescribing, and physician response forms. MEASUREMENTS AND MAIN RESULTS: There were greater improvements in dispensing to patients in the intervention group (chi2, p <.001). Significant odds ratios for the intervention group were 2.29 for AUAs discontinued, 1.98 for all improvements combined, 13.13 for improvement in listing of proper diagnosis for AUAs, and 2.84 for appropriate indication when prescribing the higher acute daily dosage. Using data from 3 months before and after the intervention, we found greater decreases in mean monthly costs (p =.044) and mean monthly quantity of AUAs dispensed (p =.049) in the intervention group. CONCLUSIONS: This intervention significantly decreased AUA dispensing to patients whose prescribers were mailed the patient-specific feedback intervention.

The Brief Medication Questionnaire: a tool for screening patient adherence and barriers to adherence.

Self-report tools for monitoring adherence can be useful in identifying patients who need assistance with their medications, assessing patient concerns, and evaluating new programs. The aim of this study is to test the validity of the Brief Medication Questionnaire (BMQ), a new self-report tool for screening adherence and barriers to adherence. The tool includes a 5-item Regimen Screen that asks patients how they took each medication in the past week, a 2-item Belief Screen that asks about drug effects and bothersome features, and a 2-item Recall Screen about potential difficulties remembering. Validity was assessed in 20 patients using the Medication Events Monitoring System (MEMS). Results varied by type of non-adherence, with the Regimen and Belief Screens having 80-100% sensitivity for "repeat" non-adherence and the Recall Screen having 90% sensitivity for "sporadic" non-adherence. The BMQ appears more sensitive than existing tools and may be useful in identifying and diagnosing adherence problems.

Costs of implementing pharmaceutical care in community pharmacies.

OBJECTIVE: To estimate the costs and benefits to community pharmacies of converting a traditional practice into one based on pharmaceutical care. SETTING: Community-based ambulatory care pharmacies. PRACTICE DESCRIPTION: Community pharmacy. PRACTICE INNOVATION: Pharmaceutical care. MAIN OUTCOME MEASURES: Costs incurred and revenues received. DESIGN: Twenty-five community pharmacies that had made the transition from traditional practice to one based on pharmaceutical care returned a survey providing data on the costs and revenues associated with the transition. RESULTS: Mean total cost of making the conversion for the 25 pharmacies was $36,207. The largest cost component associated with the transition was personnel, which had a mean cost of $16,512 per pharmacy. Mean revenues received for pharmaceutical care by these 25 pharmacies was $3,687, mainly for disease management services. Pharmacies that spent more on the conversions, and used brochures and physician detailing as well as consultants and franschises, tended to be more successful in generating revenues from pharmaceutical care. CONCLUSION: Most pharmacies that have made the conversion to pharmaceutical care have not experienced an increase in profits as a result of that conversion. More effort needs to be directed toward improving the flow of revenues obtained from providing pharmaceutical care.

Patient race and psychotropic prescribing during medical encounters.

This paper examines how patient race, rating of physical and emotional health, expression of physical, emotional, and social problem symptoms, and physician perceptions of patients' physical health, emotional health, and social problems influence psychotropic prescribing in patients with chronic illness. Data were collected at 11 geographic areas in the United States and Canada. Patient visits were audio-tape recorded and research assistants interviewed each patient after their medical visit. Physicians completed self-administered questionnaires after each visit with a participating patient. Whites were significantly more likely to receive psychotropic prescriptions than non-whites (P < 0.05). Twenty percent of white and 13.5% of black patients received prescriptions for one or more psychotropic medications. Logistic regression techniques were used to predict psychotropic prescribing to white and non-white patients respectively. Patient expression of emotional symptoms and physician perceptions of patient emotional health significantly influenced psychotropic prescribing to white patients, whereas only patient expression of emotional symptoms significantly influenced psychotropic prescribing to non-white patients. Patient expression of physical and social problem symptoms and physician perceptions of patient physical health and social problems did not influence psychotropic prescribing to white or non-white patients. The paper emphasizes the importance of training primary care physicians to probe and to provide patients with an opportunity to discuss their emotional symptoms.

Physician responses to an educational intervention on improving their long-term prescribing of sedatives.

The current study examined response forms returned by physicians in response to a Medicaid retrospective therapeutic intervention on the long-term use of sedatives. The educational intervention was designed to notify physicians about their patients' long-term use of sedatives and suggest that they reevaluate the patient's need for sedative hypnotic medication and decrease or discontinue prescribing the medication and/or suggest non-pharmacological alternatives if deemed appropriate. Forty-seven percent of physicians responded to the educational intervention. Nineteen percent of responding physicians planned to change the patient's medication in some way. The most common planned change was to decrease the dose. Physicians also stated that they would recommend one or more non-pharmacological alternatives to 17% of patients. Thirty-eight percent of physicians planned to monitor and/or counsel the patient. Over 40% of physicians reported planning no action after receiving the intervention. Twenty-six percent of physicians planned no action because of patient demand for the sedatives. The study concludes that physicians need to be better trained on how to: (1) discuss non-pharmacological treatments with patients and (2) deal with and respond to patients who demand controlled substances.

Physician vs patient initiation of psychotropic prescribing in primary care settings: a content analysis of audiotapes.

The primary goals of this study were to examine: (1) whether patients were involved actively in initiating the prescribing of psychotropic medications during interactions with their primary care physicians and (2) what variables influenced patient vs physician initiation of psychotropic prescribing. An analysis of 508 audiotapes of physician-patient interactions and interviews with each patient and physician from 11 different ambulatory care settings was conducted. Of 508 patients, 17% (n = 88) received prescriptions for one or more psychotropic medications. Forty-seven percent of repeat psychotropic prescriptions and 20% of new psychotropic prescriptions were initiated by patients. Logistic regression techniques showed that patients with higher incomes were more likely than their physicians to initiate psychotropic prescribing, whereas physicians were more likely to initiate psychotropic prescribing with lower income patients (P < 0.001). Patients who had more previous visits to their physician were as likely as their physicians to initiate psychotropic prescribing, whereas physicians were more likely to initiate psychotropic prescribing with patients who had been to see them fewer times in the past (P < 0.05).