Communication and medication refill adherence: the Diabetes Study of Northern California

Exploring the impact of compassion and leadership on patient safety and quality in healthcare systems: a narrative review

BACKGROUND

Patient safety and healthcare quality are considered integral parts of the healthcare system that are driven by a dynamic combination of human and non-human factors. This review article provides an insight into the two major human factors that impact patient safety and quality including compassion and leadership. It also discusses how compassion is different from empathy and explores the impact of both compassion and leadership on patient safety and healthcare quality. In addition, this review also provides strategies for the improvement of patient safety and healthcare quality through compassion and effective leadership.

METHODS

This narrative review explores the existing literature on compassion and leadership and their combined impact on patient safety and healthcare quality. The literature for this purpose was gathered from published research articles, reports, recommendations and guidelines.

RESULTS

The findings from the literature suggest that both compassion and transformational leadership can create a positive culture where healthcare professionals (HCPs) prioritise patient safety and quality. Leaders who exhibit compassion are more likely to inspire their teams to deliver patient-centred care and focus on error prevention.

CONCLUSION

Compassion can become an antidote for the burnout of HCPs. Compassion is a behaviour that is not only inherited but can also be learnt. Both compassionate care and transformational leadership improve organisational culture, patient experience, patient engagement, outcomes and overall healthcare excellence. We propose that transformational leadership that reinforces compassion remarkably improves patient safety, patient engagement and quality.

Personalizing Communication of Clinicians with Chronically Ill Elders in Digital Encounters-A Patient-Centered View

BACKGROUND

Chronically ill elderly patients are concerned about losing the personal connection with clinicians in digital encounters and clinicians are concerned about missing nonverbal cues that are important for the diagnosis, thus jeopardizing quality of care.

AIMS

This study validated the expectations and preferences of chronically ill elderly patients regarding specific communication messages for communication with clinicians in telemedicine.

METHODS

The sample comprised 600 elderly chronically ill patients who use telehealth. We used a conjoint-based experimental design to test numerous messages. The outcome variable is elder patient expectations from communication with clinicians in telemedicine. The independent variables were known categories of patient-clinician communication. Respondents rated each of the 24 vignettes of messages.

RESULTS

Mathematical clustering yielded three mindsets, with statistically significant differences among them. Members of mindset 1 were most concerned with non-verbal communication, members of mindset 2 prefer communication that enhances the internal locus of control, and members of mindset 3 have an external locus of control and strongly oppose any dialogue about their expectations from communication.

CONCLUSIONS

The use of the predictive algorithm that we developed enables clinicians to identify the belonging of each chronically ill elderly patient in the clinic to a sample mindset, and to accordingly personalize the communication in the digital encounters while structuring the encounter with greater specificity, therefore enhancing patient-centered care.

The effect of communication using Peplau's theory on satisfaction with nursing care in hospitalized older adults in cardiac intensive care unit: A quasi-experimental study

BACKGROUND

Patient satisfaction helps healthcare organizations to improve their quality level and nurse-patient relationship is effective in increasing satisfaction. The aim of this study was to determine the effect of communication using Peplau's theory on satisfaction with nursing care in hospitalized older adults' patients in cardiac intensive care unit.

MATERIALS AND METHODS

This quasi-experimental study was conducted by available sampling method on 78 hospitalized older adults (39 interventions, 39 control) in cardiac intensive care unit of Guilan hospitals in north of Iran in 2021. In the intervention group, Peplau's communication theory (four stages of orientation, identification, exploitation, and resolution) was implemented and the control group received routine care. At the time of discharge, patient satisfaction questionnaire of quality of nursing care was completed for both groups. Data were analyzed through descriptive and inferential statistics (independent t test, Chi-square test).

RESULTS

The mean score of nursing satisfaction in the intervention group (5.4 ± 93.0) was significantly higher than the control group (6.8 ± 75.7) (t (64) = 11.54, P < 0.001, d = 2.84). In other words, the mean satisfaction scores of nursing care in the intervention group were 17.4 units (95% confidence interval: 14.4-20.4) more than the control group.

CONCLUSION

Using Peplau's communication theory in the care of hospitalized older adults in cardiac intensive care unit can lead to improvement of satisfaction, so it is suggested to use this communication method in the care of these patients to improve the level of satisfaction, quality of care, and functional independence.

Testing proximal, intermediate, and health outcomes of patient centered communication among non-pregnant women of childbearing age with diabetes mellitus: Findings from the Medical Expenditure Panel Survey 2012-2018

Objective

To determine associations between patient-centered communication (PCC) and overall healthcare ratings, self-efficacy, and management adherence among reproductive-age women with diabetes within the framework of Epstein and Street's conceptual model.

Methods

We analyzed longitudinal data from the 2012-2018 Medical Expenditure Panel Survey. The sample included 493 non-pregnant women of childbearing age (18-45 years) with diabetes. Independent variables were domains of PCC (listening, explaining, respecting, spending time, giving instructions, among others). Dependent variables were overall healthcare ratings, self-efficacy, and management adherence. Crude and adjusted associations were evaluated.

Results

Non-pregnant women of childbearing age who reported that their provider always listened to them, explained things, showed respect, and spent enough time with them had greater odds of reporting high overall healthcare ratings. Those who reported their provider always listened to them and spent enough time with them had greater odds of reporting better diabetes care adherence than those whose health care providers did not.

Conclusion

Findings demonstrate that non-pregnant women of childbearing age who report having optimal PCC are more likely to adhere to their diabetes care regimen.

Innovation

This is the first known study using a nationally representative sample of non-pregnant women of childbearing age to examine multiple layers of PCC.

Communicative Pathways Predicting Adherence in Type II Diabetic Patients: A Mediation Analysis

Type II diabetes is a chronic health condition and its successful management requires effective patient-provider communication. Responding to a call to model pathways between provider communication and patient health outcomes, this study tested four models of type II diabetic patient adherence with four mediators. Given the complex nature of type II diabetic care, patient adherence was conceptualized as wellness, screening, medication, and treatment adherence. Mediators included patient understanding, agreement, trust, and motivation. A sample of U.S. patients with type II diabetes patients who were both under the care of a medical provider and taking medication for their type II diabetes completed online surveys (n = 793). Findings indicated that the relationships between patient-centered communication and adherence outcomes were mediated by proximal outcomes. The results contribute to the understanding of patient-centered communication, adherence behaviors, and proximal outcomes of patient understanding, agreement, trust, and motivation. Findings indicate that relationships between patient-centered communication and wellness adherence is mediated by patient motivation, patient-centered communication and screening adherence is mediated by patient agreement, trust, and motivation, and patient-centered communication and treatment adherence is mediated by patient agreement, trust, and motivation. The discussion addresses theoretical and practical implications and directions for future research.

The Association between Levels of Trust in the Healthcare System and Influenza Vaccine Hesitancy among College Students in Israel

Influenza is a contagious respiratory disease caused by the influenza virus. Vaccination proves an effective approach to preventing influenza and minimizing the risk of experiencing associated complications. However, the influenza vaccine coverage rate among Israeli college students is low due to a sense of complacency, lack of knowledge, and vaccine hesitancy. The current study examined the relationship between the level of trust in the healthcare system and influenza vaccine hesitancy among college students in Israel. This cross-sectional study was conducted via an online questionnaire in April-May 2023. In total, 610 students were surveyed, of whom 57% had been vaccinated against influenza in the past; however, only 12% were vaccinated this year. Negative, significant, and moderate relationships were found between the level of trust in the healthcare system and influenza vaccine hesitancy. Students who had been vaccinated in the past had a higher level of trust in the healthcare system and a lower level of vaccination hesitancy. The linear regression model revealed that the variables of being a woman, not Jewish, vaccinated, and trusting the Ministry of Health, family doctor, and health professionals were associated with a decrease in vaccine hesitancy. These findings are in line with previous research in the field. Based on the present results, it may be advisable to develop intervention programs aimed at increasing confidence in the healthcare system and vaccinations by providing knowledge and addressing students' concerns regarding vaccination.

Disease-Related Stigma, Stigmatizers, Causes, and Consequences: A Systematic Review

Background

Stigma is a sociological concept that is important in medicine and health because it threatens health as much as the disease itself. We aimed to explore the causes, stigmatizers, consequences and coping strategies related to the stigma of diseases by systematically analyzing relevant literature.

Methods

This systematic review examined 65 articles on Disease-Related Stigma by searching Noormags, Magiran, SID, Google Scholar, and PubMed databases. The articles were published in Persian and English between 2001 and 2022 and conducted in Iran. We used a three-step systematic review process to select articles that met the research criteria.

Results

Conflict in society, lack of knowledge, specific characteristics of the disease, and the contagious nature of disease are the main causes of stigma, leading to stigmatization by different groups such as significant others, generalized others, institutional others, and macro others. Patients experiencing stigma face various psychological, physical, and social complications, and they may use concealment as a coping strategy, which can pose a potential threat to society's general health.

Conclusion

By knowing the causes and stigmatizers of disease-related, it is possible to reduce stigma with less cost and time.

Shared Decision-Making and Cardiovascular Health: A Scientific Statement From the American Heart Association

Shared decision-making is increasingly embraced in health care and recommended in cardiovascular guidelines. Patient involvement in health care decisions, patient-clinician communication, and models of patient-centered care are critical to improve health outcomes and to promote equity, but formal models and evaluation in cardiovascular care are nascent. Shared decision-making promotes equity by involving clinicians and patients, sharing the best available evidence, and recognizing the needs, values, and experiences of individuals and their families when faced with the task of making decisions. Broad endorsement of shared decision-making as a critical component of high-quality, value-based care has raised our awareness, although uptake in clinical practice remains suboptimal for a range of patient, clinician, and system issues. Strategies effective in promoting shared decision-making include educating clinicians on communication techniques, engaging multidisciplinary medical teams, incorporating trained decision coaches, and using tools (ie, patient decision aids) at appropriate literacy and numeracy levels to support patients in their cardiovascular decisions. This scientific statement shines a light on the limited but growing body of evidence of the impact of shared decision-making on cardiovascular outcomes and the potential of shared decision-making as a driver of health equity so that everyone has just opportunities. Multilevel solutions must align to address challenges in policies and reimbursement, system-level leadership and infrastructure, clinician training, access to decision aids, and patient engagement to fully support patients and clinicians to engage in the shared decision-making process and to drive equity and improvement in cardiovascular outcomes.

Automated Strategy Feedback Can Improve the Readability of Physicians' Electronic Communications to Simulated Patients

Modern communication between health care professionals and patients increasingly relies upon secure messages (SMs) exchanged through an electronic patient portal. Despite the convenience of secure messaging, challenges include gaps between physician and patient expertise along with the asynchronous nature of such communication. Importantly, less readable SMs from physicians (e.g., too complicated) may result in patient confusion, non-adherence, and ultimately poorer health outcomes. The current simulation trial synthesizes work on patient-physician electronic communication, message readability assessments, and feedback to explore the potential for automated strategy feedback to improve the readability of physicians' SMs to patients. Within a simulated secure messaging portal featuring multiple simulated patient scenarios, computational algorithms assessed the complexity of SMs written by 67 participating physicians to patients. The messaging portal provided strategy feedback for how physician responses might be improved (e.g., adding details and information to reduce complexity). Analyses of changes in SM complexity revealed that automated strategy feedback indeed helped physicians compose and refine more readable messages. Although the effects for any individual SM were slight, the cumulative effects within and across patient scenarios showed trends of decreasing complexity. Physicians appeared to learn how to craft more readable SMs via interactions with the feedback system. Implications for secure messaging systems and physician training are discussed, along with considerations for further investigation of broader physician populations and effects on patient experience.

How is Patient Adherence Possible? A Novel Mechanistic Model of Adherence Based on Humanities

Patient non-adherence is a major contemporary medical issue because of its consequences in terms of frequency, morbidity and mortality, and health care costs. This article aims to propose a mechanistic model of adherence based on the tenet that non-adherence is the default option, as long-term adherence in chronic diseases requires sustained effort. The real question becomes, how is patient adherence possible? By focusing on adherent patients, the paper explains the mental mechanisms of adherence using concepts largely drawn from humanities, philosophy of mind, and behavioral economics and presents the findings of empirical studies supporting these hypotheses. The analysis first demonstrates the relationship between patient adherence and temporality and the influence of character traits. Further, it points out the importance of habit, which allows adherence to become non-intentional, thereby sparing patients' cognitive efforts. Finally, it points out the importance of the quality of the interaction between the person with a chronic disease and the health professional. These features explain why adherence is a syndrome (the healthy adherer phenotype), separating people into those who are safe and those who are at risk of non-adherence, non-control of diabetes, and complications. The concepts presented in this article summarize 20 years of personal clinical and philosophical reflection on patient adherence. They are mainly illustrated by examples from diabetes care but can be applied to all chronic diseases. This novel model of adherence has major practical and ethical implications, explaining the importance of patient education and shared medical decision-making in chronic disease management.

A Survey on Factors Affecting Knowledge and Satisfaction with Care Among Persons with Diabetes Mellitus in an Urban Health Centre and its Outreach Clinics in South India

Objective

To determine the level of knowledge and factors affecting knowledge and satisfaction with diabetes care among persons with diabetes at urban health centre (UHC) and community health worker (CHW)-led outreach clinics (ORC) in South India.

Methodology

A cross-sectional study was carried out using a structured questionnaire. One hundred patients at the UHC and 200 patients at the ORC were included.

Results

Patients with DM of more than eight years, with co-morbidities and maintained on insulin had good knowledge at the UHC. At the ORC, participants who received education beyond the primary level and belonging to non - Hindu religion had higher knowledge. Patients at the ORC experienced better satisfaction in terms of waiting time for appointments, consultation, registration system and counselling. At the UHC, those who received primary education or those with lower educational attainment had better satisfaction. Overall, knowledge (p = 0.03) and satisfaction (p = 0.00001) of diabetes care was better at the ORC than at the UHC.

Conclusions

Our study found better knowledge and satisfaction with diabetes care at the ORC than at the UHC. Whether or not the difference can be attributed to CHW-based clinics in the community needs to be further elucidated.

Self-reported medication adherence instruments and their applicability in low-middle income countries: a scoping review

Introduction

Medication non-adherence is an important public health issue, associated with poor clinical and economic outcomes. Globally, self-reported instruments are the most widely used method to assess medication adherence. However, the majority of these were developed in high-income countries (HICs) with a well-established health care system. Their applicability in low- and middle-income countries (LMICs) remains unclear. The objective of this study is to systematically review the applicability of content and use of self-reported adherence instruments in LMICs.

Method

A scoping review informed by a literature search in Pubmed, EBSCO, and Cochrane databases was conducted to identify studies assessing medication adherence using self-reported instruments for patients with five common chronic diseases [hypertension, diabetes, dyslipidemia, asthma, or Chronic Obstructive Pulmonary Disease (COPD)] in LMICs up to January 2022 with no constraints on publication year. Two reviewers performed the study selection process, data extraction and outcomes assessment independently. Outcomes focused on LMIC applicability of the self-reported adherence instruments assessed by (i) containing LMIC relevant adherence content; (ii) methodological quality and (iii) fees for use.

Findings

We identified 181 studies that used self-reported instruments for assessing medication adherence in LMICs. A total of 32 distinct types of self-reported instruments to assess medication adherence were identified. Of these, 14 self-reported instruments were developed in LMICs, while the remaining ones were adapted from self-reported instruments originally developed in HICs. All self-reported adherence instruments in studies included presented diverse potential challenges regarding their applicability in LMICs, included an underrepresentation of LMIC relevant non-adherence reasons, such as financial issues, use of traditional medicines, religious beliefs, lack of communication with healthcare provider, running out of medicine, and access to care. Almost half of included studies showed that the existing self-reported adherence instruments lack sufficient evidence regarding cross cultural validation and internal consistency. In 70% of the studies, fees applied for using the self-reported instruments in LMICs.

Conclusion

There seems insufficient emphasis on applicability and methodological rigor of self-reported medication adherence instruments used in LMICs. This presents an opportunity for developing a self-reported adherence instrument that is suitable to health systems and resources in LMICs.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022302215.

Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward

Type 2 diabetes disparities in the USA persist in both the prevalence of disease and diabetes-related complications. We conducted a literature review related to diabetes prevention, management, and complications across racial and ethnic groups in the USA. The objective of this review is to summarise the current understanding of diabetes disparities by examining differences between and within racial and ethnic groups and among young people (aged <18 years). We also examine the pathophysiology of diabetes as it relates to race and ethnic differences. We use a conceptual framework built on the socioecological model to categorise the causes of diabetes disparities across the lifespan looking at factors in five domains of health behaviours and social norms, public awareness, structural racism, economic development, and access to high-quality care. The range of disparities in diabetes prevalence and management in the USA calls for a community-engaged and multidisciplinary approach that must involve community partners, researchers, practitioners, health system administrators, and policy makers. We offer recommendations for each of these groups to help to promote equity in diabetes prevention and care in the USA.

Is patients' trust in clinicians related to patient-clinician racial/ethnic or gender concordance?

OBJECTIVE

To examine the relationship between patient-clinician concordance (racial/ethnic and gender) and patients' trust in their regular clinician.

METHODS

This mixed methods study used the 2019 U.S. Health Reform Monitoring Survey to examine concordance and patient trust in clinicians, and semi-structured interviews with 24 participants to explore patients' perceptions of how concordance relates to trust in their clinician.

RESULTS

Almost six in ten adults (59.8%) who had a regular clinician reported having trust in their clinician. White, Black, and Latino participants were similarly likely to report trust. Those with racial/ethnic concordant clinicians were 7.5 percentage points more likely to report trust than were those with non-concordant clinicians (62.4% vs 54.9%). This finding was consistent for men and women, and did not differ significantly across racial and ethnic groups. In interviews, while almost all participants described having trusted non-racial/ethnic concordant clinicians, several described immediately trusting concordant clinicians. In contrast, we did not observe a consistent relationship between patient-clinician gender concordance and trust.

CONCLUSION

The findings underscore the importance of increasing the number of Black and Latino clinicians, and also highlight that all clinicians need to work hard to build trust with patients from different racial/ethnic backgrounds.

The Emotional Impact of Negative Language in People With Diabetes: A Descriptive Study Using a Semantic Differential Scale

PURPOSE

Explore the emotional experience of people with diabetes as they encounter words and phrases that have been previously identified as problematic and evaluate potential differences in their emotional impact based on type of diabetes and demographic characteristics.

METHODS

A cross-sectional descriptive study employing an online survey of 107 adults with type 1 diabetes and 110 adults with type 2 diabetes. A semantic differential scale was used to examine feeling states associated with negative diabetes language. Descriptive statistics including means, standard deviations, and frequencies were calculated for all study variables. For each target word, frequencies of participants who endorsed a positive, neutral, or negative affective response on the sematic differential scale are reported.

RESULTS

People with diabetes reported feeling blamed, misunderstood, hopeless, judged, not motivated, and not trusting in response to "noncompliant," "unmotivated," "in denial," "preventable," "failed," "should," "uncontrolled," "what did you do wrong," and "you could end up blind or on dialysis." Participants who have type 1 diabetes and are female, White, more educated, and younger reported more negative feelings about the target words.

CONCLUSION

People with diabetes experience highly negative affective responses when they read and hear previously identified words and phrases considered to be judgmental and unhelpful.

The Satisfaction With Care of Patients With Schizophrenia in Taiwan: A Cross-Sectional Survey of Patient-Centered Care Domains

BACKGROUND

Pharmacological interventions combined with nonpharmacological treatments such as patient-centered care (PCC)-related activities are widely used to enhance outcomes in patients with schizophrenia. However, few studies have examined and identified the PCC factors essential to achieving better outcomes in patients with schizophrenia.

PURPOSE

This study was designed to identify the Picker-Institute-identified PCC domains associated with satisfaction and to determine which of these domains are most important in the context of schizophrenia care.

METHODS

Data were collected using patient surveys in outpatient settings and record reviews at two hospitals in northern Taiwan between November and December 2016. PCC data were collected in five domains: (a) support of patient autonomy; (b) goal setting; (c) collaboration and integration of healthcare services; (d) information, education, and communication; and (e) emotional support. The outcome measure was patient satisfaction. The study controlled for demographic factors, including age, gender, education, occupation, marriage, and urbanization level in the respondent's area of residence. Clinical characteristics included the Clinical Global Impressions severity and improvement index scores, previous admission, previous emergency department visit, and readmission within 1 year. Methods were adopted to prevent common method variance bias. Multivariable linear regression with stepwise selection and the generalized estimating equation were used to analyze the data.

RESULTS

After controlling for confounding factors, the generalized estimating equation model found only three PCC factors significantly associated with patient satisfaction, which differed slightly from the results of the multivariable linear regression. These three factors are as follows, in order of importance: information, education, and communication (parameter = 0.65 [0.37, 0.92], p < .001); emotional support (parameter = 0.52 [0.22, 0.81], p < .001); and goal setting (parameter = 0.31 [0.10, 0.51], p = .004).

CONCLUSIONS

The three critical PCC-related factors were evaluated in terms of enhancing patient satisfaction in patients with schizophrenia. Practicable strategies related to these three factors should also be developed for implementation in clinical settings.

Patients' Perceived Importance of Medication and Adherence in Polypharmacy, a Quantitative, Cross-Sectional Study Using a Questionnaire Administered in Three Doctors' Private Practices in France

BACKGROUND

Among the determinants of nonadherence, polypharmacy (common in people with multiple pathologies and especially in elderly patients), plays a major role.

OBJECTIVE

In patients who are subject to polypharmacy involving different classes of medications, the first aim is to assess the impact of medication importance given by patients on (i) medication adherence and (ii) the respective effect of intentionality and habit in medication importance and medication adherence. The second objective is to compare the importance given to medication and adherence in the different therapeutic classes.

PATIENTS AND METHODS

Patients taking 5-10 different medications for at least 1 month were included in a cross-sectional survey in three private practices in one region in France.

RESULTS

This study included 130 patients (59.2 % female) with 851 medications in total. The mean ± standard deviation (SD) age was 70.5 ± 12.2 years. The mean ± SD of medications taken was 6.9 ± 1.7. Treatment adherence had a strong positive correlation with the patient-perceived medication importance (p < 0.001). Counter-intuitively, taking a large number of medications (≥7) was associated with being fully adherent (p = 0.02). A high intentional nonadherence score was negatively associated with high medication importance (p = 0.003). Furthermore, patient-perceived medication importance was positively associated with taking treatment by habit (p = 0.03). Overall nonadherence more strongly correlated with unintentional nonadherence (p < 0.001) than with intentional nonadherence (p = 0.02). Compared to the antihypertensive class, a decrease in adherence by medication was observed in psychoanaleptics (p < 0.0001) and drugs used in diabetes class (p = 0.002), and a decrease in importance in lipid-modifying agents class (p = 0.001) and psychoanaleptics (p < 0.0001).

CONCLUSION

The perception of the importance of a medicine is associated with the place of intentionality and habit in patient adherence. Therefore, explaining the importance of a medicine should become an important part of patient education.

Psychosocial and behavioral correlates of self-efficacy in treatment adherence in older patients with comorbid hypertension and type 2 diabetes

Background

Adhering to clinical prescriptions is known to protect against the effects of uncontrolled hypertension and of acute and chronic cardiovascular diseases, including diabetes. Contextually, positive associations between self-care behaviors and psychological constructs, such as self-efficacy, are widely acknowledged in the literature. However, still little is known about the psychological factors underlying the patient’s self-efficacy. This study aimed to investigate the psychosocial and behavioral correlates of self-efficacy related to treatment adherence in older patients with comorbid hypertension and type 2 diabetes mellitus.

Participants and procedure

Italian and Polish patients (≥ 65 years; N = 180) consecutively responded to self-report questionnaires measuring psycho-social (i.e., beliefs about medicines, perceived physician’s communication effectiveness, medication-specific social sup-port, self-efficacy) and behavioral factors (i.e., pharmacological adherence, medications refill adherence, intentional non-adherence) related to treatment adherence. Between-group comparisons and regression analyses were performed.

Results

Fisher’s least significant difference (LSD) test showed significant differences between the Italian and Polish groups in all questionnaires (p < .01) with the Italian patients reporting more satisfactory scores. Younger age (β = .08, p = .045), female gender (β = 1.03, p = .042), higher medication refills adherence (β = –.07, p = .024), lower intentional non-adherence (β = –.03, p = .009), positive beliefs about medications (β = .13, p < .001), better quality of communication with the physician (β = .09, p < .001), and stronger perceived medication-specific social support (β = .06, p = .001) were significantly associat-ed with self-efficacy related to treatment adherence.

Conclusions

Future research and interventions should leverage psychosocial and behavioral factors to address self-efficacy contributing to enhancing adherence to clinical prescriptions.

Interpersonal communication-, education- and counselling-based interventions to support adherence to oral anticancer therapy: a systematic review

Background. Many factors contribute to oral anti-cancer therapy adherence, including counselling and educational support. Objective. We systematically review the literature evaluating the effectiveness of interpersonal communication-, counselling- and education-based interventions on patient adherence to oral anticancer therapy. Methods. Using search terms pertaining to medication adherence, oral anticancer therapy, and communication, education, and counselling, we conducted a systematic search for full-text, original research articles prior to 3/13/20. Two reviewers independently reviewed each paper for inclusion and charted study information. Results. Twenty-four articles were included. All considered the use of oral anticancer therapy between two defined time points. Four studies also considered the length of time a patient persisted on therapy. Half (n = 12) of the studies reported a statistically significant relationship between the intervention and medication adherence, with no consistent pattern among intervention structure/content and effectiveness. Programmes offering in-person counselling and those targeting patients with chronic myeloid leukemia (CML), tended to report positive findings. Most studies faced substantial risk of bias, and only two reported using a behavioural theory to guide interventional content. Conclusions. Findings highlight the infancy of evidence base and need for rigorous and large-scale studies grounded in established behavioural theories to advance patient-targeted educational and counselling practices supporting adherence to oral anti-cancer therapy.

Application of the skills network approach to measure physician competence in shared decision making based on self-assessment

Several approaches to and definitions of 'shared decision making' (SDM) exist, which makes measurement challenging. Recently, a skills network approach was proposed, which conceptualizes SDM competence as an organized network of interacting SDM skills. With this approach, it was possible to accurately predict observer-rated SDM competence of physicians from the patients' assessments of the physician's SDM skills. The aim of this study was to assess whether using the skills network approach allows to predict observer-rated SDM competence of physicians from their self-reported SDM skills. We conducted a secondary data analysis of an observational study, in which outpatient care physicians rated their use of SDM skills with the physician version of the 9-item Shared Decision Making Questionnaire (SDM-Q-Doc) during consultations with chronically ill adult patients. Based on the estimated association of each skill with all other skills, an SDM skills network for each physician was constructed. Network parameters were used to predict observer-rated SDM competence, which was determined from audio-recorded consultations using three widely used measures (OPTION-12, OPTION-5, Four Habits Coding Scheme). In our study, 28 physicians rated consultations with 308 patients. The skill 'deliberating the decision' was central in the population skills network averaged across physicians. The correlation between parameters of the skills networks and observer-rated competence ranged from 0.65 to 0.82 across analyses. The use and connectedness of the skill 'eliciting treatment preference of the patient' showed the strongest unique association with observer-rated competence. Thus, we found evidence that processing SDM skill ratings from the physicians' perspective according to the skills network approach offers new theoretically and empirically grounded opportunities for the assessment of SDM competence. A feasible and robust measurement of SDM competence is essential for research on SDM and can be applied for evaluating SDM competence during medical education, for training evaluation, and for quality management purposes. [A plain language summary of the study is available at https://osf.io/3wy4v.].

Self-Care Behaviors in Patients with Hypertension to Prevent Hypertensive Emergencies: a Qualitative Study Based on the Theory of Planned Behavior

Background: Hypertension is a crucial general health issue. Severe and acute hypertension needs urgent medical intervention. Self-care behaviors can help patients with hypertension in controlling blood pressure and preventing hypertensive emergencies. This study aimed to determine the perception of hypertension towards self-care behaviors using constructs of the theory of planned behavior (TPB) in critically ill patients with hypertension to prevent hypertensive emergencies.

Material and Methods: This study was conducted based on the directed qualitative content analysis of 33 critically ill patients with hypertension who participated in semi-structured interviews and focus group discussions. Results: The data were analyzed based on the four main categories of TPB. The attitude category consisted of positive and negative subcategories. The subjective norms category consisted of authority of healthcare staff, family support and approval, and influence of friends subcategories. The perceived behavioral control category included discipline, self-control, receiving consultation, individual concerns, financial problems, access to medicine, food culture, and coronavirus limitations subcategories. The behavioral intention category had intention to perform the behavior and intention to continue a behavior subcategories.

Conclusion: The results revealed the requirement for a multidimensional approach to improve attitude, subjective norms, and behavioral control for performing self-care behaviors to reduce the number of hypertensive emergencies in critically ill patients with hypertension. Factors affecting self-care included socioeconomic status, family support, governmental organizations, and participants’ health condition.

Association between COVID-19 vaccine hesitancy and trust in the medical profession and public health officials

One's personal physician, national and state or local public health officials, and the broader medical profession play important roles in encouraging vaccine uptake for COVID-19. However, the relationship between trust in these experts and vaccine hesitancy has been underexplored, particularly among racial/minority groups where historic medical mistrust may reduce uptake. Using an April 2021 online sample of US adults (n = 3041) that explored vaccine hesitancy, regression models estimate levels of trust in each of these types of experts and between trust in each of these experts and the odds of being COVID-19 vaccine takers vs refusers or hesitaters. Interaction terms assess how levels of trust in the medical profession by race/ethnicity are associated with vaccine hesitancy. Trust in each expert is positively associated with trust in other experts, except for trust in the medical profession. Only trust in one's own doctor was associated with trust in the medical profession, as measured by factor scores derived from a validated scale. Lower levels of trust in experts were significantly associated with being either a hesitater or a refuser compared to being a taker. Black respondents had higher odds of being either a hesitater or a refuser compared to white respondents but the interaction with trust was insignificant. For Hispanic respondents only, the odds of being a hesitater declined significantly when trust in the medical profession rose. Mistrust in the medical profession, one's doctor and national experts contributes to vaccine hesitancy. Mobilizing personal physicians to speak to their own patients may help.

Factors Influencing Drug Use Information Received at Primary Healthcare Centre Pharmacies in Ghana

Background

Health literacy addresses environmental, political, and social factors that determine health. Drug dispensers play a major role in educating patients on drug use to increase effective and efficient drug utilisation, thereby promoting positive healthcare outcomes. From the patients' perspective, this study examined the communication quality between patients and drug dispensers at primary healthcare centres in the Cape Coast Metropolis of Ghana.

Method

We conveniently surveyed 269 patients seeking health care at primary healthcare facilities using a researcher-constructed 13-item instrument. In SPSS version 21 software, we analysed the data using percentages, chi-square analysis, and logistic regression.

Results

Almost half of the participants (n = 132) reported low health literacy, with 81% (n = 218) reporting that drug side effects were not discussed with them at the pharmacies. The findings further indicated that health literacy and educational level predicted general communication quality between participants and drug dispensers; participants with secondary education were about 3 times more likely to report not being told of the side effects of prescribed drugs as compared with those who had completed only basic education.

Conclusions

There is still a high level of low health literacy among patients seeking healthcare at primary healthcare centres and a very high percentage of patients did not receive any education on side effects of dispensed drugs. Drug use directives from dispensers at primary healthcare facilities can make a difference between any 2 patients.

Person-Centered Maternity Care and Health Outcomes at 1 and 6 Months Postpartum

Objectives: Person-centered care has been increasingly recognized as an important aspect of health care quality, including in maternity care. Little is known about correlates and outcomes of person-centered care in maternity care in the United States. Materials and Methods: Data were from a prospective cohort of more than 3000 individuals who gave birth to a first baby in a Pennsylvania hospital. Person-centered maternity care was measured via a 13-item rating scale administered 1-month postpartum. Content validity was established through exploratory factor analysis. The resulting scale had scores ranging from 13 to 54, with Cronbach's alpha of 0.86. Using linear and logistic regression models to control for covariates, we examined associations between participants' characteristics and person-centered maternity care and between person-centered maternity care and postpartum outcomes. Results: Participants had a mean total score of 47.80 on the person-centered maternity care scale. Patient factors independently associated with more person-centered maternity care included older age, more positive attitude toward vaginal birth during pregnancy, and spontaneous vaginal birth. In adjusted models, higher person-centered maternity scale scores were strongly associated with many positive physical and mental health outcomes at 1 and 6 months postpartum. Conclusions: Our findings underscore the importance of person-centered maternity not just due to its intrinsic value but also because it may be associated with both mental and physical health outcomes through the postpartum period. Results suggest that policy efforts are necessary to ensure person-centered maternity care, especially for delivery hospitalization experience.

Gender affirming hormone therapy dosing behaviors among transgender and nonbinary adults

Gender-affirming hormones have been shown to improve psychological functioning and quality of life among transgender and nonbinary (trans) people, yet, scant research exists regarding whether and why individuals take more or less hormones than prescribed. Drawing on survey data from 379 trans people who were prescribed hormones, we utilized multivariable logistic regression models to identify factors associated with hormone-dosing behaviors and content analysis to examine the reasons for dose modifications. Overall, 24% of trans individuals took more hormones than prescribed and 57% took less. Taking more hormones than prescribed was significantly associated with having the same provider for primary and gender-affirming care and gender-based discrimination. Income and insurance coverage barriers were significantly associated with taking less hormones than prescribed. Differences by gender identity were also observed. Addressing barriers to hormone access and cost could help to ensure safe hormone-dosing behaviors and the achievement trans people's gender-affirmation goals.

An Intuitive Risk Communication Tool to Enhance Patient-Provider Partnership in Diabetes Consultation

INTRODUCTION

This technology report introduces an innovative risk communication tool developed to support providers in communicating diabetes-related risks more intuitively to people with type 2 diabetes mellitus (T2DM).

METHODS

The development process involved three main steps: (1) selecting the content and format of the risk message; (2) developing a digital interface; and (3) assessing the usability and usefulness of the tool with clinicians through validated questionnaires.

RESULTS

The tool calculates personalized risk information based on a validated simulation model (United Kingdom Prospective Diabetes Study Outcomes Model 2) and delivers it using more intuitive risk formats, such as "effective heart age" to convey cardiovascular risks. Clinicians reported high scores for the usability and usefulness of the tool, making its adoption in routine care promising.

CONCLUSIONS

Despite increased use of risk calculators in clinical care, this is the first time that such a tool has been developed in the diabetes area. Further studies are needed to confirm the benefits of using this tool on behavioral and health outcomes in T2DM populations.

A VOSviewer-Based Bibliometric Analysis of Prescription Refills

Purpose

Prescription refills are long-term prescriptions for chronic patients in stable status, which varies from country to country. A well-established prescription refill system is beneficial for chronic patients’ medication management and facilitates the efficacy of clinical care. Therefore, we carried out a bibliometric analysis to examine the development of this field.

Summary

Publications on prescription refills from 1970 to 2021 were collected in the Web of Science Core Collection (WoSCC). Search strategy TS = “prescri* refill*” OR “medi* refill*” OR “repeat prescri*” OR “repeat dispens*” OR TI = refill* was used for search. VOSviewer was applied to visualize the bibliometric analysis. A total of 319 publications were found in WoSCC. Study attention on prescription refills has shown a steady rise but is still low in recent years. The United States was the most productive country, which had the highest total citations, average citations per publication, and the highest H-index, and participated in international collaboration most frequently. The University of California system was the most productive institution. The U.S. Department of Veterans Affairs was the institution with the most citations, most average citation, and highest H-index. Sundell was the most productive author, and Steiner J. F. was the most influential author. “Adherence,” “medication,” and “therapy” were the most prominent keywords.

Conclusion

Publications on prescription refills have increased rapidly and continue to grow. The United States had the leading position in the area. It is recommended to pay closer attention to the latest hotspots, such as “Opioids,” “Surgery,” “Differentiated care,” and “HIV.”

The Role of Satisfaction Surveys: Offering an Enhanced Patient Experience for Optimum Outcomes in the Pediatric Orthopaedic Practice

As we navigate to provide the best patient care and outcomes, the patient experience has shown to be a driver that improves quality. Patient experience surveys are the primary means of measuring the perception of the care received. Positive patient experience has been linked to better patient compliance, decreased health care costs, decreased liability, and improved outcomes. Physician wellbeing and improved job satisfaction is a recognized additional benefit. Strategies have been developed to achieve these goals, enhance our practice and improve our work satisfaction and the patient experience.

Opportunities and Challenges of Integrating Food Practice into Clinical Decision-Making

BACKGROUND

Food practice plays an important role in health. Food practice data collected in daily living settings can inform clinical decisions. However, integrating such data into clinical decision-making is burdensome for both clinicians and patients, resulting in poor adherence and limited utilization. Automation offers benefits in this regard, minimizing this burden resulting in a better fit with a patient's daily living routines, and creating opportunities for better integration into clinical workflow. Although the literature on patient-generated health data (PGHD) can serve as a starting point for the automation of food practice data, more diverse characteristics of food practice data provide additional challenges.

OBJECTIVES

We describe a series of steps for integrating food practices into clinical decision-making. These steps include the following: (1) sensing food practice; (2) capturing food practice data; (3) representing food practice; (4) reflecting the information to the patient; (5) incorporating data into the EHR; (6) presenting contextualized food practice information to clinicians; and (7) integrating food practice into clinical decision-making.

METHODS

We elaborate on automation opportunities and challenges in each step, providing a summary visualization of the flow of food practice-related data from daily living settings to clinical settings.

RESULTS

We propose four implications of automating food practice hereinafter. First, there are multiple ways of automating workflow related to food practice. Second, steps may occur in daily living and others in clinical settings. Food practice data and the necessary contextual information should be integrated into clinical decision-making to enable action. Third, as accuracy becomes important for food practice data, macrolevel data may have advantages over microlevel data in some situations. Fourth, relevant systems should be designed to eliminate disparities in leveraging food practice data.

CONCLUSION

Our work confirms previously developed recommendations in the context of PGHD work and provides additional specificity on how these recommendations apply to food practice.

An Unsafe/Safe Typology in People with Type 2 Diabetes: Bridging Patients' Expectations, Personality Traits, Medication Adherence, and Clinical Outcomes

BACKGROUND

Support programs are provided to people with diabetes to help them manage their disease. However, adherence to and persistence in support programs are often low, making it difficult to demonstrate their effectiveness.

AIM

To identify the determinants of patients' perceived interest in diabetes support programs because it may be a powerful determinant of effective participation in such programs.

PATIENTS AND METHODS

An online study conducted in April 2021 in metropolitan France on 600 people with diabetes recruited from a consumer panel. A 64-item psychosocial questionnaire including a question asking to evaluate the helpfulness of a support program was used. Univariate, multivariate, and multiple correspondence analyses were performed.

RESULTS

The existence of a typology, known as Unsafe/Safe, was discovered, in which patients with type 2 diabetes respond in two distinct ways. Type U (unsafe) patients, who believe that a support program would be helpful, are more likely to be nonadherent to their treatment, have high hemoglobin A1c levels, have at least one diabetic complication, lack information regarding their disease and treatment, rate the burden of their disease and impairment of their quality of life as high, worry about their future, and are pessimistic. Type S (safe) patients have the opposite characteristics. Type U patients can be dichotomized into two broad classes: one in which they lack information regarding disease and treatment and the other in which alterations in the quality of life and burden of the disease predominate. Insulin-treated patients give more importance to the lack of information, whereas noninsulin-treated patients complain primarily about the burden of the disease and impairment of quality of life.

CONCLUSION

This study describes this new U/S typology, proposes a simple method based on a nine-item questionnaire to identify type U patients by calculating a Program Helpfulness Score described herein, and clarifies the nature of the intervention to be provided to them. This novel approach could be applied to other chronic diseases.

Perceptions of Practicing Physicians and Members of the Public on the Attributes of a "Good Doctor"

Since physician–patient relationships are a central part of the medical practice, it is essential to understand whether physicians and the general public share the same perspective on traits defining a “good doctor”. Our study compared the perceptions of physicians and members of the public on the essential traits of a “good doctor.” We conducted parallel surveys of 1000 practicing specialist-physicians, and 500 members of the public in Israel. Respondents were asked about the two most important attributes of a “good doctor” and whether they thought the physicians’ role was to reduce health disparities. Many physicians (56%) and members of the public (48%) reported that the role of physicians includes helping to reduce health disparities. Physicians emphasized the importance of non-technical skills such as humaneness and concern for patients as important traits of a “good doctor,” while the public emphasized professional and technical skills. Internal medicine physicians were more likely than surgeons to emphasize humaneness, empathy, and professionalism. Future research should focus on actionable approaches to bridge the gap in the perceptions between the groups, and that may support the formation of caring physicians embedded in a complex array of relationships within clinical and community contexts.

Patient-centered care in telemedicine - An experimental-design study

BACKGROUND

Patients using telemedicine expect health providers to meet their expectations and are concerned about losing interpersonal contact. Studies on tailoring telemedicine to patient expectations are scant. This experimental design starts to close the gap in the state-of-the-art testing of patient expectations of communication with healthcare providers in telemedicine based on the patient-centered approach. The study was conducted from June 2021 through September 2021.

METHODS

The convenience sample comprised 677 students, 298 females and 379 males, ages 18 to 64 who are all patients of one of four national health funds in Israel, using telemedicine. We used a conjoint-based experimental design. Each respondent evaluated a unique set of 24 vignettes of messages. The dependent variable was patient expectations of communication with healthcare providers in Telemedicine. The independent variables were four acknowledged categories of patient expectations of provider-patient communication.

RESULTS

Coefficients for the total panel suggest no significant differences. Applying mathematical clustering, three mindsets emerged. A Post-hoc ANOVA test indicated that the mindsets are significantly different. Members of Mindset 1 expect the provider to walk them through the change process. Members of Mindset 2 expect healthcare providers to refer them to a reliable source of information to enhance their healthcare literacy. Members of Mindset 3 expect respect, both in non-verbal conduct and for their time. We developed a prediction tool enabling to identify the mindset-belonging of each patient in the population to a mindset in the sample.

CONCLUSIONS

Findings call healthcare providers to communicate with patients via telemedicine based on mindset-tailored messages rather than based on socio-demographics for optimum patient-centered communication. Using the prediction tool, providers may identify the mindset-belonging of each patient. To enhance patient-centered care via telemedicine, providers are called upon to meet expectations by using mindset-tailored communication that structures the communication with greater specificity enhancing patient-centered care.

Precision communication: Physicians' linguistic adaptation to patients' health literacy

Little quantitative research has explored which clinician skills and behaviors facilitate communication. Mutual understanding is especially challenging when patients have limited health literacy (HL). Two strategies hypothesized to improve communication include matching the complexity of language to patients’ HL (“universal tailoring”); or always using simple language (“universal precautions”). Through computational linguistic analysis of 237,126 email exchanges between dyads of 1094 physicians and 4331 English-speaking patients, we assessed matching (concordance/discordance) between physicians’ linguistic complexity and patients’ HL, and classified physicians’ communication strategies. Among low HL patients, discordance was associated with poor understanding (P = 0.046). Physicians’ “universal tailoring” strategy was associated with better understanding for all patients (P = 0.01), while “universal precautions” was not. There was an interaction between concordance and communication strategy (P = 0.021): The combination of dyadic concordance and “universal tailoring” eliminated HL-related disparities. Physicians’ ability to adapt communication to match their patients’ HL promotes shared understanding and equity. The ‘Precision Medicine’ construct should be expanded to include the domain of ‘Precision Communication.’

A systematic review and meta-analysis of non-adherence to anti-diabetic medication: Evidence from low- and middle-income countries

BACKGROUND

Non-adherence to anti-diabetic medication is an important cause of uncontrolled blood glucose that leads to complications of diabetes. However, there is a lack of evidence on the burden of and factors associated with non-adherence to anti-diabetic medication among individuals living with diabetes in low-and middle-income countries (LMICs).

OBJECTIVES

This systematic literature review and meta-analytic synthesis aims to estimate non-adherence to anti-diabetic medication reported among individuals in LMICs and explores factors affecting non-adherence.

METHODS

We systematically searched MEDLINE and Embase to identify studies investigating non-adherence to anti-diabetic medications published from January 2000 to May 2020. Two authors carried out study selection, screening, and data extraction independently. Cross-sectional studies that had been conducted among individuals with diabetes in LMICs were eligible for the selection process. Critical appraisal of the included studies was carried out using the Newcastle Ottawa Scale. Meta-analysis was carried out using Stata 14.2. Random effects model was used to compute the pooled proportion at a 95% confidence interval (CI).

RESULTS

Forty-three studies met the inclusion criteria, of which 13 studies were used in meta-analysis. The pooled proportion of non-adherence to anti-diabetic medications using the eight-item Morisky Medication Adherence Scale (MMAS-8) was 43.4% (95% CI: 17.5-69.4; P < 0.001) and 29.1% (95% CI: 19.8-38.4; P < 0.001) when using the cut-off at 80 or 90%. The pooled proportion of non-adherence was 29.5% (95% CI: 25.5-33.5; P = .098) when using the four-item Morisky Medication Adherence Scale (MMAS-4). Using the World Health Organization (WHO) five dimensions of medication adherence framework, the factors contributing to non-adherence were varied, including disease factors, therapy-related factors, healthcare system factor, patient-centred factors, and socio-economic factors.

CONCLUSIONS

Non-adherence to anti-diabetic medication remains an ongoing challenge in LMICs and several factors operating at different levels were cited as reasons. Comprehensive intervention strategies are urgently needed to address these factors in effectively tackling medication non-adherence in LMICs.

Will Improvements in Patient Experience With Care Impact Clinical and Quality of Care Outcomes?: A Systematic Review

BACKGROUND

Patient experiences with health care have been widely used as benchmark indicators of quality for providers, health care practices, and health plans.

OBJECTIVE

The objective of this study was to summarize the literature regarding the associations between Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experiences and clinical and quality outcomes.

RESEARCH DESIGN

A systematic review of the literature was completed using PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature on December 14, 2019. Separate searches were conducted to query terms identifying CAHPS surveys with clinical and quality outcomes of care. Two reviewers completed all components of the search process.

STUDY SELECTION

Studies investigating associations between CAHPS composite ratings and health care sensitive clinical outcomes or quality measures of care were included in this review. Studies were excluded if they did not investigate patient experiences using CAHPS composite ratings or if CAHPS composites were not treated as the independent variable.

RESULTS

Nineteen studies met inclusion criteria, 10 investigating associations of CAHPS composite ratings with clinical outcomes and 9 investigating these associations with quality measures. Patient-provider communication was the most studied CAHPS composite rating and was significantly associated with self-reported physical and mental health, frequency of emergency room visits and inpatient hospital stays, hospitalization length, and CAHPS personal physician global ratings.

CONCLUSIONS

Ratings of patient experience with care may influence clinical and quality outcomes of care. However, key inconsistencies between studies affirm that more research is needed to solidify this conclusion and investigate how patient experiences differentially relate to outcomes for various patient groups.

Measuring the multiple domains of medication nonadherence: findings from a Delphi survey of adherence experts

Consensus on a gold-standard measure of patient medication nonadherence has been elusive, in part because medication nonadherence involves multiple, distinct behaviors across three phases (initiation, implementation, and persistence). To assess these behaviors, multiple measurement approaches may be needed. The purpose of this study was to identify expert-recommended approaches to measuring nonadherence behaviors. Thirty medication nonadherence experts were e-mailed two consecutive surveys. In both, respondents rated their agreement with definitions of nonadherence behaviors and measurement approaches. In the second survey, respondents rated the suitability of each measurement approach for assessing each behavior and identified the optimal measurement approach for each behavior. Consensus was achieved for eight patient medication nonadherence behaviors: not filling initial prescription and not taking first dose (noninitiation); refilling prescription late, missing doses, taking extra doses, taking doses at wrong time, and improperly administering medication (incorrect implementation); and discontinuing medication early (nonpersistence). Consensus was achieved for seven measurement approaches: self-report, prescription fill data, pill count, drug levels, electronic drug monitoring (EDM), smart technology, and direct observation. Self-report questionnaires were most commonly rated "at least somewhat suitable" for measuring behaviors. EDM was rated as optimal for measuring missing doses, taking extra doses, and taking doses at the wrong time. Prescription fill data were rated as optimal for not filling initial prescription, refilling late, and discontinuing. Direct observation was rated as optimal for measuring improper administration. Suitable and optimal measurement approaches varied across nonadherence behaviors. Researchers should select the measurement approach best suited to assessing the behavior(s) targeted in their research.

Association between Medication Non-Adherence and Increases in Hypertension and Type 2 Diabetes Medications

Importance: Medication non-adherence is highly costly and leads to worse disease control and outcomes. However, knowledge about medication adherence is often disconnected from prescribing decisions, and this disconnect may lead to inappropriate increases in medications and higher risks of adverse events. Objectives: To evaluate the association between medication non-adherence and the likelihood of increases in the intensity of medication regimens for two chronic conditions, hypertension and type 2 diabetes. Design: Cohort Study. Setting and Participants: This study used US national pharmacy claims data for Medicare Part D (ages ≥ 65) and commercial (ages 50-64) plans to evaluate medication adherence and its association with the likelihood of receiving an increase in medication intensity for patients with hypertension and/or oral diabetes medication fills. Patients had an index fill for hypertension (N = 2,536,638) and/or oral diabetes (N = 701,376) medications in January 2015. Medication fills in the follow-up period from August 2015 to December 2016 were assessed for increases in medication regimen intensity. Main Outcome(s) and Measure(s): The proportion of days covered (PDC) over 181 days was used as a measure for patient's medication adherence before a medication addition, medication increase, or dosage increase. Differences in the likelihood of experiencing an escalation in medication intensity was considered between patients with a PDC < 80% vs. PDC ≥ 80%. Results: Among Medicare Part D and commercial plan patients filling hypertension and/or oral diabetes medications, non-adherent patients were significantly more likely to experience an intensification of their medication regimens (p < 0.001). Conclusions and Relevance: This study found a significant association between non-adherence to medications and a higher likelihood of patients experiencing potentially inappropriate increases in treatment intensity. Sharing of objective patient refill data between retail pharmacies and prescribers can enable prescribers to have more targeted discussions with patients about their adherence and overall treatment plan. Additionally, it can increase safe medication prescribing and plausibly reduce adverse drug events and healthcare costs while improving patient health outcomes.

Patient and Provider Perspectives on Acceptability, Access, and Adherence to 17-Alpha-Hydroxyprogesterone Caproate for Preterm Birth Prevention

Background: Preterm birth (PTB) is a pressing maternal and child health issue with long-standing racial inequities in outcomes and care provision. 17-Alpha-hydroxyprogesterone caproate (17OHPC) has been one of few clinical interventions for recurrent PTB prevention. Little is known about the factors influencing successful administration and receipt of 17OHPC among mothers in the Medicaid program. Materials and Methods: We conducted individual semistructured interviews with 17OHPC-eligible pregnant women and obstetric providers from two academic medical centers in Philadelphia, PA. Patient participants were publicly insured, eligible for 17OHPC treatment, and purposively sampled as either (1) actively receiving treatment or (2) declining/discontinuing treatment. Providers had experience providing care to Medicaid-enrolled patients. Interview transcripts were coded and analyzed to identify themes related to treatment acceptability, access, and adherence. Results: Of the 17 patient participants, the mean age was 30 years. Ten providers (MDs, nurse practitioners, and registered nurses) were also interviewed. Factors facilitating 17OHPC uptake and adherence among patients included severity of prior PTB, provider counseling, and coordination among the clinic, pharmacy, and insurance. Pain was cited as the most significant barrier to 17OHPC for patients, while providers perceived social adversity and beliefs about patients' commitment to treatment to be primary patient barriers. For providers, clinical experience and practice guidelines contributed to their use of 17OHPC. Administrative complexity and coordination of services were the primary provider barrier to 17OHPC administration. Conclusions: Patient-provider communication is a primary driver of 17OHPC acceptability and adherence. Comprehensive patient-centered consultation may improve uptake of clinical therapies among pregnant women at high risk for PTB.

Association Between Patient-Clinician Relationships and Adherence to Antihypertensive Medications Among Black Adults: An Observational Study Design

Background We assessed the associations between patient-clinician relationships (communication and involvement in shared decision-making [SDM]) and adherence to antihypertensive medications. Methods and Results The 2010 to 2017 Medical Expenditure Panel Survey (MEPS) data were analyzed. A retrospective cohort study design was used to create a cohort of prevalent and new users of antihypertensive medications. We defined constructs of patient-clinician communication and involvement in SDM from patient responses to the standard questionnaires about satisfaction and access to care during the first year of surveys. Verified self-reported medication refill information collected during the second year of surveys was used to calculate medication refill adherence; adherence was defined as medication refill adherence ≥80%. Survey-weighted multivariable-adjusted logistic regression models were used to measure the odds ratio (OR) and 95% CI for the association between both patient-clinician constructs and adherence. Our analysis involved 2571 Black adult patients with hypertension (mean age of 58 years; SD, 14 years) who were either persistent (n=1788) or new users (n=783) of antihypertensive medications. Forty-five percent (n=1145) and 43% (n=1016) of the sample reported having high levels of communication and involvement in SDM, respectively. High, versus low, patient-clinician communication (OR, 1.38; 95% CI, 1.14-1.67) and involvement in SDM (OR, 1.32; 95% CI, 1.08-1.61) were both associated with adherence to antihypertensives after adjusting for multiple covariates. These associations persisted among a subgroup of new users of antihypertensive medications. Conclusions Patient-clinician communication and involvement in SDM are important predictors of optimal adherence to antihypertensive medication and should be targeted for improving adherence among Black adults with hypertension.

Developing and Testing Automatic Models of Patient Communicative Health Literacy Using Linguistic Features: Findings from the ECLIPPSE study

Patients with diabetes and limited health literacy (HL) may have suboptimal communication exchange with their health care providers and be at elevated risk of adverse health outcomes. These difficulties are generally attributed to patients' reduced ability to both communicate and understand health-related ideas as well as physicians' lack of skill in identifying those with limited HL. Understanding and identifying patients with barriers posed by lower HL to improve healthcare delivery and outcomes is an important research avenue. However, doing so using traditional methods has proven difficult and infeasible to scale. This study using corpus analyses, expert human ratings of HL, and natural language processing (NLP) approaches to estimate HL at the individual patient level. The goal of the study is to better understand HL from a linguistic perspective and to open new research areas to enhance population management and individualized care. Specifically, this study examines HL as a function of patients' demonstrated ability to communicate health-related information to their providers via secure messages. The study develops an NLP-based HL model and validates the model by predicting patient-related events such as medical outcomes and hospitalizations. Results indicate that the developed model predicts human ratings of HL with ~80% accuracy. Validation indicates that lower HL patients are more likely to be nonwhite and have lower educational attainment. In addition, patients with lower HL suffered more negative health outcomes and had higher healthcare service utilization.

Psychosocial Determinants of Treatment Adherence in Patients with Type 2 Diabetes - A Review

Less than 50% of patients with diabetes achieve the glycaemic goals recommended by the American Diabetes Association. The set of factors associated with adherence to treatment is very broad. Evidence suggests that psychosocial factors are related to medication adherence of patients with type 2 diabetes. Due to the lack of a clear statement from researchers regarding the relationship of psychosocial factors to adherence, an electronic search was conducted in PubMed, MEDLINE, Academic Search Ultimate, CINAHL Complete, Edition and Health Source: Nursing/Academic Edition using the following keywords "adherence", "diabetes", "social support", "stress", "anxiety and depression", "beliefs about medicine", "communication", "older age", "frailty", "cognitive impairment", "addiction", "acceptance of illness", "sense of coherence" obtaining 2758 results. After a narrowing of searches and reference scanning, 36 studies were qualified. The studies analysed showed negative effects of anxiety, diabetes distress, older age, poor communication with physicians, stress, concerns about medicines and cognitive impairment on levels of self-care and medication adherence. One study did not confirm the association of depression with adherence. Self-efficacy, social and family support, and acceptance of illness had a beneficial effect on medication adherence. In conclusion, the current evidence suggests that the relationship between psychosocial factors and adherence has reliable scientific support.

A Mixed Methods Examination of Health Care Provider Behaviors That Build Patients' Trust

OBJECTIVE

Patient trust in health care providers is associated with better health behaviors and utilization, yet provider trust has not been consistently conceptualized. This study uses qualitative methods to identify the key health provider behaviors that patients report build their trust, and data from a national U.S. survey of adults to test the robustness of the qualitative findings.

METHODS

In this mixed methods study, we conducted 40 semi-structured interviews with a diverse sample to identify the provider behaviors that build trust. We then analyzed a nationally representative survey (n = 6,517) to examine the relationship between respondents' trust in their usual provider and the key trust-related behaviors identified in the qualitative interviews.

RESULTS

Interviewees reported that health providers build trust by communicating effectively (listening and providing detailed explanations), caring about their patients (treating them as individuals, valuing their experience, and showing commitment to solving their health issues), and demonstrating competence (being knowledgeable, thorough, and solving their health issues). Trust in one's provider was highly correlated with all eight survey items measuring communication, caring, and competence.

CONCLUSIONS

To build trust with patients, health providers should actively listen, provide detailed explanations, show caring for patients, and demonstrate their knowledge.

Disparities in communication among the inpatient homeless population at a safety-net hospital

OBJECTIVE

To determine whether the homeless population experiences disparities in care and communication during inpatient hospitalizations in a safety-net hospital.

METHODS

We administered a modified Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to 112 age-sex- and education matched homeless and non-homeless adults at a university-affiliated-safety-net hospital from December 2017 through March 2018 and performed a retrospective review of medical records. Linear regression models were used to assess differences in responses to survey subscales, length of stay and other measures.

RESULTS

Homeless participants trended toward poorer ratings for all HCAHPS subscales, reaching significance for the Communication about Medications subscale, with a mean score 1.2 (95% CI 0.48-1.76) points lower compared to non-homeless sample. Length of stay was not significantly different between homeless and non-homeless participants.

CONCLUSION

In an urban safety-net hospital, disparities in communications regarding medications between hospital staff and patients were found based on housing status.

Employing computational linguistics techniques to identify limited patient health literacy: Findings from the ECLIPPSE study

OBJECTIVE

To develop novel, scalable, and valid literacy profiles for identifying limited health literacy patients by harnessing natural language processing.

DATA SOURCE

With respect to the linguistic content, we analyzed 283 216 secure messages sent by 6941 diabetes patients to physicians within an integrated system's electronic portal. Sociodemographic, clinical, and utilization data were obtained via questionnaire and electronic health records.

STUDY DESIGN

Retrospective study used natural language processing and machine learning to generate five unique "Literacy Profiles" by employing various sets of linguistic indices: Flesch-Kincaid (LP_FK); basic indices of writing complexity, including lexical diversity (LP_LD) and writing quality (LP_WQ); and advanced indices related to syntactic complexity, lexical sophistication, and diversity, modeled from self-reported (LP_SR), and expert-rated (LP_Exp) health literacy. We first determined the performance of each literacy profile relative to self-reported and expert-rated health literacy to discriminate between high and low health literacy and then assessed Literacy Profiles' relationships with known correlates of health literacy, such as patient sociodemographics and a range of health-related outcomes, including ratings of physician communication, medication adherence, diabetes control, comorbidities, and utilization.

PRINCIPAL FINDINGS

LP_SR and LP_Exp performed best in discriminating between high and low self-reported (C-statistics: 0.86 and 0.58, respectively) and expert-rated health literacy (C-statistics: 0.71 and 0.87, respectively) and were significantly associated with educational attainment, race/ethnicity, Consumer Assessment of Provider and Systems (CAHPS) scores, adherence, glycemia, comorbidities, and emergency department visits.

CONCLUSIONS

Since health literacy is a potentially remediable explanatory factor in health care disparities, the development of automated health literacy indicators represents a significant accomplishment with broad clinical and population health applications. Health systems could apply literacy profiles to efficiently determine whether quality of care and outcomes vary by patient health literacy; identify at-risk populations for targeting tailored health communications and self-management support interventions; and inform clinicians to promote improvements in individual-level care.

Patient-Provider Communication and Adherence to Cholesterol Management Advice: Findings from a Cross-Sectional Survey

High cholesterol is a preventable risk factor for heart disease. This study examines which aspects of patient-provider communication are associated with patient report of increased adherence to cholesterol management advice in a diverse, low-income patient population accessing the health care safety net, using the 2014 Health Center Patient Survey. Patient-provider communication measures included patient report of: how often a provider listened carefully, gave easy-to-understand information, knew important information about the patient's medical history, showed respect, and spent enough time with the patient. Outcome measures were patient report of following provider advice to eat fewer high fat or high cholesterol foods, manage weight, increase physical activity, or take prescribed medicine. In adjusted analyses, when patients perceived their provider always knew their medical history, patients were more likely to report taking prescribed medication (adjusted odds ratio [aOR]: 3.2; 95% confidence interval [CI]: 1.6, 6.6). Knowledge of medical history (aOR: 2.8, 95% CI: 1.4, 5.8), spending enough time (aOR: 2.3, 95% CI: 1.2, 4.4), and providing easily understandable information (aOR: 2.2, 95% CI: 1.0, 4.7) were significantly associated with report of following physical activity advice. Knowledge of medical history (aOR: 2.3, 95% CI: 1.0, 5.2) and providing easily understandable information (aOR: 3.3, 95% CI: 1.4, 7.9) were significantly associated with report of following weight management advice. This study indicates different components of patient-provider communication influence patient adherence to lifestyle modification advice and medication prescription. These results suggest a tailored approach to optimize the impact of patient-provider communication on cholesterol management advice adherence.

Challenges and solutions to employing natural language processing and machine learning to measure patients' health literacy and physician writing complexity: The ECLIPPSE study

OBJECTIVE

In the National Library of Medicine funded ECLIPPSE Project (Employing Computational Linguistics to Improve Patient-Provider Secure Emails exchange), we attempted to create novel, valid, and scalable measures of both patients' health literacy (HL) and physicians' linguistic complexity by employing natural language processing (NLP) techniques and machine learning (ML). We applied these techniques to > 400,000 patients' and physicians' secure messages (SMs) exchanged via an electronic patient portal, developing and validating an automated patient literacy profile (LP) and physician complexity profile (CP). Herein, we describe the challenges faced and the solutions implemented during this innovative endeavor.

MATERIALS AND METHODS

To describe challenges and solutions, we used two data sources: study documents and interviews with study investigators. Over the five years of the project, the team tracked their research process using a combination of Google Docs tools and an online team organization, tracking, and management tool (Asana). In year 5, the team convened a number of times to discuss, categorize, and code primary challenges and solutions.

RESULTS

We identified 23 challenges and associated approaches that emerged from three overarching process domains: (1) Data Mining related to the SM corpus; (2) Analyses using NLP indices on the SM corpus; and (3) Interdisciplinary Collaboration. With respect to Data Mining, problems included cleaning SMs to enable analyses, removing hidden caregiver proxies (e.g., other family members) and Spanish language SMs, and culling SMs to ensure that only patients' primary care physicians were included. With respect to Analyses, critical decisions needed to be made as to which computational linguistic indices and ML approaches should be selected; how to enable the NLP-based linguistic indices tools to run smoothly and to extract meaningful data from a large corpus of medical text; and how to best assess content and predictive validities of both the LP and the CP. With respect to the Interdisciplinary Collaboration, because the research required engagement between clinicians, health services researchers, biomedical informaticians, linguists, and cognitive scientists, continual effort was needed to identify and reconcile differences in scientific terminologies and resolve confusion; arrive at common understanding of tasks that needed to be completed and priorities therein; reach compromises regarding what represents "meaningful findings" in health services vs. cognitive science research; and address constraints regarding potential transportability of the final LP and CP to different health care settings.

DISCUSSION

Our study represents a process evaluation of an innovative research initiative to harness "big linguistic data" to estimate patient HL and physician linguistic complexity. Any of the challenges we identified, if left unaddressed, would have either rendered impossible the effort to generate LPs and CPs, or invalidated analytic results related to the LPs and CPs. Investigators undertaking similar research in HL or using computational linguistic methods to assess patient-clinician exchange will face similar challenges and may find our solutions helpful when designing and executing their health communications research.

Associations between patient experience and clinical outcomes in general mental health clinics: Findings from the veterans outcomes assessment survey

For mental health, evidence linking the patients' experiences of care with treatment outcomes is limited. We report findings from the Veterans Outcome Assessment (VOA) survey of Veterans beginning treatment in Veterans Health Administration (VHA) mental health programs with follow-up after approximately 3 months. In addition to assessments of symptoms and functioning, it includes key components of the Experience of Care and Health Outcomes (ECHO) survey including patient reports of communication with clinicians and of the overall quality of mental health care. For Veterans treated in VHA general mental health clinics, significant associations between ratings of communication and quality at baseline, and both retention in treatment and patient-reported outcomes assessed at follow-up demonstrate that better patient experience predicts more favorable outcomes. Further research is necessary to determine whether including them in measurement-based care could improve outcomes by facilitating the early identification of problems in providing care.

Intentionality in adherence to long-term therapies. Results from an online survey of 3,001 patients with cardio-metabolic pathologies in France

PURPOSE

Some patients make a rational choice not to follow medical prescriptions; others fail to take their medications for reasons beyond their control, such as mere forgetfulness or a weak medication routine. The aim of this study was to elucidate the functioning of patient intentionality in medication adherence.

PATIENTS AND METHODS

This online study was conducted in metropolitan France in 2019. A cross-sectional survey of 50 questions was conducted with 3001 respondents diagnosed with diabetes, hypertension, and/or hypercholesterolemia identified from a panel of 54,000 people. These questions included a validated six-item questionnaire to detect nonadherence, two questions to detect intentional nonadherence by patients, and three questions on the effects of habit. Our questionnaire also included questions on the feelings of respondents regarding their doctor's attitude to their problems and needs, their trust in general practitioners (GP) and specialists, their sense of being involved in treatment decisions, and the influence of side effects and habits on patients' adherence. This study used the strategy of focusing on strictly adherent patients in the hope of finding ways to improve adherence. For this reason, we defined adherence as the absence of a positive response to the 6-item nonadherence screening questionnaire.

RESULTS

Of 3001 respondents, 1804 were diagnosed with hypertension, 1458 with hypercholesterolemia, and 774 with diabetes. Of the total number of patients, 72% were afflicted with one disease, 21% with two ailments, and 7% with three simultaneous illnesses. One-third (33%) of the patients did not tender a positive answer to the adherence questionnaire and were deemed adherent. 1) Thirty-two percent of the patients reported occasionally omitting their medication deliberately, and 84% said they had a reason for missing doses. These statements suggesting intentional nonadherence were negatively associated with adherence as identified via multivariate analysis (P = 0.0012 and P < 0.0001, for the first and second statement, respectively). 2) Univariate analyses revealed strong associations (P < 0.0001) between strict adherence on one hand and lack of intentional nonadherence, patient age, absence of drug side effects, taking drugs by habit, feeling involved in treatment decisions, getting information about treatment, and disease, and trust in doctors, on the other hand. 3) Specifically, univariate analysis of the absence of reported side effects revealed strong associations (P < 0.0001) with adequate information about medicines and diseases and trust in GP. These original data were consistent with the concept of the nocebo effect. 4) We observed a strong association between the absence of intentional nonadherence (statement of never deliberately missing medication) and respondent statements about generally sticking to the routine (P < 0.0001), ie, "I take my medication because I am used to taking it." This important result suggests that patients are strictly adherent in two ways: the absence of intentional nonadherence and reliance on habit, which we term as "unintentional adherence." 5) Finally, a multiple correspondence analysis illustrated all statistically significant relationships found in this study.

CONCLUSION

We present a new global model of adherence in which patient adherence was improved both by reducing intentional nonadherence and by promoting the abovementioned unintentional adherence by habit. This model highlights the role of shared decision-making and the trust felt by patients in their doctors. These results could exert a major impact on medical practice and education by demonstrating the importance of physicians' attitudes, involving the patient in decisions (shared decision-making), offering information about medicines and diseases (patient education), understanding the problems of patients, and taking their needs into account (empathy). The development of these attitudes should be an important aspect of the medical curricula.

Impact of satisfaction with physician-patient communication on self-care and adherence in patients with hypertension: cross-sectional study

BACKGROUND

Hypertension (HT) requires patients to continuously monitor their blood pressure, strictly adhere to therapeutic recommendations, and self-manage their illness. A few studies indicate that physician-patient communication and the patient's satisfaction with the therapeutic relationship may affect the course and outcomes of the treatment process. Research is still lacking on the association between satisfaction with physician-patient communication and adherence to treatment or self-care in chronically ill patients. The aim of the study was to evaluate the relationship between satisfaction with physician-patient communication and self-care and adherence in patients with HT undergoing chronic treatment.

METHODS

The following instruments were used: the Adherence to Refills and Medication Scale (ARMS) for evaluating adherence (12-48 points), the Self-Care of Hypertension Inventory (SCHI) for self-care level (0-100 points), and the Communication Assessment Tool (CAT) for evaluating satisfaction with physician-patient communication. Socio-demographic and clinical data were obtained from patients' medical records. The research has a cross-sectional and observational study design. Inclusion criteria were as follows: age > 18 years, hypertension diagnosed per European Society of Hypertension (ESH) guidelines, treatment with at least one antihypertensive drug for the past 6 months, and informed consent. Cognitively impaired patients unable to complete the surveys without assistance were excluded (MMSE ≤18). Correlations between quantitative variables were analyzed using Pearson's or Spearman's correlation coefficient. Linear regression was performed. Variable distribution normality was verified using the Shapiro-Wilk test.

RESULTS

The study included 250 patients (110 male, mean age 61.23 ± 14.34) with HT, treated at a hypertension clinic. In the CAT questionnaire individual questions pertaining to satisfaction with physician communication (on the CAT) were rated "excellent" 28.4-50.4% of the time. The best-rated aspects of communication included: letting the patient talk without interruptions (50.4% "excellent" ratings), speaking in a way the patient can understand (47.6%), and paying attention to the patient (47.2%). According to patient reports, physicians most commonly omitted such aspects as encouraging the patient to ask questions (28.4%), involving them in decisions (29.2%), and discussing the next steps (35.2%). The respondents had a low level of adherence to pharmaceutical treatment (16.63 ± 4.6). In terms of self-care, they scored highest in self-care management (64.17 ± 21.18), and lowest in self-care maintenance (56.73 ± 18.57). In correlation analysis, satisfaction with physician-patient communication (total CAT score) was positively correlated with all SCHI domains (self-care maintenance β = 0.276, self-care management β = 0.208, self-care confidence β = 0.286, p < 0.05), and negatively correlated with ARMS scores (indicating better adherence).

CONCLUSIONS

Satisfaction with physician-patient communication has a significant impact on self-care and pharmaceutical adherence in patients with hypertension. The more satisfied the patient is with communication, the better their adherence and self-care.

TRIAL REGISTRATION

SIMPLE: RID.Z501.19.016.

Lifestyle factors, self-management and patient empowerment in diabetes care

Although management of diabetes mellitus is improving, inadequately managed cases still exist. Prevention of diabetes mellitus requires an integrated and holistic approach based on the origin of the disease. In Europe only half of diagnosed patients with diabetes mellitus have good glycaemic control. Inadequate glycaemic control is significantly increasing the use of healthcare resources, the medical costs and mortality rates. A review was conducted in order to summarise and discuss central themes for prevention. A search of the databases PubMed, CINAHL, Cochrane and Google Scholar between January 2010-May 2019 was undertaken. The following keywords: 'diabetes mellitus', 'cardiovascular diseases', 'empowerment', 'self-management education' and 'lifestyle factors' were used in different combinations to identify eligible articles. Important variables for the prevention of diabetes mellitus and its complications are self-management of diabetes mellitus and the management of risk factors. Education and support for self-management are fundamental when caring for people with a chronic disease like diabetes mellitus. In order to achieve effective self-management including lifestyle modification it is also crucial to motivate people. In this review, the role of the three main pillars in diabetes care are identified and discussed; patient empowerment, self-management education and lifestyle modification in the management of people with diabetes mellitus.