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Claus LE, Barton Laws M, Wilson IB, Han D, Saha S, Moore RD, Beach MC. Does the Quality of Behavior Change Counseling in Routine HIV Care Vary According to Topic and Demand? AIDS Behav 2023; 27:3780-3788. [PMID: 37792233 DOI: 10.1007/s10461-023-04135-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 10/05/2023]
Abstract
HIV clinicians face increasing time constraints. Our objective was to describe the prevalence and quality of behavior change counseling within routine HIV visits and to explore whether clinicians may provide lower quality counseling when facing increased counseling demands. We audio-recorded and transcribed encounters between 205 patients and 12 clinicians at an urban HIV primary care clinic. We identified and coded episodes of behavior change counseling to determine clinicians' consistency with motivational interviewing (MI) and used multi-level regression to evaluate counseling quality changes with each additional topic. Clinician counseling for at least one behavior was indicated in 92% of visits (mean 2.5/visit). Behavioral topics included antiretroviral medication adherence (80%, n = 163), appointment adherence (54%, n = 110), drug use (46%, n = 95), tobacco use (45%, n = 93), unsafe sex (43%, n = 89), weight management (39%, n = 80), and alcohol use (35%, n = 71). Clinician counseling was most MI-consistent when discussing drug and tobacco use and least consistent for medication and appointment adherence, unsafe sex, and alcohol use. In multilevel analyses, clinician counseling was significantly less MI-consistent (β = - 0.14, 95% CI - 0.29 to - 0.001) with each additional behavior change counseling need. This suggests that HIV ambulatory care be restructured to allocate increased time for patients with greater need for behavior change.
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Affiliation(s)
- Lauren E Claus
- Johns Hopkins University School of Medicine, 601 N. Caroline St., Baltimore, MD, 21205, USA.
| | | | - Ira B Wilson
- Brown School of Public Health, Providence, RI, USA
| | - Dingfen Han
- Department of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Somnath Saha
- Department of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D Moore
- Department of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary Catherine Beach
- Department of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
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Kunneman M, Branda ME, Ridgeway JL, Tiedje K, May CR, Linzer M, Inselman J, Buffington ALH, Coffey J, Boehm D, Deming J, Dick S, van Houten H, LeBlanc A, Liesinger J, Lima J, Nordeen J, Pencille L, Poplau S, Reed S, Vannelli A, Yost KJ, Ziegenfuss JY, Smith SA, Montori VM, Shah ND. Making sense of diabetes medication decisions: a mixed methods cluster randomized trial using a conversation aid intervention. Endocrine 2022; 75:377-391. [PMID: 34499328 PMCID: PMC8428215 DOI: 10.1007/s12020-021-02861-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/27/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE To determine the effectiveness of a shared decision-making (SDM) tool versus guideline-informed usual care in translating evidence into primary care, and to explore how use of the tool changed patient perspectives about diabetes medication decision making. METHODS In this mixed methods multicenter cluster randomized trial, we included patients with type 2 diabetes mellitus and their primary care clinicians. We compared usual care with or without a within-encounter SDM conversation aid. We assessed participant-reported decisions made and quality of SDM (knowledge, satisfaction, and decisional conflict), clinical outcomes, adherence, and observer-based patient involvement in decision-making (OPTION12-scale). We used semi-structured interviews with patients to understand their perspectives. RESULTS We enrolled 350 patients and 99 clinicians from 20 practices and interviewed 26 patients. Use of the conversation aid increased post-encounter patient knowledge (correct answers, 52% vs. 45%, p = 0.02) and clinician involvement of patients (Mean between-arm difference in OPTION12, 7.3 (95% CI 3, 12); p = 0.003). There were no between-arm differences in treatment choice, patient or clinician satisfaction, encounter length, medication adherence, or glycemic control. Qualitative analyses highlighted differences in how clinicians involved patients in decision making, with intervention patients noting how clinicians guided them through conversations using factors important to them. CONCLUSIONS Using an SDM conversation aid improved patient knowledge and involvement in SDM without impacting treatment choice, encounter length, medication adherence or improved diabetes control in patients with type 2 diabetes. Future interventions may need to focus specifically on patients with signs of poor treatment fit. CLINICAL TRIAL REGISTRATION ClinicalTrial.gov: NCT01502891.
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Affiliation(s)
- Marleen Kunneman
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Megan E Branda
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, USA
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L Ridgeway
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Kristina Tiedje
- Laboratoire d'anthropologie des enjeux contemporains, Lyon, France
| | - Carl R May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Linzer
- Department of Medicine, Hennepin Healthcare and University of Minnesota, Minneapolis, MN, USA
| | - Jonathan Inselman
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Angela L H Buffington
- Department of Psychiatry and Psychology, Mayo Clinic Health System, Mankato, MN, USA
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jordan Coffey
- Practice-Based Research Network, Mayo Clinic, Rochester, MN, US
- Center for Translational Science Activities, Mayo Clinic, Rochester, MN, USA
| | - Deborah Boehm
- Center for Patient and Provider Experience, Hennepin County Medical Center, Minneapolis, MN, USA
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
- Decision Partners for Health, Richfield, MN, USA
| | - James Deming
- Mayo Clinic Health System Northwest Wisconsin, (dept) Home Health and Hospice, Eau Claire, WI, USA
| | - Sara Dick
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Holly van Houten
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Annie LeBlanc
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
- Department of Family and Emergency Medicine, Faculty of Medicine, Laval University, Quebec, QC, Canada
| | - Juliette Liesinger
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Janet Lima
- Park Nicollet International Diabetes Center, St. Louis Park, MN, USA
| | | | - Laurie Pencille
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
- Kern Center for the Science of Health Care Deliver, Mayo Clinic, Rochester, MN, USA
| | - Sara Poplau
- Office of Professional Worklife, Hennepin Healthcare, Minneapolis, MN, USA
| | - Steven Reed
- Department of Internal Medicine, Park Nicollet Clinic, Brooklyn Center, MN, USA
| | - Anna Vannelli
- Park Nicollet International Diabetes Center, St. Louis Park, MN, USA
| | - Kathleen J Yost
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Jeanette Y Ziegenfuss
- Division of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Center for Evaluation and Survey Research, HealthPartners Institute, Bloomington, USA
| | - Steven A Smith
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Nilay D Shah
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.
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Flickinger TE, Saha S, Roter D, Korthuis PT, Sharp V, Cohn J, Moore RD, Ingersoll KS, Beach MC. Respecting patients is associated with more patient-centered communication behaviors in clinical encounters. Patient Educ Couns 2016; 99:250-5. [PMID: 26320821 PMCID: PMC5271348 DOI: 10.1016/j.pec.2015.08.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 08/11/2015] [Accepted: 08/14/2015] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Attitudes towards patients may influence how clinicians interact. We investigated whether respect for patients was associated with communication behaviors during HIV care encounters. METHODS We analyzed audio-recordings of visits between 413 adult HIV-infected patients and 45 primary HIV care providers. The independent variable was clinician-reported respect for the patient and outcomes were clinician and patient communication behaviors assessed by the Roter Interaction Analysis System (RIAS). We performed negative binomial regressions for counts outcomes and linear regressions for global outcomes. RESULTS When clinicians had higher respect for a patient, they engaged in more rapport-building, social chitchat, and positive talk. Patients of clinicians with higher respect for them engaged in more rapport-building, social chitchat, positive talk, and gave more psychosocial information. Encounters between patients and clinicians with higher respect for them had more positive clinician emotional tone [regression coefficient 2.97 (1.92-4.59)], more positive patient emotional tone [2.71 (1.75-4.21)], less clinician verbal dominance [0.81 (0.68-0.96)] and more patient-centeredness [1.28 (1.09-1.51)]. CONCLUSIONS Respect is associated with positive and patient-centered communication behaviors during encounters. PRACTICE IMPLICATIONS Clinicians should be mindful of their respectful attitudes and work to foster positive regard for patients. Educators should consider methods to enhance trainees' respect in communication skills training.
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Affiliation(s)
- Tabor E Flickinger
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Somnath Saha
- Department of Medicine, Portland VA Medical Center, Portland, OR, USA; Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Debra Roter
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - P Todd Korthuis
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Victoria Sharp
- Department of Medicine, St. Luke's Roosevelt, New York, NY, USA
| | - Jonathan Cohn
- Department of Medicine, Wayne State University, Detroit, MI, USA
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen S Ingersoll
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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Flickinger TE, Saha S, Roter D, Korthuis PT, Sharp V, Cohn J, Eggly S, Moore RD, Beach MC. Clinician empathy is associated with differences in patient-clinician communication behaviors and higher medication self-efficacy in HIV care. Patient Educ Couns 2016; 99:220-6. [PMID: 26395313 PMCID: PMC5610904 DOI: 10.1016/j.pec.2015.09.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/11/2015] [Accepted: 09/01/2015] [Indexed: 05/18/2023]
Abstract
OBJECTIVE We examined associations of clinicians' empathy with patient-clinician communication behaviors, patients' rating of care, and medication self-efficacy. METHODS We analyzed 435 adult patients and 45 clinicians at four outpatient HIV care sites in the United States. Negative binomial regressions investigated associations between clinician empathy and patient-clinician communication, assessed using the Roter Interaction Analysis System (RIAS). Logistic regressions investigated associations between clinician empathy and patient ratings of clinician communication, overall satisfaction, and medication self-efficacy. RESULTS Clinicians in the highest vs. lowest empathy tertile engaged in less explicitly emotional talk (IRR 0.79, p<0.05), while clinicians in the middle vs. lowest engaged in more positive talk (IRR 1.31, p<0.05), more questions (IRR 1.42, p<0.05), and more patient activating talk (IRR 1.43, p<0.05). Patients of higher empathy clinicians disclosed more psychosocial and biomedical information. Patients of clinicians in both the middle and highest (vs. lowest) empathy tertiles had greater odds of reporting highest medication self-efficacy (OR 1.80, 95% CI 1.16-2.80; OR 2.13, 95% CI 1.37-3.32). CONCLUSIONS Clinician empathy may be expressed through addressing patient engagement in care, by fostering cognitive, rather than primarily emotional, processing. PRACTICE IMPLICATIONS Clinicians should consider enhancing their own empathic capacity, which may encourage patients' self-efficacy in medication adherence.
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Affiliation(s)
| | - Somnath Saha
- Portland VA Medical Center, Portland, OR, USA; Oregon Health and Science University, Portland, OR, USA
| | - Debra Roter
- Johns Hopkins University, Baltimore, MD, USA
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Elwyn G, Lloyd A, May C, van der Weijden T, Stiggelbout A, Edwards A, Frosch DL, Rapley T, Barr P, Walsh T, Grande SW, Montori V, Epstein R. Collaborative deliberation: a model for patient care. Patient Educ Couns 2014; 97:158-164. [PMID: 25175366 DOI: 10.1016/j.pec.2014.07.027] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 07/04/2014] [Accepted: 07/05/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Existing theoretical work in decision making and behavior change has focused on how individuals arrive at decisions or form intentions. Less attention has been given to theorizing the requirements that might be necessary for individuals to work collaboratively to address difficult decisions, consider new alternatives, or change behaviors. The goal of this work was to develop, as a forerunner to a middle range theory, a conceptual model that considers the process of supporting patients to consider alternative health care options, in collaboration with clinicians, and others. METHODS Theory building among researchers with experience and expertise in clinician-patient communication, using an iterative cycle of discussions. RESULTS We developed a model composed of five inter-related propositions that serve as a foundation for clinical communication processes that honor the ethical principles of respecting individual agency, autonomy, and an empathic approach to practice. We named the model 'collaborative deliberation.' The propositions describe: (1) constructive interpersonal engagement, (2) recognition of alternative actions, (3) comparative learning, (4) preference construction and elicitation, and (5) preference integration. CONCLUSIONS We believe the model underpins multiple suggested approaches to clinical practice that take the form of patient centered care, motivational interviewing, goal setting, action planning, and shared decision making.
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Affiliation(s)
- Glyn Elwyn
- The Dartmouth Center for Health Care Delivery Science, Dartmouth College, USA.
| | - Amy Lloyd
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, UK
| | - Carl May
- Faculty of Health Sciences, University of Southampton, UK
| | - Trudy van der Weijden
- School Caphri, Department of Family Medicine, Maastricht University, The Netherlands
| | - Anne Stiggelbout
- Department of Medical Decision Making, Leiden University, The Netherlands
| | - Adrian Edwards
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, UK
| | - Dominick L Frosch
- Gordon and Betty Moore Foundation, USA; Department of Medicine, The University of California, Los Angeles, USA; Palo Alto Medical Foundation Research Institute, USA
| | - Tim Rapley
- Institute of Health & Society, Newcastle University, UK
| | - Paul Barr
- The Dartmouth Center for Health Care Delivery Science, Dartmouth College, USA
| | - Thom Walsh
- The Dartmouth Center for Health Care Delivery Science, Dartmouth College, USA
| | - Stuart W Grande
- The Dartmouth Center for Health Care Delivery Science, Dartmouth College, USA
| | - Victor Montori
- Health Care Delivery Research Program, Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic, USA
| | - Ronald Epstein
- Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester, USA
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