Trust in physicians and elements of the medical interaction in patients with rheumatoid arthritis and systemic lupus erythematosus

OBJECTIVE: To identify components of the patient-doctor relationship associated with trust in physicians. METHODS: We assessed 102 patients with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA) seen at publicly funded hospitals in Houston, Texas. Patients completed a self-response survey examining patient perceptions of the medical encounter and trust in their physicians. Evaluated components of physicians' behaviors included: informativeness, sensitivity to concerns, reassurance and support, patient-centeredness, and participatory decision-making style. Scales were scored 0 to 10, with higher numbers indicating more positive perceptions of communication. RESULTS: Seventy patients had RA and 32 SLE; 25% were white, 43% Latino, 31% African American, and 75% were female. Mean scores for the medical interaction and trust scales ranged from 6.2-7.1, indicating moderate degrees of positive perceptions. All components were highly and positively correlated with each other, and with trust, suggesting that these traits are all elements of a positive style of doctor-patient communication. In multivariate analysis, ethnicity, physicians' informativeness, physicians' sensitivity to concerns, patient-centeredness, disease activity, and patient trust in the US health care system were independent predictors of trust in physicians. A separate model examined the predictors of patient disclosure of information. Patient perceptions of physicians' patient-centeredness and severity of disease activity were independently predictive of patient disclosure of information. CONCLUSION: In patients with SLE and RA, trust in physicians is significantly associated with patients' ethnicity and their perceptions about specific components of physicians' communication style. Trust in physicians can be improved by using a patient-centered approach, being sensitive to patient concerns, and providing adequate clinical information. Furthermore, patients appear to be more willing to disclose concerns when physicians use a patient-centered communication style.     

Symptoms in individuals at risk of rheumatoid arthritis

An increasing interest in treating individuals at risk of rheumatoid arthritis (RA) to prevent the development of this chronic condition has focussed attention on the identification of risk factors of this disease. Most patients who develop RA progress through a preceding symptomatic phase that may take the form of arthralgia, palindromic rheumatism or unclassified arthritis before a disease currently classifiable as RA is established. An understanding of symptoms that identify individuals as being at risk of RA is a critical issue. Constellations of relevant symptoms could (1) form the basis of public health campaigns to encourage rapid consultation, (2) inform primary health care providers regarding which patients to perform additional tests in or whom to refer to a rheumatologist and (3) be included in algorithms to predict RA development. In this review, we present qualitative and quantitative data summarising current understanding of the symptoms experienced by individuals at risk of RA.     

Routes to total joint replacement surgery: Patients' and clinicians' perceptions of need

Objective

To explore patients' perspectives of need for total joint replacement associated with decision making in orthopaedic consultations for hip or knee osteoarthritis.

Methods

Twenty‐six orthopaedic consultations in 3 UK hospitals were observed and audio recorded, and semistructured interviews were conducted with the involved patients and clinicians. Data were analyzed using thematic analysis.

Results

Two main routes to orthopaedic consultation were identified: patients who waited until their symptoms were no longer bearable (holding off), and patients who sought consultation preemptively (before it gets worse). These routes were mediated by age, comparison with others, demands and desires, deterioration, and convenience. Whether patients had held off or sought help preemptively influenced their perceptions of need. Patients' perceptions of their route to orthopaedic consultation, and consequently their perception of need, were either confirmed or contradicted by clinicians.

Conclusion

When clinicians and patients have differing perceptions of need there may be ongoing patient anxiety, concern, and feelings of disempowerment. It is important for primary and secondary care clinicians to identify and explore a patient's perception of need in order to provide consistency in referral pathways and to support patient involvement in, and understanding of, shared decision making. Exploring the patient's perspective of their route to consultation is proposed as one easily achievable method of identifying patients' views on urgency of their need.     

Impairment of quality of life: rheumatoid arthritis versus sarcoidosis

BACKGROUND: Quality of life (QOL) has become an important item in health care. QOL should be a major target of treatment in chronic diseases such as rheumatoid arthritis (RA) and sarcoidosis. The aim of this study was to compare the impact of RA and sarcoidosis on patients' QOL. We expected more serious impairment of QOL in the RA group than in the sarcoidosis group. METHODS: QOL was studied in RA patients (n = 32), sarcoidosis patients (n = 37), and a healthy control group (n = 37) employing the World Health Organization Quality of Life assessment instrument (WHOQOL-100). RESULTS: In both patient groups QOL was impaired with respect to Physical Health, Level of Independence (P < 0.001), and Overall QOL and General Health (P < 0.01). Moreover, RA patients appeared to have a lower QOL with respect to Pain and Discomfort (P < 0.001) and Mobility (P < 0.001). CONCLUSIONS: In RA and sarcoidosis, fatigue and sleep were major problems. In contrast to our expectations, with respect to activities of daily living and working capacity, the two patient groups did not show any difference. Impairment of QOL was more serious and included more aspects of QOL in RA than in sarcoidosis.     

Rheumatoid arthritis patients' perceptions of mutuality in conversations with spouses/partners and their links with psychological and physical health

OBJECTIVE: Mutuality, measured as subjects' perceptions of responsiveness in conversations with their spouse/partners, is linked with women's psychological health. Our objectives were to examine physical and psychological health outcomes of married/partnered patients with rheumatoid arthritis (RA) in relation to their perceptions of their own responsiveness (self-mutuality), their partner's responsiveness (partner-mutuality), and combined responsiveness (overall mutuality), and to examine potential sex differences in the links between mutuality and depressive symptoms. METHODS: Symptoms of depression and anxiety, physical disability, and arthritis impact reported by RA patients were examined in correlation matrices with their perceptions of overall mutuality, partner-mutuality, and self-mutuality in conversations with spouses/partners in the whole sample (n = 148) and separately for men (n = 34) and women (n = 114). Sex moderation of the links between mutuality and depression was tested in hierarchical regressions. RESULTS: In the whole sample and among women, all mutuality measures had significant inverse correlations with all health outcomes. In men, physical disability was unrelated to mutuality measures, but otherwise correlations approximated those in the whole sample and for women. Sex (being female) interacted with self-mutuality, but not overall or partner-mutuality, in predicting fewer depressive symptoms. CONCLUSION: RA patients' perceptions of mutuality in conversations with spouses/partners predicted better health across a spectrum of outcomes. Overall mutuality and partner-mutuality predicted fewer depressive symptoms for both men and women, but self-mutuality appeared more important for women than for men. The clinical relevance of findings and their implications for behavioral interventions with RA patients are discussed.     

Predicting functional status in patients with rheumatoid arthritis.

OBJECTIVE: To determine whether coping strategies and illness perceptions would be predictive of outcome in a longitudinal study of patients with rheumatoid arthritis (RA). METHODS: A group of 71 patients with RA was examined on 2 occasions, one year apart. Multiple regressions were used to examine which of the illness perceptions and coping strategies explained variance on the outcome variables: visits to the outpatient clinic, number of hospital admissions, Health Assessment Questionnaire, pain, tiredness, the Hospital Anxiety and Depression Scale. RESULTS: Belief in adverse consequences of the disease was associated with more visits to the outpatient clinic. more tiredness, and higher anxiety scores. Less perceived control and less expression of emotion were associated with more hospital admissions. High scores on coping involving fostering reassuring thoughts were associated with more functional disability. More passive coping was associated with more functional disability and higher anxiety scores. More perceived symptoms were associated with more pain, more tiredness, and more depression. More avoidant coping was associated with more tiredness. Belief that the illness will last a long time was associated with higher anxiety scores. CONCLUSION: Our longitudinal data show that, after statistically controlling for the potential effects of intervening medical variables, coping strategies and illness perceptions contribute to health outcome in patients with RA. Implications for patient management are discussed.     

Increased levels of C-reactive protein in serum from blood donors before the onset of rheumatoid arthritis

OBJECTIVE: We previously reported that approximately half of the patients with rheumatoid arthritis (RA) have specific serologic abnormalities (elevated serum concentrations of IgM rheumatoid factor and/or anti-cyclic citrullinated peptide antibodies) starting several years before the onset of symptoms. In this study, the presence of serologic signs of inflammation in patients with preclinical RA was investigated with serial measurements of C-reactive protein (CRP). METHODS: Seventy-nine patients (61% female; mean age at onset of symptoms 51 years) who had been blood donors before the onset of RA were identified. Frozen serum samples from each donor were retrieved, together with 1 sample from a control donor matched for age, sex, and date of donation. CRP was measured using a highly sensitive latex-enhanced assay. The dates of donation were categorized into 15 1-year periods preceding the onset of RA symptoms. For each period, the median CRP levels in the patient and control groups were compared using the Mann-Whitney U test. The course of CRP concentrations over time in the patient group was estimated with random coefficient analysis. RESULTS: A median of 13 samples (range 1-51) per patient were available; the earliest donation was made a median of 7.5 years (range 0.4-14.5 years) before the onset of symptoms. A total of 1,078 patient samples and 1,071 control samples were tested. For all 1-year periods, the median CRP concentration was increased in the patient group compared with the control group, but this difference was statistically significant only for the periods 0-1 year, 1-2 years, and 4-5 years before the onset of symptoms. The CRP concentration increased significantly over time in patients with preclinical RA; levels were slightly higher in the group of patients who had serologic abnormalities before the onset of symptoms than in those without such serologic abnormalities. CONCLUSION: After observing specific serologic abnormalities 5 years before the onset of RA symptoms, we now report increased levels of CRP in blood donors in whom RA later developed; these increases were most common within the 2 years before the onset of symptoms. The preclinical increase in CRP levels was observed both in donors with and in those without serologic abnormalities.     

Patient experiences with atrial fibrillation and treatment with implantable atrial defibrillation therapy

BACKGROUND: Patient perspectives about their illness experiences, symptoms, and treatment are essential aspects of quality of life and provide direction for patient and provider decision making regarding innovative therapies such as implantable devices for arrhythmia. PURPOSE: The purpose of this qualitative study was to describe: 1) the experience of patients living with symptomatic, drug-refractory atrial fibrillation (AF) and 2) patient experiences and acceptance of treatment with the implantable cardioverter defibrillator (ICD) with atrial therapies (ICD-AT) including ventricular and atrial defibrillation therapy. PARTICIPANTS: Subjects were 3 women and 8 men, 35 to 80 years of age, who received the Medtronic Jewel AF 7250 ICD-AT as therapy for recurrent, drug-refractory AF, had a history of AF for 3 to 20 years and had experienced multiple treatment modalities including frequent external cardioversion in an effort to control their AF. METHODS: A semi-structured interview addressed experiences of symptoms and prior treatment for AF and experiences, concerns, and perceived benefits of the ICD-AT. Interviews were recorded and transcribed verbatim. Narratives were coded and categorized using Atlas Ti(R) software. Qualitative interpretive analysis methods were used to identify key themes. RESULTS: Before ICD-AT, patient themes focused on AF that was: 1) misdiagnosed, minimized, and poorly treated; 2) distressful because of frequent and intense AF symptoms (fatigue, dizziness, shortness of breath, and anxiety) before ICD-AT; 3) limiting of activities of daily living; 4) associated with distress from enduring previous treatment; and 5) associated with the continuous pursuit of successful treatment and maintenance of normalcy. Decision making regarding ICD-AT therapy included weighing symptom or treatment distress versus anticipated risks or benefits, hope for better outcomes, and lack of options. After ICD-AT, themes included positive perceptions of the device because of AF symptom relief, ability to resume normalcy, and medication tolerance; incorporation of shock experiences into life routines; and patient suggestions regarding preparation and social support. IMPLICATIONS: Symptoms of AF have a major negative impact on overall quality of life. Treatment with the ICD-AT confers a sense of security and reduced symptom distress. Greater provider attention to patient preparation and facilitating social support are important for future ICD-AT patient care.     

Tocilizumab and pregnancy: Four cases of pregnancy in young women with rheumatoid arthritis refractory to anti-TNF biologics with exposure to tocilizumab

Objectives: To investigate the use of tocilizumab (TCZ) in pregnant patients with active rheumatoid arthritis (RA) refractory to anti-tumour necrosis factor (TNF) agents.

Methods: We retrospectively analysed the medical records of pregnant women with active RA treated between July 2008 and January 2015 by the Division of Maternal Medicine at our hospital. Inclusion criteria for this case series included active RA refractory to anti-TNF agents and exposure to TCZ at the time of conception.

Results: Our review of 28 patient hospital records identified four patients who met the inclusion criteria. All four patients had active synovitis before starting treatment with TCZ. Successful TCZ therapy allowed them to plan to become pregnant. When pregnancy was confirmed, TCZ was terminated as soon as possible in all patients. Three patients delivered full-term infants without any adverse outcomes. One patient had a partial molar pregnancy and miscarried during gestational week 11. Two patients remained in clinical remission with low-dose prednisolone (PSL) or no treatment for RA during pregnancy.

Conclusions: TCZ may be a good alternative therapy for RA patients with symptoms that are hard to control with TNF blockers who desire to bear children.     

Delay in consultation with specialists for persons with suspected new-onset rheumatoid arthritis: a population-based study

OBJECTIVE: Care in rheumatoid arthritis (RA) is optimized by involvement of rheumatologists. We wished to determine whether patients suspected of having new-onset RA in Québec consulted with a rheumatologist, to document any delay in these consultations, and to determine factors associated with prompt consultation. METHODS: Physician reimbursement administrative data were obtained for all adults in Québec. Suspected new-onset cases of RA in the year 2000 were defined operationally as a physician visit for RA (based on the International Classification of Diseases, Ninth Revision diagnostic codes), where there had been no prior visit code to any physician for RA in the preceding 3 years. For those patients who were first diagnosed by a nonrheumatologist, Cox regression modeling was used to identify patient and physician characteristics associated with time to consultation with a rheumatologist. RESULTS: Of the 10,001 persons coded as incident RA by a nonrheumatologist, only 27.3% consulted a rheumatologist within the next 2.5-3.5 years. Of those who consulted, the median time from initial visit to a physician for RA to consultation with a rheumatologist was 79 days. The strongest predictors of shorter time to consultation were female sex, younger age, being in a higher socioeconomic class, and having greater comorbidity. CONCLUSION: Our data suggest that the vast majority of patients suspected of having new-onset RA do not receive rheumatology care. Further action should focus on this issue so that outcomes in RA may be optimized.     

Qualitative Exploration of Illness Perceptions of Rheumatoid Arthritis in the General Public

Treating patients with rheumatoid arthritis (RA) within three months of symptom onset leads to significantly improved outcomes. However, many people delay seeking medical attention. In order to understand the reasons for this delay, it is important to have a thorough understanding of public perceptions about RA. The current study investigated these perceptions using the Self‐Regulation Model (SRM) as a framework to explain how health behaviour is influenced by illness perceptions (prototypes) through qualitative interviews with 15 members of the public without RA. Interviews were audio‐recorded, transcribed and analysed using framework analysis based on SRM illness perceptions. Both accurate and inaccurate perceptions about the identity, causes, consequences, controllability and timeline of RA were identified. This highlights opportunities to enhance public knowledge about RA. These findings further support the utility of exploring prototypical beliefs of illness, suggesting their potential role in influencing help‐seeking behaviours and identifying probable drivers/barriers to early presentation. © 2016 The Authors Musculoskeletal Care Published by John Wiley & Sons Ltd.     

Faecal microbial flora and disease activity in rheumatoid arthritis during a vegan diet

To clarify the role of the faecal flora in the diet-induced decrease of rheumatoid arthritis (RA) activity, 43 RA patients were randomized into two groups: the test group to receive living food, a form of uncooked vegan diet rich in lactobacilli, and the control group to continue their ordinary omnivorous diets. Based on clinical assessments before, during and after the intervention period, a disease improvement index was constructed for each patient. According to the index, patients were assigned either to a group with a high improvement index (HI) or to a group with a low improvement index (LO). Stool samples collected from each patient before the intervention and at 1 month were analysed by direct stool sample gas-liquid chromatography of bacterial cellular fatty acids. This method has proved to be a simple and sensitive way to detect changes and differences in the faecal microbial flora between individual stool samples or groups of them. A significant, diet-induced change in the faecal flora (P = 0.001) was observed in the test group, but not in the control group. Further, in the test group, a significant (P = 0.001) difference was detected between the HI and LO categories at 1 month, but not in the pre-test samples. We conclude that a vegan diet changes the faecal microbial flora in RA patients, and changes in the faecal flora are associated with improvement in RA activity.      

Predictors of exercise and effects of exercise on symptoms, function, aerobic fitness, and disease outcomes of rheumatoid arthritis

OBJECTIVE: To determine the effects of participation in a low-impact aerobic exercise program on fatigue, pain, and depression; to examine whether intervention groups compared with a control group differed on functional (grip strength and walk time) and disease activity (total joint count, erythrocyte sedimentation rate, and C-reactive protein) measures and aerobic fitness at the end of the intervention; and to test which factors predicted exercise participation. METHODS: A convenience sample of 220 adults with rheumatoid arthritis (RA), ages 40-70, was randomized to 1 of 3 groups: class exercise, home exercise using a videotape, and control group. Measures were obtained at baseline (T1), after 6 weeks of exercise (T2), and after 12 weeks of exercise (T3). RESULTS: Using structural equation modeling, overall symptoms (latent variable for pain, fatigue, and depression) decreased significantly at T3 (P < 0.04) for the class exercise group compared with the control group. There were significant interaction effects of time and group for the functional measures of walk time and grip strength: the treatment groups improved more than the control group (P 相似文献   

HAART adherence in culturally diverse patients with HIV/AIDS: a study of male patients from a Veteran's Administration Hospital in northern California

The objective of this study was to identify the factors that influence adherence to antiretroviral medication regimens in culturally diverse populations with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) related to age, ethnicity, and intravenous drug use. The critical incident technique was used to identify factors determining adherence. Through a series of brief, focused interviews, patients were asked to recall specific incidents that affected their adherence to HIV medications. Patients' responses were grouped into categories using Ethnograph software. Two nurse experts, with 94% agreement, determined the reliability of the category listings. A chi(2) analysis compared the proportion of patients reporting each factor across age, ethnicity, and intravenous drug use categories. The total sample of 52 participants included 46 male outpatients with HIV/AIDS receiving care through a Veteran's Administration Hospital in northern California and 6 health care providers. The interviews yielded a total of 294 incidents. Six major categories were identified, and a taxonomy of critical factors determining highly active antiretroviral therapies (HAART) adherence was developed. The categories included reminders and cues (30%), planning (18%), response to HIV/AIDS (17%), HIV medication characteristics (14%), interactions with others (12%), and patient characteristics (10%). The two largest categories representing patient-related factors accounted for nearly half of the incidents. Patients most influenced by positive support from others included non-Caucasians, those under the age of 50 years, and those with fewer years of education. The taxonomy of adherence behaviors provides important information for developing culturally relevant patient adherence education programs and an essential foundation for developing future studies.     

Will outpatients complete living wills?

OBJECTIVE: To test the efficacy of two intervention methods that aimed to increase the percentage of adult clinic patients who completed living wills and placed them on file with their physicians within a four-month period. DESIGN: There were one control and two intervention groups. Surveys were separated by age and gender categories and randomly selected for the final sample. SETTING: The internal medicine outpatient clinic of a large tertiary hospital. PARTICIPANTS: All patients who visited the clinic were asked whether they would be willing to fill out a survey. The final sample included 167 adult patients who comprised three study groups. INTERVENTIONS: The first intervention relied solely on a booklet that described the Minnesota Living Will Act, general information concerning advance directives, and medical interventions that could be considered extraordinary if used for a patient in a terminal condition. The second intervention relied on both the booklet and repeated physician-initiated discussions with the patient about the probable value of a living will. MAIN RESULTS: The booklet/physician intervention was found to be significantly more effective than either the booklet-only intervention or no intervention (p less than 0.05 and 0.01, respectively). CONCLUSIONS: The physician intervention used in this population could be undertaken in any primary care clinic. Time spent in discussion before a crisis may be significantly shorter and qualitatively better than time spent in discussion with families who must make decisions during a crisis.     

Weight stigma experienced by patients with obesity in healthcare settings: A qualitative evidence synthesis

Weight stigma research is largely focused on quantifiable outcomes with inadequate representation of the perspectives of those that are affected by it. This study offers a comprehensive systematic review and synthesis of weight stigma experienced in healthcare settings, from the perspective of patients living with obesity. A total of 1340 studies was screened, of which 32 were included in the final synthesis. Thematic synthesis generated three overarching analytical themes: (1) verbal and non-verbal communication of stigma, (2) weight stigma impacts the provision of care, and (3) weight stigma and systemic barriers to healthcare. The first theme relates to the communication of weight stigma perceived by patients within patient–provider interactions. The second theme describes the patients' perceptions of how weight stigma impacts upon care provision. The third theme highlighted the perceived systemic barriers faced by patients when negotiating the healthcare system. Patient suggestions to reduce weight stigma in healthcare settings are also presented. Weight stigma experienced within interpersonal interactions migrates to the provision of care, mediates gaining equitable access to services, and perpetuates a poor systemic infrastructure to support the needs of patients with obesity. A non-collaborative approach to practice and treatment renders patients feeling they have no control over their own healthcare requirements.     

Does practice mirror the evidence base in the treatment of rheumatoid arthritis?

A large base of evidence exists regarding treatments for rheumatoid arthritis (RA) and how they may be used to preserve long-term function and improve patient outcomes. However, little is known about whether real-life rheumatology practice reflects the evidence base. This survey aimed to capture differing perceptions among rheumatologists in the identification and treatment of patients and to understand how their management of and treatment decisions for patients with RA may be influenced by the current published literature. Rheumatologists from five European countries and Canada participated in a survey between April and May 2006 to establish how rheumatologists identify and treat particular patient types in everyday practice. In total, 458 rheumatologists responded to the online and telephone survey. Rapidly progressing disease was overwhelmingly recognized (97%) as a distinct subtype among patients with RA, and the majority (88%) of respondents make treatment decisions based on this distinction. Most rheumatologists use measures including C-reactive protein, erythrocyte sedimentation rate, tender/swollen joint counts, and X-ray progression to diagnose and monitor this particular group of patients; a minority (30%) used magnetic resonance imaging to identify and monitor patients with rapidly progressing disease. Although treatment goals for these patients were similar among rheumatologists, the treatment approach varied considerably across countries. Overall, rheumatologists agree on the management goals for patients with rapidly progressing RA; however, their treatment patterns have some dissimilarities.