Patient–provider race-concordance: does it matter in improving minority patients’ health outcomes?

Objective. To understand if patient–provider race-concordance is associated with improved health outcomes for minorities.

Design. A comprehensive review of published research literature (1980–2008) using MEDLINE, HealthSTAR, and CINAHL databases were conducted. Studies were included if they had at least one research question examining the effect of patient–provider race-concordance on minority patients’ health outcomes and pertained to minorities in the USA. The database search and data analysis were each independently conducted by two authors. The review was limited to data analysis in tabular and text format. A meta-analysis was not possible due to the discrepancy in methods and outcomes across studies.

Results. Twenty-seven studies met the inclusion criteria. Combined, the studies were based on data from 56,276 patients and only 1,756 providers. Whites/Caucasians (37.6%) and Blacks/African Americans (31.5%), followed by Hispanics/Latinos (13.3%), and Asians/Pacific Islanders (4.3%) comprised the majority of the patient sample. The median sample of providers was only 16 for African Americans, 10 for Asians and two for Hispanics. The review presented mixed results. Of the 27 studies, patient–provider race-concordance was associated with positive health outcomes for minorities in only nine studies (33%), while eight studies (30%) found no association of race-concordance with the outcomes studied and 10 (37%) presented mixed findings. Analysis suggested that having a provider of same race did not improve ‘receipt of services’ for minorities. No clear pattern of findings emerged in the domains of healthcare utilization, patient–provider communication, preference, satisfaction, or perception of respect.

Conclusions. There is inconclusive evidence to support that patient–provider race-concordance is associated with positive health outcomes for minorities. Studies were limited to four racial/ethnic groups and generally employed small samples of minorities. Further research is needed to understand what health outcomes may be more sensitive to cultural proximity between patients and providers, and what patient, provider and setting-level variables may moderate or mediate these outcomes.     

Intra- and interobserver variability in detection and assessment of calcified and noncalcified coronary artery plaques using 64-slice computed tomography

Objective Multislice computed tomography (MSCT) is an emerging noninvasive technique for detecting coronary plaques. The present study investigated agreement in the detection and characterization of coronary plaques and reproducibility of volumetric analysis. Methods A total of 20 patients underwent MSCT coronary angiography using 64 * 0.5 mm detector collimation. Two readers independently visually evaluated all MSCT datasets for the presence of coronary plaques (n = 82 in 262 coronary segments) and then classified them as calcified, mixed and noncalcified. In addition, one of the readers also manually determined total volumes as well as calcified and noncalcified volumes of each plaque. After a period of at least 4 weeks the complete volumetric analysis was repeated. Results Interobserver agreement was good for detection of coronary plaques on the segment level (weighted κ = 0.88, 95% CI [0.76, 0.95]). However, there was only moderate interobserver agreement for plaques classification (unweighted κ = 0.45, 95% CI [0.35, 0.61]). Intraobserver agreement was good for plaque detection on segment level (weighted κ = 0.90, 95% CI [0.77, 0.96]), while it was moderate with respect to their characterization (unweighted κ = 0.65, 95% CI [0.55, 0.80]). There was moderate reproducibility for total plaque volume (limits of agreement = ±6 mm³ at a mean measured volume of 10 mm³ and = ±28 mm³ at a mean measured volume of 100 mm³). Variation of relative differences significantly decreased for total volume and noncalcified volume with increasing mean volume. Conclusions Detection and volumetry of plaques by means of MSCT shows good to moderate reproducibility. Agreement of volume measurements depends on plaque size. Variation of relative differences decrease with increasing mean plaque volume.     

Freehand real-time elastography: impact of scanning parameters on image quality and in vitro intra- and interobserver validations

Real-time elastography is a method for visualization of the elastic properties of soft tissue and may potentially enable differentiation between malignant and benign pathologic lesions. Our aim was to validate the method on a tissue-mimicking (TM) phantom and to evaluate the influence of different scanning parameters and investigator variability. A TM-phantom containing eight spherical inclusions with known storage modulus was examined using two different transducers on an ultrasound (US) scanner equipped with software for real-time elasticity imaging. The ultrasound transducers were moved vertically in a repetitive manner to induce strain. Two investigators performed series of standardized elastography scans applying a 0-4 categorical quality scale to evaluate the influence of seven parameters: dynamic range of elasticity, region-of-interest, frequency of transducer movement, rejection of elastogram noise, frame rate, persistence and smoothing. Subsequently, repeated examinations of four selected inclusions were performed using a visual analog scale (VAS) where investigators marked a 100 mm horizontal line representing the span in image quality based on experience from the first examination. The hardest and softest inclusions were imaged more clearly than the inclusions with elasticity more similar to the background material. Intraobserver agreement on elastogram quality was good (kappa: 0.67 - 0.75) and interobserver agreement average (kappa: 0.55 - 0.56) when using the categorical scale. The subsequent VAS evaluation gave intraclass-correlation coefficients for the two observers of 0.98 and 0.93, respectively, and an interclass-correlation coefficient of 0.93. Real-time elastography adequately visualized isoechoic inclusions with different elastic properties in a TM-phantom with acceptable intra- and interobserver agreement. Dynamic range of elasticity was the parameter with most impact on the elastographic visualization of inclusions.     

A test of concordance between patient and psychiatrist valuations of multiple treatment goals for schizophrenia

Background While much discussion has been placed on the problem of poor compliance in the treatment of schizophrenia, there has been little discussion on the concordance between patients and psychiatrists, an important contributing factor to patient‐centred care. Objective To estimate the concordance between patients’ and psychiatrists’ (ordinal and cardinal) valuations of multiple goals for schizophrenia treatment and to illustrate the utility of the self‐explicated method in valuing a large number of treatment goals. Design Twenty treatment goals were identified during focus groups and literature review and were presented to patients and psychiatrists during structured interviews. Respondents were asked to rank the multiple treatment goals and rate them on a 5‐point Likert scale. Three scores were calculated based on the ranking (1–20), rating (Likert scale) (1–5) and a self‐explicated method estimated as the product of rating and ranking score (1–100). Concordance was tested using Spearman’s rho for overall ordinal rankings and via anova and F‐test for the cardinal values assigned to a specific treatment goal. Participants A total of 105 outpatients diagnosed with schizophrenia and 160 psychiatrists in Germany. Results Patient and psychiatrist values were concordant when the ordinal properties of their valuations were assessed by rating (ρ = 0.63; P = 0.002), ranking (ρ = 0.51; P = 0.02) and self‐explicated methods (ρ = 0.54; P = 0.01). Significant discordances were found when comparing the cardinal value placed on any given treatment goal using all three approaches, but the self‐explicated method produced a more discerning statistic. Relative to patients, psychiatrists significantly (P < 0.05) overvalued reduced lack of emotion, improved sexual pleasure and improved communication while undervaluing reuptake of activities of daily living, improved satisfaction and recovered capacity for work. Conclusions While there is an overall concordance between patients’ and psychiatrists’ valuation, significantly different valuations on specific goals can be identified. Here, psychiatrists tend to focus on ‘textbook’ outcomes, while patients are more concerned with functioning and living a normal life. This study also demonstrates the importance of comparing the concordance in treatment goals and the importance of preference‐based methods, such as the self‐explicated method, in the study of concordance.     

Do the British Guidelines for Asthma Management facilitate concordance?

BACKGROUND: Asthma is an example of a common, chronic illness in which clinicians are encouraged to promote concordance and adhere to guidelines. Some existing research suggests that these aims may be incompatible. OBJECTIVES: To describe patient goals for life and for asthma management in order to inform concordance with people with asthma. DESIGN: A cross-sectional, qualitative survey. SETTING AND PARTICIPANTS: A purposive sample of 47 adults with asthma from Dundee, UK. The subjects were identified from general practice asthma registers and had a range of ages and asthma severity but no significant comorbidity. METHODS: Tape-recorded semi-structured interviews. The topic guide was based on the literature and had been piloted in a previous study. RESULTS: The participants focussed on improving their lives, only aiming to improve their asthma as a means of improving their lives. Three aspects of asthma were reported to help or hinder improving life: the use of asthma medication, trigger avoidance and exercise. People integrated these three aspects of asthma in order to maximize life. CONCLUSIONS: The study supports the more individualized goals of the recently revised British Guidelines for Asthma Management but highlights the need to develop this further in future revisions. It also provides an explanation for patients' acceptance of less than 'perfect' asthma control and it suggests that shared goals may be achieved in practice by considering the advantages and disadvantages of medication and allergen avoidance on everyday life rather than on asthma.     

血液透析专科护士应具备专业知识的调查研究

目的探讨血液透析专科护士应具备的专业知识,为培养血液透析专科护士设置培训内容提供依据。方法应用德尔菲法对北京、上海和黑龙江等地35位专家就血液透析专科护士应具备的专业知识进行2轮函询与论证。结果专家的权威程度为0.85,专家意见的集中程度高;2轮调查专家意见的和谐系数分别为0.27、0.41（均P〈0.01）。血液透析专科护士应具备的专业知识包括专科理论知识、专科实践知识和护理相关知识3大类34个条目。专家意见较一致的前几个条目为透析设备的管理、血管通路的管理、血液透析的观察技术、血液透析中即刻并发症的处理、血液透析患者及家属的心理护理、血液透析患者生活质量的评价、血液透析中心的护理风险管理等。结论专家对确定的血液透析专科知识协调程度较高,可将其作为血液透析专科护士培训内容,以提高护士专业知识水平。     

Disease concordances amongst marital partners: Not ‘way of life’ or mortality data artifact

Mortality statistics for Great Britain (1979–1980, 1982–1983) for more than 500 occupations and 20 different causes of death were examined. The paper demonstrates that there is clear concordance of cause of death between men and married women which can be linked to the occupation of the male. Various possible explanations are considered including shared social class and way of life and the suggestion that the associations reported are the result of various forms of statistical bias inherent in Standardized Mortality Ratio statistics. It is proposed that the occupation of the male is an important mediator of the disease concordance observed and that this is consistent with a psychosocial hypothesis, although longitudinal empirical research would be required to establish this.     

High familial risks for cerebral palsy implicate partial heritable aetiology

Cerebral palsy is the commonest cause of severe childhood disability, the aetiology of which is largely unknown. Data on familial aggregation of cerebral palsy are very limited. We defined familial risks for siblings who were hospitalised because of cerebral palsy in Sweden. A nationwide database for neurological diseases was constructed by linking the Multigeneration Register to the Hospital Discharge Register for the years 1987-2001. Standardised hospitalisation ratios (SHRs) were calculated for affected singletons and twins by comparing them with siblings who had no cerebral palsy. A total of 3997 patients were recorded with cerebral palsy. Familial cerebral palsy was uncommon, and it accounted for 1.6% of all cerebral palsy cases. However, for parents who had had one affected child the risk of recurrence in another child was considerably increased. Parents of one affected child had a 4.8-fold risk of having a second affected child, and where the siblings were twins, the risk was 29-fold. These familial risks were particularly high in some clinical subgroups: 17-25 in singletons and 37-155 in twins, including hemiplegia, diplegia and quadriplegia. The remarkably high familial risks are difficult to explain without some contribution of heritable factors. The lack of discordant pairs may suggest that heritable factors are disorder type-specific. Affected concordant sibling pairs should be subjected to molecular studies aiming at identifying the susceptibility gene.