Rheumatology health care providers’ views and practices on obesity and smoking cessation management in rheumatoid arthritis

Clinical Rheumatology - To assess rheumatology health care providers’ (HCPs) knowledge, beliefs, self-efficacy, practices, and perceived barriers pertaining to weight management and smoking...     

Transfer is not a transition – voices of Jamaican adolescents with HIV and their health care providers

Increasing access to antiretroviral therapy in resource-limited settings (RLS) has resulted in the survival of perinatally HIV-infected children into adulthood. We characterized the transition process from pediatric to adult care by conducting semi-structured interviews of HIV-infected adolescents and health care providers in Jamaica. Using an inductive content analytic approach, four themes emerged: (1) Transition should be holistic and a process; (2) Pediatric clinics were like families; (3) Rootedness in the pediatric clinic; and (4) Need for adolescent-centered services to bridge the gap between pediatric and adult-centered services. Adolescent informed- and centered-transition approach may result in better outcomes for HIV-infected adolescents.     

Are HIV care providers talking with patients about safer sex and disclosure?: A multi-clinic assessment

OBJECTIVES: To examine HIV-positive patients' reports of whether HIV care providers ever talked with them about practicing safer sex and disclosing seropositive status to sex partners. DESIGN: Cross-sectional survey (1998-1999) of HIV-positive men and women sampled randomly at six public HIV clinics in California. METHODS: Participants were interviewed and asked whether applicable clinic providers (physician, physician assistant, nurse practitioner, nurse, social worker, health educator, psychologist, psychiatrist) ever talked with them about safer sex or disclosure. Responses were analyzed by clinic site, HIV medical status (viral load), demographic, and behavioral variables (unprotected intercourse, non-disclosure). RESULTS: The sample (n = 839) included heterosexual men (n = 127), men who have sex with men (MSM; n = 607), and women (n = 105). Thirty-nine percent were white, 36% Hispanic, 17% black, and 8% other/mixed ethnicity. Overall, 71% reported that an applicable provider had talked with them at least once about safer sex (range across clinics, 52-94%); 50% reported discussion of disclosure (range across clinics, 31-78%). Discussion of safer sex was more prevalent with physicians than with other clinic staff. In multivariate analyses, in addition to significant clinic differences, MSM (versus heterosexual men) and whites (versus blacks or Hispanics) were less likely to receive prevention messages on these topics. Patients' behaviors (unsafe sex, non-disclosure) and HIV medical status were not independently associated with provider communication. CONCLUSIONS: HIV clinics differed substantially in the percentage of patients who reported that they received prevention messages from clinic staff. Care providers should assess and overcome barriers to providing prevention messages to patients.     

Patients’ attitudes toward health care providers collecting information about their race and ethnicity

BACKGROUND: Experts recommend that health care providers (HCPs) collect patients' race/ethnicity, but HCPs worry that this may alienate patients. OBJECTIVE: To determine patients' attitudes toward HCPs collecting race/ethnicity data. DESIGN: Cross-sectional survey. PARTICIPANTS: General Internal Medicine patients (n=220). MEASUREMENTS: Perceived importance of having HCPs collect race/ethnicity data, their concerns about this, comfort level providing this information, and reactions to 4 statements explaining the rationale for collecting this. RESULTS: Approximately 80% somewhat or strongly agreed that HCPs should collect information on patients' race/ethnicity. However, 28% had significant discomfort (score 5 or less on 10-point scale) reporting their own race/ethnicity to a clerk, and 58% were somewhat or very concerned that this information could be used to discriminate against patients. Compared with whites, blacks, and Hispanics felt less strongly that HCPs should collect race/ethnicity data from patients (P=.04 for both pairwise comparisons), and blacks were less comfortable reporting their own race/ethnicity than whites (P=.03). Telling patients that this information would be used for monitoring quality of care improved comfort more than telling patients that the data collected (a) was mandated by others, (b) would be used to guide staff hiring and training, and (c) would be used to ensure the patient got the best care possible. CONCLUSIONS: Most patients think HCPs should collect information about race/ethnicity, but many feel uncomfortable giving this information, especially among minorities. Health care providers can increase patients' comfort levels by telling them this will be used to monitor quality of care.     

The experience and management of HIV stigma among HIV-negative adults in heterosexual serodiscordant relationships in New York City

Despite treatment advances that have improved the health and life expectancy of HIV-positive people and contribute to the prevention of HIV transmission, HIV stigma is still frequently experienced by HIV-infected individuals and those close to them. This study investigated the types of HIV-related stigma experienced by HIV-negative adults in serodiscordant heterosexual relationships when their partner’s HIV-positive status was revealed to family and friends and their strategies to manage such stigma. In-depth interviews were conducted in New York City with 56 men and 44 women who were HIV negative and had been in a relationship for at least six months with an HIV-positive partner of the opposite sex. Those who had disclosed the HIV status of their partner to family or friends experienced four main types of stigmatizing behaviours: distancing (avoidance of the participant or his/her partner for fear of infection), depreciation of the partner (being told their partner is not worthy of them), violation of privacy (people spreading the information that the partner is HIV positive), or accusations (being told that it was wrong to be in a relationship with HIV-positive people or to try to conceive with them). Participants described four main ways of managing actual or anticipated stigma: secrecy (not disclosing the HIV status of their partner to anyone), avoidance (breaking ties with people who held stigmatizing views), seeking support from their partner or the HIV-positive community (e.g., HIV-related organizations or their partner’s family or friends), or education (informing family or friends about HIV treatment and prevention). Findings show that HIV-related “courtesy” stigma is frequently experienced by HIV-negative people in serodiscordant relationships but often can be managed. Offering support to individuals in serodiscordant relationships can improve the quality of life of HIV-positive people and their HIV-negative partners and potentially reduce HIV stigma.     

Addressing smoking among people living with HIV: a cross-sectional survey of Australian HIV health practitioners’ practices and attitudes

People living with HIV (PLHIV) have high rates of tobacco smoking, and smoking is a leading cause of premature mortality and morbidity. It is important to understand HIV healthcare providers’ practices and attitudes towards addressing smoking with their patients. An online survey that measured: (i) use of the 5A framework for addressing smoking (Ask, Assess, Advise, Assist, Arrange) and (ii) attitudes and barriers to addressing smoking cessation was distributed by relevant professional bodies. Eligible participants were Australian health practitioners providing healthcare to PLHIV. Of the 179 respondents, most reported practising at least one of the 5As: Ask (94%); Assess (78%); Advise (82%); Assist (89%); and Arrange (73%). Practising the full 5A framework (completing at least one activity from each A) was less common (62%) and associated with having undertaken smoking cessation training (OR 2.1, CI 1.1–3.9), being a medical practitioner (OR 6.0, CI 3.1–11.6), having greater perceived knowledge and resources (OR 1.7, CI 1.3–2.4) and more positive attitudes (OR 1.5, CI 1.1–2.0). Common barriers to delivering cessation assistance related to knowledge and availability of resources. Development and greater dissemination of effective smoking cessation training and resources may be required to ensure healthcare practitioners have the capacity to complete all aspects of the 5A framework for smoking cessation and support their patients with HIV who smoke.     

Primary care providers’ awareness,knowledge, and practice with regard to cardiovascular risk in patients with rheumatoid arthritis

Clinical Rheumatology - Rheumatoid arthritis (RA) is a systemic auto-inflammatory disease associated with increased cardiovascular risk. Early identification and aggressive cardiovascular risk...     

Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents?

BACKGROUND: Although opioids are central to acute pain management, numerous studies have shown that many physicians prescribe them incorrectly, resulting in inadequate pain management and side effects. We assessed whether a case-based palliative medicine curriculum could improve medical house staff opioid prescribing practices. DESIGN: Prospective chart review of consecutive pharmacy and billing records of patients who received an opioid during hospitalization before and after the implementation of a curricular intervention, consisting of 10 one-hour case-based modules, including 2 pain management seminars. MEASUREMENTS: Consecutive pharmacy and billing records of patients who were cared for by medical residents (n = 733) and a comparison group of neurology and rehabilitative medicine patients (n = 273) that received an opioid during hospitalization in 8-month periods before (1/1/97 to 4/30/97) and after (1/1/99 to 4/30/99) the implementation of the curriculum on the medical service were reviewed. Three outcomes were measured: 1) percent of opioid orders for meperidine; 2) percent of opioid orders with concomminant bowel regimen; and 3) percent of opioid orders using adjuvant nonsteroidal anti-inflammatory drugs (NSAIDs). MAIN RESULTS: The percentage of patients receiving meperidine decreased in the study group, but not in the comparison group. The percentages receiving NSAIDs and bowel medications increased in both groups. In multivariate logistic models controlling for age and race, the odds of an experimental group patient receiving meperidine in the post-period decreased to 0.55 (95% confidence interval [95% CI], 0.32 to 0.96), while the odds of receiving a bowel medication or NSAID increased to 1.48 (95% CI, 1.07 to 2.03) and 1.53 (95% CI, 1.01 to 2.32), respectively. In the comparison group models, the odds of receiving a NSAID in the post-period increased significantly to 2.27 (95% CI, 1.10 to 4.67), but the odds of receiving a bowel medication (0.45; 95% CI, 0.74 to 2.00) or meperidine (0.85; 95% CI, 0.51 to 2.30) were not significantly different from baseline. CONCLUSIONS: This palliative care curriculum was associated with a sustained (>6 months) improvement in medical residents' opioid prescribing practices. Further research is needed to understand the changes that occurred and how they can be translated into improved patient outcomes.     

Integrating family planning into HIV care in western Kenya: HIV care providers’ perspectives and experiences one year following integration

With high rates of unintended pregnancy in sub-Saharan Africa, integration of family planning (FP) into HIV care is being explored as a strategy to reduce unmet need for contraception. Perspectives and experiences of healthcare providers are critical in order to create sustainable models of integrated care. This qualitative study offers insight into how HIV care providers view and experience the benefits and challenges of providing integrated FP/HIV services in Nyanza Province, Kenya. Sixteen individual interviews were conducted among healthcare workers at six public sector HIV care facilities one year after the implementation of integrated FP and HIV services. Data were transcribed and analyzed qualitatively using grounded theory methods and Atlas.ti. Providers reported a number of benefits of integrated services that they believed increased the uptake and continuation of contraceptive methods. They felt that integrated services enabled them to reach a larger number of female and male patients and in a more efficient way for patients compared to non-integrated services. Availability of FP services in the same place as HIV care also eliminated the need for most referrals, which many providers saw as a barrier for patients seeking FP. Providers reported many challenges to providing integrated services, including the lack of space, time, and sufficient staff, inadequate training, and commodity shortages. Despite these challenges, the vast majority of providers was supportive of FP/HIV integration and found integrated services to be beneficial to HIV-infected patients. Providers' concerns relating to staffing, infrastructure, and training need to be addressed in order to create sustainable, cost-effective FP/HIV integrated service models.     

Physicians’ attitudes and practices in the evaluation and treatment of irritable bowel syndrome

Objective. Irritable bowel syndrome (IBS) is a common disorder characterized by abdominal discomfort and disordered bowel habits. Despite the high prevalence of IBS, little is known about how physicians perceive this condition. The aims of our study were to measure physicians’ understanding of IBS, to assess their attitudes towards patients with IBS, and to determine whether there are differences in the way Internal Medicine physicians (IM), Family Practice physicians (FP), and Gastroenterology physicians (GI) evaluate and treat IBS patients. Material and methods. A survey was sent to 3000 physicians nationwide, 1000 each to IM, FP, and GI. The survey contained 35 questions assessing demographics, the etiology and pathophysiology of IBS, the use of diagnostic tests, and practice patterns and attitudes. Results. Of the deliverable questionnaires, 501 were returned completed; 472 of the respondents interviewed only adult patients, representing the cohort for this analysis. The mean age of all respondents was 47; most were men (80%). IM and FP made a new diagnosis of IBS 1.3–1.6 times each week, while GI made a new diagnosis 5.4 times each week (p<0.0001). Compared with the perceptions of FP and IM, GI felt that IBS patients were less sick than other patients (p<0.001), although they required more time per visit. More GI compared with FP and IM stated that prior infection and a history of abuse were the causes of IBS (p<0.01), while FP were more likely to believe that diet was a cause of IBS (p<0.01). GI felt a new diagnosis of IBS could be made without further testing 42% of the time. FP and IM felt that one-third of IBS patients needed referral to a GI. Conclusions. The attitudes and practice patterns of physicians towards patients with IBS differ depending on practice specialty. This may be due to differences in training, the ability to perform specialized tests, and/or differences in referral patterns. Further training may improve the ability of physicians in all specialties confidently to diagnose and treat patients with IBS.