When the safety net of treatment has been removed: Patients’ unmet needs at the completion of treatment for haematological malignancies

Objective

To determine patients’ information, emotional and support needs at the completion of treatment for a haematological malignancy.

Methods

A self-report questionnaire was mailed to 113 adult patients.

Results

Sixty-six questionnaires were returned. The most frequently endorsed patient needs related to care co-ordination and help to manage the fear of recurrence. The most frequently endorsed unmet needs included managing the fear of recurrence, the need for a case-manager and the need for communication between treating doctors. Predictors of unmet needs included younger patients (p = 0.01), marital status (p = 0.03) and employment (p = 0.03). Almost two-thirds of patients (59%) reported they would have found it helpful to talk with a health care professional about their experience of diagnosis and treatment at the completion of treatment and endorsed significantly more need in the arenas of Quality of Life (p = 0.03) and Emotional and Relationships (p = 0.04).

Conclusion

This study provides valuable data on haematological cancer patients’ needs in the first 12 months of finishing treatment. It appears that many needs emerge or remain unresolved at this time.

Practice implications

An opportunity for patients to talk with a health professional about making the transition from active treatment to extended survivorship may be helpful.     

Validating the Medical Data Interpretation Test in a Dutch population

Objective

To validate the Dutch translation of the Medical Data Interpretation Test.

Methods

A test–retest design with a 2-week interval was used.

Results

The intraclass correlation coefficient (ICC = .82), the limits-of-agreement interval (LOA = −8.96 to 2.48) and the test–retest reliability (Pearson's r = 86) suggest that the Dutch translation has good reproducibility. Construct validity was tested by two hypotheses, both of which were confirmed. University participants had higher test scores than non-university participants (p = .02), and males did not score differently than females (p = .61).

Conclusion

The results suggest that the Dutch version of the Medical Data Interpretation Test is an adequate scale to assess ability to interpret medical data.

Practice implications

Assessing patients’ numeracy skills before a counseling session will enable the counselor to adjust subsequent communication accordingly and, as such, improve the session's effectiveness.     

Beliefs about generic drugs among elderly adults in hospital-based primary care practices

Objective

This study aimed to characterize seniors’ beliefs about generic drugs, and examine potential correlates of these beliefs, including socioeconomic and health status variables, health literacy, and physician communication skills.

Methods

Older adults (≥65 years) were interviewed in two primary care practices of an inner-city, tertiary care hospital (n = 311). Beliefs about generics were measured using a scale that compared generic and brand name drugs across four domains. Beliefs were modeled with multivariable linear regression.

Results

Negative beliefs about generics were associated with non-white race (p < 0.0001), lower education (p = 0.008) and income (p = 0.001), and having Medicaid coverage (p = 0.001). Individuals with low health literacy and who reported that their physicians had poor communication skills were more likely to hold negative views (p < 0.0001 and p = 0.003, respectively). In multivariable analysis, black race (β = −2.30, p = 0.006) and inadequate health literacy (β = −2.17, p = 0.0004) remained strongly associated with negative views about generic drugs. Poor physician communication skills also predicted negative beliefs about generics but the association was not significant for all levels of communication skill.

Conclusion

Many low-income seniors mistrust generic medications, especially African-Americans and seniors with low health literacy.

Practice implications

Educational efforts to promote generic medications should account for patients’ health literacy and cultural backgrounds.     

Evaluation of a psychoeducation program for Chinese clients with schizophrenia and their family caregivers

Objectives

To evaluate the effectiveness of a psychoeducation program for Chinese clients with schizophrenia and their family caregivers.

Methods

A randomized controlled trial was conducted. Seventy-three clients with a diagnosis of schizophrenia and their caregivers (n = 73) were recruited and randomized into a study (n = 36) and control group (n = 37). Ten psychoeducation sessions were provided to the study group. The outcomes were measured at the baseline, immediately after (post-1), six months (post-2), and 12 months after the intervention (post-3).

Results

There were significant treatment effects across time for all client outcomes: adherence to medication (p < 0.01), mental status (p < 0.01), and insight into illness (p < 0.01). However, no significant differences were found between groups at the post-3 measures for all client outcomes. For the caregivers, significant group differences were only detected in self-efficacy at the post-1 (p = 0.007) and post-2 (p < 0.001) measures, the level of satisfaction at the post-1 (p = 0.033) and post-2 (p < 0.021) measures, and the perception of family burden at the post-2 measures (p = 0.043).

Conclusion

A psychoeducation intervention had positive effects on Chinese clients and their caregivers. However, these effects might not be sustained 12 months after the intervention.

Practice implications

To substantiate its effects, psychoeducation should be an ongoing intervention, with its outcomes constantly evaluated.     

A comparison of two educational interventions for the cognitive empowerment of ambulatory orthopaedic surgery patients

Objective

The aim of this study was to compare the cognitive empowerment of ambulatory orthopaedic surgery patients when using Internet-based education (experiment) in contrast to face to face education conducted by a nurse (control).

Methods

Elective ambulatory orthopaedic surgery patients were randomized to either an experiment group (n = 72) receiving Internet-based education, or to a control group (n = 75) receiving face-to-face education with a nurse. The data were collected at three different time points: before the preoperative education session, after preoperative education and 2 weeks after the operation. Three structured instruments were used: the Knowledge Test, the Sufficiency of Knowledge and the Orthopaedic Patient Knowledge Instrument.

Results

Patients in both groups showed improvement in their knowledge. However, patients who received Internet-based education improved their knowledge level significantly more in the ethical (p = 0.005) and functional (p = 0.023) dimensions and also in total (p = 0.033) than those patients who underwent face-to-face education with a nurse. In addition, patients in the experiment group had higher scores in sufficiency of knowledge in the experiential (p = 0.050) and financial (p = 0.048) dimensions and, moreover, their scores in sufficiency of knowledge in the ethical dimension improved significantly more (p = 0.008) during the study period than patients in the control group.

Conclusion

Improvements in the patients’ level and sufficiency of knowledge within both groups indicates an increase in patients’ cognitive empowerment.

Practice implications

Internet-based education can be used in ambulatory orthopaedic surgery patient education for increasing patients’ cognitive empowerment.     

AASAP: a program to increase recruitment and retention in clinical trials

Objective

To evaluate a theory based, subject-centered, staff/subject communication program, AASAP (anticipate, acknowledge, standardize, accept, plan), to increase recruitment and retention in RCTs.

Methods

AASAP was evaluated with logistical regression by comparing rates of recruitment (at telephone screening, baseline assessment, initial intervention) and intervention retention (over 16 weeks) before (−AASAP) and after (+AASAP) it was introduced to a 3-arm RCT to reduce disease distress among highly distressed subjects with type 2 diabetes.

Results

Included were 250 subjects in −AASAP and 338 in +AASAP. Significant improvement in recruitment occurred at each of the 3 recruitment stages: agreed at screening (OR = 2.52; p < 0.001), attended baseline assessment (OR = 1.91; p < 0.001), attended initial intervention (OR = 1.46; p < 0.03). Higher education and shorter diabetes duration predicted better recruitment in −AASAP (OR = 2.23; p < 0.001), but not in +AASAP. AASAP also improved intervention retention over 16 weeks (OR = 3.46; p < 0.05).

Conclusion

AASAP is a structured program of subject/staff communication that helps improve external validity by enhancing both subject recruitment and retention.

Practical implications

AASAP can be taught to non-professional staff and can be adapted to a variety of health settings. It can also be used by clinicians to engage patients in programs of ongoing care.     

Physicians’ attitudes towards disclosure of prognostic information: A survey among a representative cross-section of 1605 Norwegian physicians

Objective

To investigate if attitudes towards disclosure of prognostic information vary by speciality, previous experience and demographic factors in a general physician population.

Methods

A postal survey among a representative sample of Norwegian physicians across all specialities (N = 1605), using a translated questionnaire previously used to study attitudes towards disclosing prognostic information among US internists.

Results

A response rate of 70% was obtained after one reminder. 85% of the responders agreed to the helpfulness of an optimistic attitude. A factor analysis revealed three meaningful factors: ‘Prognostic communication is stressful’, ‘Fearing loss of reputation’ and ‘Reinforcement of positive prospects’. In multivariable models significantly more female than male physicians found aspects of prognostication straining (β = 0.143, p < 0.001). Those more experienced in communication of prognostic information towards end of life were less likely to support using reinforcement of positive prospects (β = 0.067, p = 0.001).

Conclusion

After years of focusing on patient autonomy and open communication between patient and physician many Norwegian physicians display attitudes that might hide the true content of prognostic information from the patients.

Practice implications

Many physicians think they are inadequately trained in prognostication and communication of prognostic information, suggesting that increased education and training are needed if patients’ wishes for information on prognosis are to be met in an individualised manner.     

Rationale, design and baseline data from the Pre-diabetes Risk Education and Physical Activity Recommendation and Encouragement (PREPARE) programme study: a randomized controlled trial

Objective

The PREPARE programme study is a randomized controlled trial which aims to determine whether structured education can be used to increase physical activity and improve glucose tolerance in individuals with impaired glucose tolerance (IGT). This paper outlines the rationale, design and baseline data from the PREPARE programme study.

Methods

Individuals with IGT were recruited from ongoing diabetes screening programmes. Outcomes included an oral glucose tolerance test, physical activity (piezoelectric pedometer) and psychological determinants.

Results

103 individuals (male n = 65; female n = 38) were recruited, 28% of whom were from a South Asian ethnic background. At baseline the participants’ mean age and BMI were 64 ± 9 years and 29.4 ± 4.5 kg/m² respectively. Steps per day were associated with 2-h glucose (ρ = −0.22, p = 0.03), fasting glucose (ρ = −0.22, p = 0.04), HDL-cholesterol (ρ = 0.23, p = 0.02), triglycerides (ρ = −0.22, p = 0.03) and body fat percentage (ρ = −0.26, p = 0.01). Mean self-efficacy scores were significantly (p < 0.01) higher for walking than for any other form of exercise. Participants reported high levels of concern about their IGT status but were confident that exercise would help treat/control IGT.

Conclusion

This study demonstrates the importance of developing effective physical activity and self-management programmes for individuals with IGT.

Practice implications

This study provides a detailed framework for the promotion of physical activity in a population identified with an increased risk of developing type 2 diabetes which, if successful, could feasibly be implemented in a primary health care or community setting.     

The influence of diabetes psychosocial attributes and self-management practices on change in diabetes status

Objective

To examine the influence of diabetes psychosocial attributes and self-management on glycemic control and diabetes status change.

Methods

Using data from the Health and Retirement Study, a nationally representative longitudinal study of U.S. adults >51 years, we examined cross-sectional relationships among diabetes psychosocial attributes (self-efficacy, risk awareness, care understanding, prioritization of diabetes, and emotional distress), self-management ratings, and glycemic control. We then explored whether self-management ratings and psychosocial attributes in 2003 predicted change in diabetes status in 2004.

Results

In multivariate analyses (N = 1834), all diabetes psychosocial attributes were associated with self-management ratings, with self-efficacy and diabetes distress having the strongest relationships (adj coeff = 8.1, p < 0.01 and −4.1, p < 0.01, respectively). Lower self-management ratings in 2003 were associated cross-sectionally with higher hemoglobin A1C (adj coeff = 0.16, p < 0.01), and with perceived worsening diabetes status in 2004 (adj OR = 1.36, p < 0.05), with much of this latter relationship explained by diabetes distress.

Conclusion

Psychosocial attributes, most notably diabetes-related emotional distress, contribute to difficulty with diabetes self-management, poor glycemic control, and worsening diabetes status over time.

Practice implications

Self-management and adherence interventions should target psychosocial attributes such as disease-related emotional distress.     

Factors affecting frequency of communication about family health history with family members and doctors in a medically underserved population

Objective

Family history contributes to risk for many common chronic diseases. Little research has investigated patient factors affecting communication of this information.

Methods

1061 adult community health center patients were surveyed. We examined factors related to frequency of discussions about family health history (FHH) with family members and doctors.

Results

Patients who talked frequently with family members about FHH were more likely to report a family history of cancer (p = .012) and heart disease (p < .001), seek health information frequently in newspapers (p < .001) and in general (p < .001), and be female (p < .001). Patients who talked frequently with doctors about FHH were more likely to report a family history of heart disease (p = .011), meet physical activity recommendations (p = .022), seek health information frequently in newspapers (p < .001) and in general (p < .001), be female (p < .001), and not have experienced racial discrimination in healthcare (p < .001).

Conclusion

Patients with a family history of some diseases, those not meeting physical activity recommendations, and those who do not frequently seek health information may not have ongoing FHH discussions.

Practice implications

Interventions are needed to encourage providers to update patients’ family histories systematically and assist patients in initiating FHH conversations in order to use this information for disease prevention and control.     

Training medical students to conduct motivational interviewing: a randomized controlled trial

Objective

To examine the effectiveness of motivational interviewing (MI) training among medical students.

Methods

All students (n = 131) (year 5) at Lausanne Medical School, Switzerland were randomized into an experimental or a control group. After a training in basic communication skills (control condition), an 8-h MI training was completed by 84.8% students in the exprimental group. One week later, students in both groups were invited to meet with two standardized patients. MI skills were coded by blinded research assistants using the Motivational Interviewing Treatment Integrity 3.0.

Results

Superior MI performance was shown for trained versus control students, as demonstrated by higher scores for “Empathy” [p < 0.001] and “MI Spirit” [p < 0.001]. Scores were similar between groups for “Direction”, indicating that students in both groups invited the patient to talk about behavior change. Behavior counts assessment demonstrated better performance in MI in trained versus untrained students regarding occurences of MI-adherent behavior [p < 0.001], MI non-adherent behavior [p < 0.001], Closed questions [p < 0.001], Open questions [p = 0.001], simple reflections [p = 0.03], and Complex reflections [p < 0.001]. Occurrences were similar between groups regarding “Giving information”.

Conclusion

An 8-h training workshop was associated with improved MI performance.

Practice implications

These findings lend support for the implementation of MI training in medical schools.     

Correlates of low dietary energy reporting in free-living elderly: the MEDIS study

Objectives

To evaluate the prevalence of low energy reporting (LER) and associations between LER and lifestyle, psychological and clinical parameters, in elderly people living in eastern Mediterranean islands.

Methods

1190 men and women, aged 65–100 years, participated in this cross-sectional study. Socio-demographic, clinical and lifestyle characteristics were recorded for the study participants. Among others, the ratio of energy intake to estimated basal metabolic rate (EI/BMR) was calculated and was used for the assessment of LER.

Results

Prevalence of LER was 47.7%. Lower EI/BMR (i.e., higher risk for LER) was associated with older age (p = 0.001), male sex (p < 0.001), higher body mass index (BMI; p = 0.04), lower adherence to the Mediterranean diet (p < 0.001) and non-current smoking (p = 0.007). The sex-specific analysis revealed that, lower EI/BMR values were associated with lower adherence to the Mediterranean diet and being non-current smoker in both men and women (p ≤ 0.05), as well as with older age (p = 0.01), higher BMI (p = 0.02) and hypercholesterolemia (p = 0.02), only in women.

Conclusion

In elderly, several clinical and lifestyle factors seem to be related to LER, and they should be taken into account in their nutritional assessment.     

A randomised controlled trial of lay-led self-management for people with multiple sclerosis

Objective

To determine the impact of the Chronic Disease Self-Management Course (CDSMC) on people with multiple sclerosis (MS).

Methods

2-group, randomised, controlled trial with Intervention Group (IG) and Waiting-List Control Group (WLCG). Additional data were collected from a Comparison Group (CG) who chose not to attend the CDSMC. Participants completed baseline questionnaires; IG participants attended the CDSMC immediately; all participants were assessed at 4-months and 12-months.

Results

216 baseline questionnaires were returned; 73% were female, mean age 51.1 years, mean disease duration 12.0 years. Results showed that the CDSMC had an impact on self-management self-efficacy (ES 0.30, p = 0.009 for the IG) and MSIS physical status (ES 0.12 for the IG, p = 0.005). There were no other statistically significant changes. However, trends towards improvement on depression (ES 0.21 for the IG, p = 0.05) and MS self-efficacy (ES 0.16 for the IG, p = 0.04) were noted. All improvements were maintained at 12-months. At baseline, CG participants were older, had longer disease duration (p < 0.01) and less anxiety (p = 0.009) compared to RCT participants.

Conclusion

The CDSMC provides some small positive effects for people with MS. Motivation to attend may be linked to psychological distress and disease duration.

Practice implications

The CDSMC may be of value for those with mild anxiety/depression who need extra support. Attendance early in the disease course is recommended.     

Patient knowledge of blood pressure target is associated with improved blood pressure control in chronic kidney disease

Objective

To describe patient hypertension knowledge and associations with blood pressure measurements.

Methods

Patients with chronic kidney disease (CKD) were asked about the impact of high blood pressure on kidneys and their target blood pressure goal. Systolic blood pressure was measured using automated sphygmomanometers.

Results

In 338 adults with hypertension and pre-dialysis CKD, the median [IQR] age was 59 [47,68] years, 45% [n = 152] were women, and 18% [n = 62] were non-white. Lower systolic blood pressure (SBP) was associated with female sex (SBP mmHg median [IQR] 132 [117,149] women vs. 137 [124,152] men; p = 0.04), less advanced CKD (SBP 134 [122,147] stages 1–2 vs. 132 [118,148] stage 3 vs. 140 [125,156] stages 4–5; p = 0.01), and patient ability to correctly identify SBP goal (SBP 134 [119,150] correct vs. 141 [125,154] incorrect; p = 0.05). In adjusted analysis, knowledge of blood pressure goal remained independently associated with lower SBP (−9.96 mmHg [−19.97, −1.95] in correct respondents vs. incorrect; p < 0.001).

Conclusion

Patient knowledge of goal blood pressure is independently associated with improved blood pressure control.

Practice implications

Interventions to improve patient knowledge of specific blood pressure targets may have an important role in optimizing blood pressure management.     

More hypothyroidism and less hyperthyroidism with sufficient iodine nutrition compared to mild iodine deficiency—A comparative population-based study of older people

Objective

To assess the occurrence of thyroid disorders and autoimmunity in a geriatric population with long-standing recommended iodine intake of natural origin compared to mild iodine deficiency.

Design and setting

Cross-sectional, comparative, population-based study in two areas with different iodine intakes due to different tap water iodine contents.

Participants

Residents of Randers (n = 212) or Skagen (n = 218), Denmark, aged 75–80 years.

Measures

Blood samples were collected for measuring thyrotropin (TSH), triiodothyronine, thyroxine, thyroid peroxidase antibody (TPOAb), thyroglobulin antibody (TGAb), thyroglobulin (TG); iodine excretion estimated from iodine and creatinine measured in spot urine samples; questionnaire on history of thyroid disease, medication and vitamin use; clinical examination of the neck.

Results

Median urinary iodine excretion was 50 μg/24 h in Randers and 177 μg/24 h in Skagen (p < 0.001). A history of thyroid disease was reported by 40 (9.3%) dominated by goitre (n = 22) in Randers and hypothyroidism and Graves Disease (n = 15) in Skagen (p < 0.001). We found visible goitre in 26% of Randers dwellers and none in Skagen (p < 0.001). Hyperthyroidism with TSH below the reference range was present in 26% of Randers and 6% of Skagen dwellers while 6% and 13%, respectively, were hypothyroid with TSH above the reference range (p < 0.001). More Randers than Skagen participants harboured a thyroid antibody (42% vs. 32%, p = 0.006).

Conclusions

Recommended iodine intake associated with more hypothyroidism, less hyperthyroidism and goiters, low TGAb prevalence and lower TG level in serum than did iodine deficiency. TPOAb was similar in the iodine replete and deficient geriatric populations.     

Degree and correlates of cardiac knowledge and awareness among cardiac inpatients

Objective

To investigate the degree of CHD awareness as well as symptom, risk factor, and treatment knowledge in a broad sample of cardiac inpatients, and to examine its sociodemographic, clinical and psychosocial correlates.

Methods

1308 CHD inpatients (351 [27.0%] female), recruited from 11 acute care sites in Ontario, participated in this cross-sectional study. Participants were provided with a survey which included a knowledge questionnaire among other measures, and clinical data were extracted from medical charts.

Results

855 (68.8%) respondents cited heart disease as the leading cause of death in men, versus only 458 (37.0%) in women. Participants with less than high school education (p < .001), an annual family income less than $50,000CAD (p = .022), low functional capacity (p = .042), who were currently smoking (p = .022), who had no family history of heart disease (p < .001), and who had a perception of low personal control (p = .033) had significantly lower CHD knowledge.

Conclusions

Awareness of CHD is not optimal, especially among women, South Asians, and those of low socioeconomic status. CHD patients have a moderate level of disease knowledge overall, but greater education is needed.

Practice implications

Tailored educational approaches may be necessary for those of low socioeconomic status, particularly with regard to the nature of CHD, tests and treatments.     

The effect of using standardized patients or peer role play on ratings of undergraduate communication training: a randomized controlled trial

Objectives

Considering the expense of standardized patients (SP) for training communication skills and the convenience of peer role playing (RP) there is a surprising lack of studies directly comparing the two methods.

Methods

Fifth year medical students (N = 103) were assigned to three groups receiving a training in counseling parents of sick children with RP (N = 34) or SP (N = 35) or to a control group (CG, N = 34). We assessed self-efficacy, as well as objective performance in parent–physician communication using questionnaires and the Calgary-Cambridge-Observation-Guide Checklist in a six-station OSCE, respectively.

Results

The training led to an increase in self-efficacy ratings and in the post-intervention OSCE score after RP (p < .021 and p < .001 respectively) and SP-training (p < .007 and p < .006 respectively) compared to controls. Surprisingly, this benefit was higher after RP than after SP-training (p < .021) due to significantly higher performance in the domain understanding of parents’ perspective (p < .001).

Conclusion

Both RP and SP are valuable tools for training specific communication skills. RP offer a methodological advantage in fostering empathy for patient perspectives.

Practice implications

Both peer-role-play and standardized patients hold specific benefits for communication training. Peer-role-play seems to foster a more empathic approach towards patients’ concerns justifying its prominent role in medical curricula.     

BLCA-4 expression is related to MMP-9, VEGF, IL-1α and IL-8 in bladder cancer but not to PEDF, TNF-α or angiogenesis

Aim

BLCA-4 is a specific nuclear matrix protein found in bladder cancer and there is a dearth of study on functional analysis upon this factor. We aimed to discover whether BLCA-4 is related to angiogenesis in bladder cancer.

Methods

Fifty-three bladder cancer samples were included for immunohistochemical staining of BLCA-4, matrix metalloproteinase-9 (MMP-9), vascular endothelial growth factor (VEGF), interleukin-1α (IL-1α), IL-8, pigment epithelium-derived factor (PEDF), tumour necrosis factor-α (TNF-α) and von Willebrand factor (vWF) for microvessel density (MVD). Expressional levels were scored and grouped by clinicopathological parametres for statistical analysis for correlations.

Results

Positive correlations were identified between expression of BLCA-4 and IL-1α (p = 0.038), IL-8 (p = 0.001), VEGF (p = 0.002), and MMP-9 (p = 0.013). No correlation was found for PEDF (p = 0.182), TNF-α (p = 0.531) or MVD (p = 0.932). Positive correlations were also obtained in cases of advanced grade or stage, larger, recurrent and multiple tumours. Positive correlation between BLCA-4 and MMP-9 was also found in papillary urothelial neoplasm of low malignant potential (PUNLMP).

Conclusion

BLCA-4 may not effect pro-angiogenic pathways in bladder cancer, it can however interact with IL-1α, IL-8, VEGF and MMP-9 to enhance tumourigenesis and tumour invasiveness.     

Disparities in patient reports of communications to inform decision making in the DECISIONS survey

Objective

To identify patient- and decision-type predictors of two key aspects of informed decision making: discussing the cons (not just the pros) of medical interventions and asking patients what they want to do.

Methods

Using data from 2473 members of the DECISIONS survey, a nationally representative sample of U.S. adults age 40+, we used logistic regression analysis to identify which patient characteristics predicted patient reports of healthcare providers discussing cons or eliciting preferences about one of 9 common medical decisions.

Results

Multiple demographic characteristics predicted both discussions of cons and elicitations of preferences, although the specific characteristics varied between decision contexts. In particular, African-American respondents reported being more likely to receive a discussion of the cons of cancer screening (OR = 1.69, p < 0.05) yet less likely to have been asked their opinion about either getting a cancer screening test (OR = 0.56, p < 0.05) or initiating medications (OR = 0.53, p < 0.05). Significant cross-decision variations remained even after controlling for patient characteristics.

Conclusions

Important disparities in patient communication and involvement appear to exist both between different types of medical decisions and between different types of patients.

Practice implications

Providers must make sure to consistently discuss the cons of treatment and to solicit input from all patients, especially African-Americans.