Osteoporosis risk perceptions among patients who have sustained a fragility fracture

Objective

To explore the perceptions of patients who have sustained a fragility fracture regarding their future fracture risk and the beliefs underlying their perceptions.

Methods

Patients with fragility fracture participated in a telephone interview. Quantitative and qualitative methods were used to characterize patient characteristics and perspectives of future fracture risk. Content analysis of qualitative statements was independently performed by three investigators to identify common themes and contrasting statements, and the findings were discussed to ensure consensus.

Results

Consistent themes were identified among participant responses irrespective of whether they responded “yes”, “no” or “unsure” when asked whether they were at increased fracture risk: (1) patients’ perception of risk was influenced by whether or not they believed they had osteoporosis, which may be altered by interaction with health care providers; (2) patients’ had their own perceptions of their bone health; (3) patients’ attributed their risk to their own actions or “carefulness”; and (4) patients’ had specific beliefs about their fracture and determinants of fracture risk.

Conclusion

Patients who experience fragility fractures develop perceptions about future fracture risk that are influenced by interactions with health care providers, as well as beliefs about their fracture and beliefs that they can modify their risk.

Practice implications

Health care providers should discuss strategies for fracture prevention with all patients after fragility fracture to ensure that patients understand that participation in preventative behaviours can modify their risk.     

What perceptions do patients have of decision making (DM)? Toward an integrative patient-centered care model. A qualitative study using focus-group interviews

Objective

To understand patients’ perceptions of decision making and identify relationships among decision-making models.

Methods

This qualitative study was made up of four focus group interviews (elderly persons, users of health support groups, students, and rural inhabitants). Participants were asked to report their perceptions of decision making in three written clinical scenarios (hypertension, breast cancer, prostate cancer). The analysis was based on the principles of grounded theory.

Results

Most patients perceived decision making as shared decision making, a deliberative question–response interaction with the physician that allowed patients to be experts in obtaining clearer information, participating in the care process, and negotiating compromises with physician preferences. Requesting second opinions allowed patients to maintain control, even within the paternalistic model preferred by elderly persons. Facilitating factors (trust, qualitative non-verbal communication, time to think) and obstacles (serious/emergency situations, perceived inadequate scientific competence, problems making requests, fear of knowing) were also part of shared decision making.

Conclusion and practice implications

In the global concept of patient-centered care, shared decision making can be flexible and can integrate paternalistic and informative models. Physicians’ expertise should be associated with biomedical and relational skills through listening to, informing, and advising patients, and by supporting patients’ choices.     

Cancer patients' expressions of emotional cues and concerns and oncology nurses' responses, in an online patient-nurse communication service

Objective

To (1) investigate emotional cues and concerns (C&;C) of cancer patients expressed in e-mail communication with oncology nurses in an online patient–nurse communication service (OPNC), and (2) explore how nurses responded to patients’ C&;C.

Methods

283 e-messages sent from 38 breast and 22 prostate cancer patients and 286 e-responses from five oncology nurses were coded with the Verona Coding Definitions of Emotional Sequences.

Results

We identified 102 cues and 33 concerns expressed in patients’ messages. Cues indicating expression of uncertainty or hope, occurred most frequently (in 38.5% of messages), followed by concerns (in 24.4% of messages). Nurses responded to 85.2% of patients’ C&;Cs; more than half of patients’ C&;Cs were met with a mixture of information giving and empathic responses.

Conclusion

Patients with breast and prostate cancer express many C&;C in e-mail communications with oncology nurses, who demonstrated satisfactory sensitivity to patients’ emotions in their responses to patients.

Practice implications

Offering e-communication with oncology nurses to cancer patients is a promising and feasible supplement to usual care to address and relieve patients’ concerns and emotional distress during illness and recovery.     

Patients' and health professionals' views and experiences of atrial fibrillation and oral-anticoagulant therapy: a qualitative meta-synthesis

Objective

Atrial fibrillation (AF) patients are prescribed oral-anticoagulant (OAC) therapy, often warfarin, to reduce stroke risk. We explored existing qualitative evidence about patients’ and health professionals’ experiences of OAC therapy.

Methods

Systematic searches of eight bibliographic databases were conducted. Quality was appraised using the Critical Appraisal Skills Programme tool and data from ten studies were synthesised qualitatively.

Results

Four third-order constructs, emerged from the final step in the analysis process: (1) diagnosing AF and the communication of information, (2) deciding on OAC therapy, (3) challenges revolving around patient issues, and (4) healthcare challenges. Synthesis uncovered perspectives that could not be achieved through individual studies.

Conclusion

Physicians’ and patients’ experiences present a dichotomy of opinion on decision-making, which requires further exploration and changes in practice. Outcomes of workload pressure on both health professionals and patients should be investigated. The need for on-going support and education to patients and physicians is critical to achieve best practice and treatment adherence.

Practice implications

Such research could encourage health professionals to understand and attend better to the needs and concerns of the patient. Additionally these findings can be used to inform researchers and healthcare providers in developing educational interventions with both patients and health professionals.     

Patient compliance with telephone triage recommendations: a meta-analytic review

Objective

To systematically investigate the extent to which patients comply with triage advice from telenurses and to identify factors that potentially influence compliance.

Methods

Findings from 13 studies identified through interdisciplinary research databases (1990–2010) were meta-analyzed. Separate pooled analyses compared patients’ compliance rates for emergency services and office care (13 outcomes), emergency services and self care (13 outcomes), and self care and office care (12 outcomes).

Results

Overall patient compliance was 62%, but varied by intensity of care recommended with low compliance rates for advice to see a general practitioner. Reasons for noncompliance include patients reporting to have heard a different disposition, patients’ intentions and health beliefs.

Conclusion

Patient compliance to triage recommendations was influenced by the interactive role of patient perceptions and the quality of provider communication, both of which were mediated by access to health services. Further research is needed to clarify whether noncompliance is attributable to poor communication by the nurse or patient misinterpretation.

Practice implications

We highlight the need for communication-skills training in a telephone-consultation context that is patient centered, and specifically addresses building active listening and active advising skills and advantages to structuring the call.     

Developing instruments to measure the quality of decisions: early results for a set of symptom-driven decisions

Objective

To identify a set of critical facts and key goals and concerns for five common medical conditions, benign prostate disease, hip and knee osteoarthritis, herniated disc and spinal stenosis and examine the validity of the method for identifying these items.

Methods

Investigators identified facts and goals through literature reviews and qualitative work with patients and providers. A cross-sectional survey of patients and providers was conducted to examine the accuracy, importance and completeness of the identified items.

Results

42 facts (6–16 per condition) and 31 goals and concerns (4–13 per condition) were identified. 182 responses were obtained from patients (76.5% response rate) and 113 responses from providers (78% response rate). Overall, the facts were accurate, important and complete across all conditions. For one condition (hip osteoarthritis), the goals did not meet the criteria for completeness. There was more disagreement between patients and providers around the ranking of goals than of facts.

Conclusions

Overall, respondents found the identified facts and goals accurate, important and complete. Significant differences between patients’ and providers’ rankings highlight the importance of including both perspectives.

Practice implications

Instruments to measure whether or not patients are informed and the extent to which treatments reflect patients’ goals must balance patients’ and providers’ perspectives when selecting items to include.     

A questionnaire on treatment satisfaction and disease specific knowledge among patients with acute coronary syndrome. I: Are treatment satisfaction and disease specific knowledge continuous latent traits?

Objective

To assess psychometric properties of a questionnaire covering treatment satisfaction and disease-specific knowledge among patients discharged after treatment for acute coronary syndrome.

Methods

Comparative scaling of the questionnaire using latent class analysis (LCA) and exploratory factor analysis (EFA) in a consecutive sample of 2015 patients.

Results

LCA revealed four qualitatively differing patterns of patients’ knowledge and five distinct patterns of treatment satisfaction. EFA for patients’ knowledge identified four uncorrelated “dimensions”. Patient satisfaction was scored in a two-factor solution despite proven heterogeneity of persons.

Conclusions

LCA was helpful to identify classes of patients that cannot be scaled according to a latent trait model.

Practice implications

Specific patterns of insufficient disease-specific knowledge and satisfaction requiring specific interventions became visible.     

Lung cancer patients' perceptions of informed consent documents

Objective

To compare patients’ perceptions and preferences of two different versions of informed consent documents.

Methods

Patients eligible for a trial of palliative chemotherapy for lung cancer (N = 22) were randomly assigned to receive either an original consent document or a shortened version written for the present study. Semi-structured interviews were conducted after the patients had read the consent documents. The interviews were transcribed verbatim and analysed using qualitative content analysis.

Results

Few differences between the two groups were found with respect to patients’ assessment of the amount of content and the most important information in the documents. Information about disease and treatment seemed to be of most interest for the patients, while information about research aspects of the study such as financing, confidentiality and publishing (formalities) was judged to be of lesser relevance. Two patients who read the original document indicated that they treated the formalities as secondary.

Conclusion

Patients seemed to pay little attention to the research aspects, and thus risked to misunderstand the main point of the consent document.

Practice implications

The structure of consent documents should clarify for the readers that they are asked to take part in research, and that participation is voluntary.     

Patients’ evaluation of quality of care in general practice: What are the cultural and linguistic barriers?

Objective

Increased migration implies increased contacts for physicians with patients from diverse cultural backgrounds who have different expectations about healthcare. How satisfied are immigrant patients, and how do they perceive the quality of care? This study investigated which patient characteristics (such as cultural views and language proficiency) are related to patients’ satisfaction and perceived quality of care.

Methods

Patients (n = 663) from 38 general practices in Rotterdam (The Netherlands) were interviewed. General satisfaction with the general practitioner (GP) was measured by a report mark. Perceived quality of care was measured using the ‘Quote-mi’ scale (quality of care through the patient's eyes—for migrants), which contains an ethnic-specific subscale and a communication process subscale. Using multilevel regression techniques, the relation between patient characteristics (ethnicity, age, education, Dutch language proficiency, cultural views) and satisfaction and perceived quality of care was analysed.

Results

In general, patients seemed fairly satisfied. Non-Western patients perceived less quality of care and were less satisfied than Dutch-born patients. The older the patients and the more modern cultural views they had, the more satisfied they were about the GP in general, as well as about the communication process. However, non-Western patients holding more modern views were the most critical regarding the ethnic-specific quality items. The poorer patients’ Dutch language proficiency, the more negative they were about the communication process.

Conclusion

It is concluded that next to communication aspects, especially when the patient's proficiency in Dutch is poor, physician awareness about the patient's cultural views is very important during the consultation. This holds especially true when the immigrant patient seems to be more or less acculturated.

Practice implications

Medical students and physicians should be trained to become aware of the relevance of patients’ different cultural backgrounds. It is also recommended to offer facilities to bridge the language barrier, by making use of interpreters or cultural mediators.     

Discrete choice as a method for exploring education preferences in a Danish population of patients with type 2 diabetes

Objective

To determine preferences among patients with type 2 diabetes for content and format of patient education.

Methods

Using discrete choice methods, we surveyed patients about their preferences for patient education. We investigated preferred content and format regarding education on living well with diabetes, preventing complications, healthy eating, exercising, and psychosocial issues related to diabetes.

Results

We obtained usable responses from 2187 patients with type 2 diabetes. Acquiring competencies to live a fulfilling life with diabetes, adjust diet and exercise habits, and prevent complications was significantly more highly valued than was simply being informed about these topics. Patients preferred to be involved in the planning of their diabetes care and valued individually tailored content higher than prescheduled content. Women and younger patients found diet and exercise significantly more important than did men, and patients with poorly controlled diabetes valued all education and support more highly than did patients in better control.

Conclusion

Patients with type 2 diabetes prefer to be actively involved in educational activities, to develop competencies to prevent and manage complications, and to involve their social network in supporting them.

Practice implications

Future patient education should enhance participation and competence development and include relatives.     

Self-management of chronic low back pain: An exploration of the impact of a patient-centered website

Objective

This paper examines from a qualitative approach the role of a patient-centered website – named “Oneself” – on patients’ chronic low back pain self-management attitudes and behaviors in the Italian part of Switzerland.

Methods

In-depth interviews have been conducted with a purposive and convenient sample of 18 chronic low back pain sufferers who had used Oneself during 6 months. Data collection and analysis were driven by grounded theory.

Results

Reported positive effects of the use of Oneself on self-management attitudes and behaviors include self-comprehension, improvement of argumentative abilities, orientation, development of self-confidence and maintenance of a high level of attention. In some cases, participants affirm to have experienced negative effects such as confusion and discouragement. The individual's previous awareness of cLBP and level of self-management plays a main role in the way people use the website and in its impact. Based on this criterium, a typology of four patterns of use is drawn.

Conclusion

Patient-centered websites are useful for enhancing self-management of chronic low back pain. However, individuals take advantage of this means differently, based on their stage of advancement in the self-management process.

Practice implications

Information and supports provided online should be tailored according to people's stage of advancement.     

Why should I talk about emotion? Communication patterns associated with physician discussion of patient expressions of negative emotion in hospital admission encounters

Objective

To describe hospital-based physicians’ responses to patients’ verbal expressions of negative emotion and identify patterns of further communication associated with different responses.

Methods

Qualitative analysis of physician–patient admission encounters audio-recorded between August 2008 and March 2009 at two hospitals within a university system. A codebook was iteratively developed to identify patients’ verbal expressions of negative emotion. We categorized physicians’ responses by their immediate effect on further discussion of emotion – focused away (away), focused neither toward nor away (neutral), and focused toward (toward) – and examined further communication patterns following each response type.

Results

In 79 patients’ encounters with 27 physicians, the median expression of negative emotion was 1, range 0–14. Physician responses were 25% away, 43% neutral, and 32% toward. Neutral and toward responses elicited patient perspectives, concerns, social and spiritual issues, and goals for care. Toward responses demonstrated physicians’ support, contributing to physician–patient alignment and agreement about treatment.

Conclusion

Responding to expressions of negative emotion neutrally or with statements that focus toward emotion elicits clinically relevant information and is associated with positive physician–patient relationship and care outcomes.

Practice implications

Providers should respond to expressions of negative emotion with statements that allow for or explicitly encourage further discussion of emotion.     

Validation of a patient-centered culturally sensitive health care provider inventory using a national sample of adult patients

Objective

The Tucker-Culturally Sensitive Health Care Provider Inventory – Patient Form (T-CSHCPI-PF) is an inventory for culturally diverse patients to evaluate provider cultural sensitivity in the health care process. The T-CSHCPI-PF is novel in that it assesses provider cultural sensitivity as defined by culturally diverse patients. The purpose of the present study was to determine the factor structure and internal consistency reliability of the T-CSHCPI-PF.

Method

A sample of 1648 adult patients was recruited by staff at 67 health care sites across the United States. These patients anonymously completed the T-CSHCPI-PF, a demographic data questionnaire, and a patient satisfaction questionnaire.

Results

Confirmatory factor analyses of the TCSHCPI-PF revealed that it has three factors with high internal consistency and validity.

Conclusion

It is concluded that the T-CSHCPI-PF is a psychometrically strong and useful inventory for assessing the cultural sensitivity of health care providers.

Practical implications

The T-CSHCPI-PF may be a useful inventory for obtaining patients’ feedback on their providers’ cultural sensitivity and for assessing the effectiveness of trainings to promote patient-centered cultural sensitivity among providers.     

Patient comprehension and attitudes toward maintenance chemotherapy for lung cancer

Objective

Maintenance chemotherapy is a recently approved approach to the treatment of advanced non-small cell lung cancer (NSCLC). We sought to gain insight into patients’ perceptions of maintenance chemotherapy using qualitative methods.

Methods

We conducted thematic content analysis of focus groups at a freestanding cancer center and at an associated safety-net county hospital. Patients with advanced NSCLC who had started but not yet completed first-line platinum doublet chemotherapy were provided visual and written explanations of maintenance chemotherapy before being guided in group discussion.

Results

Key themes to emerge for consideration of maintenance chemotherapy included: (1) survival benefits, disease control, and “buying time”; (2) the importance of “doing something”; (3) quality of life concerns; (4) the role of provider opinion/preference; and (5) the importance of logistics.

Conclusions

Patients undergoing first-line chemotherapy for advanced NSCLC were able to understand the concept of maintenance chemotherapy, distinguish it from traditional treatment paradigms, identify pros and cons of this approach, and convey reasons for considering it.

Practice implications

Advances in oncology care that alter therapy modalities and delivery may significantly impact patient perceptions and treatment experiences. Clinical team members may wish to elicit treatment preferences of first-line patients through clinical discussion that anticipate these considerations.     

Thinking outside the black box: The importance of context in understanding the impact of a preoperative education nursing intervention among Chinese cardiac patients

Objective

In a randomized controlled trial of a preoperative education intervention conducted for Chinese cardiac patients, we observed a greater effect on symptoms of anxiety and depression than that reported with regard to similar interventions in western care settings. The objective of this qualitative study was to help explain the findings of the trial by exploring Chinese patients’ experience of seeking and receiving information before cardiac surgery.

Methods

Semi-structured interviews were conducted with a purposive sample of 20 trial participants before discharge (ten from the preoperative education group; ten from the usual care control group). Data were analyzed using a thematic analysis approach.

Results

A total of five themes were generated: the role of reputation and hierarchy; gaining strength from knowledge; information as a low priority; being kept in the dark; and learning through peer support.

Conclusion

In health care systems where service users are given relatively little information, interventions designed to inform patients about their treatment are likely to have a much greater impact on their psychological health.

Practice implications

Providers of services for patients undergoing cardiac surgery in China should be encouraged to incorporate information giving into routine practice, tailored according to individual need.     

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.     

Postoperative information needs and communication barriers of esophageal cancer patients

Objective

Given the poor prognosis of esophageal cancer and the impact of surgery on health-related quality of life (HRQL), addressing patients’ postoperative information needs is important. This study aimed to examine (1) the content and type of patients’ information needs and (2) patient perceived facilitators and barriers to patient participation.

Methods

Interviews were conducted with 20 purposefully selected esophageal cancer patients. Open and structured questions were alternated. The transcribed interviews were analysed inductively and deductively, using MAXqda.

Results

Patients’ post-operative information needs concerned HRQL, medical care and prognosis, covering several sub-domains. Different types of needs were identified, e.g., requests for information about cause, course and self-management. Barriers to patient participation mostly reflected beliefs and skills, and could be categorized into agenda and communication barriers. Facilitators of patient participation reflected physician, patient and interaction characteristics, companion support and pre-visit preparation. Many patients saw merit in pre-visit preparation interventions; few endorsed skill-building interventions.

Conclusion

This study listed the postoperative information needs of esophageal cancer patients. Moreover, it gained insight into patient-perceived barriers and facilitators of patient participation.

Practice implications

The findings demonstrate what information physicians should have available and informs interventions to support patients in meeting their information needs.     

Barriers and enablers in the implementation of a provider-based intervention to stimulate culturally appropriate hypertension education

Objective

To identify barriers and enablers influencing the implementation of an intervention to stimulate culturally appropriate hypertension education (CAHE) among health care providers in primary care.

Methods

The intervention was piloted in three Dutch health centers. It consists of a toolkit for CAHE, training, and feedback meetings for hypertension educators. Data were collected from 16 hypertension educators (nurse practitioners and general practice assistants) during feedback meetings and analyzed using qualitative content analysis.

Results

Perceived barriers to the implementation of the intervention fell into three main categories: political context (health care system financing); organizational factors (ongoing organizational changes, work environment, time constraints and staffing) and care provider-related factors (routines, attitudes, computer and educational skills, and cultural background). Few barriers were specifically related to the delivery of CAHE (e.g. resistance to registering ethnicity). Enabling strategies addressing these barriers consisted of reorganizing practice procedures, team coordination, and providing reminders and additional instructions to hypertension educators.

Conclusion and practice implications

The adoption of a tool for CAHE by care providers can be accomplished if barriers are identified and addressed. The majority of these barriers are commonly associated with the implementation of health care innovations in general and do not indicate resistance to providing culturally appropriate care.     

Exploring online support spaces: using cluster analysis to examine breast cancer, diabetes and fibromyalgia support groups

Objective

This study sought to characterize and compare online discussion forums for three conditions: breast cancer, type 1 diabetes and fibromyalgia. Though there has been considerable work examining online support groups, few studies have considered differences in discussion content between health conditions. In addition, in contrast to the extant literature, this study sought to employ a semi-automated approach to examine health-related online communities.

Methods

Online discussion content for the three conditions was compiled, pre-processed, and clustered at the thread level using the bisecting k-means algorithm.

Results

Though the clusters for each condition differed, the clusters fell into a set of common categories: Generic, Support, Patient-Centered, Experiential Knowledge, Treatments/Procedures, Medications, and Condition Management.

Conclusion

The cluster analyses facilitate an increased understanding of various aspects of patient experience, including significant emotional and temporal aspects of the illness experience.

Practice implications

The clusters highlighted the changing nature of patients’ information needs. Information provided to patients should be tailored to address their needs at various points during their illness. In addition, cluster analysis may be integrated into online support groups or other types of online interventions to assist patients in finding information.