Evaluation of the "Consultation and Relational Empathy" (CARE) measure by means of Rasch-analysis at the example of cancer patients

Objective

The aims of this study are: (1) analysis of unidimensionality of the German version of the “Consultation and Relational Empathy” (CARE) measure and (2) identification of moderating variables affecting the scale structure.

Methods

The CARE-measure was evaluated by means of Rasch-analysis in a sample of N = 326 cancer patients. Association of diagnosis and treatment as well as patients’ characteristics was analyzed by person-fit measures and Differential Item Functioning.

Results

Nine of the original 10 CARE items fit to the Rasch-model. For breast and prostate cancer, as well as for patients taking complementary and alternative medicine treatment, item biases affect the scale structure. Furthermore, older patients and patients with higher social support exhibit substantial deviations from model predictions.

Conclusions

Only the nine-item version of the CARE-measure allows for the unidimensional assessment of physician empathy. Especially for specific diagnosis and treatment groups, the CARE-items indicate variations in the underlying latent construct of physician empathy.

Practice implications

The CARE_R-measure provides a theory-based and psychometrically sound basis for the assessment of PE. It can be used to enhance the fairness of the assessment and to further identify valuable information about the influence of patient characteristics on the structure of the construct PE.     

Lipopolysaccharide levels are elevated in dengue virus infected patients and correlate with disease severity

Background

Although in the majority of cases dengue virus (DENV) infection results in a self-limiting febrile disease, it can cause severe plasma leakage in a minority of patients. The appearance of plasma leakage indicates an increased permeability of the vascular wall. In this study we investigated if DENV infection can lead to leakage of lipopolysaccharide (LPS) from the intestine into the blood of the patient, indicative of an increased permeability of the intestinal mucosal barrier.

Objectives

The aim of this study was to investigate if LPS levels were elevated in DENV infected patients and if these levels correlated with disease severity.

Study design

LPS levels in the blood of DENV infected children were determined using the Limulus Amebocyte Lysate assay. To determine disease severity we used the 1997-WHO criteria, the expert physician's judgement and a score that focused on plasma leakage in particular. Furthermore, the modulatory factors LPS binding protein (LBP) and sCD14, as well as the immune activation marker neopterin were determined.

Results

We showed significantly elevated LPS levels in plasma of DENV infected children compared to healthy controls. The plasma leakage severity score had the strongest correlation with levels of LPS. LBP, sCD14 and neopterin were elevated compared to healthy controls.

Conclusion

In this study we show evidence of elevated LPS levels during DENV infection. Moreover, a correlation between LPS levels and disease severity was found, especially when disease severity was determined in terms of plasma leakage.     

Relationship of insulin resistance to psychobehavioral characteristics of overweight and obese African American children

Objectives

The objective of this study was to evaluate the relationships of insulin resistance to positive as well as negative dimensions of the child's emotions, behavior and personality (hereafter referred to as “psychobehavioral characteristics”) in a convenience sample of inner-city, overweight and obese, African American children.

Methods

A secondary analysis was performed on a sample of 127 children ages 9-12 yr old who were participating in a community-based, Type 2 diabetes prevention program. Psychobehavioral characteristics of children were assessed using both child and parent ratings derived from the Behavioral Assessment for Children, 2nd edition (BASC-2). Body fatness was evaluated using anthropometric techniques, and insulin resistance (HOMA-IR) was calculated from fasting glucose and insulin concentrations. Hierarchical multiple linear regression models were employed with BASC scales as dependent variables and HOMA-IR as the independent variable of interest.

Results

After adjusting for child age, pubertal stage, gender, family socioeconomic index, and intervention group assignment, child HOMA-IR was related at p < 0.05 to less favorable scores for parent-report of behavioral symptoms and externalizing problems composites, and to content scales for bullying and negative emotionality. Additionally, child HOMA-IR was related at p < 0.01 to less favorable scores for child-report inattention/hyperactivity composite. Body fatness suppressed the unfavorable relationship between HOMA-IR and these and other psychobehavioral characteristics as the degree of significance was higher following adjustment for body fatness in this cohort.

Conclusion

More than one psychobehavioral characteristic were associated with body fatness and insulin resistance in the overweight children of this study. Whether the associations are due to several, or only one, of these psychobehavioral characteristics could not be determined. A much larger and future study will be needed to determine which, if any, of these psychobehavioral characteristics are independently associated with insulin resistance in overweight children.     

Medical nutrition therapy for overweight youth in their medical home: The KIDPOWER experience

Objective

To determine the feasibility and impact of implementing a standardized medical nutrition therapy (MNT) protocol to treat overweight children in their medical home. Primary outcomes evaluated were changes in eating behaviors, television habits, and weight status.

Methods

A MNT protocol with handouts (known as KIDPOWER) was delivered by a registered dietitian (RD) to overweight children (2-20 years) in 9 primary care practices in a rural community. A medical record review yielded height, weight and selected patient/parent reported eating and TV behaviors from each MNT visit. Mean values were compared by paired samples t-tests. Changes in behaviors and BMI z score were compared using repeated measures ANOVA.

Results

For patients with at least three MNT visits (n = 109) significant improvements in eating and TV viewing habits were seen by the third visit. Weight status, as determined by a significant decline in mean BMI z score, was improved.

Conclusion

The KIDPOWER protocol delivered by a RD in the pediatric medical home aided overweight youth in making behavior changes that positively impacted their weight status.

Practice implications

Reimbursement to RDs for treating childhood obesity is improving and KIDPOWER provides a model and tools for community practice.     

Advance care planning for patients with COPD: past, present and future

Objective

To discuss the importance, current status and directions for improvement of advance care planning and communication about end-of-life care for patients with Chronic Obstructive Pulmonary Disease (COPD).

Methods

Narrative review of the currently available literature regarding advance care planning and communication about end-of-life care in COPD.

Results

Advance care planning, including patient-clinician communication about end-of-life care, can improve outcomes for patients and their families and may be particularly important for patients with COPD. Patient-clinician communication is needed to inform and prepare patients about their diagnosis, treatment, prognosis, and what dying might be like. It is necessary to help patients and their clinicians understand patient preferences for life-sustaining treatments. Despite these advantages, advance care planning and conversations about end-of-life care in current practice are limited and their quality is often poor.

Conclusion

Advance care planning can improve outcomes for patients and their relatives. Recent studies provide directions for how to facilitate advance care planning for patients with COPD.

Practice implications

Advance care planning ought to be part of care for patients with advanced COPD. Future studies should focus on interventions to facilitate advance care planning in patients with COPD with the goal of improving the quality of end-of-life care.     

Development of an ICF-based patient education program

Objective

To describe the development of an ICF-based patient education program, to present the results of its pilot test and to present the adaptations and final version of the program.

Methods

The education program was developed in five steps: (1) definition of relevant areas of functioning, (2) development of strategies to enhance self-efficacy in these areas, (3) development of material and instructions, (4) definition of modules and setting and (5) performance of a pilot test targeting acceptability and feasibility of the program.

Results

Eleven stroke patients were enrolled in the pilot test. The intervention was well accepted on the part of participants. The developed patient education program is structured in three modules. Module 1 targets to increase patients’ understanding of their current level of functioning. Module 2 targets to identify concrete problems and corresponding solutions regarding limited areas. Module 3 is a refresher session.

Conclusion

Feasibility and acceptability of the intervention were verified and a final version of the patient education program was developed. The effectiveness of the program will be evaluated in a randomized controlled trial.

Practice implications

Due to the universality of the ICF and availability of ICF tools, it is possible to adapt the intervention to different chronic conditions.     

Health literacy awareness training for healthcare workers: improving knowledge and intentions to use clear communication techniques

Objective

Health literacy is a growing concern as its relationship with health outcomes becomes clearer. Efforts to enhance awareness of patient health literacy in health professional education have focused on physicians, and the objective of this research was to provide an initial assessment of a training session designed for healthcare workers of all kinds.

Methods

Pre- and post-surveys were completed by 166 participants (N = 166) in training sessions designed to improve knowledge of health literacy and instruction in clear communication techniques. Participants provided baseline and post-training assessments of perceived knowledge of health literacy and use of strategies to improve communication with low health literate audiences.

Results

Participants, initially overestimating their own knowledge of health literacy, improved on outcome measures regarding perceived health literacy knowledge. Participants also indicated strong intentions to use clear communication techniques covered in the training.

Conclusion

Results suggest there is an opportunity and need to improve health literacy training for healthcare workers of all kinds. Widespread adoption of health literacy training programs would improve the delivery of healthcare to low health literate patients.

Practice implications

Participants initially overestimated their knowledge of health literacy, suggesting a need to improve initial training and continuing medical education regarding health literacy.     

Immunohistochemical staining of cancer stem cell markers in hepatocellular carcinoma

Background

Cancer stem cells (CSCs) are thought to be a critical subpopulation in tumor development, progression, metastasis and recurrence, and the identification of these cells is an initial step in understanding their role in oncogenesis and in seeking valuable markers for diagnosis or development of targeting therapeutics.

Aims

To identify CSCs in hepatocellular carcinoma (HCC) specimens and define their tissue specificity.

Methods

Immunohistochemical staining of CSC markers: CD44, CD90, CD133 and aldehyde dehydrogenase (ALDH) was performed in 25 HCC specimens, 4 hepatoblastomas, 8 peri-malignant tissues, and 19 cases of viral hepatitis.

Results

The positivity of CD44 staining in HCC specimens was significantly lower than in viral hepatitis specimens. The positive rate of CD133 in HCC was similar to viral hepatitis specimens. CD133⁺ cells were largely localized to ALDH-positive cells in HCC as revealed by confocal microscopy. In contrast, the co-expression of both markers was visualized within vessels or in the portal areas in viral hepatitis. Moreover, among 7 liver specimens adjacent to HCC tissue, 3-6 samples were positive for CD44, CD90, CD133 and ALDH, especially in dysplastic cells. One of 4 hepatoblastoma cases was positive for all these markers; whereas, the other three specimens were negative for all these CSC markers.

Conclusions

In HCC and dysplastic tissues, clusters of CD133⁺/ALDH^high cells were identified. The use of cancer stem cell markers to screen tissues with chronic liver diseases provides limited guidance in the identification of malignant cells.     

Wellness in community living adults: the Weigh to Life program

Objective

To examine physiological and health-related quality of life (HRQOL) outcomes in community living adults attending a 12-week combined lifestyle wellness program.

Methods

A sample of overweight and obese adults (n = 319) and a subgroup who also had diabetes (n = 46 of 319) were studied. The program focuses on dietary, physical activity, and behavioral strategies to promote cardiovascular health. Baseline and 12-week measures were obtained.

Results

In the total sample, all physiological and HRQOL outcomes improved (p < .05), except HDL. High attendance was associated with the highest weight loss. In the diabetic subgroup, weight, steps/day, low density lipoprotein, and most aspects of HRQOL improved significantly.

Conclusion

Physiological and HRQOL benefits can be gained from a 12-week combined lifestyle program; greater benefits were obtained with higher attendance. Although the diabetic subgroup was not large, positive outcomes were realized.

Practice implications

The 12-week combined lifestyle program shows promise for improving outcomes in community living overweight and obese adults who may also be diabetic. By attending class, participants are reminded about strategies they are to apply during the 12-week program and, by program end, they are equipped with a tool kit of strategies for use in everyday life.     

The efficacy of psychologically based interventions to improve anxiety, depression and quality of life in COPD: A systematic review and meta-analysis

Objective

To systematically evaluate the efficacy of psychologically based interventions for addressing psychological outcomes in patients with chronic obstructive pulmonary disease (COPD).

Methods

Electronic databases, key journals and reference lists of included studies were scrutinised for inclusion; in addition authors were contacted for potential unpublished research. Nine studies were identified for inclusion. Data was extracted by two reviewers independently using a standardised extraction sheet and a series of meta-analyses completed for measures of anxiety, depression and quality of life.

Results

Eight studies evaluated a cognitive behavioural- or psychotherapeutically based intervention and one study evaluated taped progressive muscle relaxation. The studies revealed some evidence for the interventions’ impact on anxiety, but, taken together interventions had limited effectiveness. The meta-analyses that were conducted revealed a small effect for anxiety only.

Conclusion

The results are discussed considering the limitations of the research and previous work in this area. A systematic evaluation of psychological interventions on psychological co-morbidity in patients with COPD is recommended.

Practice implications

There is some evidence that psychological interventions impact anxiety and this should be explored further and more interventions should target quality of life.     

Shared decision making in medicine: The influence of situational treatment factors

Objective

Although shared decision making (SDM) has become increasingly important in bioethical discussions and clinical practice, it is not clear in which treatment situations SDM is suitable. We address this question by investigating social norms on the appropriateness of SDM in different situations.

Methods

We conducted qualitative expert interviews with patients, general practitioners, and health administration and research professionals.

Results

SDM was considered to be most important in severe illness and chronic condition. Furthermore, SDM was indicated to be required if there is more than one therapeutic option, especially if it is not clear which option is best. Interviewees classified end-of-life decisions and decisions about prevention as those that primarily should be made by informed patients. On the other hand a paternalistic decision was considered most appropriate in emergency situations and when the patient does not want to participate in decision making.

Conclusion

This study demonstrates that multiple situational factors and their interactions must be considered regarding the scope of SDM in medical consultation.

Practice implications

Research addressing this question will help physicians adjust their consultation style and allow implementations of SDM and decision aids to be tailored more appropriately to complex treatment situations.     

Development and psychometric properties of a self report measure to assess clinicians' practices in self management support for patients with long term conditions

Objective

This paper presents a process of developing practices in self management support (PSMS) - a measure assessing clinicians’ self reported use of self management support practices in clinical consultations for patients with long term conditions (LTCs).

Methods

The development process comprised the following steps: literature review to define what skills clinicians need to effectively support patients to self manage, review of existing measures of SMS practices, construction of an initial pool of items, E Delphi study pilot survey to select items for final measure, data collection to confirm the factor structure and internal consistency of the final measure.

Results

The PSMS comprises three subscales: Clinical SMS (14 items), Patient Centeredness (4 items) and Organizational SMS (7 items). All subscales have very good internal reliability (Cronbach α: 0.94, 0.78 and 0.85; all item-total correlations above 0.50).

Conclusions and practice implications

We believe PSMS measure is suitable for both research and programme evaluation in UK clinical settings. To complete the process of measure development we are now planning to conduct further analyses to establish the validity of PSMS measure in UK and non UK healthcare settings and test the validity of PSMS measure on a wider range of other LTC groups.     

Impact of patient obesity on the patient-provider relationship

Objective

Health professionals’ weight bias may impair obese patients’ interactions with providers. However, few studies have examined how negative provider attitudes affect the patient-provider relationship for obese patients. We hypothesized that higher patient body mass index (BMI) would be negatively associated with patient-provider relationship quality.

Methods

We analyzed data from the 2007 Health Tracking Household Survey. BMI was the independent variable, and patient-perceived quality of the patient-provider relationship was the outcome. We performed log-binominal regression analyses accounting for complex survey design to examine the association of BMI with the patient-provider relationship.

Results

Of the 15,197 adult survey respondents, the 6427 who answered the quality of care questions were eligible for analysis. Overall, 29% had a normal range BMI, 34% were overweight, and 37% were obese. We found few differences in ratings of the patient-provider relationship for overweight and obese respondents when compared to respondents with a normal range BMI.

Conclusion

These unexpected findings may have occurred due to patients’ inability to perceive providers’ weight bias, measurement error in questionnaire items, or decreasing weight bias among health professionals.

Practice implications

Patient's positive perceptions of providers may indicate promise for health professionals acting as motivators of behavior change in obese patients.     

Employing immersive virtual environments for innovative experiments in health care communication

Objective

This report reviews the literature for studies that employ immersive virtual environment technology methods to conduct experimental studies in health care communication. Advantages and challenges of using these tools for research in this area are also discussed.

Methods

A literature search was conducted using the Scopus database. Results were hand searched to identify the body of studies, conducted since 1995, that are related to the report objective.

Results

The review identified four relevant studies that stem from two unique projects. One project focused on the impact of a clinician's characteristics and behavior on health care communication, the other focused on the characteristics of the patient. Both projects illustrate key methodological advantages conferred by immersive virtual environments, including, ability to maintain simultaneously high experimental control and realism, ability to manipulate variables in new ways, and unique behavioral measurement opportunities.

Conclusion

Though implementation challenges exist for immersive virtual environment-based research methods, given the technology's unique capabilities, benefits can outweigh the costs in many instances.

Practice implications

Immersive virtual environments may therefore prove an important addition to the array of tools available for advancing our understanding of communication in health care.     

Impact of patient level factors on the improvement of the ABCs of diabetes

Objective

To determine which patient factors contribute to improvements in the ABCs of diabetes following a multi-faceted diabetes care intervention.

Methods

A multi-level, cluster design, randomized controlled trial examined the effectiveness of a Chronic Care Model (CCM) intervention in an underserved community (n = 119).

Results

Improvements in glycemic control were experienced among older subjects (p = 0.02), those with higher scores on the WHO-10 Quality of Well-Being Subscale 1 (p = 0.05), and those in the CCM group (p = 0.04). Insulin use was associated with greater improvements in SBP and DBP. Those taking insulin (p = 0.07), and those more satisfied with their diabetes care and ready to make a behavior change (p = 0.08) experienced larger improvements in Non-HDLc. Medication treatment intensification (TI) did not significantly impact the ABCs.

Conclusion

Psychosocial and sociodemographic factors explained more of the variation in the ABCs than TI, and are important contributors to clinical improvement.

Practice Implications

Providers may be able to identify and intervene on patients who are at risk for developing diabetes complications and improve the consistency, quality, and effectiveness of patient care.     

Using the Extended Health Belief Model to understand siblings’ perceptions of risk for hereditary hemochromatosis

Objective

This research focuses on individuals’ reactions to news that a sibling has been diagnosed with hereditary hemochromatosis (HH). We used the Extended Health Belief Model (EHBM) to frame our analysis of siblings’ perceptions of risk for HH and decision of whether to obtain diagnostic testing.

Method

60 patient and 25 sibling interviews were transcribed and thematically analyzed for the six components of the EHBM.

Results

Patient and sibling reports of siblings’ perceptions were categorized into the six components of the EHBM: susceptibility, severity, benefits, barriers, cue to action, and self-efficacy.

Conclusion

In the case of HH, siblings’ perceptions of HH are varied and include a range of motivators and barriers that may impact family-based detection. Family-based detection can often play an important part of effective public health strategies to address inherited risk of disease. Further research should examine the EHBM with other genetic conditions.

Practice implications

This analysis using the EHBM suggests areas of importance for message development for both medical personnel and HH patients to promote diagnostic testing of at-risk siblings.     

A biomedical sensor system for real-time monitoring of astronauts’ physiological parameters during extra-vehicular activities

Objective

To design and test an embedded biomedical sensor system that can monitor astronauts’ comprehensive physiological parameters, and provide real-time data display during extra-vehicle activities (EVA) in the space exploration.

Methods

An embedded system was developed with an array of biomedical sensors that can be integrated into the spacesuit. Wired communications were tested for physiological data acquisition and data transmission to a computer mounted on the spacesuit during task performances simulating EVA sessions.

Results

The sensor integration, data collection and communication, and the real-time data monitoring were successfully validated in the NASA field tests.

Conclusions

The developed system may work as an embedded system for monitoring health status during long-term space mission.     

Shedding light on the dark side of doctor-patient interactions: verbal and nonverbal messages physicians communicate during error disclosures

Objective

Existing investigations on medical error disclosures have neglected the fact that a disproportionately large amount of the meaning in messages is derived from nonverbal cues. This study provides an empirical assessment of the verbal and nonverbal messages physicians communicate when disclosing medical errors to standardized patients.

Methods

Sixty hypothetical error disclosures by a volunteer sample of attending physicians were videotaped, coded, and statistically analyzed.

Results

Physicians used friendly, smooth, approaching and invested nonverbal styles as they disclosed medical errors to standardized patients. Female physicians smiled more and were more attentive to patients than male physicians, and physicians tended to exhibit more positive affect in the form of facial pleasantness toward angry female patients than toward angry male patients. Furthermore, physicians touched and smiled at patients more frequently at the beginning and at the end of their error disclosures, and displayed decreased attentiveness and interactional fluency.

Conclusion

Future research needs to examine which disclosure styles patients perceive as competent, and to assess their causal impacts on objective and relational disclosure outcomes.

Practice implications

This study provides an important baseline understanding of medical error disclosures that is essential for the successful implementation of empirically based training programs.     

Doctors in a Southeast Asian country communicate sub-optimally regardless of patients' educational background

Objective

To explore the relationship between the style of doctor-patient communication and patients’ educational background in a Southeast Asian teaching hospital setting using the Roter Interaction Analysis System (RIAS).

Methods

We analyzed a total of 245 audio-taped consultations involving 30 internal medicine residents with 7-10 patients each in the internal medicine outpatient clinics. The patients were categorized into a group with a high and a group with a low educational level. We ranked the data into 41 RIAS utterances and RIAS-based composite categories in order of observed frequency during consultations.

Results

The residents invariantly used a paternalistic style irrespective of patients’ educational background. The RIAS utterances and the composite categories show no significant relationship between communication style and patients’ educational level.

Conclusion

Doctors in a Southeast Asian country use a paternalistic communication style during consultations, regardless of patients’ educational background.

Practice implication

To approach a more partnership doctor-patient communication, culture and clinical environment concern of Southeast Asian should be further investigated.