How poorer quality of life in adolescence predicts subsequent type 1 diabetes management and control

Objective

Detriments in quality of life (QOL) may contribute to the common, costly decline in adolescents’ type 1 diabetes management and control, yet we know little about how this might happen.

Methods

Participants were 150 adolescents (age 13–18) with type 1 diabetes and their parents. We constructed a latent QOL variable from a multi-informant, multi-domain assessment when participants entered the study. The QOL variable was examined in relation to prospective assessments of diabetes management (blood glucose monitoring frequency; BGM) and control (hemoglobin A1c). We used an indirect path model to test the links among these variables, using bias-corrected bootstrapping.

Results

Poorer QOL at baseline was indirectly linked with higher A1c at 12 months via less frequent BGM obtained at 6 months (b = −0.01, 95% CI = −0.025, −0.004, p < 0.05). Older age (b = −0.32), longer diabetes duration (b = −0.07), and insulin delivery via injections versus the insulin pump (b = 0.67) were covariates of less frequent BGM, and unmarried caregiver status was associated with higher A1c (b = −0.76), all ps < 0.05.

Conclusions

In this study, poorer QOL acted as a barrier to effective diabetes management, subsequently altering diabetes control.

Practice implications

Efforts to monitor and enhance QOL may hold promise for improving adolescents’ diabetes outcomes in the future.     

Self-management support in “real-world” settings: An empowerment-based intervention

Objective

This study examined the impact of a 6-month, empowerment-based diabetes self-management support (DSMS) intervention on clinical outcomes, self-care behaviors, and quality of life (QOL) compared to a 6-month control period.

Methods

This control-intervention cohort study recruited 77 African-American adults with type 2 diabetes. Baseline, 6-month, and 12-month assessments measured A1C, weight, body mass index (BMI), blood pressure, lipids, self-care behaviors, and QOL. During the control period, participants received weekly educational newsletters. During the intervention period, participants attended weekly DSMS groups as frequently as they needed. Sessions were guided by participants’ self-management questions and concerns, and also emphasized experiential learning, coping, problem-solving, and goal-setting.

Results

The control period found significant improvements for diastolic BP (p < 0.05), serum cholesterol (p < 0.001), following a healthy diet (p < 0.01), and monitoring blood glucose (p < 0.01). The intervention period found significant additional improvements for A1C (p < 0.001), weight (p < 0.05), BMI (p < 0.05), and LDL (p < 0.001). Compared to the control period, participation in the intervention led to a significant reduction in A1C (p < 0.01).

Conclusion

Findings suggest that an empowerment-based, DSMS intervention is promising for improving and/or maintaining diabetes-related health, particularly A1C.

Practical implications

Incorporating empowerment principles in DSMS interventions may be useful for supporting patients’ self-management efforts in “real-world” settings.     

Talking about obesity with clients: Preferred terms and communication styles of UK pre-registration dieticians,doctors, and nurses

Objective

To describe trainee healthcare professionals’ preferred terms when talking about obesity, their beliefs about initiating discussions about weight, and their confidence about consulting with obese people.

Methods

A self-completed questionnaire collected data on demographics, preferred terms, beliefs about initiation of discussions, confidence and training needs from 1036 pre-registration dieticians, nurses and doctors.

Results

Participants’ preferred terms when raising the issue of obesity with clients were BMI (mean = .96), weight (mean = .71) and unhealthy BMI (mean = .43). When defining a client's bodyweight, students endorsed the euphemism ‘your weight may be damaging your health’ (67.6%). A proactive, collaborative communication style was preferred by 34.9% of participants. 58.2% of participants felt confident about discussing obesity with clients and 95.1% felt that that more training would be useful.

Conclusion

It is reassuring that UK trainee healthcare professionals avoid value-laden terms and broadly endorse words preferred by people with obesity. It is, however, concerning that the majority of participants did not favor a proactive, collaborative communication style.

Practice implications

Educators of tomorrow's healthcare professionals could take advantage of students’ desire for more training on how to effectively talk to clients with obesity about their weight. Such training would, however, require the development of clear guidelines on terminology and communication styles.     

Provider communication effects medication adherence in hypertensive African Americans

Objective

To evaluate the effect of patients’ perceptions of providers’ communication on medication adherence in hypertensive African Americans.

Methods

Cross-sectional study of 439 patients with poorly controlled hypertension followed in community-based healthcare practices in the New York metropolitan area. Patients’ rating of their providers’ communication was assessed with a perceived communication style questionnaire,while medication adherence was assessed with the Morisky self-report measure.

Results

Majority of participants were female, low-income, and had high school level educations, with mean age of 58 years. Fifty-five percent reported being nonadherent with their medications; and 51% rated their provider's communication to be non-collaborative. In multivariate analysis adjusted for patient demographics and covariates (depressive symptoms, provider degree), communication rated as collaborative was associated with better medication adherence (β = −.11, p = .03). Other significant correlates of medication adherence independent of perceived communication were age (β = .13, p = .02) and depressive symptoms (β = −.18, p = .001).

Conclusion

Provider communication rated as more collaborative was associated with better adherence to antihypertensive medications in a sample of low-income hypertensive African-American patients.

Practice implications

The quality of patient–provider communication is a potentially modifiable element of the medical relationship that may affect health outcomes in this high-risk patient population.     

Shared decision-making in cardiology: Do patients want it and do doctors provide it?

Objective

Doctors should involve their patients in making decisions about their care. We studied patients with heart disease to assess if shared decision-making occurs and to study factors that predict patients’ choices or influence cardiologists’ behaviour.

Methods

85 patients attending for arteriography were assessed to elicit preferred involvement in decision-making, perception of involvement, and confidence in the decision.

Results

40% of patients wished to be involved in decisions. Preferences were unrelated to demographic factors. Cardiologists involved patients more in decisions concerning severe disease (p = 0.056). Involvement varied between cardiologists (p = 0.001). The mean duration of consultations was 5.5 min. Patients’ confidence in decisions correlated with duration (p = 0.001), explicit reference to a decision that needed to be made (p = 0.0026), and perceived, but not observed, involvement in decision-making (p = 0.05).

Conclusion

This study highlighted the complexity of doctor–patient communication. Irrespective of preferences for involvement, patients were more confident in decisions in which they perceived more involvement or which were the products of longer consultations.

Practice implications

Patients’ confidence in clinical decisions can be increased by increasing consultation length and increasing their perception of involvement. Patients perceive more involvement in decisions when doctors specifically identify the need for treatment decisions early in the consultation.     

Avoiding the term ‘obesity’: An experimental study of the impact of doctors’ language on patients’ beliefs

Objective

GPs sometimes use euphemisms rather than medical terms. The present study aimed to explore the relative impact of using the term ‘obese’ compared to GPs’ preferred euphemism on patients’ beliefs about the problem.

Methods

A cross sectional survey followed by an experimental study was used with two conditions: the term ‘obese’ versus the GPs’ preferred euphemism. In the cross sectional survey, GPs’ (n = 19) described their preferred use of term. In the experimental study, patients (n = 449) from one General Practice in West London then completed a set of ratings about their beliefs following a vignette using either the term ‘obese’ or the GPs’ preferred euphemism.

Results

The first stage of the study showed that GPs avoided using the term ‘obese’ and preferred to use a euphemism. The most commonly used euphemism was ‘your weight may be damaging your health’. The second stage showed that the term ‘obese’ made patients believe that the problem had more serious consequences and made them feel more anxious and upset than when the same symptoms were labelled using the euphemism. When analysed according to the patient's own BMI, however, the results showed that the term ‘obese’ had a greater emotional impact than the euphemism only on patients who were not obese; obese patients found the euphemism more upsetting.

Conclusion

GPs avoid using the term ‘obese’ for fear of upsetting patients. This term, whilst making the problem appear more serious is only more upsetting for non-obese patients.

Practice implications

GPs choice of term therefore needs to reflect whether they want the patients to be upset or whether they want them to accept the seriousness of their problem.     

Communication matters: The impact of communication and participation in decision making on breast cancer patients’ depression and quality of life

Objective

This study explored the impact of breast cancer patients’ experiences of physician–patient communication and participation in decision making on patient depression and quality of life three and six months after primary treatment.

Methods

Participants were 135 German breast cancer patients, recruited within a week after the beginning of treatment. Women were asked to complete a self-administered questionnaire at baseline and three and six months later.

Results

Patients who rated their level of information at baseline as high were less depressed after three (p = .010) and six months (p < .001) and experienced higher quality of life after three (p < .001) and six months (p = .049). Patients who participated as much as they had wanted were more satisfied with the decision making process (p < .001) and had lower depression scores three months later (p = .005). The level of participation itself (passive, collaborative, active) and the treatment type had no impact.

Conclusion

The findings reveal the significance of physician–patient communication and stress the meaning of baseline depression for later adjustment.

Practice implications

A high level of information and tailoring the involvement in decision making to patients’ desired level can help patients to better cope with their illness. Physicians should assess and treat depression early in cancer treatment.     

Implementation and outcomes of telephone disclosure of clinical BRCA1/2 test results

Objectives

With an increasing demand for genetic services, effective and efficient delivery models for genetic testing are needed.

Methods

In this prospective single-arm communication study, participants received clinical BRCA1/2 results by telephone with a genetic counselor and completed surveys at baseline, after telephone disclosure (TD) and after in-person clinical follow-up.

Results

Sixty percent of women agreed to participate; 73% of decliners preferred in-person communication. Anxiety decreased from baseline to post-TD (p = 0.03) and satisfaction increased (p < 0.01). Knowledge did not change significantly from baseline to post-TD, but was higher post-clinical follow-up (p = 0.04). Cancer patients had greater declines in state anxiety and African-American participants reported less increase in satisfaction. 28% of participants did not return for in-person clinical follow-up, particularly those with less formal education, and higher post-disclosure anxiety and depression (p < 0.01).

Conclusions

Telephone disclosure of BRCA1/2 test results may not be associated with negative cognitive and affective responses among willing patients, although some subgroups may experience less favorable responses. Some patients do not return for in-person clinical follow-up and longitudinal outcomes are unknown.

Practice implications

Further evaluation of longitudinal outcomes of telephone disclosure and differences among subgroups can inform how to best incorporate telephone communication into delivery of genetic services.     

Impact of life-threatening risk information on the evolution of patients’ anxiety and risk recall: The specific context of informed consent for experimental stem cell transplant

Objective

This study examines risk recall and evolution of patients’ anxiety after transmission of life-threatening risk information in an informed consent procedure for experimental HSCT.

Methods

Informed consent interviews were audio-recorded and transcribed. Patient risk recall was obtained through comparing information provided in the interview to information recalled by patients following the interview. The evolution of patients’ anxiety was assessed through comparing patients’ post- to patients’ pre-interview anxiety using the STAI-State. Physicians’ communication skills and risk framing were analyzed.

Results

Twenty patients were included. Patients recalled on average 4 risks (S.D. = 1.6) out of 9 different risks transmitted (S.D. = 2) which corresponds to a recall rate of 44% (S.D. = 15.5). Patients’ anxiety remained on average stable (Mean = 0.4; S.D. = 9.1). Linear regression analysis showed that risk recall was predicted positively by the number of risks transmitted (B = .30; P = .032) and by patients’ problem-focused coping (B = .21; P = .008). The evolution of anxiety was predicted positively by the number of times benefits were transmitted (B = .83; P = .003) and negatively by the level of anxiety before the interview (B = −.50; P = .001).

Conclusion

Results show the limits of patients’ risk recall in the context of informed consent for a life-threatening procedure.

Practice implications

This study highlights the necessity to develop strategies allowing tailoring of risk transmission to every patient's needs.     

Does being informed and feeling informed affect patients’ trust in their radiation oncologist?

Objective

We investigated whether the content of information provided by radiation oncologists and their information giving performance increase patients’ trust in them.

Methods

Questionnaires were used to assess radiotherapy patients (n = 111) characteristics before their first consultation, perception of information giving after the first consultation and trust before the follow-up consultation. Videotaped consultations were scored for the content of the information provided and information giving performance.

Results

Patients mean trust score was 4.5 (sd = 0.77). The more anxious patients were, the less they tended to fully trust their radiation oncologist (p = 0.03). Patients’ age, gender, educational attainment and anxious disposition together explained 7%; radiation oncologists’ information giving (content and performance) explained 3%, and patients’ perception of radiation oncologists’ information-giving explained an additional 4% of the variance in trust scores.

Conclusion

It can be questioned whether trust is a sensitive patient reported outcome of quality of communication in highly vulnerable patients.

Practice implications

It is important to note that trust may not be a good patient reported outcome of quality of care. Concerning radiation oncologists’ information giving performance, our data suggest that they can particularly improve their assessments of patients’ understanding.     

Development of a behaviour change communication tool for medical students: The ‘Tent Pegs’ booklet

Objective

To describe the development and validation of a behaviour change communication tool for medical students.

Methods

Behaviour change techniques (BCTs) were identified within the literature and used to inform a communication tool to support medical students in discussing health-related behaviour change with patients. BCTs were organized into an accessible format for medical students (the ‘Tent Pegs’ booklet) and validated using discriminant content validity methods with 11 expert judges.

Results

One-sample t-tests showed that judges reliably mapped BCTs onto six of the seven Tent Pegs domains (confidence rating means ranged from 4.0 to 5.1 out of 10, all p ≤ 0.002). Only BCTs within the ‘empowering people to change’ domain were not significantly different from the value zero (mean confidence rating = 1.2, p > 0.05); these BCTs were most frequently allocated to the ‘addressing thoughts and emotions’ domain instead.

Conclusion

BCTs within the Tent Pegs booklet are reliably allocated to corresponding behaviour change domains with the exception of those within the ‘empowering people to change’ domain.

Practice implications

The existing evidence-base on BCTs can be used to directly inform development of a communication tool to support medical students facilitate health behaviour change with patients.     

Older cancer patients’ information and communication needs: What they want is what they get?

Objective

To evaluate what information and communication aspects older cancer patients (≥65) consider important in preparing for chemotherapy treatment (CT), the extent to which this corresponds with what oncology nurses consider important, and the extent to which nurses attend to these aspects during real-life educational visits in oncology.

Methods

The QUOTE^chemo was used to have patients (n = 116) and nurses (n = 123) rate the importance of 66 aspects of patient education. Subsequently, the implementation of these 66 aspects during videotaped nursing visits (n = 155) with older cancer patients receiving CT for the first time was examined.

Results

Older cancer patients attached most importance to ‘treatment-related information’, ‘rehabilitation information’, ‘affective communication’ and discussing ‘realistic expectations’. Nurses placed great importance to almost all aspects except to discussing ‘realistic expectations’. Discrepancies were found between expressed importance and the actual performance during the videotaped consultations, particularly in discussing realistic expectations, coping information, interpersonal communication, and tailored communication.

Conclusion

Results pointed to aspects that need improvement to ensure high quality patient education tailored to the patients’ needs.

Practice implications

To make sure older cancer patients’ needs are met, more attention should be paid to the development of interventions supporting both needs assessment and fulfillment.     

Mastery and perceived autonomy support are correlates of Dutch diabetes patients’ self-management and quality of life

Objective

The aim of this study was to assess the associations between type 2 diabetes patients’ mastery and perceived autonomy support and their self-management skills and health-related quality of life (HRQOL).

Methods

A cross-sectional questionnaire survey was conducted among 3352 patients with type 2 diabetes. Key variables were assessed with validated questionnaires.

Results

Patients’ mastery and perceived autonomy support correlated positively with their self-management skills (r = 0.34, p < 0.001; r = 0.37, p < 0.001) and HRQOL (r = 0.37, p < 0.001; r = 0.15, p < 0.001). In the linear regression analysis, mastery and perceived autonomy support were positive correlates of self-management (β = 0.23; p < 0.001; β = 0.25; p < 0.001). Patients with more physical or psychological complications had significantly lower scores on mastery, perceived autonomy support, self-management and HRQOL.

Conclusion

Our results indicate the importance of mastery in relation to diabetes patients’ perceived autonomy support, self-management skills and HRQOL.

Practice implications

Since a greater sense of mastery is likely to increase patients’ autonomous motivation to cope with their disease, interventions can aim to influence patients’ motivational regulation. In addition, we confirmed the need for autonomy support to improve patients’ self-management skills. Professionals can be trained to be autonomy-supportive, which relates to person-centered approaches such as motivational interviewing (MI).     

Existing instruments for assessing physician communication skills: Are they valid in a computerized setting?

Objectives

This study aims to highlight the differences in physicians’ scores on two communication assessment tools: the SEGUE and an EMR-specific communication skills checklist. The first tool ignores the presence of the EMR in the exam room and the second, though not formally validated, rather focuses on it.

Methods

We use the Wilcoxon Signed Ranks Test to compare physicians’ scores on each of the tools during 16 simulated medical encounters that were rated by two different raters.

Results

Results show a significant difference between physicians’ scores on each tool (z = −3.519, p < 0.05 for the first rater, and z = −3.521, p < 0.05 for the second rater), while scores on the EMR-specific communication skills checklist were significantly and consistently lower.

Conclusion

These results imply that current communication assessment tools that do not incorporate items that are relevant for communication tasks during EMR use may produce inaccurate results.

Practice implications

We therefore suggest that a new instrument, possibly an extension of existing ones, should be developed and empirically validated.     

Giving residents tools to talk about behavior change: A motivational interviewing curriculum description and evaluation

Objective

To determine whether a motivational interviewing (MI) curriculum is effective in teaching internal medicine residents core MI skills and the empathic, nonjudgmental MI style.

Methods

Nineteen third-year residents met for 12 h with a faculty instructor. Teaching methods included lecture, written exercises, a simulated patient exercise, and discussion of residents’ behavior change issues.

Results

Residents’ adoption of MI skills was evaluated before and after the course with the Helpful Responses Questionnaire. Residents decreased use of closed-ended questions (from a score of 1.13 to 0.37, p = 0.036) and MI roadblocks (4.00–1.08, p < 0.001), and increased the use of reflections (1.87–4.87, p < 0.001), and use of MI strategies (0.45–0.97, p = 0.017). Residents’ use of open-ended questions decreased from 1.97 to a mean of 1.05, p = 0.023. Residents’ ratings of the course on a 5-point scale varied from 3.7 for written exercises to 4.6/5 for the simulated patient exercise. After the course, residents rated behavior change counseling skills as more important.

Discussion and conclusion

A 12-h course increased residents’ use of core MI communication skills in a written measure, and was highly rated.

Practice implications

Future work should examine whether teaching of the empathic, collaborative MI stance impacts patient outcomes.     

What parents want from emails with their pediatrician: Implications for teaching communication skills

Objective

Physician–patient email communication is increasing but trainees receive no education on this communication medium. Research eliciting patient preferences about email communication could inform training. Investigators elicited parents’ perspectives on physician–parent email communication and compared parent and faculty assessments of medical students’ emails.

Methods

This mixed methods study explored physician–parent email communication in 5 parent focus groups using qualitative analyses to identify themes. Differences between faculty and parent assessment scores for students’ email responses were calculated using univariate general linear modeling.

Results

Themes that emerged were: (1) Building the Relationship, (2) Clarity of Communication and (3) Expectations. Parents criticized student's statements as condescending. The sum of assessment scores by parents and faculty were moderately correlated (r(44) = .407, P < .01), but parents gave students lower scores on “acknowledges validity/expresses empathy” (P = .01) and higher scores on “provides next steps” (P < .01) and “identifies issues” (P < .01).

Conclusion

Parents place value on students’ abilities to communicate clearly and convey respect and empathy in email. Parent and faculty perspectives on email communication are similar but not the same.

Practice implications

Differences between parental and faculty assessments of medical students’ emails supports the need for the involvement of patients and families in email communication curriculum development.     

Patients’ trust in their physician—Psychometric properties of the Dutch version of the “Wake Forest Physician Trust Scale”

Objective

Aim was to investigate the psychometric properties of a Dutch version of the “Wake Forest Physician Trust Scale”, which intends to measure patients’ trust in their physician.

Methods

A random sample of internal medicine patients visiting the outpatient clinic completed the questionnaire (N = 201). Dimensionality, reliability and validity of the instrument were examined.

Results

The structure of the questionnaire was best explained by a unidimensional construct. Reliability was confirmed: internal consistency was high (α = .88), and mean item-total correlations were all above .40. Construct validity was indicated by patients’ trust in their physician correlating significantly and as hypothesized with (1) satisfaction with their physician (r = .64), (2) with the length of the patient–physician relationship (r = .28), (3) with their willingness to recommend their physician (r = .71) and (4) their unwillingness to switch their physician (r = .61).

Conclusion

The results suggest the Dutch version of the Wake Forest Physician Trust Scale to be a psychometrically sound instrument to assess patients’ interpersonal trust.

Practice implications

Trust is a key feature of the patient–physician relationship, yet has been scarcely researched in other than Anglophone cultures. An adequate Dutch trust questionnaire forms the first step to gaining more knowledge about patient–physician trust in another culture and health care setting.     

Patient–clinician information engagement increases treatment decision satisfaction among cancer patients through feeling of being informed

Objective

Examine how patient–clinician information engagement (PCIE) may operate through feeling informed to influence patients’ treatment decision satisfaction (TDS).

Methods

Randomly drawn sample (N = 2013) from Pennsylvania Cancer Registry, comprised of breast, prostate and colon cancer patients completed mail surveys in the Fall of 2006 (response rate = 64%) and Fall of 2007. Of 2013 baseline respondents, 85% agreed to participate in follow-up survey (N = 1703). Of those who agreed, 76% (N = 1293) completed follow-up surveys. The sample was split between males and females. The majority of participants were White, over the age of 50, married, and with a high school degree. Most reported having been diagnosed with in situ and local cancer.

Results

PCIE was related to concurrent TDS (β = .06) and feeling informed (β = .15), after confounder adjustments. A mediation analysis was consistent with PCIE affecting TDS through feeling informed. Baseline PCIE predicted feeling informed (β = .04) measured 1 year later, after adjustments for baseline feeling informed and other confounders. Feeling informed was related to concurrent TDS (β = .35) after confounder adjustment and follow-up TDS (β = .13) after baseline TDS and confounder adjustment.

Conclusion

Results suggest PCIE affects TDS in part through patients’ feeling informed.

Practice implications

PCIE may be important in determining patients’ level of feeling informed and TDS.     

Physicians’ decision-making style and psychosocial outcomes among cancer survivors

Objective

We evaluated pathways linking physicians’ decision-making style with cancer survivors’ health-related quality of life (HRQOL).

Methods

We analyzed survey data from 623 survivors diagnosed with leukemia, colorectal, or bladder cancer in Northern California, 2–5 years prior to the study. Of these, 395 reported making a medical decision in the past 12 months and were asked about their physician's decision-making style. We evaluated the association of physician style with proximal communication outcomes (trust and participation self-efficacy), intermediate cognitive outcomes (perceived control and uncertainty), and distal health outcomes (physical and mental HRQOL).

Results

Overall, 54% of survivors reported a sub-optimal decision-making style for their physician. With the exception of physical health, physician style was associated with all proximal, intermediate, and distal outcomes (p ≤ 0.01). We identified two significant pathways by which a participatory physician style may be associated with survivors’ mental health: (1) by increasing survivors’ participation self-efficacy and thereby enhancing their perceptions of personal control (p < 0.01); (2) by enhancing survivors’ level of trust and thereby reducing their perceptions of uncertainty (p < 0.05).

Conclusion

A participatory physician style may improve survivors’ mental health by a complex two-step mechanism of improving survivors’ proximal communication and intermediate cognitive outcomes.

Practice implications

Physicians who adopt a participatory decision-making style are likely to facilitate patient empowerment and enhance patients’ HRQOL.     

Does health coaching change patients’ trust in their primary care provider?

Objective

To assess the impact of health coaching on patients’ in their primary care provider.

Methods

Randomized controlled trial comparing health coaching with usual care.

Participants

Low-income English or Spanish speaking patients age 18–75 with poorly controlled type 2 diabetes, hypertension and/or hyperlipidemia.

Main outcome measure

Patient trust in their primary care provider measured by the 11-item Trust in Physician Scale, converted to a 0–100 scale.

Analysis

Linear mixed modeling.

Results

A total of 441 patients were randomized to receive 12 months of health coaching (n = 224) vs. usual care (n = 217). At baseline, the two groups were similar to those in the usual care group with respect to demographic characteristics and levels of trust in their provider. After 12 months, the mean trust level had increased more in patients receiving health coaching (3.9 vs. 1.5, p = 0.47), this difference remained significant after adjustment for number of visits to primary care providers (adjusted p = .03).

Conclusions

Health coaching appears to increase patients trust in their primary care providers.

Practice Implications

Primary care providers should consider adding health coaches to their team as a way to enhance their relationship with their patients.