Health status: patient and physician judgments.

Patients at a rehabilitation center in Derbyshire, England, were asked to assess their own functional abilities at admission and again at discharge, using an 82-item questionnaire concerning 12 areas of daily living. Questionnaire responses were correlated with results of physical examinations, assessments by center personnel, and assessments of capacity for specific body movements. The highest correlations were observed in areas that related most directly to physical movements and to dressing and toileting. The results suggest that self-assessment of health status using this questionnaire may provide a viable alternative to judgments made by trained assessors.     

Living wills and substituted judgments: a critical analysis

In the literature three mechanisms are commonly distinguished to make decisions about the care of incompetent patients: A living will, a substituted judgment by a surrogate (who may or may not hold the “power of attorney”), and a best interest judgment. Almost universally, the third mechanism is deemed the worst possible of the three, to be invoked only when the former two are unavailable. In this article, I argue in favor of best interest judgments. The evermore common aversion of best interest judgments entails a risk that health care providers withdraw from the decision-making process, abandoning patients (or their family members) to these most difficult of decisions about life and death. My approach in this article is primarily negative, that is, I criticize the alleged superiority of the living will and substituted judgment. The latter two mechanisms gain their alleged superiority because they are supposedly morally neutral, whereas the best interest judgment entails a value judgment on behalf of the patient. I argue that on closer inspection living wills and substituted judgments are not morally neutral; indeed, they generally rely on best interest judgments, even if those are not made explicit. This revised version was published online in July 2006 with corrections to the Cover Date.     

Shared decision making in hypertension: the impact of patient preferences on treatment choice

BACKGROUND:Recent guidelines for treatment of hypertension advocate a multifactorial approach based on absolute risk of a cardiovascular event. However, this does not take any account of individual patient values or preferences for health outcomes that result from having hypertension. OBJECTIVE:Our aim was to investigate the impact of patient preferences on treatment recommendations for hypertension using individual decision analysis. METHODS:We carried out an observational study based on interviews with 52 hypertensive patients. Patient preferences were measured using the standard gamble method. Associations between outcome of the individual decision analyses (recommendation to accept or decline antihypertensive medication) and treatment guidelines based on blood pressure and absolute cardiovascular risk were investigated. Adherence to medication during the 6 months following the interview was also assessed. RESULTS:Individual patient preferences have a substantial impact on the proportion of patients for whom drug treatment would be recommended. In 52 patients interviewed, decision analysis indicated that 29 [56%, 95% confidence interval (CI) 41--70] should be treated, compared with 27 (52%, 38--66) using a cardiovascular risk of > or =10% over 5 years and 19 (37%, 24--51) using a systolic blood pressure of > or =160 mmHG: There was marked disagreement between the decision analysis and these recommendations (kappas 0.18 or less). There was no relationship between outcome of the decision analysis and adherence to medication [chi-square (1 d.f.) = 0.5, P = 0.5]. CONCLUSIONS:Quantifying patients' preferences and using decision analysis as a shared decision-making aid appears to have an impact on whether patients would be recommended for antihypertensive medication. Further evaluation of this method as a shared decision-making tool is warranted.     

Cataract extraction: patient characteristics and preferences

This paper reports the results of a comparative study of inpatient and day case patients undergoing a cataract extraction with intraocular lens implant. An assessment was made of their home circumstances, and included questions about their health and hobbies before and after surgery. The results show that patients were generally optimistic about their capabilities after the operation, and that most were pleased to have been randomly allocated to their particular group. There were no statistically significant differences between day cases and inpatients, suggesting a possibility of choice for patients within available resources.     

Nutrition information needs during cardiac rehabilitation: perceptions of the cardiac patient and spouse

A survey instrument, which was developed from personal interviews with participants in a cardiac rehabilitation program, was administered at two hospital-based Phase II cardiac rehabilitation programs. Thirty-five patients (28 men, 7 women) and 29 spouses (5 men, 24 women) responded to survey items designed to investigate how subjects perceived themselves dealing with the cardiac diet, what questions they were asking, and how answers to those questions would help them. Subjects in the patient group (which was 80% male) most frequently asked questions dealing with compliance and the diet's benefits. Subjects in the spouse group (which was 83% female) most frequently asked questions relating to food selection. Participants indicated that having their questions answered would help them make decisions, be motivated, feel in control, and plan. Participants' overall attitude toward the diet was positive because patients were willing to make changes in their diet; however, more than half the sample thought food labels were difficult to understand and grocery shopping was difficult. We conclude that nutrition education programs that address individual needs and uses for nutrition information could enhance the learning process in group settings such as cardiac rehabilitation programs.     

Status of life-areas: congruence/noncongruence in ESRD patient and spouse perceptions

Perceptions of ESRD patients' satisfaction with, and abilities in, 13 life-areas were assessed in 50 patients and their spouses by means of a series of linear rating scales. Patient and spouse views were congruent on 10 dimensions. Noncongruence existed only on perception of the patient's satisfaction with his/her medical situation, perception of the patient's ability to care for self, and perception of the patient's satisfaction with feelings about self. This noncongruence was especially pronounced in certain patient subgroups, and explanations related to the nature of ESRD and its treatment are suggested. We recommend that future studies examine not only perceptions of patients' satisfaction but also perceptions of the spouse's own satisfaction with various life-areas.     

Predictors of patient entry into alcohol treatment after initial diagnosis

To improve the quality of care for alcohol-related disorders, key transitions in the continuum of care, including treatment entry, must be fully understood. The purpose of this study was to investigate identifiable predictors of patient entry into a substance-use treatment program following the initial diagnosis of an alcohol-related disorder on a medical or surgical inpatient unit. An administrative computerized database was used to identify the sample for this study. Inpatient and outpatient records were obtained from the Little Rock VAMC/DHCP. Predictors of patient entry into treatment within six months of the initial diagnosis of an alcohol related disorder included age younger than than 60 (odds ratio [OR]=4.6), not married (OR=1.7), primary diagnosis of an alcohol-related disorder (OR=7.7), diagnosis of a comorbid drug (OR=4.3) or psychiatric disorder (OR=3.6), diagnosis by a medical as opposed to a surgical specialty (OR=6.0), and African American (OR=1.7).     

Nutritional management of the adult patient undergoing peritoneal dialysis.

Until the last few years, maintenance peritoneal dialysis (PD) often was associated with progressive wasting due to frequent episodes of peritonitis, loss of considerable amounts of protein into the dialysate, and poor nutritional intake. Recently, available techniques have made PD a feasible alternative for the long-term care of the patient with end-stage renal failure. The incidence of peritonitis has been markedly reduced, and protein loss is only 4 to 20 gm. per dialysis treatment. Preliminary studies have shown no differences in the nutritional status of patients undergoing PD or hemodialysis, although both groups have evidenced malnutrition. In the patient undergoing PD, daily intakes of 1.2 to 1.5 gm. protein and 35 kcal per kilogram body weight are recommended. During times of stress, parenteral administration of nutrients may be necessary. Dietary supplements may often be required chronically. Careful studies are needed to difine the nutritional needs of the patient undergoing PD.     

The other side of teledermatology: patient preferences

We studied patient preferences for a real-time teledermatology consultation or a conventional dermatology consultation. Dermatology patients were given the option of being seen by a dermatologist at their outlying primary care site via telemedicine or of being examined face-to-face by the same dermatologist at the primary care site. The same dermatologist provided the teleconsultations and the conventional consultations. During a 16-month study period, 52 patients were evaluated via telemedicine and 46 patients were seen face-to-face. The demographics for both study groups were similar. Those patients who selected telemedicine were more likely to have seen a dermatologist fewer than twice during the previous year, more likely to self-describe themselves in excellent health and more likely to choose a face-to-face evaluation when presenting with a possible skin cancer or a mole. Patients aged 56 years or less tended to be more likely to be seen via telemedicine, although the association with age was not significant (P = 0.06). This information may help providers to devise strategies to direct patients to telemedicine if and when it is appropriate.     

Predictors of inappropriate hospital stay: a clinical case study.

OBJECTIVE: To assess the reasons for inappropriate patient stay (IPS) and to identify possible predictors of this inappropriate stay. DESIGN: The reasons for IPS were analyzed in a cross-sectional survey at two surgical one gynecologic and one obstetric ward, using a sample of 610 days of hospital stay by means of the Dutch Appropriateness Evaluation Protocol. SETTING: The study was conducted at the University Hospital Maastricht, a 715-bed hospital with a regional and teaching function, located in the southern part of The Netherlands. RESULTS: Results indicate that > 20% of the hospital stay was inappropriate. The reasons for IPS were statistically significantly related to the patients' age, the availability of home care and medical specialty. In a predictive model, only the specialty proved to be a predictor of IPS. Most of the IPS occurred during the first days of hospital stay and the days before the patient's discharge. CONCLUSION: A substantial proportion of hospital stay was found to be inappropriate, due to hospital procedures and the inability to refer patients to other care facilities or care providers. Analysis of the causes of IPS provided useful data for improvement actions. Efficient use of hospital resources should be promoted by reducing the delay in interventions and discharge procedures.     

Negotiating access to medical treatment and the making of patient citizenship: the case of hepatitis C treatment

Drawing on qualitative interview accounts with people who have injected drugs, we deploy ideas of biological and therapeutic citizenship to explore how the negotiation of access to hepatitis C treatment enacts patient citizenship potential. We find that the patient citizenship made through hepatitis C treatment divides those who are deserving from those who are not, largely in relation to their presentations of self‐control, responsibility and recovery regarding drug use. Accessing treatment requires that patients negotiate their entitlement by reflexively producing the patient citizen role expected of them. In this context of rationed treatment expectation, access to treatment is constructed in relation to gratitude rather than entitlement. Rationed treatment expectation also interplays with a utilitarian approach to hepatitis C expertise. Accounts of the bio‐effects of hepatitis C and its treatment as uncertain further weaken the potential for shared illness identity and biosocial membership as well as contributing to treatment delay. We conclude that the construction of hepatitis C treatment as a negotiation of ‘recovery towards normality’ positions people who continue to use or inject drugs as beyond patient citizenship. Our findings underscore the situated limits of therapeutic and biological citizenship, emphasising that these processes are unavoidably forces of governance.     

Predictors of satisfaction with surgical treatment.

OBJECTIVE: To investigate prospectively which medical, psychosocial or treatment-related factors predicted treatment satisfaction and to evaluate the adequacy of a preceding retrospective study which had examined the same factors. Furthermore, to examine the predictors and the stability of the major determinants of patient treatment satisfaction. DESIGN: Assessments made before admission, at discharge and 2 and 4 months after discharge were used to predict both the level and the rate of change in satisfaction with different aspects of treatment. SETTING: Three surgical departments at a University Hospital. STUDY PARTICIPANTS: Four-hundred and eighty-two patients electively admitted for several surgical conditions. RESULTS: The central treatment-related measures were the same in the retrospective and prospective studies: global satisfaction with treatment (GS), perceived quality of contact with the nursing (QCN) and medical staff (QCM) and provision of adequate treatment information (INF). More of the variance in GS was explained in the prospective study (48.7% versus 36.3%). GS was most influenced by treatment-related factors with QCN as the strongest predictor in both studies. Only a small portion of the variance in QCN and QCM could be accounted for by the characteristics of the patients. INF was predicted by characteristics of the patients, their illness and life situation and by treatment-related factors. QCN was the strongest predictor of INF. The relationships with the nursing and medical personnel appear to be the major determinants of both patient treatment satisfaction and patients' reception of adequate information about their condition and its treatment.     

Further insight into the perception of quantitative information: judgments of gist in treatment decisions.

PURPOSE: To compare relative accuracy and relative response times (RTs) as well as impact of foreground and background colors in a treatment decision context of judging larger/smaller when the following elements are added to the graphics studied previously: 1) a number (the displayed percentage), 2) a referent scale, and 3) a number and a referent scale. METHOD: An experiment compared pie charts, vertical bars, horizontal bars, digits, systematic ovals, and random ovals. On each trial, participants saw 2 percentages (in 1 format) and were asked to choose the larger chance of survival or the smaller chance of side effects. Outcomes were errors and RT. Formats were either black and white or blue and yellow; background color was either white or blue. Participants were 216 volunteers from the community older than 50 years. RESULTS: Formats with a number produced the same relative errors and relative RT as the formats with a number and scale. Formats with only a scale, however, shifted relative performance: Errors increased with more difficult formats (pie charts and random ovals by 3%-4% v. approximately 1% with other formats), but RT decreased with easier formats (vertical bars, horizontal bars, and systematic ovals decreased 100-200 ms v. an increase of 0-300 ms with other formats). Vertical bars with scales were the fastest and most accurately processed. Neither foreground nor background color had any impact on either outcome. CONCLUSIONS: For supporting older people's judgments of relative extent, risk information is best presented using vertical bars with a scale; the format systematic ovals with a scale are among the next most easily processed.     

Predicting elderly outpatients' life-sustaining treatment preferences over time: the majority rules.

BACKGROUND: This study describes longitudinal changes in the composition and accuracy of modal life-sustaining treatment preferences as predictors of patients' treatment preferences. METHOD: Healthy outpatients age 65 and older and their surrogate decision makers recorded preferences for 4 treatments in 9 hypothetical illness scenarios 3 times over a period of 2 years. A statistical prediction model, based on patients' modal preferences, was created using initial responses and updated 2 years later. RESULTS: When reestimating the model at 2 years, 4 of 27 items in the model created using baseline responses no longer reached the threshold for inclusion, but 5 new items did meet criteria. All modal preference changes reflected a trend toward refusing treatment. Both the original and updated models were more accurate in predicting patients' preferences than were surrogates making concurrent predictions. Adding covariates (e.g., gender, age, presence of plans for future medical care) did not alter the model's predictive superiority over surrogates. CONCLUSIONS: Models using modal preferences are useful to patients, surrogates, and physicians when trying to accurately discern end-of-life treatment choices, but the models must be updated periodically.     

Symptom-based outcome measures for asthma: the use of discrete choice methods to assess patient preferences.

This paper reports on an application of discrete choice modelling to the measurement of patient preferences over asthma symptoms. A sample of patients with moderate to severe asthma was asked to choose between a series of pairs of scenarios characterised by different combinations of asthma symptoms. Their responses were analysed using a random effects ordered probit model. The results implied that patients weighted some symptoms more highly than others. Discrete choice modelling proved to be a useful approach for developing preference based outcome measures, although the results show how, in contexts where preferences over health care outcomes based on symptoms or some measure of health status are involved, a conventional linear additive model may not always be suitable.     

Balancing statistical data and clinician judgments in the diagnosis of patient educational needs

Survey content is necessarily limited by the investigators' foresight and by prior research on their subject of inquiry. Clinical data must supplement statistical data whenever the prior research is insufficient to delineate exactly what problems to expect. The differing perspectives on needs of patients sometimes set up competing demands. This calls for strategies based on a programmatic or population perspective that identifies the commonalities in patient educational needs from the statistical profiles, while at the same time allowing for the development of interventions that provide for as much tailoring of the educational experience based on clinical judgments as possible. By combining the community health education perspective with a clinical perspective, we were able to design interventions that responded to the educational needs of a population of low-income, black hypertensive patients. A needs assessment process that combined these perspectives began with a historical and community assessment of the problem in its most general terms. A second phase focused on the most important behavioral and organizational points for intervention. A third phase required formal assessment of predisposing, enabling, and reinforcing factors that may be determining the priority behaviors of health care organizational problems. Finally, clinical and administrative judgment sharpened and supplemented the educational interventions that were suggested by statistical data from formal surveys. Behavioral science theory was applied usefully in all these phases.At the time this study was conducted, the authors were all with the Health Services Research and Development Center and Division of Health Education, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21205. Dr. Green is now Director of the Office of Health Promotion, DHEW. Dr. Lewis is currently with the Department of Community Health Care Systems, School of Nursing, University of Washington, Seattle. Correspondence and reprint requests should be addressed to Lawrence W. Green, Office of Health Promotion, Office of the Assistant Secretary for Health, U.S. Department of Health, Education, and Welfare, Room 721B, Hubert Humphrey Building, 300 Independence Avenue, S.W., Washington, D.C. 20201.Parts of this paper were presented at the Second Annual Needs Assessment Conference, March 28–31, 1978, in Louisville, Kentucky; the National Conference on High Blood Pressure Control, Los Angeles, April 3, 1978; and Endocrinology Rounds at the Indiana University Diabetes Research and Training Institute, Indianapolis, January 29, 1979. This research was supported by Grant Nos. 1R25 HL 17016-03 and IT32-H10710 from the National Heart, Lung, and Blood Institute. The authors would like to acknowledge the support and consultation of Drs. Carol Johns and R. Patterson Russell of the Johns Hopkins Hospital and of Robert Bertera, Michael Bowler, A. Judith Chwalow, Sigrid Deeds, Marion Field Fass, Brian Flynn, Michael Gross, Donald Morisky, Patricia Mullen, and Sam Shapiro of the Health Services Research and Development Center and the School of Hygiene and Public Health, Johns Hopkins University.