Shared decision making for the allergist

ObjectiveShared decision making (SDM) is becoming more commonly appreciated and used in medical practice as a way to empower patients who are facing treatment preference-sensitive conditions, such as allergic rhinitis, atopic dermatitis, food allergy, and persistent asthma. The purpose of this review is to educate the allergy health care provider about how SDM works and provide practical advice and allergist-specific SDM resources.Data SourcesPubMed and online patient decision aid resources.Study SelectionsStudies and reviews relevant to SDM and patient decision aids relevant to the allergy health care provider were selected for discussion.ResultsThere are ethical, practical, economic, and psychological imperatives for the implementation of quality SDM, particularly for chronic diseases. Many benefits and barriers of SDM have been identified and models have been developed to encourage implementation of quality SDM. For the allergy health care provider, SDM for asthma has been shown to improve adherence, outcomes, and patient satisfaction with care. Patient decision aids are useful tools for SDM and have recently been developed for allergen immunotherapy, severe asthma, and atopic dermatitis.ConclusionEffective SDM has been shown to improve adherence and lead to better outcomes. SDM should be universally implemented as a key component of patient-centered health care. Allergy health care providers should work with their patients to reach treatment decisions that align with their values and preferences.     

Does provider adherence to a treatment guideline change clinical outcomes for patients with bipolar disorder? Results from the Texas Medication Algorithm Project

BACKGROUND: Despite increasing adoption of clinical practice guidelines in psychiatry, there is little measurement of provider implementation of these recommendations, and the resulting impact on clinical outcomes. The current study describes one effort to measure these relationships in a cohort of public sector out-patients with bipolar disorder.METHOD:Participants were enrolled in the algorithm intervention of the Texas Medication Algorithm Project (TMAP). Study methods and the adherence scoring algorithm have been described elsewhere. The current paper addresses the relationships between patient characteristics, provider experience with the algorithm, provider adherence, and clinical outcomes. Measurement of provider adherence includes evaluation of visit frequency, medication choice and dosing, and response to patient symptoms. An exploratory composite 'adherence by visit' score was developed for these analyses.RESULTS: A total of 1948 visits from 141 subjects were evaluated, and utilized a two-stage declining effects model. Providers with more experience using the algorithm tended to adhere less to treatment recommendations. Few patient factors significantly impacted provider adherence. Increased adherence to algorithm recommendations was associated with larger decreases in overall psychiatric symptoms and depressive symptoms over time, but did not impact either immediate or long-term reductions in manic symptoms.CONCLUSIONS: Greater provider adherence to treatment guideline recommendations was associated with greater reductions in depressive symptoms and overall psychiatric symptoms over time. Additional research is needed to refine measurement and to further clarify these relationships.     

Patient–provider communication and cancer screening among unmarried women

Objectives

Unmarried women are less likely than married women to receive recommended cancer screenings. Patient–provider communication is a consistent predictor of cancer screening among women. The purpose of this study was to investigate the relationship between patient and provider communication, barriers to cancer screening, and on-schedule breast and cervical cancer screening (BCCS) among unmarried women.

Methods

Data were from the Cancer Screening Project for Women, a 2003–2005 survey examining cancer screening practices. We computed polytomous logistic regression models to examine the relationship between communication (communication about tests, communication about sexual and intimate relationships), barriers to screening, and on-schedule BCCS among unmarried women.

Results

A total of 630 women were enrolled, and 605 women completed the baseline questionnaire. Overall, more than 60% reported on-schedule BCCS. More than half reported that their providers communicated about BCCS most or all of the time. Fewer than half communicated about sexual history and intimate relationships. Women who reported that their providers communicated about screening tests and their sexual and intimate relationships were more likely to be on-schedule for BCCS.

Conclusion

Patient–provider communication about multiple topics may encourage women to remain on-schedule for their recommended cancer screenings. Longitudinal research should be conducted to examine whether communication predicts BCCS, and to examine how patient and provider characteristics may influence communication in order to promote adherence to screening guidelines for unmarried women.

Practice implications

Comprehensive communication that goes beyond information about screening tests may impact adherence to cancer screening guidelines.     

Facilitating Practitioner Flexibility Within an Empirically Supported Intervention: Lessons From a System of Parenting Support

[Clin Psychol Sci Prac 17: 238–252, 2010] Reluctance by practitioners to follow manuals is often cited as a reason for the lack of adoption of empirically supported treatments (ESTs). We contend that rigid adherence to the therapeutic techniques described in a manual is neither necessary nor desirable. Rather, practitioners should flexibly deliver interventions to meet the diverse needs of consumers, but in such a way that the intervention is not moved beyond its evidence base. This tension between adherence and flexibility is reframed as an issue of practitioner generalization. The present article draws on the authors’ experiences from disseminating the Triple P‐Positive Parenting Program to describe a number of strategies that can both safeguard the fidelity with which ESTs are delivered and encourage their flexible delivery.     

Medication adherence: A practical measurement selection guide using case studies

ObjectivesMedication adherence is a complex problem and can be evaluated using a variety of methods. There is no single or perfect strategy to assess adherence. The “best” measure depends on contextual factors. Our objective is to provide a practical, illustrative guide for selecting the most appropriate measure of medication adherence in common contexts.MethodsWe present three case studies – from the perspectives of an academic researcher, health care payer, and clinical care provider – to describe common problems and processes for measuring medication adherence, as well as proposing possible solutions.ResultsThe most appropriate measure will depend on the context (tightly controlled clinical trial setting vs. clinical setting), intended purpose (research vs. clinical), available resources (data, personnel, materials, and funding), time (quick screening vs. comprehensive review), and phase of interest (initiation, implementation, or discontinuation). Framing the problem of medication non-adherence and methods for measuring adherence are discussed using three representative case studies.ConclusionsA simple tool is provided that may help stakeholders interested in medication adherence make decisions regarding the appropriate selection of measures.Practice implicationsA medication adherence measure should be selected through the lens of each situation’s unique objectives, resources, and needs.     

Evaluating challenges for improving medically unexplained symptoms in US military veterans via provider communication

ObjectivesMedically unexplained symptoms (MUS) are common, with particularly high rates observed in military veterans. Effective patient-provider-communication is thought to be a key aspect of care; however there have been few empirical studies on the association between communication and outcomes for patients with MUS. We evaluate whether discussing veterans’ MUS-illness representations and good interpersonal skills have the potential to promote MUS-treatment adherence and improvement.MethodsVeterans experiencing MUS (n = 204) reported on their primary care providers’ communication about illness representations and interpersonal skills; correlation, regression, and bootstrap-mediation analyses were conducted to test hypotheses regarding veteran-reported outcomes. Main outcomes included satisfaction with the provider, MUS-treatment adherence, intentions to adhere, and expectations for MUS improvement.ResultsVeterans reported infrequent discussion of MUS illness representations but high degrees of provider interpersonal skills. Communication regarding patients’ illness representations and treatment expectations was significantly related to treatment adherence and adherence intentions; provider interpersonal skills were not. Both were related to veteran satisfaction.Conclusions and practice implicationsProviders’ interpersonal skills may be important in chronic illness contexts, such as MUS, by contributing to satisfaction with the provider. The current study suggests that providers may better promote MUS-treatment adherence through discussing MUS illness representations and treatment expectations.     

Decision-making competence and adherence to treatment in adolescents with diabetes

OBJECTIVE: To examine decision-making competence (the ability to form effective plans for managing different situations) in a sample of adolescents with type I diabetes and their parents. We hypothesized that adolescent decision-making competence would mediate the relationship between parent-adolescent communication and adherence to treatment. METHODS: The sample consisted of 63 adolescents and their parents. Parent-adolescent communication during a problem-solving task was assessed, as well as adolescent maladaptive decision-making (adolescent report), adherence to treatment (parent and provider report; number of glucose tests), and metabolic control (HbA1C). RESULTS: Parent-adolescent communication was associated with adherence to treatment but not with adolescent decision-making. Poorer decision-making was associated with lower adherence per parent report but not provider report or the number of glucose tests. Decision-making competence did not mediate the relationships between parent-adolescent communication and adherence. CONCLUSIONS: These results are consistent with prior research demonstrating associations between parent-adolescent communication and adherence and identify adolescent decision-making competence as another potentially important correlate of adherence. These findings highlight several areas for future research.     

The presence of accountability in digital interventions targeting non-adherence: A review

ObjectivesProvider-centered accountability, defined as the anticipation of a social interaction between a patient and their provider, increases patients’ adherence to prescribed treatment. Digital adherence interventions based on accountability may be especially effective at promoting adherence. The current study aimed to assess whether publications on digital adherence interventions discuss accountability, include intervention components related to accountability, and measure feelings of patient accountability as an outcome.MethodsPubMed was queried between January 2010 and March 2021 to identify randomized controlled trials incorporating digital adherence interventions. Full-text articles were assessed for participant demographics, interventions utilized, outcomes, and intervention effectiveness.ResultsA total of 131 publications met inclusion criteria. Only four publications discussed accountability as a potential factor influencing patient adherence. Although 11% of publications included an intervention with direct accountability, only one did so by design. None of the included studies assessed feelings of accountability as an outcome.ConclusionsWhile provider-centered accountability has the potential to boost the efficacy of digital adherence interventions, accountability is rarely incorporated in studies of such interventions.Practice implicationsAdditional investigation into the influence of accountability on adherence interventions will allow for the development of these interventions as effective tools applicable to the full range of patients.     

Automated telecommunication interventions to promote adherence to cardio-metabolic medications: meta-analysis of effectiveness and meta-regression of behaviour change techniques

Automated telecommunication interventions, including short message service and interactive voice response, are increasingly being used to promote adherence to medications prescribed for cardio-metabolic conditions. This systematic review aimed to comprehensively assess the effectiveness of such interventions to support medication adherence, and to identify the behaviour change techniques (BCTs) and other intervention characteristics that are positively associated with greater intervention effectiveness. Meta-analysis of 17 randomised controlled trials showed a small but statistically significant effect on medication adherence, OR?=?1.89, 95% CI [1.51, 2.36], I²?=?89%, N?=?25,101. Multivariable meta-regression analysis including eight BCTs explained 88% of the observed variance in effect size (ES). The BCTs ‘tailored’ and ‘information about health consequences’ were positively and significantly associated with ES. Future studies could explore whether the inclusion of these and/or additional techniques (e.g., ‘implementation intentions’) would increase the effect of automated telecommunication interventions, using rigorous designs and objective outcome measures.     

Adapted motivational interviewing for brief healthcare consultations: A systematic review and meta-analysis of treatment fidelity in real-world evaluations of behaviour change counselling

Background

Behaviour change counselling (BCC) is an adaptation of motivational interviewing (MI) designed to maximize the effectiveness of time-limited health behaviour change consultations. To improve intervention quality and understanding of treatment effects, it is recommended that evaluations of health behaviour change interventions incorporate existing fidelity frameworks (e.g. The National Institutes of Health [NIH] Behaviour Change Consortium) and ensure that treatment fidelity is assessed and reported.

Purpose

This systematic review was designed to examine (a) adherence to NIH fidelity recommendations, (b) provider fidelity to BCC and (c) impact of these variables on the real-world effectiveness of BCC for adult health behaviours and outcomes.

Methods and Results

Searches of 10 electronic databases yielded 110 eligible publications describing 58 unique studies examining BCC delivered within real-world healthcare settings by existing providers. Mean study adherence to NIH fidelity recommendations was 63.31% (Range 26.83%–96.23%). Pooled effect size (Hedges g) for short-term and long-term outcomes was .19 (95% CI [.11, .27]) and .09 (95% CI [.04, .13]), respectively. In separate, random-effects meta-regressions, neither short-term nor long-term effect sizes were significantly modified by adherence to NIH fidelity recommendations. For the subgroup of short-term alcohol studies (n = 10), a significant inverse relationship was detected (Coefficient = −.0114, 95% CI [−.0187, −.0041], p = .0021). Inadequate and inconsistent reporting within the included studies precluded planned meta-regression between provider fidelity and BCC effect size.

Conclusions

Further evidence is needed to clarify whether adherence to fidelity recommendations modifies intervention effects. Efforts to promote transparent consideration, evaluation and reporting of fidelity are urgently needed. Research and clinical implications are discussed.     

Perceived organizational affiliation and its effects on patient trust: Role modeling with embodied conversational agents

ObjectiveVerbal and non-verbal behaviors, which are known as “relational contextualization cues”, relay information about relationships and how they are structured. We developed a computer-simulated provider conducting an informed consent process for clinical research to investigate the effects of a provider’s alignment of interests with a patient, the research team, or a neutral party on patient trust in the provider.MethodsParticipants (N = 43) interacted with a simulated provider for a research informed consent process in a three-arm, counterbalanced, within-subjects experiment. Participants reported their trust in the simulated provider after each treatment.ResultsParticipants successfully recognized the alignment manipulation, and perceived the patient-aligned provider as more trustworthy than the other providers. Participants were also more satisfied with the patient-aligned provider, liked this provider more, expressed more desire to continue working with this provider, and stated that they were significantly more likely to sign the consent form after interacting with this provider compared to the other two.ConclusionRelational contextualization that aligns with the patient increases trust, satisfaction, and willingness to enroll in the context of research informed consent.Practice implicationsHealth providers should align themselves with patients’ interests.     

More Than Telemonitoring: Health Provider Use and Nonuse of Life-Log Data in Irritable Bowel Syndrome and Weight Management

Background

The quantified self, self-monitoring or life-logging movement is a trend to incorporate technology into data acquisition on aspects of a person''s daily life in terms of inputs (eg food consumed), states (eg mood), and performance (mental and physical). Consumer self-monitoring mobile phone apps have been widely studied and used to promote healthy behavior changes. Data collected through life-logging apps also have the potential to support clinical care.

Objective

We sought to develop an in-depth understanding of providers’ facilitators and barriers to successfully integrating life-log data into their practices and creating better experiences. We specifically investigated three research questions: How do providers currently use patient-collected life-log data in clinical practice? What are provider concerns and needs with respect to this data? What are the constraints for providers to integrate this type of data into their workflows?

Methods

We interviewed 21 health care providers—physicians, dietitians, a nurse practitioner, and a behavioral psychologist—who work with obese and irritable bowel syndrome patients. We transcribed and analyzed interviews according to thematic analysis and an affinity diagramming process.

Results

Providers reported using self-monitoring data to enhance provider-patient communication, develop personalized treatment plans, and to motivate and educate patients, in addition to using them as diagnostic and adherence tools. However, limitations associated with current systems and workflows create barriers to regular and effective review of this data. These barriers include a lack of time to review detailed records, questions about providers'' expertise to review it, and skepticism about additional benefits offered by reviewing data. Current self-monitoring tools also often lack flexibility, standardized formats, and mechanisms to share data with providers.

Conclusions

Variations in provider needs affect tracking and reviewing needs. Systems to support diagnosis might require better reliability and resolution, while systems to support interaction should support collaborative reflection and communication. Automatic synthesis of data logs could help providers focus on educational goals while communication of contextual information might help providers better understand patient values. We also discuss how current mobile apps and provider systems do, and do not, support these goals, and future design opportunities to realize the potential benefits of using life-logging tools in clinical care.     

Engagement and Affective Communication During Pediatric Nephrology Clinic Visits: Associations with Medication Adherence

ObjectiveTo evaluate whether engagement and affective communication among adolescents and young adults (AYAs) with chronic kidney disease (CKD), caregivers, and pediatric nephrology providers during outpatient clinic visits predicts antihypertensive medication adherence.MethodsAYAs (n = 60, M age = 15.4 years, SD = 2.7, 40% female, 43% African American/Black) and caregivers (n = 60, 73% female) attended audio-recorded clinic visits with pediatric nephrologists (n = 12, 75% female). Recordings were analyzed using global affect ratings of the Roter Interactional Analysis System. Antihypertensive medication adherence was monitored electronically before and after clinic visits. A linear regression model evaluated associations between affect ratings and post-visit adherence.ResultsAYAs took 84% of doses (SD = 20%) pre-visit and 82% of doses (SD = 24%) post-visit. Higher AYA engagement (β = 0.03, p = .01) and the absence of provider negative affect (β=-0.15, p = .04) were associated with higher post-visit adherence, controlling for pre-visit adherence, AYA sex, age, and race, and clustered by provider.ConclusionsPost-visit adherence was higher when AYAs were rated as more engaged and providers as less negative.Practice ImplicationsAYAs with lower engagement may benefit from further adherence assessment. Communication strategies designed to more actively engage AYAs in their care and diminish provider conveyance of negative affect during clinic visits may positively influence adherence among AYAs with CKD.     

Differences in BRCA counseling and testing practices based on ordering provider type

PurposeThe purpose of this study was to assess potential differences in genetic counseling services delivered by board-certified genetic health-care providers versus non–genetic health-care providers. We evaluated (i) patient recall and content of pretest genetic counseling for hereditary breast and ovarian cancer and (ii) whether full BRCA1 and 2 gene sequencing was performed when less expensive single-site or Ashkenazi Jewish founder mutation testing may have been sufficient.MethodsParticipants completed a questionnaire and provided BRCA test reports that included testing provider and type of test. Chi-square tests and logistic regression were used for analysis.ResultsOf 473 participants, >90% were white, female, and BRCA mutation carriers. Of the 276 (58%) with genetic health-care provider involvement, 97% recalled a pretest discussion as compared with 59% of those without genetic health-care provider involvement (P < 0.001). Among the subgroup who recalled a pretest discussion (n = 385), those with genetic health-care provider involvement indicated higher adherence to eight recognized genetic counseling elements, four of which were statistically significant. Furthermore, involvement of a genetic health-care provider halved the likelihood that comprehensive BRCA testing was ordered among the 266 for whom single-site or multisite-3 testing may have been sufficient (P = 0.02).ConclusionOur results suggest that genetic health-care provider involvement is associated with adherence to nationally recommended genetic counseling practices and could potentially reduce costs of BRCA genetic testing.Genet Med advance online publication 12 June 2014     

Discrimination, distrust, and racial/ethnic disparities in antiretroviral therapy adherence among a national sample of HIV-infected patients

OBJECTIVE: Although discriminatory health care experiences and health care provider distrust have been shown to be associated with health care disparities, little is known about their contribution to racial/ethnic disparities in antiretroviral therapy adherence. We therefore sought to assess the extent to which discriminatory health care experiences and health care provider distrust influence treatment-related attitudes, beliefs, and self-reported adherence in a national sample of HIV-infected patients. STUDY DESIGN: This secondary analysis used data from the HIV Cost and Services Utilization Study. We used structural equation modeling to identify pathways from minority status to adherence through discrimination, distrust, and treatment-related attitudes and beliefs. PARTICIPANTS: The sample was the 1886 participants who completed the baseline and 2 follow-up interviews and were prescribed antiretroviral therapy at the second follow-up interview (54% white, 28% black, 14% Hispanic, and 3% others). RESULTS: Minorities were less likely to report perfect adherence than whites (40% vs. 50%, P < or = 0.001). Over one third (40%) of all participants reporting ever having discriminatory health care experiences since having HIV, and 24% did not completely or almost completely trust their health care providers. The effect of minority status on adherence persisted in the full model. More discrimination predicted greater distrust, weaker treatment benefit beliefs, and, in turn, poorer adherence. Distrust affected adherence by increasing treatment-related psychological distress and weakening treatment benefit beliefs. CONCLUSIONS: The relationship between minority status and adherence was not fully explained by patient-level factors. Future studies should consider conceptualizing minority status as a contextual factor rather than predictor.     

Parents’ adherence to pediatric health and safety guidelines: Importance of patient-provider relationships

Objective

To examine 1) parent-provider communication about pediatric health/safety guidelines, 2) trust in child’s provider, 3) comfort discussing guidelines, 4) agreement with guideline advice, 5) self-efficacy following guidelines, and their impact on guideline adherence.

Breast and cervical cancer screening for women with mental illness: patient and provider perspectives on improving linkages between primary care and mental health

Summary Objective: Previous research suggests that women with mental illness may be at increased risk for breast and cervical cancer. This qualitative study of patients and primary care and mental health providers explored challenges to accessing and providing breast and cervical cancer screening for women with mental illness. Method: Key informant patient and provider participants were recruited from a community health setting and teaching hospital. Narrative data from 1) interviews with women in a community primary care setting (n = 16); 2) telephone interviews with women with mental illness (n = 16); and 3) focus groups with primary care providers (n = 9) and mental health providers (n = 26) were collected. Results: Patient, provider, and system factors that may contribute to suboptimal cancer screening among women with mental illness were identified. Communication between primary care and mental health providers was noted as a key area for intervention to enhance screening. Barriers to and possibilities for a more proactive role for mental health providers were also considered. Conclusions: Both patient and provider study participants emphasized the need to address communication gaps between primary care and mental health providers and to promote the active collaboration of mental health providers in preventive cancer screening for women with mental illness.     

Development of Therapist Adherence in Relation to Treatment Outcomes of Adolescents with Behavioral Problems

Therapist adherence to the treatment manual is assumed to be crucial for adequate implementation and subsequent achievement of the intended, positive treatment outcomes. Although adherence has been mostly studied as a static factor, recent studies suggest that adherence might be dynamic and changes over time. We investigated how parent-perceived adherence to the multisystemic therapy (MST) model develops during treatment and how this development is related to treatment outcomes up to 18 months posttreatment, controlling for the effect of alliance. We used routinely collected data from 848 adolescents (66% male and 76% Western, M age = 15.25 years) and their caregivers participating in MST, a family- and community-based intervention for antisocial adolescents. Adherence and alliance were measured monthly through phone interviews with the caregivers using the Therapist Adherence Measure–Revised. Outcomes were assessed at the end of the treatment and at 18 months posttreatment using the scale Rule-Breaking Behavior of the Child Behavior Checklist and two MST Ultimate Outcomes (i.e., police contact and out-of-home placement). On average, adherence showed an increasing and then flattening slope. The initial level of adherence predicted treatment outcomes at the end of treatment but not at 18 months posttreatment. Change in adherence did not predict treatment outcomes after controlling for alliance. We advocate the need to consider the dynamic nature of adherence in research as well as clinical practice. Change in adherence during treatment, as well as its association with outcome, is likely to be dependent on the adherence measure being used.