Understanding healing relationships in primary care

PURPOSE Clinicians often have an intuitive understanding of how their relationships with patients foster healing. Yet we know little empirically about the experience of healing and how it occurs between clinicians and patients. Our purpose was to create a model that identifies how healing relationships are developed and maintained.METHODS Primary care clinicians were purposefully selected as exemplar healers. Patients were selected by these clinicians as having experienced healing relationships. In-depth interviews, designed to elicit stories of healing relationships, were conducted with patients and clinicians separately. A multidisciplinary team analyzed the interviews using an iterative process, leading to the development of case studies for each clinician-patient dyad. A comparative analysis across dyads was conducted to identify common components of healing relationshipsRESULTS Three key processes emerged as fostering healing relationships: (1) valuing/creating a nonjudgmental emotional bond; (2) appreciating power/consciously managing clinician power in ways that would most benefit the patient; and (3) abiding/displaying a commitment to caring for patients over time. Three relational outcomes result from these processes: trust, hope, and a sense of being known. Clinician competencies that facilitate these processes are self-confidence, emotional self-management, mindfulness, and knowledge.CONCLUSIONS Healing relationships have an underlying structure and lead to important patient-centered outcomes. This conceptual model of clinician-patient healing relationships may be generalizable to other kinds of healing relationships.     

Racial/ethnic variation in health care satisfaction: The role of acculturation

This study examined the role of acculturation and racial/ethnic variation in health care satisfaction among four different racial/ethnic groups. The study sample consisted of 41,560 adults from the 2011 California Health Interview Survey. Health care satisfaction was measured via two questions regarding doctors’ listening and explanations. Guided by Andersen’s behavioral model of health care use, multivariate logistic regressions were conducted. Hispanic and Asian respondents showed the lowest levels of satisfaction with their doctors’ listening and explanations, respectively. Acculturation was found to be a significant predictor of health care satisfaction. Health care professionals should develop ways of expanding culturally competent health care professionals, who are aware of racial/ethnic variation in health care satisfaction.     

Patient versus general practitioner perception of problems with treatment adherence in type 2 diabetes: From adherence to concordance

Abstract

Objectives: To determine the prevalence of problems with treatment adherence among type-2 diabetic patients with regards to medication, dietary advice, and physical activity; to identify the associated clinical and psychosocial factors; and to investigate the degree of agreement between patient-perceived and GP-perceived adherence. Methods: Consecutive patients were solicited during visits to 39 GPs. In total, 521 patients self-reported on treatment adherence, anxiety and depression, and disease perception. The GPs reported clinical and laboratory data and patients' adherence. A multivariate analysis identified the factors associated with adherence problems. Results: Problems of adherence to medication, dietary advice, and physical activity recommendations were reported by 17%, 62%, and 47% of the patients, respectively. Six independent factors were found associated with adherence problems: young age, body-mass index (BMI) > 30 kg/m², glycosylated haemoglobin (HbA_1c) > 8%, single life, depression, and perception of medication as a constraint. Agreement between patients’ and GPs’ assessments of treatment problems reached 70%. Conclusion: In type 2 diabetes, problems with dietary advice or physical activity are far more frequent than problems with medication, and not all physicians are fully aware of patients’ problems. More active listening and shared decision-making should enhance adherence and improve outcomes.     

New kinds of care, new kinds of relationships: how purchasing services affects relationships in giving and receiving personal assistance

This paper draws on interviews with users of direct payments and focus group discussions with the personal assistants (PAs) who assist them with personal and daily living activities. It discusses the benefits and the drawbacks of directly employing such assistance, from the perspectives of both the purchasers and the providers of these services. The paper shows that direct payments can enable disabled people to purchase a much wider range of flexible help, better continuity, greater control and an enhanced quality of life, compared with conventional services. PAs also valued the trust and close relationships they developed with their employers. However, these benefits were much less marked when direct payment users recruited and employed personal assistants through care agencies. On the other hand, both direct payment users and PAs also sometimes experienced difficulties in managing the relationships between them. Some of these problems could be alleviated by changes in the support provided by direct payment schemes themselves; other difficulties were more intractable and arose from the nature of the work and the close relationships which it entailed. The paper recommends a number of measures which could reduce the risks and vulnerability of both disabled direct payment users and personal assistants, without reducing the enhanced quality of life which direct payments can confer.     

Healing in primary care: a vision shared by patients, physicians, nurses, and clinical staff

PURPOSE We wanted to understand the views of patients and clinicians on the central concept of healing and to identify major facilitators of and barriers to promoting healing in primary care.METHODS We undertook a qualitative analysis of focus group discussions. Participants were drawn from primary care clinics of a large, integrated, health care system in Washington State in 2005. Nine focus groups included 84 participants: 28 patients, 23 primary care physicians (19 family physicians), 20 registered nurses, 11 licensed practical nurses, and 2 medical assistants. Randomly sampled established patients were aged from 21 to 65 years; 71% were female.RESULTS We found remarkable concordance across focus groups and among types of participants in the definition of healing: Healing is a dynamic process of recovering from a trauma or illness by working toward realistic goals, restoring function, and regaining a personal sense of balance and peace. Healing is a multidimensional process with physical, emotional, and spiritual dimensions. The key themes are as follows: (1) healing is multidimensional and holistic; (2) healing is a process, a journey; (3) the goal of healing is recovery or restoration; (4) healing requires the person to reach a place of personal balance and acceptance; and (5) relationships are essential to healing. Factors that facilitate healing help build relationships, improve communication, and share responsibility between the patient and clinician. Major barriers are logistical factors that limit high-quality time with healing professionals.CONCLUSIONS Patients and health care team members share a vision of healing and agree on ways to enhance the process in primary care.     

'Meeting people where they're at': experiences of family physicians engaging women who use illicit drugs

PURPOSE There is little research exploring the experiences of family physicians caring for women who use illicit drugs. This study explores the experiences of these physicians in order to better understand the process of engaging these women in the patient-physician relationship.METHODS We conducted a phenomenologic, qualitative study using individual, in-depth interviews with 10 family physicians working in inner-city Toronto and Ottawa, Ontario. An iterative and interpretive analysis was used.RESULTS Three broad themes emerged from the analysis. The predominant theme was that of the patient-physician relationship, which consisted of 2 phases: the engagement phase and the maintenance phase. During the engagement phase, issues such as access and women’s experiences of trauma and violence were evident and impeded participants’ ability to engage with this population. As such, the patient-physician relationship during the engagement phase was tenuous. Trust and presence were paramount during this phase. Once a family physician engaged a woman, the transition to the maintenance phase was made. Within the maintenance phase, 2 subthemes were identified: continuity of care and “meeting people where they’re at” (finding common ground).CONCLUSIONS This study identified a 2-phase process of the patient-physician relationship from the perspective of family physicians caring for women using illicit drugs: the engagement and maintenance phases. Our findings identified strategies to support the patient-physician relationship during each of these phases that have implications for improving the health of these women.     

Annals Journal Club: Frequency and Prioritization of Patient Health Risks from a Structured Health Risk Assessment

PURPOSE

To describe the frequency and patient-reported readiness to change, desire to discuss, and perceived importance of 13 health risk factors in a diverse range of primary care practices.

METHODS

Patients (n = 1,707) in 9 primary care practices in the My Own Health Report (MOHR) trial reported general, behavioral, and psychosocial risk factors (body mass index [BMI], health status, diet, physical activity, sleep, drug use, stress, anxiety or worry, and depression). We classified responses as “at risk” or “healthy” for each factor, and patients indicated their readiness to change and/or desire to discuss identified risk factors with providers. Patients also selected 1 of the factors they were ready to change as most important. We then calculated frequencies within and across these factors and examined variation by patient characteristics and across practices.

RESULTS

On average, patients had 5.8 (SD = 2.12; range, 0–13) unhealthy behaviors and mental health risk factors. About 55% of patients had more than 6 risk factors. On average, patients wanted to change 1.2 and discuss 0.7 risks. The most common risks were inadequate fruit/vegetable consumption (84.5%) and overweight/obesity (79.6%). Patients were most ready to change BMI (33.3%) and depression (30.7%), and most wanted to discuss depression (41.9%) and anxiety or worry (35.2%). Overall, patients rated health status as most important.

CONCLUSIONS

Implementing routine comprehensive health risk assessments in primary care will likely identify a high number of behavioral and psychosocial health risks. By soliciting patient priorities, providers and patients can better manage counseling and behavior change.     

Understanding a collaborative effort to reduce racial and ethnic disparities in health care: contributions from social network analysis

Quality improvement collaboratives have become a common strategy for improving health care. This paper uses social network analysis to study the relationships among organizations participating in a large scale public-private collaboration among major health plans to reduce racial and ethnic disparities in health care in the United States. Pre-existing ties, the collaborative process, participants' perceived contributions, and the overall organizational standing of participants were examined. Findings suggest that sponsors and support organizations, along with a few of the health plans, form the core of this network and act as the "glue" that holds the collaboration together. Most health plans (and one or two support organizations) are in the periphery. While health plans do not interact much with one another, their interactions with the core organizations provided a way of helping achieve health plans' disparities goals. The findings illustrate the role sponsors can play in encouraging organizations to voluntarily work together to achieve social ends while also highlighting the challenges.     

Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID‐19 pandemic

ObjectiveThe COVID‐19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all‐cause mortality during the COVID‐19 pandemic, stratified by race and ethnicity.Data SourcesAdministrative data from the Veterans Health Administration''s Corporate Data Warehouse.Study DesignWe use pre‐pandemic data to estimate mortality risk models using five‐fold cross‐validation and quasi‐Poisson regression. Models were stratified by a combined race‐ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects.Data CollectionWe queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016–2020. Veterans were excluded from analyses if they were missing county of residence or race‐ethnicity data. Data were then aggregated to the county‐year level and stratified by race‐ethnicity.Principal FindingsOverall, Veterans'' mortality rates were 16% above normal during March–December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non‐Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%–24%), while Native American Veterans had the highest increase (40%, 95% CI 17%–73%). Black Veterans (32%, 95% CI 27%–39%) and Hispanic Veterans (26%, 95% CI 17%–36%) had somewhat lower excess mortality, although these changes were significantly higher compared to White Veterans. Disparities were smaller than in the general population.ConclusionsMinoritized Veterans experienced higher rates excess of mortality during the COVID‐19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long‐standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.     

A test of concordance between patient and psychiatrist valuations of multiple treatment goals for schizophrenia

Background While much discussion has been placed on the problem of poor compliance in the treatment of schizophrenia, there has been little discussion on the concordance between patients and psychiatrists, an important contributing factor to patient‐centred care. Objective To estimate the concordance between patients’ and psychiatrists’ (ordinal and cardinal) valuations of multiple goals for schizophrenia treatment and to illustrate the utility of the self‐explicated method in valuing a large number of treatment goals. Design Twenty treatment goals were identified during focus groups and literature review and were presented to patients and psychiatrists during structured interviews. Respondents were asked to rank the multiple treatment goals and rate them on a 5‐point Likert scale. Three scores were calculated based on the ranking (1–20), rating (Likert scale) (1–5) and a self‐explicated method estimated as the product of rating and ranking score (1–100). Concordance was tested using Spearman’s rho for overall ordinal rankings and via anova and F‐test for the cardinal values assigned to a specific treatment goal. Participants A total of 105 outpatients diagnosed with schizophrenia and 160 psychiatrists in Germany. Results Patient and psychiatrist values were concordant when the ordinal properties of their valuations were assessed by rating (ρ = 0.63; P = 0.002), ranking (ρ = 0.51; P = 0.02) and self‐explicated methods (ρ = 0.54; P = 0.01). Significant discordances were found when comparing the cardinal value placed on any given treatment goal using all three approaches, but the self‐explicated method produced a more discerning statistic. Relative to patients, psychiatrists significantly (P < 0.05) overvalued reduced lack of emotion, improved sexual pleasure and improved communication while undervaluing reuptake of activities of daily living, improved satisfaction and recovered capacity for work. Conclusions While there is an overall concordance between patients’ and psychiatrists’ valuation, significantly different valuations on specific goals can be identified. Here, psychiatrists tend to focus on ‘textbook’ outcomes, while patients are more concerned with functioning and living a normal life. This study also demonstrates the importance of comparing the concordance in treatment goals and the importance of preference‐based methods, such as the self‐explicated method, in the study of concordance.     

Developing and Validating a Conceptual Model of Recurring Problems in Teaching Clinic

Recurrent problems in medical teaching clinic are common and difficult to address because of complex interpersonal dynamics. To minimize this difficulty, we developed a conceptual model that simplifies problems and identifies the root cause of tension between groups in clinic. We used recursive analysis and modeling of the data from a larger multi-site, multi-method study of problems in teaching clinic. The first dataset from this study consisted of problem lists generated and prioritized by knowledgeable insiders from each site. The second dataset was a cultural consensus analysis independently performed at each site. The final model was checked for face validity and construct validity (using model predictions versus prior data and convergent/discriminant analysis). The study was performed in five Veterans Affairs teaching clinics in the U.S. Our final model, the Perception of Care Map, is a pentagram with five critical perspectives of the clinic visit. These five perspectives are structured care, educational care, relationship-based care, algorithmic care and efficient care. Each group emphasizes one or more of these perspectives, and group locations on the conceptual map explain the observed tensions between groups. Validity of the model is high. The Perception of Care Map may be a useful adjunct for understanding and addressing recurrent problems in teaching clinic. This material is based upon work supported by the Office of Research and Development, Health Services R&D Service, Department of Veterans Affairs (Grants PCC 98-010 and PCC 01-178).     

医院兼职孕期管理师团队的建设与成效

总结了医院兼职孕期管理师团队建设的现实意义、人员设置与工作职责、工作方法等。通过孕期管理师的指导,孕妇产检的依从性、产检工作的满意度与孕期知识的掌握度都得到提高,妊娠期并发症和剖宫产率显著下降,对孕期保健具有重要意义。     

The association between care experiences and parent ratings of care for different racial, ethnic, and language groups in a Medicaid population

Objective. To examine the association between care experiences and parent ratings of care within racial/ethnic/language subgroups. Data Source. National Consumer Assessment of Healthcare Providers and Systems Benchmarking Database 3.0 (2003–2006). Sample Characteristics. 111,139 parents of minor Medicaid managed care enrollees. Study Design. Cross‐sectional observational study predicting “poor” (0–5 on 0–10 scale) parent ratings of personal doctor, specialist, health care, and health plan from care experiences for different parent race/ethnicity/language subgroups (Latino/Spanish, Latino/English, white, and black). Principal Findings. Care experiences had similar associations with the probability of poor parent ratings of care across the four racial/ethnic/language subgroups (p>.20). A one standard deviation improvement in the doctor communication care experience was associated with about half the frequency of poor ratings of care for personal doctor and health care in all subgroups (p<.05). Sensitivity analysis of individual communication items found that failure to provide explanations to children predicted poor ratings of care only among whites, who also weighed the length of physician interaction more heavily than other subgroups. Conclusions. Communication‐based interventions may improve experiences and ratings of care for all subgroups, although implementation of these interventions may need to consider preferences associated with race, ethnicity, and language.