Considering the Issue of Dual Use in Veterans Affairs Patients: Implications & Opportunities for Improved Communication & Counseling

This study sought to ascertain perceptions of communication responsibility in veterans identified as using more than one health care system, otherwise known as dual users. Three hundred and fifteen veterans identified as dual users completed a telephone-based survey including questions about their perspectives regarding communication in the context of dual use. Nearly half (47.3%) indicated that that they believed it was primarily their responsibility to either directly communicate or facilitate communication between their Veterans Affairs (VA) and non-VA providers. Only 11.3% reported that it should be the responsibility of their VA provider, 19.6% believed that their non-VA provider should be responsible, and 7.3% believed both should be involved. Finally, 14.4% believed another person was responsible, such as a system administrator or patient representative. Of those patients indicating that it was their responsibility, a majority (61.7%) indicated that they preferred active involvement in their health care. Patient-centered care allows patients the opportunity to help facilitate communication between multiple health care systems, such as when using VA and non-VA providers, if they so choose. However, given that patient preferences for involvement vary considerably, it is likely that a multifaceted approach to this problem is necessary, involving patients, providers, and other system-level stakeholders. These data suggest a need to inquire about preferred patient roles and counsel patients regarding methods of communication that may serve to decrease fragmentation of care.     

Pediatric Obesity Management in Rural Clinics in California and the Role of Telehealth in Distance Education

Objective: To determine health care provider needs related to pediatric obesity management in rural California and to explore strategies to improve care through telehealth. Methods: Cross‐sectional survey of health care providers who treated children and adolescents at 41 rural clinics with existing telehealth connectivity. Results: Most of the 135 respondents were family physicians at designated rural health clinics serving low‐income families. Respondents had practiced in rural areas for an average of 10 years. Most providers rated their self‐efficacy in managing pediatric obesity as 2 or 3 on a 5‐point scale. The barriers most frequently reported by health care providers were lack of local weight management programs, lack of patient motivation, and lack of family involvement in treatment. Providers reported that the resources they would find most helpful were readily accessible patient education materials, strategies to link patients with community treatment programs and training in brief, focused counseling skills. Three‐quarters of providers already used telehealth for distance learning. Providers reported very high interest in participating in continuing education on pediatric obesity delivered by telehealth, specifically Internet communication with specialists, web‐based education, and interactive video case‐conferencing. Conclusions: Rural health care providers face several barriers related to pediatric obesity management. Targeted interventions provided via telehealth to rural health care providers may enhance the care of obese children and adolescents. The results of this study provide directions and priorities for the design of appropriate interventions.     

The Relationship of Patient–Provider Communication on Quality of Life among African-American and White Cancer Survivors

Prior research has demonstrated poorer patient–provider communication ratings among African American compared to White patients. The quality of patient–provider communication has been shown to impact treatment outcomes among cancer patients. A secondary data analysis design was used to determine the relationship of six patient–provider communication variables on the physical health quality of life (PHQOL) and mental health quality of life (MHQOL) of African American and White cancer patients (N = 479). We also examined whether the relationship between communication patterns and QOL differed based on race/ethnicity. Mean physical and mental health QOL scores for the sample were 69.8 and 77.6, respectively. After controlling for significant sociodemographic, clinical, and hospital variables, results showed that patients who experienced fewer interpersonal communication barriers who were more satisfied with the information given by providers had higher PHQOL and MHQOL scores. Additionally, patients who felt more comfort in asking questions or had fewer unmet information needs had higher MHQOL. A stratified analysis showed that the relationship of overall satisfaction with information on MHQOL was stronger among African American patients than White patients. Future research should focus on the development of interventions to improve patient–provider communication as a means for enhancing QOL outcomes among cancer survivors.     

The Provider’s Body in the Therapeutic Relationship: How Complementary and Alternative Medicine Providers Describe Their Work as Healers

ABSTRACT

Although the body is central to health outcomes, the provider’s body has been largely absent in the provider–patient relationship. Drawing upon semi-structured interviews with complementary and alternative medicine (CAM) providers (N = 17), this study examines how CAM providers use their body to characterize their work as healers. The findings suggest the provider’s self-reflexive awareness of their own body’s illness and faith experiences informs their understanding of the patients’ experience of health and disease. The study foregrounds the intersubjective nature of the provider–patient relationship as an embodied interaction in the mutual construction of therapeutic goals. Provider reflection on their own bodies to make sense of their patients’ experiences emphasizes provider–patient coproduction of meaning and suggests ways for including the provider’s self-reflexive awareness of their own body in a patient-centered healthcare relationship in ways that benefit both the patient and the provider.     

Patient–Provider Sexually Transmitted Infection Prevention Communication among Young Adult Sexual Minority Cisgender Women and Nonbinary Assigned Female at Birth Individuals

BackgroundHealth care providers are an important source of sexually transmitted infection (STI) prevention information for young adult sexual minority women (SMW). However, very few studies have described patient–provider STI communication in this understudied and underserved population. We explore sexual minority women's experiences communicating with health care providers about sexual health, with particular attention to STI prevention, to inform programs and practices that address their unique needs and concerns.MethodsWe conducted 29 in-depth interviews with sexual minority cisgender women and nonbinary assigned female at birth (AFAB) individuals aged 18–36 years. The sample included White (55%), Asian (31%), Black (17.2%), and Latina (3.4%) participants. We used thematic analysis with deductive and inductive coding to identify themes related to patient–provider STI prevention communication.ResultsHeteronormative health care provider assumptions inhibited participants' willingness to disclose their sexual orientation and discuss sexual health issues with providers. Most sexual health conversations focused on pregnancy and contraception, which many felt was irrelevant to them, and limited STI prevention recommendations to condom use. Participants reported that some providers lacked medical knowledge on AFAB-to-AFAB STI transmission and were not able to provide relevant STI prevention information. Providers' bias related to gender identity and race/ethnicity furthered some participants' mistrust generated from providers’ heteronormative assumptions.ConclusionsOur study describes several barriers that AFAB sexual minorities felt inhibited their patient–provider sexual health communication. Interventions are needed to improve patient–provider STI prevention conversations with AFAB sexual minorities so they can access the sexual health information they need to effectively protect themselves from STIs.     

Why ‘Optimal’ Payment for Healthcare Providers Can Never be Optimal Under Community Rating

This article extends the existing literature on optimal provider payment by accounting for consumer heterogeneity in preferences for health insurance and healthcare. This heterogeneity breaks down the separation of the relationship between providers and the health insurer and the relationship between consumers and the insurer. Both experimental and market evidence for a high degree of heterogeneity are presented. Given heterogeneity, a uniform policy fails to effectively control moral hazard, while incentives for risk selection created by community rating cannot be neutralized through risk adjustment. Consumer heterogeneity spills over into relationships with providers, such that a uniform contract with providers also cannot be optimal. The decisive condition for ensuring optimality of provider payment is to replace community rating (which violates the principle of marginal cost pricing) with risk rating of contributions combined with subsidization targeted at high risks with low incomes.     

The Role of Patient–Provider Communication in Engagement and Re-engagement in HIV Treatment in Bamako,Mali: A Qualitative Study

Mounting evidence in sub-Saharan Africa suggests poor patient-provider communication (PPC) negatively impacts patient engagement (retention in care and adherence to medication) in antiretroviral therapy (ART) programs. In Bamako, Mali, where 36% of ART patients are lost to follow-up within 12 months of initiating treatment, we aimed to define features of positive PPC according to patient values and explore the mechanisms by which these features may sustain engagement and re-engagement according to patient and provider experiences. We conducted 33 in-depth interviews and 7 focus groups with 69 patients and 17 providers in five ART clinics. Regarding sustaining engagement, participants highlighted “establishing rapport” as a foundational feature of effective PPC, but also described how “responding to emotional needs”, “eliciting patient conflicts and perspective” and “partnering to mitigate conflicts” functioned to address barriers to engagement and increase connectedness to care. Patients who had disengaged felt that “communicating reacceptance” may have prompted them re-engage sooner and that tailored “partnering to mitigate conflicts” would be more effective in sustaining re-engagement than the standard adherence education providers typically offer. Optimizing provider skills related to these key PPC features may help maximize ART patient engagement, ultimately improving health outcomes and decreasing HIV transmission in sub-Saharan Africa.     

Relationship of disability prevention to patient health status and satisfaction with primary care provider

A sample of 625 patients aged 18 to 65 with primary care visits was used to explore the relationship of disability prevention to patient health status and satisfaction with health care provider. Disability prevention and the patient-provider relationship, the latter a potential mediating factor, were measured using reliable and valid scales. The joint effects of disability prevention and a strong patient-provider relationship were associated with decreased risks for poor physical health, as measured by the Medical Outcomes Study 12-item short-form health survey, decreased restricted activity days, and overall satisfaction with their primary care provider. Patient-provider relationship was independently associated with increased patient satisfaction with the provider overall and endorsement of the provider to family or friends. The evidence questions the conventional wisdom among some primary care providers that incorporating disability prevention principles into their daily practice jeopardizes patient satisfaction. These results suggest that primary care providers with strong patient-provider relationships can successfully add disability prevention to their practice.     

Acceptability and feasibility of integration of HIV care services into antenatal clinics in rural Kenya: a qualitative provider interview study

The aim of this study was to explore the perspectives of healthcare providers on the advantages and disadvantages of integrating HIV care services, including highly active antiretroviral therapy (HAART), into antenatal care (ANC) clinics in rural Kenya. We conducted a qualitative study using in-depth interviews and thematic analysis; 36 healthcare providers from six health centres in Nyanza Province, Kenya participated. Effects on service providers included increased workload due to the incorporation of specialised HIV services into ANC clinics. Providers observed that integration results in decreased patient time spent at the health facility, increased efficiency and closer provider-patient relationships; all leading to increased patient satisfaction. Providers also said that women would be more likely to receive HAART and adhere to their treatment as a result of improved confidentiality and decreased stigma. However, a minority of providers noted that integration could result in longer appointment times for HIV-positive women at ANC clinics leading to inadvertent disclosure. Integration could lead to strengthened ANC, postpartum care, prevention of mother-to-child transmission and HIV care for women and their families. However, integration efforts need to take into account potential negative effects on ANC provider workload, disclosure and the quality of care.     

Acceptability and feasibility of integration of HIV care services into antenatal clinics in rural Kenya: A qualitative provider interview study

Abstract

The aim of this study was to explore the perspectives of healthcare providers on the advantages and disadvantages of integrating HIV care services, including highly active antiretroviral therapy (HAART), into antenatal care (ANC) clinics in rural Kenya. We conducted a qualitative study using in-depth interviews and thematic analysis; 36 healthcare providers from six health centres in Nyanza Province, Kenya participated. Effects on service providers included increased workload due to the incorporation of specialised HIV services into ANC clinics. Providers observed that integration results in decreased patient time spent at the health facility, increased efficiency and closer provider-patient relationships; all leading to increased patient satisfaction. Providers also said that women would be more likely to receive HAART and adhere to their treatment as a result of improved confidentiality and decreased stigma. However, a minority of providers noted that integration could result in longer appointment times for HIV-positive women at ANC clinics leading to inadvertent disclosure. Integration could lead to strengthened ANC, postpartum care, prevention of mother-to-child transmission and HIV care for women and their families. However, integration efforts need to take into account potential negative effects on ANC provider workload, disclosure and the quality of care.     

Holding health providers in developing countries accountable to consumers: a synthesis of relevant scholarship

Health care providers in low-income countries often treat consumers poorly. Many providers do not consider it their responsibility to listen carefully to consumer preferences, to facilitate access to care, to offer detailed information, or to treat patients with respect. A lack of provider accountability to health consumers may have adverse effects on the quality of health care they provide, and ultimately on health outcomes. This paper synthesizes relevant research on health provision in low-, middle- and high-income countries with the aim of identifying factors that shape health provider accountability to consumers, and discerning promising interventions to enhance responsiveness. Drawing on this scholarship, we develop a framework that classifies factors into two categories: those concerning the health system and those that pertain to social influences. Among the health systems factors that may shape provider accountability are oversight mechanisms, revenue sources, and the nature of competition in the health sector-all influences that may lead providers to be accountable to entities other than consumers, such as governments and donors. Among the social factors we explore are consumer power, especially information levels, and provider beliefs surrounding accountability. Evidence on factors and interventions shaping health provider accountability is thin. For this reason, it is not possible to draw firm conclusions on what works to enhance accountability. This being said, research does suggest four mechanisms that may improve provider responsiveness: 1. Creating official community participation mechanisms in the context of health service decentralization; 2. Enhancing the quality of health information that consumers receive; 3. Establishing community groups that empower consumers to take action; 4. Including non-governmental organizations in efforts to expand access to care. This synthesis reviews evidence on these and other interventions, and points to future research needs to build knowledge on how to enhance health provider accountability to consumers.     

Perceptions about collaborative decisions: perceived provider effectiveness among 2003 and 2007 Health Information National Trends Survey (HINTS) respondents

Patient-provider communication is an important element in cancer treatment and prevention. We examined the degree of concordance perceived to exist between the patient's preferences for inclusion in decision-making processes and their actual experiences among two population-based cohorts of U.S. adults with and without cancer histories who were surveyed in 2003 and 2007. Associations were examined between selected sociodemographic characteristics of respondents and the extent to which respondents perceived their health providers "always" involved them in decisions about their health to the extent desired. Data came from the Health Information National Trends Survey (HINTS), and SPSS and SAS-Callable SUDAAN statistical packages were used to analyze the data. Results showed a decrement in the proportion of favorable responses between 2003 and 2007. While there was no gender effect on the reported perceptions in either year, there was a significant effect of ethnicity (p?=?.001) in both years. Age, income, and employment were also independently associated (p?=?.001) in 2007. In contrast to 2003, higher education was significantly associated with communication satisfaction, as was having a cancer diagnosis, in 2007. There was a significant relationship between several sociodemographic variables and respondent perceptions about the consistency with which providers included patients as desired in decision-making. We conclude that communication between patient and provider remains suboptimal in cancer prevention and treatment.     

“Open Your Heart First of All”: Perspectives of Holistic Providers in Costa Rica About Communication in the Provision of Health Care

Research documents how the care the holistic providers offer represents the quality communication that patients often do not receive from their biomedical providers. However, research investigating the perspectives of holistic providers concerning the role they see themselves playing in the provision of health is limited. This research explores the perceptions of holistic providers in Costa Rica about their communication with their patients. The results reveal two practices of communication—authenticating and integrating as central to providers' communication with patients in the provision of holistic health care. Providers describe their communication as an exploration of an anatomy of pain/suffering, including investigating the location, timing, length, intensity, and overall rhythm of the patient's condition and sense making that leads them to seek the care of a holistic provider. Most holistic providers see their role as being careful or full of care and suggest that they have an obligation to open their heart first of all.     

Impact of an educational video on patient decision making in early breast cancer treatment.

Previous research suggests that patient education programs promoting shared decision making (SDM) may improve patient satisfaction and outcomes, yet controlled clinical trials are lacking. The authors evaluate the impact of an early breast cancer treatment educational video on patients' decisional preferences and behavior. Newly diagnosed stage I/stage II breast cancer patients were assigned to SDM video program or control groups in alternating months. Surveys were administered prior to the provider visit and 1 week following the treatment decision. Variables assessed included autonomy preferences, perceived involvement in care, satisfaction, and treatment choice. There were no significant intervention effects on informational/decisional preferences, anxiety, knowledge, or satisfaction. Although 25% of SDM patients chose mastectomy compared to 14% of controls, this difference was not statistically significant. Eventhough enthusiasm for SDM programs remains high among some patients and providers, this study found only modest benefits.     

Physicians’ Reactions to Patients Taking a Position: Sequence Analysis of Admission Interviews in Orthopedic Rehabilitation

Little is known about how patients influence health care providers’ communication behavior, although this knowledge may contribute to the understanding of the reciprocal influence of patient and provider communication and the pathways between communication and health care outcomes. Therefore, the aim of this study was to explore patients’ active communication behaviors and how this affects the immediate communication behavior of physicians. We coded 27 admission interviews from three German orthopedic rehabilitation centers with an adapted version of the Roter Interaction Analysis System. The data were analyzed using correlations and sequence analysis, specifically lag analysis. In this article, we report findings in relation to patients taking a position and physicians’ reactions. The analysis showed that while all patients took up a position during their consultation, they very rarely contradicted the physician. Moreover, many instances of patients’ expression of opinion were strongly determined by physicians’ behavior. When physicians asked patients for their opinions they often used alternative questions or closed questions that limited patients’ answering possibilities. While the lag analyses showed that patient communication behavior can influence physician communication, in the majority of instances patients’ expression of opinions did not lead to a discussion or shared decision making.     

‘They can’t report abuse,they can’t move out. They are at the mercy of these men’: exploring connections between intimate partner violence,gender and HIV in South African clinical settings

This qualitative study captured South African female health provider perspectives of intimate partner violence in female patients, gender norms and consequences for patients’ health. Findings indicated female patients’ health behaviours were predicated on sociocultural norms of submission to men’s authority and economic dependence on their partners. Respondents described how men’s preferences and health decision-making in clinics affected their patients’ health. Adverse gender norms and gender inequalities affected women’s opportunities to be healthy, contributing to HIV risk and undermining effective HIV management in this context. Some providers, seeking to deliver a standard of quality healthcare to their female patients, demonstrated a willingness to challenge patriarchal gender relations. Findings enhance understanding of how socially-sanctioned gender norms, intimate partner violence and HIV are synergistic, also reaffirming the need for integrated HIV-intimate partner violence responses in multi-sector national strategic plans. Health providers’ intimate knowledge of the lived experiences of female patients with intimate partner violence and/or HIV deepens understanding of how adverse gender norms generate health risks for women in ways that may inform policy and clinical practice in South Africa and other high-HIV prevalence settings.     

A Mixed-Methods Study of Patient–Provider E-Mail Content in a Safety-Net Setting

To explore the content of patient–provider e-mails in a safety-net primary care clinic, we conducted a content analysis using inductive and deductive coding of e-mail exchanges (n = 31) collected from January through November 2013. Participants were English-speaking adult patients with a chronic condition (or their caregivers) cared for at a single publicly funded general internal medicine clinic and their primary care providers (attending general internist physicians, clinical fellows, internal medicine residents, and nurse practitioners). All e-mails were nonurgent. Patients included a medical update in 19% of all e-mails. Patients requested action in 77% of e-mails, and the most common requests overall were for action regarding medications or treatment (29%). Requests for information were less common (45% of e-mails). Patient requests (n = 56) were resolved in 84% of e-mail exchanges, resulting in 63 actions. These results show that patients in safety-net clinics are capable of safely and effectively using electronic messaging for between-visit communication with providers. Safety-net systems should implement electronic communications tools as soon as possible to increase health care access and enhance patients' involvement in their care.     

A stochastic model of acute-care decisions based on patient and provider heterogeneity

The primary cause of preventable death in many hospitals is the failure to recognize and/or rescue patients from acute physiologic deterioration (APD). APD affects all hospitalized patients, potentially causing cardiac arrest and death. Identifying APD is difficult, and response timing is critical - delays in response represent a significant and modifiable patient safety issue. Hospitals have instituted rapid response systems or teams (RRT) to provide timely critical care for APD, with thresholds that trigger the involvement of critical care expertise. The National Early Warning Score (NEWS) was developed to define these thresholds. However, current triggers are inconsistent and ignore patient-specific factors. Further, acute care is delivered by providers with different clinical experience, resulting in quality-of-care variation. This article documents a semi-Markov decision process model of APD that incorporates patient and provider heterogeneity. The model allows for stochastically changing health states, while determining patient subpopulation-specific RRT-activation thresholds. The objective function minimizes the total time associated with patient deterioration and stabilization; and the relative values of nursing and RRT times can be modified. A case study from January 2011 to December 2012 identified six subpopulations. RRT activation was optimal for patients in “slightly concerning” health states (NEWS?>?0) for all subpopulations, except surgical patients with low risk of deterioration for whom RRT was activated in “concerning” states (NEWS?>?4). Clustering methods identified provider clusters considering RRT-activation preferences and estimation of stabilization-related resource needs. Providers with conservative resource estimates preferred waiting over activating RRT. This study provides simple practical rules for personalized acute care delivery.