Discordance between physician's and parent's global assessments in juvenile idiopathic arthritis

OBJECTIVE: To investigate the discrepancy between physician's and parent's global assessments of disease status and the factors explaining discordance in patients with juvenile idiopathic arthritis (JIA). METHODS: The mothers of 197 patients with JIA rated the child's overall well-being on a 10 cm visual analogue scale (VAS) and the attending physician rated the child's overall disease activity on a 10 cm VAS. A discordance score was calculated by subtracting the physician's global assessment from that of the parent's, leading to the definition of three patient groups: (1) no discordance, when physician's and parent's assessments were within 1 cm of each other; (2) negative discordance, when parent's assessment was underrated relative to the physician; and (3) positive discordance, when parent's assessment was over-rated relative to the physician. Negative and positive discordance was defined as 'marked' when the difference between the two assessments was greater than 3 cm. RESULTS: No discordance was found in 40.6% of the patients. Negative discordance was found in 51.3% of the patients, with 34% showing marked discordance. Positive discordance was found in 8.1% of the patients, with 2% showing marked discordance. Significant differences between groups included a shorter disease duration among patients with a markedly positive discordance (P = 0.02) and a greater frequency of ongoing second-line drug therapy among patients with no discordance or with positive discordance (P = 0.008). Patients with no discordance or with marked positive discordance had a significantly lower joint counts (P = 0.02-0.004). CONCLUSION: Parents and physicians often perceive the health status of children with JIA differently, with parents providing most frequently lower rating.     

Development and validation of a preliminary definition of minimal disease activity in patients with juvenile idiopathic arthritis

OBJECTIVE: To develop and validate a definition of minimal disease activity (MDA) in patients with juvenile idiopathic arthritis (JIA). METHODS: The clinical charts of JIA patients followed over a 16-year period were reviewed to identify visits with high disease activity and MDA, defined on the basis of therapeutic decisions made by the attending physician. For each JIA activity measure recorded at the time of the visit, the cutoff value that best identified states of MDA was calculated by means of the area under the receiver operating characteristic curve analysis. A definition of MDA for oligoarthritis and polyarthritis was set up after testing the relative power of each variable in a multivariate analysis. Validation procedures included assessment of discriminant and construct validity. RESULTS: The definition that resulted from the analyses led to establish that a state of MDA could be defined as the presence of a physician global assessment < or =2.5 cm and a swollen joint count of 0 in patients with oligoarthritis; and as the presence of a physician global assessment < or =3.4 cm, a parent global assessment < or =2.1 cm, and a swollen joint count < or =1 in patients with polyarthritis. Validation procedures demonstrated that the MDA definition had good discriminant and construct validity in the context of both observational studies and controlled trials. CONCLUSION: We developed a preliminary definition of MDA in patients with JIA that represents a useful treatment target state and is proposed for inclusion as an outcome measure in future observational studies and clinical trials in patients with JIA.     

American College of Rheumatology provisional criteria for defining clinical inactive disease in select categories of juvenile idiopathic arthritis

Objective

To prospectively validate the preliminary criteria for clinical inactive disease (CID) in patients with select categories of juvenile idiopathic arthritis (JIA).

Methods

We used the process for development of classification and response criteria recommended by the American College of Rheumatology Quality of Care Committee. Patient‐visit profiles were extracted from the phase III randomized controlled trial of infliximab in polyarticular‐course JIA (i.e., patients considered to resemble those with select categories of JIA) and sent to an international group of expert physician raters. Using the physician ratings as the gold standard, the sensitivity and specificity were calculated using the preliminary criteria. Modifications to the criteria were made, and these were sent to a larger group of pediatric rheumatologists to determine quantitative, face, and content validity.

Results

Variables weighted heaviest by physicians when making their judgment were the number of joints with active arthritis, erythrocyte sedimentation rate (ESR), physician's global assessment, and duration of morning stiffness. Three modifications were made: the definition of uveitis, the definition of abnormal ESR, and the addition of morning stiffness. These changes did not alter the accuracy of the preliminary set.

Conclusion

The modified criteria, termed the “criteria for CID in select categories of JIA,” have excellent feasibility and face, content, criterion, and discriminant validity to detect CID in select categories of JIA. The small changes made to the preliminary criteria set did not alter the area under the receiver operating characteristic curve (0.954) or accuracy (91%), but have increased face and content validity.     

Brief report: Physician discomfort and variability with disability assessments

BACKGROUND: Completing a disability assessment is a common physician task; yet, little formal training is available. OBJECTIVE: To assess physician comfort with disability assessments, and evaluate their consistency. DESIGN: We conducted 2 separate surveys. The "Comfort" survey asked physicians to rate their comfort (1 = very uncomfortable to 10 = very comfortable) with 12 potentially uncomfortable tasks, including disability assessment. The second survey described 2 different patients requesting disability assessment, 1 with acute and the other with chronic back pain; participants assigned each a level of disability. PARTICIPANTS: Resident and staff physicians at an urban county hospital. RESULTS: For 54 physicians returning "Comfort" surveys, disability assessment had the lowest average comfort rating (4.3, SD 1.9) compared with all other tasks (mean ratings ranged from 4.8 to 8.0). For the 73 physicians returning the "Disability Cases" survey, 88% found Case 1 qualified for limited employment, but varied on the types of limitations imposed. For Case 2, 39% assigned no disability, 39% limited employment, and 22% full disability. CONCLUSIONS: Our pilot studies support the hypothesis that physicians are not comfortable with disability assessment, and their assessments can be highly variable. Physician discomfort and lack of training may contribute to variability in disability assessments.     

Responsiveness of clinical measures to flare of disease activity in juvenile idiopathic arthritis

OBJECTIVE: To compare the responsiveness of clinical measures in the assessment of disease flare in patients with juvenile idiopathic arthritis (JIA). METHODS: The clinical records of all consecutive patients with JIA who were diagnosed between 1995 and 2000 were retrospectively reviewed. In each patient, all visits made during follow-up were analyzed and those meeting the criteria for disease flare were recorded. The definition of flare was based on the therapeutic alterations made by the attending physician. Responsiveness of JIA clinical measures to relevant increase in disease activity (a flare) was evaluated by assessing the score change of each measure from a visit made 6 (+/- 3) months before a flare and the flare visit. Responsiveness statistics included the standardized response mean (SRM) and the effect size (ES). RESULTS: A total of 115 patients, who were followed for 0.5 to 6.2 years (mean 2.8 years), were studied. During follow-up, 51 patients (44%) experienced 1 or more disease flares, with the total number of flares being 75. Strong responsiveness (ES and SRM > or = 0.8) to increase in disease activity was demonstrated by the physician's and parent's global assessments, the global articular severity score, and the morning stiffness. The active, swollen and painful joint counts, the swelling, pain on motion/tenderness and limited range of motion (LROM) scores, and the erythrocyte sedimentation rate revealed moderate responsiveness (ES and SRM > or = 0.5). The poorest performances (ES and/or SRM < 0.5) were provided by the parent's assessment of pain, the functional ability tool, the number of joints with LROM, the LROM score, the C-reactive protein, the white blood cell and platelet count, and the hemoglobin level. CONCLUSION: Our analysis suggests that the swollen or painful joint counts are better suited than the count of joints with LROM for the assessment of disease flare in patients with JIA.     

Assessment of disease activity in juvenile idiopathic arthritis. The number and the size of joints matter

OBJECTIVE: Variables for assessment of disease activity of juvenile idiopathic arthritis (JIA) were studied, in order to develop a disease activity score for children with JIA. METHODS: One randomly chosen hospital visit was studied for each of 312 patients with JIA, with regard to disease activity variables. The physician global assessment score visual analog scale (physician GA) was used as a dependent variable in comparisons between potential disease activity variables. Previous studies have shown this variable to be the most sensitive to changes in JIA disease activity and to be comparable between patients. RESULTS: Based on Spearman's rank order correlation the number of active joints had a strong association with the physician GA. The median physician GA score rose markedly for each active large joint, but less for small joints, although small joints were also statistically important in assessing disease activity. Among the laboratory data, the erythrocyte sedimentation rate, C-reactive protein level, and platelet count showed weak correlations to the physician GA. CONCLUSION: In preparation of a disease activity score for children with JIA the importance of both the number and size of joints involved needs further evaluation.     

Satisfaction with the outpatient encounter

OBJECTIVE: To compare patients' and physicians' visit-specific satisfaction in an internal medicine outpatient setting, and to explain their respective views. DESIGN: Patients' and physicians' background characteristics were assessed prior to outpatient encounters. Immediately after the encounter, both patients and physicians completed a questionnaire assessing satisfaction with the visit. SETTING: The outpatient division of an academic teaching hospital. PARTICIPANTS: Thirty residents and specialists in general internal medicine, rheumatology, and gastroenterology, and 330 patients having a follow-up appointment with one of these physicians. MEASUREMENTS AND MAIN RESULTS: Patients' and physicians' visit-specific satisfaction was assessed using 5 Visual Analogue Scales (0 to 100). Patients' overall satisfaction was higher than physicians' satisfaction (mean 81 vs. 66), and correlation of patients' and physicians' overall satisfaction with the specific visit was medium sized (r= .28, P < .001). Patients' satisfaction ratings were associated with their previsit self-efficacy in communicating with their physician (P < .001) and with visiting a female physician (P < .01). Physicians' satisfaction was associated with patients' higher educational level (P < .05), primary language being Dutch (P < .001), better mental health (P < .05), and preference for receiving less than full information (P < .05). CONCLUSIONS: In an outpatient setting, patients' visit-specific satisfaction ratings were substantially higher than, and only moderately associated with, physicians' ratings of the same visit. The dissimilar predictors explaining patients' and physicians' satisfaction suggest that patients and physicians form their opinion about a consultation in different ways. Hence, when evaluating outpatient encounters, physicians' satisfaction has additional value to patients' satisfaction in establishing quality of care.     

Unmet expectations for care and the patient-physician relationship

OBJECTIVE: To profile patients likely to have unmet expectations for care, examine the effects of such expectations, and investigate how physicians' responses to patients' requests affect the development of unfulfilled expectations. DESIGN: Patient and physician questionnaires were administered before and after outpatient visits. A follow-up telephone survey was administered 2 weeks post visit. SETTING: The offices of 45 family practice, internal medicine, and cardiology physicians. PATIENTS: Nine hundred nine adults reporting a health problem or concern. MEASUREMENTS AND MAIN RESULTS: Before their visits, patients rated their general health and trust in the index physician. After the visit, patients reported upon 8 types of unmet expectations and any request they made. Two weeks thereafter, patients rated their visit satisfaction, improvement, and intention to adhere to the physician's advice. They also reported any postvisit health system contacts. Overall, 11.6% of patients reported >/=1 unmet expectation. Visits in which a patient held an unmet expectation were rated by physicians as less satisfying and more effortful. At follow-up, patients who perceived an unmet expectation for care also reported less satisfaction with their visits, less improvement, and weaker intentions to adhere. Patients with an unmet expectation related to clinical resource allocation had more postvisit health system contacts. Unmet expectations were typically reported by a patient whose request for a resource was not fulfilled. CONCLUSIONS: Unmet expectations adversely affect patients and physicians alike. Physicians' nonfulfillment of patients' requests plays a significant role in patients' beliefs that their physicians did not meet their expectations for care.     

The effect of discussions about advance directives on patients’ satisfaction with primary care

BACKGROUND: Discussions of end-of-life care should be held prior to acute, disabling events. Many barriers to having such discussions during primary care exist. These barriers include time constraints, communication difficulties, and perhaps physicians' anxiety that patients might react negatively to such discussions. OBJECTIVE: To assess the impact of discussions of advance directives on patients' satisfaction with their primary care physicians and outpatient visits. DESIGN: Prospective cohort study of patients enrolled in a randomized, controlled trial of the use of computers to remind primary care physicians to discuss advance directives with their elderly, chronically ill patients. SETTING: Academic primary care general internal medicine practice affiliated with an urban teaching hospital. PARTICIPANTS: Six hundred eighty-six patients who were at least 75 years old, or at least 50 years old with serious underlying disease, and their 87 primary care physicians (57 residents, 30 faculty general internists) participated in the study. MEASUREMENTS AND MAIN RESULTS: We assessed patients' satisfaction with their primary care physicians and visits via interviews held in the waiting room after completed visits. Controlling for satisfaction at enrollment and physician, patient, and visit factors, discussing advance directives was associated with greater satisfaction with the physician (P =.052). At follow-up, the strongest predictor of satisfaction with the primary care visit was having previously discussed advance directives with that physician (P =.004), with a trend towards greater visit satisfaction when discussions were held during that visit (P =.069). The percentage of patients scoring a visit as "excellent" increased from 34% for visits without prior advance directive discussions to 51% for visits with such discussions (P =.003). CONCLUSIONS: Elderly patients with chronic illnesses were more satisfied with their primary care physicians and outpatient visits when advanced directives were discussed. The improvement in visit satisfaction was substantial and persistent. This should encourage physicians to initiate such discussions to overcome communication barriers might result in reduced patient satisfaction levels.     

Anabolic steroid users' attitudes towards physicians

AIMS: To assess anabolic-androgenic steroid (AAS) users' trust in the knowledge and advice of physicians. DESIGN: Interviews of AAS users and non-users. SETTING: Research offices. PARTICIPANTS: Eighty weight-lifters (43 AAS users, 37 non-users) recruited by advertisement in Massachusetts and Florida, USA. MEASUREMENTS: Personal interviews and questionnaire responses, including subjects' ratings of physicians' knowledge regarding various health- and drug-related topics. AAS users also rated their level of trust in various sources of information about AAS. FINDINGS: Both groups of subjects gave physicians high ratings on knowledge about general health, cigarette smoking, alcohol, and conventional illicit drugs, but gave physicians markedly and significantly lower ratings on knowledge about AAS. When rating sources of information on AAS, users scored physicians as no more reliable than their friends, Internet sites, or the person(s) who sold them the steroids. Forty percent of users trusted information on AAS from their drug dealers at least as much as information from any physician that they had seen, and 56% had never revealed their AAS use to any physician. CONCLUSION: AAS users show little trust in physicians' knowledge about AAS, and often do not disclose their AAS use to physicians. These attitudes compromise physicians' ability to educate or treat AAS users. Physicians can respond to these problems by learning more about AAS and by maintaining a high index of suspicion when evaluating athletic male patients.     

Improving physicians’ HIV risk-assessment skills using announced and unannounced standardized patients

OBJECTIVE: To evaluate feasibility and to validate a rating scale for two educational programs that use standardized patient-instructors (SPIs) in the office setting to improve physicians' HIV risk communication skills. DESIGN: Pilot randomized trial of announced and unannounced SPIs. PARTICIPANTS/SETTINGS: Twenty four primary care physicians in the Rochester, NY, area. MEASUREMENTS: The Rochester HIV Interview Rating Scale (RHIRS), HIV test ordering, physician satisfaction questionnaire. RESULTS: Physicians found the intervention useful, and predicted a positive effect on their future HIV-related communication. HIV test ordering and RHIRS scores increased similarly in both intervention groups. Announced SPI visits were more convenient and preferred by physicians. Cost for each SPI visit was $75. CONCLUSIONS: A brief office-based intervention using SPIs was feasible, well-accepted, convenient, and inexpensive. Announced SPIs were preferred to unannounced SPIs. Pilot results suggesting improvement in HIV-related communication should be confirmed in a larger randomized trial.     

Development of validated disease activity and damage indices for the juvenile idiopathic inflammatory myopathies. I. Physician,parent, and patient global assessments

Objective. To determine the reliability, content validity, and responsiveness of physician global assessments of disease activity and damage in the juvenile idiopathic inflammatory myopathies (IIM), and to investigate concordance among physician, parent, and patient global ratings. Methods. Sixteen pediatric rheumatologists rated 10 juvenile IIM paper patient cases for global disease activity and damage, and assessed the importance of 51 clinical and laboratory parameters in formulating their global assessments. Then, 117 juvenile IIM patients were enrolled in a protocol to examine the relationship between Likert and visual analog scale global assessments, their sensitivity to change, and the comparability of physician, parent, and patient global ratings. Results. Pediatric rheumatologists demonstrated excellent interrater reliability in their global assessments of juvenile IIM disease activity and damage (97.7% and 94.7% agreement among raters, respectively), and agreed on a core set of clinical parameters in formulating their judgments. Likert scale ratings correlated with those on a visual analog scale, and both were comparable in responsiveness (standardized response means −0.56 for disease activity, 0.02 [Likert] and 0.14 [visual analog] for damage, measured over 8 months). Parent global ratings of disease activity correlated with physician assessments, but were not colinear (Spearman's correlation [r] = 0.41−0.45). Patient global disease activity assessments correlated with those done by parents (r = 0.57−0.84) and physicians (r = 0.37−0.63), but demonstrated less responsiveness (standardized response means −0.21 and −0.12, respectively, over 8 months). Conclusion. Physician global assessments of juvenile IIM disease activity and damage demonstrated high interrater reliability and were shown to be comprehensive measures. Both physician and parent disease activity assessments should be considered valuable as quantitative measures for evaluating therapeutic responses in juvenile IIM patients.     

Derivation of the SLEDAI. A disease activity index for lupus patients. The Committee on Prognosis Studies in SLE.

OBJECTIVE. To standardize outcome measures in systemic lupus erythematosus (SLE). Three indices were identified which could adequately describe outcome (disease activity, damage from disease, and health status); we describe here the development of the Disease Activity Index. METHODS. Twenty-four variables were identified as important factors in a disease activity index. These were used to generate 574 patient profiles, which were rated on a disease activity scale of 0-10 by 14 rheumatologists. A second rating of 10 of the profiles yielded scores that were not significantly different from the first, indicating that experienced clinicians can reliably make global estimates of disease activity. Multiple regression models were used to estimate the relative importance of the 24 clinical variables in the physicians' global rating of disease activity. These were estimated on a "training set" of 75% of physicians' ratings, and then validated on a "testing set," consisting of the remaining 25% of physicians' ratings. RESULTS. The explanatory power of the models in the training set was high (R2 = 0.93). The models' regression coefficients for the organ systems were simplified for easier use in clinical practice. This generated a "weighted" index of 9 organ systems for disease activity in SLE, the SLEDAI, as follows: 8 for central nervous system and vascular, 4 for renal and musculoskeletal, 2 for serosal, dermal, immunologic, and 1 for constitutional and hematologic. The maximum theoretical score is 105, but in practice, few patients have scores greater than 45. The SLEDAI predicted well the physicians' ratings in the testing set (Pearson's correlation coefficients = 0.64-0.79). CONCLUSION. The SLEDAI is a validated model of experienced clinicians' global assessments of disease activity in lupus. It represents the consensus of a group of experts in the field of lupus research.     

Level of agreement between children, parents, and physicians in rating pain intensity in juvenile idiopathic arthritis

OBJECTIVE: To investigate the level of agreement between patients, mothers, fathers, and physicians in rating pain intensity in juvenile idiopathic arthritis (JIA), and to identify factors explaining discrepancies between raters. METHODS: Ninety-four children with JIA and their mothers and fathers were asked to rate independently the intensity of present pain and pain in the previous week on a visual analog scale. The physicians rated pain intensity after physical examination. Agreement between raters was determined using intraclass correlation coefficient and Bland and Altman method. Correlations of explanatory variables with discordance in rating pain intensity were determined by univariate and multivariate analyses. Explanatory variables included sex, age, JIA category, disease duration, results of study ratings, joint inflammation measures, and erythrocyte sedimentation rate. RESULTS: Agreement in rating present pain was moderate between children and mothers, but was poor between children and fathers and children and physicians. The agreement in rating pain in the previous week was moderate between children and mothers and children and fathers. Mother-father agreement was good. Parents and physicians agreed at a moderate level. In multiple regression analyses, only intensity of present pain was significantly associated with discordance within child-mother, child-father, and child-physician dyads. CONCLUSION: Children's ratings of pain were only in moderate agreement with those of their parents and were in poor agreement with those of the physicians, whereas the father and mothers agreed at a good level. The intensity of pain was the strongest determinant of discordance between children and other raters.     

The disease activity score is not suitable as the sole criterion for initiation and evaluation of anti-tumor necrosis factor therapy in the clinic: discordance between assessment measures and limitations in questionnaire use for regulatory purposes

OBJECTIVE: The Disease Activity Score (DAS) is widely used in clinical trials. A DAS of 5.1 defines the level of severe rheumatoid arthritis (RA) and is the criterion for the initiation of anti-tumor necrosis factor therapy in the UK and The Netherlands. In North America, similar rules are sometimes imposed. However, it is not known how accurately the DAS characterizes RA activity. The present study was undertaken to determine the concordance between DAS scores and physicians' assessments of RA activity, to investigate factors relating to discrepancies, and to assess the suitability of using the DAS in individual patients. METHODS: Six hundred sixty-nine RA patients were assessed using the DAS and other clinical measures. A physician's global estimate of RA activity was performed using an 11-point predefined scale and a standard definition of disease activity. RESULTS: The DAS and physician global assessment had substantially different distributions of values. The level of agreement (Kendall's tau-a) between DAS scores and physician global assessments was 49% (95% confidence interval 45-53%), Lin's coefficient of concordance was 0.62, and the Bland-Altman 95% limits of agreement were -3.17 and 3.99. These results suggest poor-to-moderate concordance between the 2 measures of disease activity. CONCLUSION: The DAS and the physician's assessment of RA activity do not approach, value, and weight RA variables to the same extent, suggesting that RA activity is not evaluated similarly by North American physicians and with the DAS. The scales do not have acceptable levels of concordance. There is too much inherent variability in the DAS and other RA scales (e.g., the Health Assessment Questionnaire) to recommend them as sole determinants of RA activity for clinical or regulatory purposes.     

Effect of student involvement on patient perceptions of ambulatory care visits: a randomized controlled trial

OBJECTIVE: To determine if patient satisfaction with ambulatory care visits differs when medical students participate in the visit. DESIGN: Randomized controlled trial. SETTING: Academic general internal medicine practice. PARTICIPANTS: Outpatients randomly assigned to see an attending physician only (N = 66) or an attending physician plus medical student (N = 68). MEASUREMENTS AND MAIN RESULTS: Patient perceptions of the office visit were determined by telephone survey. Overall office visit satisfaction was higher for the "attending physician only" group (61% vs 48% excellent), although this was not statistically significant (P =.16). There was no difference between the study groups for patient ratings of their physician overall (80% vs 85% excellent; P =.44). In subsidiary analyses, patients who rated their attending physician as "excellent" rated the overall office visit significantly higher in the "attending physician only" group (74% vs 55%; P =.04). Among patients in the "attending physician plus medical student" group, 40% indicated that medical student involvement "probably" or "definitely" did not improve their care, and 30% responded that they "probably" or "definitely" did not want to see a student at subsequent office visits. CONCLUSIONS: Although our sample size was small, we found no significant decrement in patient ratings of office visit satisfaction from medical student involvement in a global satisfaction survey. However, a significant number of patients expressed discontent with student involvement in the visit when asked directly. Global assessment of patient satisfaction may lack sensitivity for detection of dissatisfaction. Future research in this area should employ more sensitive measures of patient satisfaction.     

Reliability and validity of six systems for the clinical assessment of disease activity in systemic lupus erythematosus

Six systems for defining and evaluating disease activity in patients with systemic lupus erythematosus (SLE) (the Ropes system, the National Institutes of Health [NIH] system, the New York Hospital for Special Surgery system, the British Isles Lupus Assessment Group [BILAG] scale, the University of Toronto SLE Disease Activity Index [SLE-DAI], and the Systemic Lupus Activity Measure [SLAM]) were tested on 25 SLE patients who were selected to represent a range of disease activity. The patients were evaluated independently by 2 physicians on 2 occasions approximately 1 month apart. Differences between patients demonstrated the largest source of variation in scores, accounting for 56-84% of the total variance, depending on the instrument. Differences between physicians (i.e., error) showed the next largest variation, 11-28% of the total variance, and differences between visits made up 5-16% of the total. The BILAG, SLE-DAI, and SLAM had the best inter-visit and inter-rater reliability. Convergent validity was shown by the strong correlations of scores among the different instruments (r = 0.81-0.97). All instruments correlated highly with the physicians' clinical impression of disease but less well with their evaluation of disease severity. The number of American Rheumatism Association criteria for SLE that were met by the patients correlated poorly with the physicians' global evaluation and with the scores of the instruments. The patients' self-reported disease activity scores correlated highly with the physicians' assessments of disease activity (r = 0.85-0.91), and the mean values from self-reports and from physicians' assessments were nearly equal. In contrast, severity scores correlated less well between self-reports and physician assessments (r = 0.49-0.69), and mean self-reported severity values were lower than the means from physicians. The BILAG, SLE-DAI, and SLAM systems appear to have better psychometric properties than the others for clinical research.     

Unsaid but not forgotten: patients' unvoiced desires in office visits

OBJECTIVES: To examine patient, physician, and health care system characteristics associated with unvoiced desires for action, as well as the consequences of these unspoken requests. PATIENTS AND METHODS: Patient surveys were administered before, immediately after, and 2 weeks after outpatient visits in the practices of 45 family practice, internal medicine, and cardiology physicians working in a multispecialty group practice or group model health maintenance organization. Data were collected at the index visit from 909 patients, of whom 97.6% were surveyed 2 weeks after the outpatient visit. Before the visit, patients rated their trust in the physician, health concerns, and health status. After the visit, patients reported on various types of unexpressed desires and rated their visit satisfaction. At follow-up, patients rated their satisfaction, health concerns, and health status, and also described their postvisit health care use. Evaluations of the visit were also obtained from physicians. RESULTS: Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician. Patients with unvoiced desires evaluated the physician and visit less positively; these encounters were evaluated by physicians as requiring more effort. Holding an unvoiced desire was associated with less symptom improvement, but did not affect postvisit health care use. CONCLUSIONS: Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement. Implications of these findings for clinical practice are examined.     

Is physician self-disclosure related to patient evaluation of office visits?

CONTEXT: Physician self-disclosure has been viewed either positively or negatively, but little is known about how patients respond to physician self-disclosure. OBJECTIVE: To explore the possible relationship of physician self-disclosure to patient satisfaction. DESIGN: Routine office visits were audiotaped and coded for physician self-disclosure using the Roter Interaction Analysis System (RIAS). Physician self-disclosure was defined as a statement describing the physician's personal experience that has medical and/or emotional relevance for the patient. We stratified our analysis by physician specialty and compared patient satisfaction following visits in which physician self-disclosure did or did not occur. PARTICIPANTS: Patients (N= 1,265) who visited 59 primary care physicians and 65 surgeons. MAIN OUTCOME MEASURE: Patient satisfaction following the visit. RESULTS: Physician self-disclosure occurred in 17% (102/589) of primary care visits and 14% (93/676) of surgical visits. Following visits in which a primary care physician self-disclosed, fewer patients reported feelings of warmth/friendliness (37% vs 52%; P =.008) and reassurance/comfort (42% vs 55%; P =.027), and fewer reported being very satisfied with the visit (74% vs 83%; P =.031). Following visits in which a surgeon self-disclosed, more patients reported feelings of warmth/friendliness (60% vs 45%; P =.009) and reassurance/comfort (59% vs 47%; P=.044), and more reported being very satisfied with the visit (88% vs 75%; P =.007). After adjustment for patient characteristics, length of the visit, and other physician communication behaviors, primary care patients remained less satisfied (adjusted odds ratio [AOR], 0.45; 95% confidence interval [CI], 0.24 to 0.81) and surgical patients more satisfied (AOR, 2.22; 95% CI, 1.12 to 4.50) after visits in which the physician self-disclosed. CONCLUSIONS: Physician self-disclosure is significantly associated with higher patient satisfaction ratings for surgical visits and lower patient satisfaction ratings for primary care visits. Further study is needed to explore these intriguing findings and to define the circumstances under which physician self-disclosure is either well or poorly received.     

Reliability and validity of systemic lupus activity measure-revised (SLAM-R) for measuring clinical disease activity in systemic lupus erythematosus.

New clinical scales for semiquantitating disease activity in systemic lupus erythematosus (SLE) are widely used in research. They are reliable and valid measures. One of the original scales, the Systemic Lupus Activity Measure (SLAM), has been modified based on experience with it in multi-observer studies and training of individuals in its use. We tested the psychometric properties of the revised SLAM (SLAM-R). SLAM-R was tested on 30 SLE patients, who fulfilled 1997 revised ACR criteria and were selected to represent a range of disease activity. The patients were evaluated independently by two physicians, who studied the instruction booklet and who had never used SLAM-R, on two occasions 2-4 weeks apart. At the first visit, the physician's global assessment of activity using visual analog scale, anti-dsDNA Ab, C3 and C4 were checked for construct validity. The psychometric properties were analyzed with nested analysis of variance and Pearson's correlation coefficient using SAS. All patients were female, the median age was 31 (15-52) y, and the mean score of SLAM-R was 10.5 +/- 5.3 (3-26). Estimates of reliability were 0.78 of inter-rater, 0.61 of inter-visit, 0.76 of physician 1 between visits, and 0.56 of physician 2 between visits. Among subcategories except 'Eye,' the 'Gastrointestinal' category had the highest (0.96) and the 'Neuromotor' category had the lowest inter-rater reliability (0.50). With respect to construct validity, the correlation of SLAM-R scores with the disease activity variables except C4 was high and statistically significant. In conclusion, the SLAM-R is reliable and valid for measuring clinical disease activity in SLE.