Veterans’ perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication

ObjectivesDrawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication.MethodsWe interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach.ResultsParticipants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers’ fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication.ConclusionOur findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans.Practice ImplicationsWe discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers’ burnout.     

Factors affecting the communication experiences of newly diagnosed colorectal cancer patients

Objective

This study assessed patient-centered communication (PCC) among newly diagnosed colorectal cancer patients. PCC, a key part of patient-centered care, contributes directly and indirectly to health-related quality of life, satisfaction with care, and other outcomes.

Self-perceived provision of patient centered care by healthcare professionals: The role of emotional intelligence and general self-efficacy

ObjectiveThis study aimed to investigate whether healthcare professionals’ emotional intelligence (EI) is associated with self-perceived provision of patient-centered care (PCC), taking into account the potential mediating effect of general self-efficacy (GSE).MethodsA sample of 318 healthcare professionals, recruited in 2015 among four hospitals in Italy, completed the Provider-Patient Relationship Questionnaire, the Emotional Intelligence Scale, and the General Self-Efficacy scale. A structural equation model was tested with GSE mediating the relationship between EI and self-perceived provision of PCC. Groups of participants based on gender, profession, and work setting were also compared on the study variables.ResultsEI had direct effects on the self-perceived provision of PCC dimensions. GSE partially mediated only the relationship between EI and involving the patient in care. Healthcare professionals in rehabilitation units showed higher self-perceived provision of PCC than those in acute care or ambulatory services.ConclusionSelf-perceived provision of PCC seems to have the potential to be improved by EI and to be distinguishable from GSE.Practice implicationsSince EI can be developed, findings of this study have potential implications for improving PCC through continuing education interventions for healthcare professionals.     

Educational considerations based on medical student use of polygenic risk information and apparent race in a simulated consultation

PurposeTo craft evidence-based educational approaches related to polygenic risk score (PRS) implementation, it is crucial to forecast issues and biases that may arise when PRS are introduced in clinical care.MethodsMedical students (N = 84) were randomized to a simulated primary care encounter with a Black or White virtual reality–based patient and received either a direct-to-consumer–style PRS report for 5 common complex conditions or control information. The virtual patient inquired about 2 health concerns and her genetic report in the encounter. Data sources included participants’ verbalizations in the simulation, care plan recommendations, and self-report outcomes.ResultsWhen medical students received PRSs, they rated the patient as less healthy and requiring more strict advice. Patterns suggest that PRSs influenced specific medical recommendations related to the patient’s concerns, despite student reports that participants did not use it for that purpose. We observed complex patterns regarding the effect of patient race on recommendations and behaviors.ConclusionEducational approaches should consider potential unintentional influences of PRSs on decision-making and evaluate ways that they may be applied inconsistently across patients from different racial groups.     

The effect of cancer treatment summaries on patient-centered communication and quality of care for cancer survivors: A pooled cross-sectional HINTS analysis

ObjectiveProvision of cancer treatment summaries to patients is recommended to improve patient-centered communication (PCC). The objective of this study is to assess relationships between cancer treatment summary receipt, PCC, and quality of care (QOC).MethodsLinear and logistic regression of cross-sectional data from the Health Information National Trends Survey (HINTS) was conducted using data from years 2012, 2014, and 2017. The independent variable was receipt of treatment summary; the dependent variables were overall PCC score, six domains of PCC, and QOC.ResultsIn the pooled sample, 36.9% of patients with cancer treatment history reported receiving a treatment summary. There was a significant positive association between overall PCC score and treatment summary receipt, and higher odds of high scores for the PCC domains “responding to emotions” and “managing uncertainty.” We did not observe significant associations between treatment summary receipt and other PCC domains or QOC.ConclusionProviding patients cancer treatment summaries may improve PCC, but fewer than half of patients reported receiving one of these summaries.Practice ImplicationsProviding cancer treatment summaries is important, however, providing them without engaging in additional communication may be insufficient to improve all patient-centered care domains or quality of care.     

A longitudinal study of third-year medical students’ communication competence,communication anxiety,and attitudes toward patient-centered care

ObjectiveWe investigated changes in medical students’ communication competence and communication anxiety during their third year of training when they are immersed in formative clinical experiences that shape their patient-centered care and communication skills.MethodsWe invited 282 students to complete a longitudinal, four-phase online survey during their third-year. Our response rate was 62.8% at Phase I (n = 177), 34.0% at Phase II (n = 96), 37.9% at Phase III (n = 107), and 48.9% at Phase IV (n = 138). Measures included communication competence, communication anxiety, and patient-centered attitudes and orientation. We employed hierarchical linear modeling to analyze the data.ResultsStudents’ communication competence and anxiety improved over time. Female students reported greater communication anxiety and less competence related to information giving. At each phase, patient-centered attitudes significantly predicted communication competence and communication anxiety.ConclusionStudents’ competence and anxiety regarding communication during medical encounters improve during their third year and are significantly influenced by their attitudes and orientation towards patient-centered care and communication.Practice implicationsSchools should integrate curriculum that fosters positive attitudes toward patient-centered communication and provides opportunities to practice complex communication skills, which may increase competence and recognition that patient-centered communication is an important clinical skill.     

Racial disparities in patients hospitalized for COVID-19

BackgroundThe COVID-19 pandemic has demonstrated the significance of health disparities across populations with older adults and minoritized groups being disproportionately affected. Data during the COVID-19 pandemic demonstrated higher infection rates, hospitalization rates, morbidity, and potentially greater mortality in Black, Hispanic, and Native Americans compared to Whites.MethodsThis is a retrospective cohort study of de-identified patient data from 178 hospitals across the United States. Outcome variables were the length of stay, in-hospital mortality, disease severity, and discharge disposition. Outcomes were stratified by sex and racial groups.ResultsOf 45,360 patients, 22% were Black, 35% were Hispanic, 37% were White, and 6% were Other. The overall mortality rate was 15% across all groups but was 17% for White patients, 10% for Black patients, 14% for Hispanic patients, and 15% for patients categorized as Other. However, White patients have higher median age on admission (71 years) compared to Blacks (60 years), Hispanics (57 years), and Other (61 years). Race remained statistically significant in a multivariable model that included age, sex, and race. 6484 patients required ICU admission, intubation, and hemodynamic support. This burden was disproportionate across racial groups, with 15.6% of Blacks and 13.9% of non-Blacks having such critical disease (p < 0.0001, z-test for proportions).ConclusionsIn this national study of admitted patients with COVID-19, White patients admitted were older on average compared to other racial/ethnic groups and had a higher mortality rate compared to non-Whites hospitalized for COVID-19. Black patients were significantly more likely to require admission to the ICU, mechanical ventilation, and hemodynamic support. These COVID-19 health disparities highlight the importance of addressing social and structural determinants of health.     

Affective states and racial identity among African-American women with trichotillomania

Affective correlates of hair pulling were investigated in a sample of 43 African-American women with trichotillomania. The relationship among affective correlates and dimensions of racial identity was also examined. Via phone interview, participants completed the hair-pulling survey on which they rated the intensity of 10 different affective states across three different points in the hair-pulling episode (before, during and after). Participants also completed the Multidimensional Inventory of Racial Identity, which assesses racial identity across the dimensions of centrality, regard and ideology. Univariate analyses identified the feelings of being bored, happy, anxious, guilty and relieved as reflecting a time difference. Negative correlations were found among the racial identity dimension of private regard and the affective correlates of happy and relief that were experienced during and after pulling. Negative correlations were found between the racial identity dimension of humanist ideology and relieved affect as well as humanist ideology and relieved affect during a pulling episode. In light of the results, the importance of understanding and assessing cultural factors in the affective experience of African-American women with trichotillomania is discussed.     

Striking a balance: Health care providers’ experiences with home-based,patient-centered care for older people—A meta-synthesis of qualitative studies

ObjectiveThe aim of this article was to synthesize research findings about health care providers’ experiences of patient-centered care in the home setting.MethodsThis is a meta-synthesis of qualitative findings using the analytical method of meta-ethnography developed by Noblit and Hare. We performed a systematic literature search in seven databases and assessed potential studies against eligibility criteria and quality. Subsequently, 10 primary studies were included for analysis.ResultsThe core theme “being a balance artist” emerged from the synthesis, incorporating the participants’ experiences when faced with conflicting and competing responsibilities and needs. Two subthemes—“balancing the older clients’ needs against organizational demands” and “balancing the older clients’ needs against professional standards”—further elaborated on this core theme.ConclusionHealth care providers’ experiences indicate that organizational factors play a crucial role in shaping the conditions for patient-centered care for older people in the home setting.Practice implicationsTo motivate and facilitate health care providers to move to a more patient-centered practice, it is important to expand the values of patient-centered care beyond the clinical encounter into the organization.     

Patients’ challenges,competencies, and perceived support in dealing with information needs – A qualitative analysis in patients with breast and gynecological cancer

ObjectivesThis study aimed to investigate challenges, competencies, and support in breast and gynecological cancer patients when dealing with information needs and how health literacy as an interplay of these factors might be improved.MethodsSemi-structured interviews were conducted with patients in acute care (n = 19), undergoing rehabilitation (n = 20) or attending self-help groups (n = 16). Interviews were analyzed using content analysis.ResultsChallenges: gain information according to own needs, internet as information source, information evaluation and decisions, doctor-patient communication, situationally limited information processing, difficult access to information. Competencies: self-regulation of information needs, media and social competencies, communication skills in the doctor-patient conversation, internet competencies, self-directed decisions according to own needs, interest/self-efficacy, previous knowledge, trust in the doctor. Support: by professionals (e.g., patient-centered communication), relatives (e.g., support during consultations), peers (e.g., exchange), facilities (e.g., clinics).ConclusionsOur findings provide insight into challenges and competencies relevant to patients’ health literacy and the influence of support. The individuality of the interplay highlights the relevance of an active patient role and patient-centered care.Practice implicationsPatients’ health literacy should be improved in (psycho)oncological work by both reducing challenges (e.g., by communication skills training, involving relatives) and promoting competencies (e.g., by needs- and competence-oriented information offers).     

Do health literacy disparities explain racial disparities in family-centered care for youths with special health care needs?

ObjectiveTo explore the relationship among youth health literacy, parental health literacy, and family-centered care (FCC) for youth with special health care needs (YSHCN) and assess potential racial disparities.MethodsHL and FCC were assessed in 486 Medicaid-enrolled YSHCN (ages 12–18) and their healthcare-responsible parent/caregiver. Analyses assessed racial differences in HL and FCC for parents and youth using logistic regression.ResultsHalf of youth and over 80 percent of parents had adequate HL (REALM score ≥62). Adequate HL was significantly lower in African Americans (AA) for both YSHCN and parents. Only 57 % of parents and 29 % of YSHCN reported FCC. AA YSHCN reported significantly lower levels of FCC compared to White YSHCN. AA parents trended lower for FCC compared to Whites, though the disparity was not significant. AA youth and parents had significantly lower odds of reporting that doctors spent enough time with them compared to Whites.ConclusionResults suggest that AA and those with less than adequate health literacy experience lower FCC, however the relationship between race and health literacy does not explain the racial disparity in FCC.Practical ImplicationsProvider time spent focused on HL may not reduce the racial disparity in FCC, but opportunities for improvement exist.     

Preferences for patient-centered care among cancer survivors 5 years post-diagnosis

ObjectiveOur primary objective was to identify predictors associated with preferences for patient-centered care among cancer survivors and the association between cancer health literacy and patient-centered care preferences.MethodsCross sectional analyses of N = 345 adult cancer survivors (5 years post cancer diagnosis) attending follow-ups at University Malaya Medical Centre, Malaysia. Face-to face-interviews were conducted using the 30-item Cancer Health Literacy Test and the Patient-Practitioner Orientation Scale to determine preference for patient-centered care.ResultsCancer survivors’ preference for patient-centered care was associated with a higher cancer health literacy score, higher educational level, being employed, breast cancer diagnosis, and not desiring psychological support [F (14, 327) = 11.25, p < 0.001, R² = 0.325].ConclusionFindings from this study provide insights into preferences for patient-centered care among cancer survivors during receipt of follow-up care, which remains an understudied phase of cancer care delivery.Practice implicationsEfforts are needed to ensure different preferences for care are taken into account particularly in the setting of variable cancer health literacy.     

Development of observational rating scales for evaluating patient-centered communication within a whole health approach to care

ContextTeaching and evaluating patient-centered communication (PCC) skills that incorporate holistic approaches are increasingly relevant.ObjectiveThis study describes the development of the Observational Whole Health Measure (OWHM) for evaluating the extent to which primary care providers in the Veterans Health Administration engaged in PCC in the context of a holistic approach to care known as “Whole Health.”Design and SettingObservational rating scales were created based on content from a national whole health clinical education program in the VA and refined from audio recordings of patient-provider interactions in primary care clinical encounters. Unpaired t-tests and Cohen's d were conducted to measure overall quality of what really matters and whole health goal setting and plan development.Participants65 clinical encounters across 8 providers before and after participating in the training were included for analysis.InterventionThe intervention used for creating rating scales is a 2.5 day whole health clinical education program designed to teach providers PCC skills to identify what matters most for the patients and develop a patient-centered health plan that incorporates integrative health approaches to care.Main outcome measureQuality scores (0–4) were used to measure number of instances and extent to which providers explored what matters most to patients, dimensions of whole health, and development of a whole health plan tailored to patient's goals.ResultsWe developed the Observational Whole Health Measure (OWHM) that captures changes in provider communication. Significant differences in overall quality of whole health goal setting and plan development were detected between pre- and post-encounters, demonstrating a sensitivity to change. With the rise of integrative health approaches being adopted across clinical settings, the observational rating scales created in this study are likely to have increasing relevance.     

Shared decision making,patient-centered communication and patient satisfaction – A cross-sectional analysis

ObjectivesThe integration of shared decision making (SDM) and patient-centered communication (PCC) is needed to actively involve patients in decision making. This study examined the relationship between shared decision making and patient-centered communication.MethodsIn 82 videotaped hospital outpatient consultations by 41 medical specialists from 18 disciplines, we assessed the extent of shared decision making by the OPTION⁵ score and patient-centered communication by the Four Habits Coding Scheme (4HCS), and analyzed the occurrence of a high versus low degree (above or below median) of SDM and/or PCC, and its relation to patient satisfaction scores.ResultsIn comparison to earlier studies, we observed comparable 4HCS scores and relatively low OPTION⁵ scores. The correlation between the two was weak (r = 0.29, p = 0.009). In 38% of consultations, we observed a combination of high SDM and low PCC scores or vice versa. The combination of a high SDM and high PCC, which was observed in 23% of consultations, was associated with significantly higher patient satisfaction scores.ConclusionShared decision making and patient-centered communication are not synonymous and do not always co-exist.Practice implicationsThe value of integrated training of shared decision making and patient-centered communication should be further explored.     

Review of the patient-centered communication landscape in multiple myeloma and other hematologic malignancies

ObjectivesTo identify factors limiting and facilitating patient-centered communication (PCC) in the United States hematology-oncology setting, with a focus on multiple myeloma (MM), given the limited attention to PCC and rapid pace of change that has taken place in this setting.MethodsA literature search was performed from 2007 to 2017 to identify published articles and congress abstracts related to clinician-patient communication and treatment decision-making in oncology. Search results were evaluated by year of publication and disease area. A thematic assessment was performed to identify factors limiting and promoting PCC for patients with MM and other hematologic malignancies.ResultsOf the 6673 publications initially retrieved, 18 exclusively reported findings in patients with hematologic malignancies and were included in this review. We identified three critical, but modifiable, barriers to PCC in the hematologic malignancy setting, including insufficient information exchange, treatment goal misalignment, and discordant role preferences in treatment decision-making. Factors that enhanced interaction quality included educational programs for clinicians and patients.ConclusionsPatients with MM and other hematologic malignancies experience a distinct set of challenges that may affect PCC.Practice ImplicationsClinicians have the opportunity to improve patient care by proactively addressing the identified barriers and implementing strategies demonstrated to improve PCC.     

Sleepless in COVID-19: racial disparities during the pandemic as a consequence of structural inequity

Study ObjectivesInsomnia has been on the rise during the 2019 coronavirus disease (COVID-19) pandemic, which may disproportionately affect racial minorities. This study characterized racial disparities in insomnia during the pandemic and evaluated mechanisms for such disparities.MethodsParticipants included 196 adults (48 Black) from a 2016–2017 clinical trial of insomnia treatment who were reevaluated in April 2020. Race was evaluated as a predictor of change in insomnia, impact of COVID-19, and COVID-19 stress. Mediation models using the PRODCLIN method evaluated the extent to which: (1) COVID-19 impact accounted for Black-White disparities in change in insomnia, and (2) COVID-19 stress accounted for associations between discrimination and change in insomnia.ResultsIncreases in insomnia symptoms during COVID-19 were greater in Black compared to White participants, with 4.3 times the odds of severe insomnia (Insomnia Severity Index ≥ 22). Symptom severity was associated with pre-pandemic experiences of discrimination. Black participants were also disproportionately impacted by COVID-19, with twice the odds of irreparable loss of income/employment and four times the rate of COVID-19 diagnoses in their sociofamilial network compared to White participants. The disproportionate impact of COVID-19 accounted for 69.2% of the relationship between race and change in insomnia severity, and COVID-19 related stress accounted for 66.5% of the relationship between prior history of racial discrimination and change in insomnia severity.ConclusionsBlack-White disparities in insomnia severity during COVID-19 may be driven by structural inequities resulting in the disproportionate impact of COVID-19 on Black Americans. Results lend support for the minority stress model in the context of sleep health.Clinical Trial RegistrationSleep to Prevent Evolving Affecting Disorders (SPREAD). NCT number: NCT02988375. https://clinicaltrials.gov/ct2/show/NCT02988375.     

The Relationship between Racial Residential Segregation and Black-White Disparities in Fatal Police Shootings at the City Level, 2013–2017

BackgroundAlthough there is a disparity in the rates of fatal police shootings of Black victims compared to White victims throughout the nation, the magnitude of this racial disparity varies widely between cities. Examining the reasons behind this vast variation in the racial disparity in fatal police shootings across different localities could be helpful in identifying the underlying causes of this problem. Therefore, the objective of this study was to assess potential causes of the Black-White racial disparities in police shootings at the city level.MethodsUsing a cross-sectional design, we examined the relationship between the level of racial residential segregation in a city and the ratio of the rates of fatal police shootings of Black people compared to White people within that city during the period 2013–2017, using data from 69 of the largest cities in the United States. Using linear regression analysis, we modeled the ratio of Black to White fatal police shooting rates as a function of the level of racial segregation in each city as measured by the index of dissimilarity calculated at the Census block level. We controlled for several factors at the city level that might be expected to influence the rate of police shootings by race/ethnicity, including the level of deprivation of the Black population in economic status, the degree of Black representation in the city's police force, the relative size of the police force, crime rates, racial composition of the city, and city population.ResultsThe level of racial residential segregation was significantly associated with the racial disparity in fatal police shooting rates. For each one standard deviation increase in the index of dissimilarity, the ratio of Black to White fatal police shooting rates increased by 44.4% (95% confidence interval, 17.1%–71.7%).ConclusionsRacial residential segregation is a significant predictor of the magnitude of the Black-White disparity in fatal police shootings at the city level. Efforts to ameliorate the problem of fatal police violence must move beyond the individual level and consider the interaction between law enforcement officers and the neighborhoods that they police.