Disclosure of natural product use to primary care physicians: a cross-sectional survey of naturopathic clinic attendees

OBJECTIVE: To determine factors that predict disclosure of natural product use by patients to their primary care physicians. METHODS: An 18-item survey about health care use and communication was distributed to patients who presented to the Canadian College of Naturopathic Medicine in March 2003. We examined correlations between responses and created a multivariable logistic regression model to explore which factors were associated with patients' discussion of natural product use with their primary care physicians. RESULTS: The survey was given to 198 patients, 174 of whom responded (response rate, 87.9%). Most respondents (161 [92.5%] of 174) made use of natural products, and many (61 [41.5%] of 147) reported that they did not discuss natural product use with their primary care physician. The most significant factor predictive of patients having discussed natural product use with their primary care physician was having their primary care physician ask about natural product use (odds ratio, 18.77; 95% confidence interval, 5.06-69.62). Most respondents (107 [69.9%] of 153) indicated that their primary care physician did not ask about natural product use. CONCLUSIONS: An important number of patients who visit a naturopathic clinic do not disclose natural product use to their primary care physicians. Our findings suggest that disclosure rates could be improved by physicians taking a more active role in asking their patients about natural product use.     

Disclosure decisions of rural African American men living with HIV disease.

A qualitative study was conducted to explore disclosure decisions of rural African American men living with HIV disease. The sample consisted of 20 HIV-infected African American men living in the rural South who had been diagnosed with HIV for at least 6 months. Audiotaped semistructured interviews were used for data determination. The men were questioned about who they had told about their disease, reactions to their disclosures, and their advice to others about disclosing. Results showed that initially the men did not disclose their disease to others, and many of them continued not to disclose. They were concerned about negative consequences such as rejection, fear of contagion, and the recipients telling others. If and when they disclosed, it was likely to be to sexual partners, immediate family members, and health care providers. Their decision not to disclose protected them from the possible negative reactions, but it also limited the amount of social and emotional support they received related to their HIV disease.     

Disclosure decisions within transition narratives: How ex-drug users decide what information to share when working toward employment in the substance misuse field

Ex-user narratives often “end” at the point where treatment ends, leaving much to discover regarding what happens next. Within this post-treatment experience, ex-users making the transition to work in the drugs field must decide whether or not to disclose their past substance use and, if they do disclose, further personal decision-making relates to how much to disclose, to whom, and in what context. This article explores ex-drug users’ decisions around disclose of their background to colleagues and service users. In-depth narrative interviews were undertaken with 11 ex-drug users to explore their journey to become substance misuse practitioners and their decisions around disclosure within this transition. Process-mapping was used to enable participants to structure their story in their own way. Following thematic analysis, it became apparent that most participants received little or no guidance regarding disclosure. In the absence of clear guidelines regarding personal disclosures, reflective practice could be seen as a potential tool to enable participants to assess such risks and rewards. Alongside personal reflexivity, consideration should be given by service providers to disclosure policies, induction and ongoing training, and supervision in order to support ex-user drug workers’ disclosure decision-making.     

Documenting patients' end-of-life decisions

The anguish families experience when they are asked to make health care decisions for incompetent members has stimulated the search for an adequate procedure to document patients' end-of-life decisions. This study explores a method of recording competent patients' wishes via a "value history," a questionnaire that can guide families and the health care team during an incompetent person's terminal illness. Questions addressed were these: Can a primary care physician gather information from competent patients about their care before they become incompetent? Can a nurse practitioner gather the information as efficiently as a physician? Do patients want this information recorded in their charts? and, Is the primary care office as well as the patient's home an appropriate location to obtain a value history? Four hundred patients were invited to record their wishes for future care. Patients expressed that they wanted to be told the truth about their health and their health care, and they wanted to participate in decision-making, even while dying. The majority did not want to be maintained indefinitely on life-support systems. Patient responses were similar regardless of whether the NP or physician conducted the interview. A primary care office or patient's home are both suitable for filling out the value history. Because of the enthusiastic patient responses, the authors recommend that value histories become a routine part of a patient's medical record.     

Disclosure of confidential information by mental health nurses,of patients they assess to be a risk of harm to self or others: An integrative review

There is a duty of confidentiality on the part of mental health nurses when they handle confidential patient information. Nonetheless, it may be necessary to disclose confidential information of a patient if the patient is assessed as being a risk to self or others, to protect the patient or others from harm. However, disclosing information inappropriately may constitute a breach of confidentiality. There is a paucity of information on how mental health nurses understand the rules of confidentiality when deciding to withhold or disclose confidential information in these circumstances. An integrative review of the literature was undertaken to explore the disclosure of confidential information by mental health nurses when they assess a patient as being a risk of harm. The findings indicate the rules of confidentiality are not well understood, or are not adhered to by mental health nurses. Risk assessments were found to underpin deliberations to withhold or disclose confidential information of a patient, despite risk being difficult to predict with any certainty. For risk assessment, mental health nurses were noted to prefer their unstructured clinical judgement over actuarial methods; and defer to their clinical intuition over scores of a structured risk assessment instrument, when making structured clinical judgement‐backed decisions in this area of their practice. Gaps in the literature that may be addressed by future empirical research were revealed during this integrative review.     

Do Patients Refusing Transport Remember Descriptions of Risks after Initial Advanced Life Support Assessment?

Abstract. Objective : To determine patient recall and understanding of instructions given to patients who refuse transport after initial paramedic assessment and medical treatment. Methods : Following patient consent, a phone interview was completed for consecutive persons living in a large urban area for whom 9-1-1 was contacted but who subsequently refused transport after advanced life support (ALS) assessment. Subjects were asked about their recall of explained risks and benefits of transport, their understanding of those risks at the time of assessment, and subsequent use of medical care, including hospitalization. Results : From October 1, 1996, to February 23, 1997, 324 people refused transport after ALS arrival. Sixty-eight people could not be contacted, providing a response rate of 79% (256/324). Six percent were subsequently admitted to the hospital for the same problem and an additional 59% sought care from a health care provider (66 ED visits, 63 personal physician, 16 urgent care, 5 other). There were no unexpected deaths. Ninety (35%) respondents were still experiencing symptoms at the time of phone contact. Despite the routine practice of providing a verbal explanation of risks and written instructions, only 141 (55%) recalled receiving written instructions and 56 (22%) recalled an explanation of risks. Twenty-six percent believed they did not fully understand their conditions or circumstances surrounding the 9-1-1 call when they refused transport and 18% would now take an ambulance if the same incident were to recur. Conclusion : A substantial proportion of patients refusing transport do not recall receiving verbal or ritten instructions and would reconsider their transport decision, raising doubts about people's ability to make informed decisions at a time of great vulnerability. The majority of patients accessed health care after refusing transport and 6% were hospitalized.     

A Cross-Cultural Investigation of Suicidal Disclosures and Attitudes in Austrian and Turkish University Students

The prevalence of suicidal behavior and the nature of attitudes toward suicide differ in Austria and Turkey. To see if there were differences in disclosure, 351 Turkish and 310 Austrian students answered questions about disclosing suicidal thoughts. More Austrian than Turkish students reported suicidal ideation and believed that suicidal people disclose their plans, but suicidal disclosures were equally common in the two groups. Compared to Austria, suicidal disclosures in Turkey met with more positive social reactions that may facilitate a successful social support process. These findings imply that prevention efforts should reduce the stigma around suicidal disclosures.     

Blood-donor perceptions of health history screening with a computer-assisted self-administered interview

BACKGROUND: Computer-assisted self-interviewing (CASI) has been shown to promote disclosures of sensitive information. Using CASI to screen blood-donor candidates might encourage reports of deferrable risks without discouraging eligible donors. STUDY DESIGN AND METHODS: In 1998, an anonymous mail survey was sent to donors from eight blood centers. The relationship of donor demographics, donation history, and infectious risks (HIV test-seeking behavior, unreported deferrable risk, or reactive donor-screening test result) on attitudes toward CASI were assessed. RESULTS: Of 92,581 blood donors surveyed, 52,650 (57%) responded; of these, 4713 (7%) had an infectious risk. Among donors with risks, 29 percent felt they would be encouraged to reveal personal data, and 7 percent reported they would be discouraged from donating by CASI. Young, minority, female, and first-time donors were the most likely to report that CASI would encourage personal disclosures. Among donors without risks, 5 percent felt CASI would discourage them from donating. CONCLUSIONS: Although most donors felt their donation practices would not be influenced, CASI might reduce the proportion of donors with infectious risks by fostering personal disclosures and self-deferrals. The potential for CASI to improve donor screening and increase appropriate self-deferrals should be balanced against the possible loss of reluctant safe donors.     

Complying with the Health Insurance Portability and Accountability Act. Privacy standards.

The Privacy Rule: Limits the use and disclosure of PHI to purposes of treatment, payment, or routine health care operations. Requires covered entities to provide advance notice to the public of its policy governing disclosure of PHI. Requires entities covered by the Standard to secure general client consent to use and to disclose PHI for treatment, payment, or routine health care operations and to obtain specific client authorization to use or to disclose PHI for all other purposes unless the disclosure is specifically permitted without consent or authorization (e.g., a covered entity may disclose PHI to a health care oversight agency such as the Office of the Inspector General without first obtaining client authorization). In certain situations, a covered entity need only obtain client agreement to disclose PHI which may be oral or inferred from the circumstances surrounding the disclosure. For example, a covered entity could disclose PHI to a relative caring for the individual who is the subject of the health information. Expects covered entities to take measures to protect PHI from both inadvertent and deliberate misuse and disclosure. Requires, except in certain circumstances, the amount of PHI disclosed on any occasion to be limited to the minimum necessary to achieve the purpose of the disclosure. Gives individuals more control of their health information by permitting them to review and amend health information pertaining to themselves and to demand an accounting of persons to whom their health information has been disclosed. Establishes terms under which a covered entity may disclose PHI to a business associate. Permits states to maintain state laws that are more stringent than the Privacy Rule. The statute provides for significant civil and criminal penalties for failure to comply with the Standards. Violations are punishable by fines as much as $250,000 and 10 years imprisonment. The HHS, Office of Civil Rights is charged with enforcing the Standards. The HHS is expected to issue a single Enforcement Rule applicable to all three of the HIPAA Administrative Simplification Standards. Many worksite records will not be protected under the HIPAA Privacy Rule because employers are not covered entities and few occupational health professionals meet the criteria of being considered a covered entity. Nevertheless, occupational health professionals need to be knowledgeable about the application of HIPAA in the occupational health care setting. Furthermore, given that the Rule does not preempt state privacy laws that are more stringent than the Standards, occupational health professionals should monitor legislative activity related to privacy in the states in which they practice. To date, Oregon, Texas, and New Jersey have broadened HIPAA's definitions to create more covered entities and services.     

Patient Disclosure about Herb and Supplement Use among Adults in the US

Analyses of 2002 National Health Interview supplement on complementary and alternative medicine (NHI%AM) indicate that approximately 38 million adults in the US (18.9% of the population) used natural herbs or supplements in the preceding 12 months, but only one-third told their physician about this use. The objectives of this study are: (i) to determine subpopulation rates of patient–physician communication about herbal product and natural supplement use and (ii) to identify the relative influence of patient factors and interaction factors associated with patient-physician communication about herb and supplement use. Logistic secondary analysis was done by using the complementary and alternative medicine supplement of the 2002 National Health Interview Survey. Subjects were a random stratified sample of US adults who used herbs in the past 12 months (n = 5196) and self-reported rates of disclosure to physicians about herb and supplement use. Results show that disclosure rates were significantly lower for males, younger adults, racial and ethnic minorities and less intensive users of medical care. Across subpopulations, disclosure was the exception rather than the norm. Given the potential risks of delayed or inappropriate treatment and adverse drug reactions and interactions, physicians should be aware of herb and supplement use and counsel patients on the potential risks and benefits of these treatments.     

Stroke-related knowledge and health behaviors among poststroke patients in inpatient rehabilitation

OBJECTIVE: To measure stroke knowledge and prestroke personal health behaviors of stroke patients undergoing inpatient rehabilitation and their caregivers. DESIGN: Prospective cohort. SETTING: Academic rehabilitation hospital. PARTICIPANTS: A total of 130 stroke patients and 85 caregivers interviewed after ischemic stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Stroke Education Assessment measured stroke knowledge and prestroke personal health behaviors. RESULTS: Large deficiencies in patient and caregiver stroke knowledge were found. Fifty-two percent of patients could not name any stroke risk factors, 52% were unable to name a stroke warning sign, and 35% were unable to identify appropriate actions to take in a stroke emergency. Older patients were less knowledgeable than younger patients. Caregivers were more knowledgeable than patients. Regarding prestroke personal health behaviors, 28% of patients reported medication nonadherence, 26% did not see their primary care physician in the preceding year, and less than 40% of patients with diabetes or hypertension reported diets consistent with these diagnoses. CONCLUSIONS: Stroke patients participating in inpatient rehabilitation and their caregivers have large gaps in stroke knowledge and have suboptimal personal health behaviors, thereby putting patients at high risk for recurrent stroke. Our finding highlights the need to develop stroke-education programs for rehabilitating patients that are effective in closing these gaps in knowledge and personal health behaviors.     

Awareness of the Care Team in Electronic Health Records

OBJECTIVE: To support collaboration and clinician-targeted decision support, electronic health records (EHRs) must contain accurate information about patients' care providers. The objective of this study was to evaluate two approaches for care provider identification employed within a commercial EHR at a large academic medical center. METHODS: We performed a retrospective review of EHR data for 121 patients in two cardiology wards during a four-week period. System audit logs of chart accesses were analyzed to identify the clinicians who were likely participating in the patients' hospital care. The audit log data were compared with two functions in the EHR for documenting care team membership: 1) a vendor-supplied module called "Care Providers", and 2) a custom "Designate Provider" order that was created primarily to improve accuracy of the attending physician of record documentation. RESULTS: For patients with a 3-5 day hospital stay, an average of 30.8 clinicians accessed the electronic chart, including 10.2 nurses, 1.4 attending physicians, 2.3 residents, and 5.4 physician assistants. The Care Providers module identified 2.7 clinicians/patient (1.8 attending physicians and 0.9 nurses). The Designate Provider order identified 2.1 clinicians/patient (1.1 attending physicians, 0.2 resident physicians, and 0.8 physician assistants). Information about other members of patients' care teams (social workers, dietitians, pharmacists, etc.) was absent. CONCLUSIONS: The two methods for specifying care team information failed to identify numerous individuals involved in patients' care, suggesting that commercial EHRs may not provide adequate tools for care team designation. Improvements to EHR tools could foster greater collaboration among care teams and reduce communication-related risks to patient safety.     

Risk factor control in coronary heart disease. Who needs it?

Most patients seen in the offices of primary care physicians in the United States have habits that put them at needlessly high risk of coronary heart disease. These patients usually report that they would like help from their physician in changing their habits. Peer group pressure, however, tends to discourage change. In comparison with making large changes in selected individuals, making small changes in the expectations and behaviors of an entire peer group is easier and will lead to greater changes in disease rates. All patients seen by a physician should have a periodic nutritional assessment, smoking assessment, and blood pressure measurement. Those patients who do not smoke, are normotensive, and have optimal dietary patterns should be vigorously praised. Those who have less than optimal risk factor behaviors should receive further intervention.     

Measuring patient expectations: does the instrument affect satisfaction or expectations?

BACKGROUND: Fulfillment of patients' expectations may influence health care utilization, affect patient satisfaction, and be used to indicate quality of care. Several different instruments have been used to measure expectations, yet little is known about how different assessment methods affect outcomes. OBJECTIVE: The object of the study was to determine whether different measurement instruments elicit different numbers and types of expectations and different levels of patient satisfaction. DESIGN: Patients waiting to see their physician were randomly assigned to receive 1 of 2 commonly used instruments assessing expectations or were assigned to a third (control) group that was not asked about expectations. After the visit, patients in all 3 groups were asked about their satisfaction and services they received. SUBJECTS: The study subjects were 290 male, primary care outpatients in a VA general medicine clinic. MEASURES: A "short" instrument asked about 3 general expectations for tests, referrals, and new medications, while a "long" instrument nested similar questions within a more detailed list. Wording also differed between the 2 instruments. The short instrument asked patients what they wanted; the long instrument asked patients what they thought was necessary for the physician to do. Satisfaction was measured with a visit-specific questionnaire and a more general assessment of physician interpersonal skills. RESULTS: Patients receiving the long instrument were more likely to express expectations for tests (83% vs. 28%, P <0.001), referrals (40% vs. 18%, P <0.001), and new medications (45% vs. 28%, P <0.001). The groups differed in the number of unmet expectations: 40% of the long instrument group reported at least 1 unmet expectation compared with 19% of the short instrument group (P <0.001). Satisfaction was similar among the 3 groups. CONCLUSIONS: These different instruments elicit different numbers of expectations but do not affect patient satisfaction.     

Diagnosis disclosure by family caregivers to children who have perinatally acquired HIV disease: when the time comes.

BACKGROUND: Children with perinatally acquired HIV disease (PAHD) can be relatively symptom-free and live to school age and older. These children often confront their caregivers with questions about the illness and complex treatments; however, caregivers may try to avoid disclosing the diagnosis of PAHD to the child. PURPOSE: To generate a substantive theory that describes and explains how family caregivers manage diagnosis disclosure to a child who has PAHD. METHOD: Using grounded theory, a substantive theory was constructed based on the accounts of 18 ethnically diverse families. Eight families had 10 children with PAHD who had been told their diagnosis. Ten families had 10 children with PAHD who had not been told their diagnosis. RESULTS: The basic social psychological problem was identified as caregiver readiness to disclose the diagnosis. When the Time Comes was identified as the central phenomenon linked to the problem of caregiver readiness. Causal conditions, intervening conditions, and strategic responses of caregivers and children were discovered and are inextricably linked to the central phenomenon. CONCLUSIONS: The process by which family caregivers respond to diagnosis disclosure to children with PAHD is based on the perceived self-readiness of the caregiver to disclose the diagnosis and illness-related information to their child.     

Health care screening for men who have sex with men

Men who have sex with men often do not reveal their sexual practices or sexual orientation to their physician. Lack of disclosure from the patient, discomfort or inadequate training of the physician, perceived or real hostility from medical staff, and insufficient screening guidelines limit preventive care. Because of greater societal stresses, lack of emotional support, and practice of unsafe sex, men who have sex with men are at increased risk for sexually transmitted diseases (including human immunodeficiency virus infection), anal cancer, psychologic and behavioral disorders, drug abuse, and eating disorders. Recent trends indicate an increasing rate of sexual risk-taking among these men, particularly if they are young. Periodic screening should include a yearly health risk and physical assessment as well as a thorough sexual and psychologic history. The physician should ask questions about sexual orientation in a nonjudgmental manner; furthermore, confidentiality should be addressed and maintained. Office practices and staff should be similarly nonjudgmental, with confidentiality maintained. Targeted screening for sexually transmitted diseases, depression, substance abuse, and other disorders should be performed routinely. Screening guidelines, while inconsistent and subject to change, offer some useful suggestions for the care of men who have sex with men.     

Improving family communications at the end of life: implications for length of stay in the intensive care unit and resource use.

BACKGROUND: Inadequate communication persists between healthcare professionals and patients and patients' families in intensive care units. Unwanted or ineffective treatments can occur when patients' goals of care are unknown or not honored, increasing costs and care. Having the primary physician provide medical information and then having a physician and clinical nurse specialist team improve opportunities for patients and their families to process that information could improve the situation. This model has not been tested for its effect on patients' outcomes and resource utilization. OBJECTIVES: To evaluate the effect of a communication team that included a physician and a clinical nurse specialist on length of stay and costs for patients near the end of life in the intensive care unit. METHODS: During a 1-year period, patients judged to be at high risk for death (N = 151) were divided into 2 groups: 43 patients who were cared for by the medical director teamed with a clinical nurse specialist and 108 patients who received standard care, provided by an attending physician. RESULTS: Compared with the control group, patients in the intervention group had significantly shorter stays in both the intensive care unit (6.1 vs 9.5 days) and the hospital (11.3 vs 16.4 days) and had lower fixed ($15,559 vs $24,080) and variable ($5087 vs $8035) costs. CONCLUSIONS: Use of a physician and a clinical nurse specialist focused on improving communication with patients and patients' families reduced lengths of stay and resource utilization.