Toward a VA Women's Health Research Agenda: Setting Evidence-based Priorities to Improve the Health and Health Care of Women Veterans

The expansion of women in the military is reshaping the veteran population, with women now constituting the fastest growing segment of eligible VA health care users. In recognition of the changing demographics and special health care needs of women, the VA Office of Research & Development recently sponsored the first national VA Women's Health Research Agenda-setting conference to map research priorities to the needs of women veterans and position VA as a national leader in Women's Health Research. This paper summarizes the process and outcomes of this effort, outlining VA's research priorities for biomedical, clinical, rehabilitation, and health services research.     

Training Clinicians with Communication Skills Needed to Match Medical Treatments to Patient Values

Most clinicians currently in practice did not receive the evidence‐based communication skills training they need to provide high‐quality communication for seriously ill older adults and their families. Clinician communication skills are a critical factor in achieving a patient and family understanding of their illness that enables them to share in decision making that will result in medical treatments and social supports that are aligned with their goals and values. Research demonstrates that existing clinician competence in communication skills is extremely variable, that most clinicians need specific communication training to have an adequate level of skill, and that evidence‐based training is efficacious. A conservative estimate suggests that more than 219,000 physicians and advance practice providers (APPs) (50% of physicians in high‐contact subspecialties and 25% of all APPs) could benefit from training. Combining evidence‐based clinician training with health system workflow redesign would likely maximize the impact of this training. We conclude with recommendations designed to address gaps in communication skills through effective training and health system changes in the service of enabling all patients with serious illness and their families to receive care aligned with their personal priorities. J Am Geriatr Soc 67:S435–S441, 2019.     

The Impact of Alexithymia on Asthma Patient Management and Communication with Health Care Providers: A Pilot Study

Background and objectives. Alexithymia is a personality trait associated with difficulty identifying and verbalizing feelings. It has been associated with poorly controlled asthma and near-fatal asthma. The primary objectives were to () determine the prevalence of alexithymia in a group of moderate to severe asthmatics who attended an Outpatient Clinic; and () investigate the relationship between alexithymia and asthma control, management, and communication. Methods. Twenty-five moderate to severe asthma patients were recruited from the Royal Adelaide Hospital Outpatient Respiratory Clinic. Participants were either mailed the questionnaire pack or completed it after a clinic appointment. Existing validated questionnaires were used to collect data. The primary outcome measures were alexithymia, asthma control, adherence to medication; patient satisfaction with communication with health care providers and health-related quality of life. Data were analyzed using Pearson correlations, linear regression and analysis of variance (ANOVA) in SPSS. A p value ≤ 0.05 was required for statistical significance. Results. A total of 11 male (44%) and 14 female (56%) patients with moderate to severe persistent asthma (mean age 44 years ± 11) participated. Alexithymia scores ranged between 23.0-76.0 ( = 48.3, SD = 13.2); 12% of participants reported high alexithymia scores, 32% reported borderline alexithymia scores, and 56% reported low alexithymia scores. Alexithymia mean scores were not statistically different across sociodemographic variables. A higher alexithymia score was associated with worse asthma control score (r = 0.57, p < 0.01) (where higher asthma control scores indicate worse asthma control); poor adherence (p = 0.03), and worse quality of life (r = - 0.65, p < 0.01). Alexithymia score was not correlated with satisfaction with communication (r = ? 0.27, p = 0.2).), or the number of hospitalizations for asthma (p = 0.25). Conclusions. This is the first study to investigate relationships between alexithymia, asthma control, asthma management and communication with health care professionals. The study reaffirms associations between alexithymia and asthma control, but a larger sample size is needed to determine the impact of alexithymia on self-management and provision of clinical care for asthma.     

Association of Communication Between Hospital-based Physicians and Primary Care Providers with Patient Outcomes

BACKGROUND  Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes. METHODS  We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient’s PCP was associated with the 30-day composite outcome. RESULTS  A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 – 1.34), the presence of a discharge summary (0.84, 95% CI 0.57–1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73–1.59). CONCLUSION  Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample. This paper was presented at the Society for General Internal Medicine Annual Meeting in April 2006.     

Patient Satisfaction with Primary Care Office-Based Buprenorphine/Naloxone Treatment

Background Factors associated with satisfaction among patients receiving primary care–based buprenorphine/naloxone are unknown. Objective To identify factors related to patient satisfaction in patients receiving primary care–based buprenorphine/naloxone that varied in counseling intensity (20 vs 45 minutes) and office visit frequency (weekly vs thrice weekly). Design and Participants One hundred and forty-two opioid-dependent subjects. Measurements Demographics, drug treatment history, and substance use status at baseline and during treatment were collected. The primary outcome was patient satisfaction at 12 weeks. Results Patients’ mean overall satisfaction score was 4.4 (out of 5). Patients were most satisfied with the medication and ancillary services and indicated strong willingness to refer a substance-abusing friend for the same treatment. Patients were least satisfied with their interactions with other opioid-dependent patients, referrals to Narcotics Anonymous, and the inconvenience of the treatment location. Female gender (β = .17, P = .04) and non-White ethnicity/race (β = .17, P = .04) independently predicted patient satisfaction. Patients who received briefer counseling and buprenorphine/naloxone dispensed weekly had greater satisfaction than those whose medication was dispensed thrice weekly (mean difference 4.9, 95% confidence interval 0.08 to 9.80, P = .03). Conclusions Patients are satisfied with primary care office-based buprenorphine/naloxone. Providers should consider the identified barriers to patient satisfaction. The findings of this study were presented in part at the 67th annual scientific meeting of the College on Problems of Drug Dependence, Orlando, FL, 22 June 2005.     

Patient Difficulty Using Tablet Computers to Screen in Primary Care

Background Patient-administered computerized questionnaires represent a novel tool to assist primary care physicians in the delivery of preventive health care. Objective The aim of this study was to assess patient-reported ease of use with a self-administered tablet computer-based questionnaire in routine clinical care. Design All patients seen in a university-based primary care practice were asked to provide routine screening information using a touch-screen tablet computer-based questionnaire. Patients reported difficulty using the tablet computer after completion of their first questionnaire. Patients Ten thousand nine hundred ninety-nine patients completed the questionnaire between January 2004 and January 2006. Measurements We calculated rates of reporting difficulty (no difficulty, some difficulty, or a lot of difficulty) using the tablet computers based on patient age, sex, race, educational attainment, marital status, and number of comorbid medical conditions. We constructed multivariable ordered logistic models to identify predictors of increased self-reported difficulty using the computer. Results The majority of patients (84%) reported no difficulty using the tablet computers to complete the questionnaire, with only 3% reporting a lot of difficulty. Significant predictors of reporting more difficulty included increasing age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.05–1.05)]; Asian race (OR 2.3, 95% CI 1.8–2.9); African American race (OR 1.4, 95% CI 1.2–1.6); less than a high school education (OR 3.0, 95% CI 2.6–3.4); and the presence of comorbid medical conditions (1–2: OR 1.3, 95% CI 1.2–1.5; ≥3: OR 1.7 95% CI 1.5–2.1). Conclusions The majority of primary care patients reported no difficulty using a self-administered tablet computer-based questionnaire. While computerized questionnaires present opportunities to collect routine screening information from patients, attention must be paid to vulnerable groups.     

Interdisciplinary Collaboration in Gerontology and Geriatrics in Latin America: Conceptual Approaches and Health Care Teams

The underlying rationale to support interdisciplinary collaboration in geriatrics and gerontology is based on the complexity of elderly care. The most important characteristic about interdisciplinary health care teams for older people in Latin America is their subjective-basis framework. In other regions, teams are organized according to a theoretical knowledge basis with well-justified priorities, functions, and long-term goals, in Latin America teams are arranged according to subjective interests on solving their problems. Three distinct approaches of interdisciplinary collaboration in gerontology are proposed. The first approach is grounded in the scientific rationalism of European origin. Denominated “logical-rational approach,” its core is to identify the significance of knowledge. The second approach is grounded in pragmatism and is more associated with a North American tradition. The core of this approach consists in enhancing the skills and competences of each participant; denominated “logical-instrumental approach.” The third approach denominated “logical-subjective approach” has a Latin America origin. Its core consists in taking into account the internal and emotional dimensions of the team. These conceptual frameworks based in geographical contexts will permit establishing the differences and shared characteristics of interdisciplinary collaboration in geriatrics and gerontology to look for operational answers to solve the “complex problems” of older adults.     

A Patient Safety and Transitions of Care Curriculum for Third-Year Medical Students

The elderly are the most vulnerable to adverse events during and after hospitalization. This study sought to evaluate the effectiveness of a curriculum on patient safety and transitions of care for medical students during an Internal Medicine-Geriatrics Clerkship on students’ knowledge, skills, and attitudes. The curriculum included didactics on patient safety, health literacy, discharge planning and transitions of care, and postdischarge visits to patients. Analysis of pre- and postassessments showed afterwards students were significantly more comfortable assessing a patient’s health literacy and confident performing a medication reconciliation, providing education regarding medications, and identifying barriers during transitions. More students were able to identify the most common source of adverse events after discharge (86% vs. 62% before), risk factors for low health literacy (28% vs. 14%), and ways to assess a patient’s health literacy (14% vs. 2%). It was feasible to implement a postdischarge visit assignment in an urban tertiary care setting and only required on average of approximately an one and one half hours for students to complete.     

Limited Health Literacy is a Barrier to Medication Reconciliation in Ambulatory Care

Background Limited health literacy may influence patients’ ability to identify medications taken; a serious concern for ambulatory safety and quality. Objective To assess the relationship between health literacy, patient recall of antihypertensive medications, and reconciliation between patient self-report and the medical record. Design In-person interviews, literacy assessment, medical records abstraction. Participants Adults with hypertension at three community health centers. Measurement We measured health literacy using the short-form Test of Functional Health Literacy in Adults. Patients were asked about the medications they took for blood pressure. Their responses were compared with the medical record. Results Of 119 participants, 37 (31%) had inadequate health literacy. Patients with inadequate health literacy were less able to name any of their antihypertensive medications compared to those with adequate health literacy (40.5% vs 68.3%, p = 0.005). After adjusting for age and income, this difference remained (adjusted odds ratio [OR] = 2.9, 95% confidence interval [95%CI] = 1.3–6.7). Agreement between patient reported medications and the medical record was low: 64.9% of patients with inadequate and 37.8% with adequate literacy had no medications common to both lists. Conclusions Limited health literacy was associated with a greater number of unreconciled medications. Future studies should investigate how this may impact safety and hypertension control. Presented in part at the American Medical Association/AMA Foundation Health Literacy and Patient Safety Conference, November 16, 2006, Chicago. IL.     

Effect of a Biopsychosocial Approach on Patient Satisfaction and Patterns of Care

BACKGROUND:  There is a growing tendency to include in medical curricula teaching programs that promote a biopsychosocial (BPS) approach to patient care. However, we know of no attempts to assess their effect on patterns of care and health care expenditures.
OBJECTIVE:  To determine whether 1) a teaching intervention aiming to promote a BPS approach to care affects the duration of the doctor-patient encounter, health expenditures, and patient satisfaction with care, and 2) the teaching method employed affects these outcomes.
METHODS:  We compared two teaching methods. The first one (didactic) consisted of reading assignments, lectures, and group discussions. The second (interactive) consisted of reading assignments, small group discussions, Balint groups, and role-playing exercises. We videotaped patient encounters 1 month before and 6 months after the teaching interventions, and recorded the duration of the videotaped encounters and whether the doctor had prescribed medications, ordered tests, and referred the patient to consultants. Patient satisfaction was measured by a structured questionnaire.
RESULTS:  Both teaching interventions were followed by a reduction in medications prescribed and by improved patient satisfaction. Compared to the didactic group, the interactive group prescribed even fewer medications, ordered fewer laboratory examinations, and elicited higher scores of patient satisfaction. The average duration of the encounters after the didactic and interactive teaching interventions was longer than that before by 36 and 42 seconds, respectively.
CONCLUSIONS:  A BPS teaching intervention may reduce health care expenditures and enhance patients' satisfaction, without changing markedly the duration of the encounter. An interactive method of instruction was more effective in achieving these objectives than a didactic one.     

Patient priorities of care in rheumatology outpatient clinics: a qualitative study

Objective: To provide more understanding of what rheumatoid arthritis (RA) patients want and need from an outpatient visit. Methods: 25 patients who experienced care in a nurse practitioner clinic (n = 10), junior doctor clinic (n = 9) or consultant clinic (n = 6) in a large teaching hospital in West Yorkshire were interviewed about their perceptions and experiences of care. Interviews were approximately 1¹/₂ hours in duration and were carried out in a neutral environment by a research nurse. Interview data were subjected to atheoretical content analysis, which resulted in the identification of emergent themes. Results: Five main themes emerged from the analysis of interview data: 1) patients want to be communicated to clearly and effectively and value positive relationships with practitioners. These help to give patients confidence in the care they are receiving; 2) patients want to feel in control of their condition and tend to refuse interventions as a way of gaining control; 3) patients want to be given clear explanations during consultations, and want information in oral and written forms; 4) patients want to be able to access practitioners between scheduled appointments as a way of gaining reassurance; and 5) patients want to feel valued by society through having their difficulties appreciated and understood by others. Conclusion: This research adds to the body of evidence on what patients want from their rheumatology care, and each theme has clear implications for future practice. Copyright © 2007 John Wiley & Sons, Ltd.     

Feasibility of Spotlight Consultations Tool in Routine Care: Real-World Evidence

Background:Burnout in people with diabetes and healthcare professionals (HCPs) is at an all-time high. Spotlight AQ, a novel “smart” adaptive patient questionnaire, is designed to improve consultations by rapidly identifying patient priorities and presenting these in the context of best-practice care pathways to aid consultations. We aimed to determine Spotlight AQ’s feasibility in routine care.Materials and Methods:The Spotlight prototype tool was trialed at three centers: two UK primary care centers and one US specialist center (June-September 2020). Participants with type 1 (T1D) or type 2 diabetes (T2D) completed the questionnaire prior to their routine consultations. Results were immediately available and formed the basis of the clinical discussion and decision-making within the clinic visit.Results:A convenience sample of 49 adults took part, n=31 T1D, (n=18 female); and n=18 T2D (n=10 male, n=4 female, n=4 gender unreported). Each identified two priority concerns. “Psychological burden of diabetes” was the most common priority concern (T1D n = 27, 87.1%) followed by “gaining more skills about particular aspects of diabetes” (T1D n=19, 61.3%), “improving support around me” (n=8, 25.8%) and “diabetes-related treatment issues” (n=8, 25.8%). Burden of diabetes was widespread as was lack of confidence around self-management. Similarly, psychological burden of diabetes was the primary concern for participants with T2D (n=18,100%) followed by “gaining more skills about aspects of diabetes” (n=7, 38.9%), “improving support around me” (n=7, 38.9%) and “diabetes-related treatment issues” (n=4; 22.2%).Conclusions:Spotlight AQ is acceptable and feasible for use in routine care. Gaining more skills and addressing the psychological burden of diabetes are high-priority areas that must be addressed to reduce high levels of distress.     

High Medical Cost Burdens, Patient Trust, and Perceived Quality of Care

BACKGROUND  The financial burden of medical care expenses is increasing for American families. However, the association between high medical cost burdens and patient trust in physicians is not known. OBJECTIVE  To examine the association between high medical cost burdens and self-reported measures of patient trust and perceived quality of care. METHODS  Cross-sectional household survey based on random-digit dialing and conducted largely by telephone, supplemented by in-person interviews of households with no telephones. The sample for this analysis includes 32,210 adults who reported having a physician as their regular source of care. Measures of patient trust include overall trust, confidence in being referred to a specialist, and belief that the physician uses more services than necessary. Perceived quality measures include thoroughness of exam, ability to listen, and ability to explain. RESULTS  In adjusted analyses, persons with high medical cost burdens had greater odds of lacking trust in their physician to put their needs above all else (OR = 1.43, CI = 1.19, 1.73), not referring them to specialists (OR = 1.39, CI = 1.22, 1.58), and performing unnecessary tests (OR = 1.42, CI = 1.20, 1.62). Patients with high medical cost burdens also had more negative assessments of the thoroughness of care they receive from their physician (OR = 1.26, CI = 1.02, 1.56). The association of high medical cost burdens with patient trust and perceived quality of care was greatest for privately insured persons. CONCLUSION  The rising cost of medical care threatens a vital aspect of the effective delivery of medical care–patient trust in their physician and continuity of care. Exposing patients to more of the costs could lead to greater skepticism and less trust of physicians’ decision-making, thereby making health-care delivery less effective.