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With
this issue we include abstracts from the 2005 11th Annual HMO Research
Network Conference, held in Santa Fe, New Mexico, that focused on "Translating
Research into Practice."
From
KP Northern California, KP Northwest, KP Southern California:
Physician
and patient perspectives on clinician-patient communication during clinic
visits: Do you see what I see?
Sung
SH, Price M, Tallman K, Janisse T, Frankel R, Gascay D, Godfrey T, Huberman
A, Hsu J.
background:
Despite its importance in forming clinical relationships, there is limited
information on how patients and physicians perceive their own communication
during outpatient visits. We examined physician and patient perspectives
on physician skills and behaviors during actual outpatient visits.
methods:
Using facilitated individual reviews, we asked primary care physicians
(n = 15) and two of their regularly scheduled patients (n = 30) to watch
videotapes of their own visit and identify significant communication
skills or behaviors. Using content analysis, two coders independently
categorized the comments into themes, using transcripts of the facilitated
reviews. The coders agreed on 70% of the coding categories; a third
coder resolved any discrepant response codes. We compared the frequency
of themes noted by physicians and patients.
results:
Subjects made 904 total comments (mean = 15.1 per visit; 17.1 physician
and 13.0 patient comments), which were categorized into 18 themes. The
most prevalent themes identified by both physicians and patients were:
physician explanation skills (58.3%) and listening skills (55.0%). One
physician stated, "I think one thing that is important is to give
people information as you go ... people are very anxious about the physical
... let them know it's normal or what you find and what it means. Because
at the end, you may forget to mention it or it may be just too much
information [to discuss all at once]." Compared with patients,
more physicians focused on communication skills to improve visit/time
management, while more patients focused on the importance of physician
attitudes toward communication (93% vs 20% and 0% vs 47% for physicians
and patients respectively).
conclusions:
The facilitated review approach could help identify useful communication
skills and opportunities from both physician and patient perspectives.
These preliminary finding also suggest some discrepancies exist in the
two perspectives, such as physician attitudes. Additional research is
needed to better understand how physicians and patients view clinical
communication.
From
National Cancer Institute, Group Health Cooperative, Henry Ford Health
System, KP Northern California, KP Southern California, KP Northwest,
KP Hawaii, KP Colorado, University of Massachusetts Medical School,
and Cancer Research and Biostatistics:
Secondary
prevention: Priorities in breast cancer screening; recruitment, detection,
or follow-up?
Taplin
SH, Ichikawa L, Yood MU, Manos MM, Geiger AM, Weinmann S, Gilbert J,
Mouchawar J, Leyden WA, Altaras R, Beverly RK, Casso D, Westbrook EO,
Bischoff K, Zapka JG, Barlow WE.
background:
Despite high screening rates within seven integrated health plans, 17%
of invasive cancers are late-stage. But, screening is a process not
just a test. To set priorities regarding how to further reduce late-stage
disease, it is important to understand whether and where the screening
process broke down within these plans.
methods:
We conducted retrospective reviews of chart and automated data for
three years prior to diagnoses of late-stage (metastatic and/or tumor
size >3 cm)(cases) and early-stage breast cancers (controls) in 1995-1999
among an identifiable population of >8.2 million people. We categorized
their first screening mammogram in the 13-36 months prior to diagnosis
as 1) none (absence of screening), 2) negative (absence of detection)
or 3) positive (potential breakdown in follow-up). We compared the proportion
(two-sided test) of cases and controls and estimated the likelihood
of late-stage as a function of race and refusal-of-breast-care. Among
late-stage cases, we evaluated demographic characteristics associated
with absence of screening.
results:
The distributions of absence of screening, absence of detection, and
potential breakdown in follow-up differed among case (52.1%, 39.5%,
and 8.4%, respectively) and control (34.4%, 56.9%, and 8.8%, respectively)
subjects (p = .03). Among all women, the odds of having late-stage cancer
were higher among women with an "absence of screening" (OR
= 2.17, 95% CI = 1.84 to 2.56; p < .001) or who refused care prior
to the study period (OR = 3.16, 95% CI = 2.11 to 4.73). Among late-stage
disease subjects, women were more likely to be in the absence of screening
group if they were aged 75 years or older (OR = 2.77, 95% CI = 2.10
to 3.65), unmarried (OR = 1.78, 95% CI = 1.41 to 2.24), or without a
family history of breast cancer (OR = 1.84, 95% CI = 1.45-2.34). A higher
proportion of women from census blocks with less than a 50% likelihood
of a college education (58.5% versus 49.4%; p + 0.003), or an annual
income of less than $75,000 (54.4% versus 42.9%; p = 0.004) were in
the absence of screening category compared to all other categories combined.
conclusions:
To further reduce late-stage breast cancer occurrence, top priority
for screening implementation should be given to reaching unscreened
women, including those who are older, unmarried, low income, and less
educated.
From
KP Colorado:
Rehabilitation
characteristics in community-dwelling, nonagenarian patients admitted
to skilled nursing facilities.
Conner
DA, Barnes C.
background:
The distinction of "65 years of age and older" is increasingly
recognized as an artificial one. Geriatric researchers are beginning
to recognize distinct groups of older adults. We examined rehabilitation
characteristics of community-dwelling HMO nonagenarian members (90 years
of age and older) who received rehabilitation in skilled nursing facilities.
methods:
Retrospective analysis of the records of 928 community-dwelling HMO
members 90 years of age and older, admitted to one of seven skilled
nursing facility for rehabilitation following a hospitalization or decline
in function. Measures included admission motor and cognitive FIM, days
post onset, medical complexity, age, gender, therapy hours, days of
therapy, and total FIM gain at discharge. Logistic regression determined
significant predictors of the proportion of patients discharged to the
community (home, board and care, or an assisted-living facility), and
adequate rehabilitation progress defined as a gain of one or more FIM
points per day.
results:
Average age was 92.8 years (range: aged 90-to-107 years). Average SNF
length of stay was 10.9 days. Sixty-three percent of patients were discharged
to a community setting. Patients discharged to the community were admitted
with significantly greater total FIM, cognitive FIM, and motor FIM,
as well as fewer days post onset and lower medical complexity. Admission
motor and cognitive FIM were significant predictors of discharge to
the community. Patients achieving adequate rehabilitation progress were
admitted with significantly greater total FIM, cognitive FIM, and motor
FIM, and lower medical complexity. Predictors of adequate progress included
admission cognitive FIM, admission motor FIM, and days post onset.
conclusions:
More than 60% of patients, 90 years old and older, were discharged to
a community setting following rehabilitation. Admission cognitive and
motor FIM, medical complexity, and days post onset are important measures
influencing rehabilitation outcomes in this older population.
From
HealthPartners:
The
impact of comorbid depression on CHD in the elderly: Health status and
clinical outcomes.
Whitebird
RR, Rush WA, O'Connor PJ, Asche SE, Solberg LI, Rush MM.
background:
Depression has been established as a significant risk factor for
patients with chronic heart disease (CHD) with growing interest focused
not only on quality-of-life concerns, but on the effects depression
may have on important clinical and health status factors. The purpose
of this investigation was to examine the impact of depression on important
clinical and health status measures in older adults with CHD.
methods:
Data are from a four-year multisite collaborative study that used a
combination of survey, chart audit, and administrative data to examine
improvement strategies that lead to best care practices for patients
with chronic disease including CHD. Depression was assessed using the
PHQ2 to identify the cardinal signs of depression. Logistic and multiple
regression analyses were used to examine the relationship between depression
and clinical measures including blood pressure, LDL lipid measurement
and perceived health status measures.
results:
Depression was not significantly related to clinical outcomes of LDL,
SBP, or DPB, but was significantly related to poorer perceived health
status measures including decreased physical health (p < .001) and
physical activity (p < .001), increased arthritis (p < .0001),
and poorer patient assessment of their primary health care (p < .004).
Depression was also significantly related to lower psychosocial functioning
including lower perceived social support (p < .0001) and strongly
held beliefs that CHD is a future threat and currently causing problems
in their life (p < .0001).
conclusions:
These findings suggest that depression has significant implications
for physical and psychosocial health and should be assessed and monitored
in providing care for elderly patients with CHD.
