•First-person storytelling (FPS) has been used in only 22 studies.•FPS can improve health-related attitudes, knowledge, behaviors, and outcomes.•FPS has been studied primarily in cancer, diabetes, ...and hypertension.•FPS may be most effective with low income patients and racial/ethnic minorities.
First-person storytelling (FPS) has the potential to engage patients in changing behavior differently than didactic education. We assessed the prevalence of FPS in health education interventions; whether published FPS research has shown improvements in attitudinal, knowledge, behavioral, or clinical outcomes; and whether randomized controlled trials (RCTs) including FPS have shown more effectiveness than non-FPS interventions.
A scoping review of FPS studies published before October 2019 in five medical databases was conducted.
22 out of 10,363 identified studies met eligibility criteria. FPS has been studied primarily in cancer, diabetes, and hypertension. Of the 12 RCTs, compared to controls, patients receiving FPS interventions improved attitudes (N = 6 studies) and knowledge (N = 1), improved health behaviors like quitting smoking (N = 6), and improved clinical outcomes like lowering A1C levels (N = 3). Of the 10 non-RCT studies, compared to baseline assessments, patients who received FPS interventions had improved knowledge (N = 1), attitudes (N = 3), clinical outcomes (N = 4), and improved health behaviors (N = 7).
While rarely used, FPS interventions can improve patient health attitudes and outcomes. Future research should expand FPS to new health areas and determine best practices for developing FPS interventions.
FPS may be particularly effective with low income patients and racial/ethnic minorities.
Although warfarin and other anticoagulants can prevent ischemic events, they can cause hemorrhage. Quantifying the rate of hemorrhage is crucial for determining the risks and net benefits of ...prescribing antithrombotic therapy. Our objective was to find a bleeding classification scheme that could quantify the risk of hemorrhage in elderly patients with atrial fibrillation.
We combined bleeding risk factors from existing classification schemes into a new scheme, HEMORR
2HAGES, and validated all bleeding classification schemes. We scored HEMORR
2HAGES by adding 2 points for a prior bleed and 1 point for each of the other risk factors:
hepatic or renal disease,
ethanol abuse,
malignancy, older (age > 75 years),
reduced platelet count or function,
hypertension (uncontrolled),
anemia,
genetic factors,
excessive fall risk, and
stroke. We used data from quality improvement organizations representing 7 states to assemble a registry of 3791 Medicare beneficiaries with atrial fibrillation.
There were 162 hospital admissions with an
International Classification of Diseases, Ninth Revision, Clinical Modification code for hemorrhage. With each additional point, the rate of bleeding per 100 patient-years of warfarin increased: 1.9 for 0, 2.5 for 1, 5.3 for 2, 8.4 for 3, 10.4 for 4, and 12.3 for ≥5 points. In patients prescribed warfarin, HEMORR
2HAGES had greater predictive accuracy (
c statistic 0.67) than other bleed prediction schemes (
P < .001).
Adaptations of existing classification schemes, especially a new bleeding risk scheme, HEMORR
2HAGES, can quantify the risk of hemorrhage and aid in the management of antithrombotic therapy.
Objectives: We sought to determine which ICD-9-CM codes in Medicare Part A data identify cardiovascular and stroke risk factors. Design and Participants: This was a cross-sectional study comparing ...ICD-9-CM data to structured medical record review from 23,657 Medicare beneficiaries aged 20 to 105 years who had atrial fibrillation. Measurements: Quality improvement organizations used standardized abstraction instruments to determine the presence of 9 cardiovascular and stroke risk factors. Using the chart abstractions as the gold standard, we assessed the accuracy of ICD-9-CM codes to identify these risk factors. Main Results: ICD-9-CM codes for all risk factors had high specificity (>0.95) and low sensitivity (≤0.76). The positive predictive values were greater than 0.95 for 5 common, chronic risk factors-coronary artery disease, stroke/transient ischemic attack, heart failure, diabetes, and hypertension. The sixth common risk factor, valvular heart disease, had a positive predictive value of 0.93. For all 6 common risk factors, negative predictive values ranged from 0.52 to 0.91. The rare risk factors-arterial peripheral embolus, intracranial hemorrhage, and deep venous thrombosis-had high negative predictive value (≥0.98) but moderate positive predictive values (range, 0.54-0.77) in this population. Conclusions: Using ICD-9-CM codes alone, heart failure, coronary artery disease, diabetes, hypertension, and stroke can be ruled in but not necessarily ruled out. Where feasible, review of additional data (eg, physician notes or imaging studies) should be used to confirm the diagnosis of valvular disease, arterial peripheral embolus, intracranial hemorrhage, and deep venous thrombosis.
Introduction:
Dialysis centers must provide transplant education to patients but often do not address the risks and benefits of living and deceased donor transplant.
Research Questions:
In a group ...randomized controlled trial of 20 dialysis centers and 253 patients, we assessed whether the Explore Transplant education program increased patients’ readiness to pursue transplant, transplant knowledge, informed transplant decision-making, discussions about transplant with potential living donors, pursuit and receipt of living or deceased donor transplant, and whether these effects varied by race.
Methods:
Patients at participating dialysis centers were randomized to receive either (1) a 4-module Explore Transplant education program, including videos, printed materials, and transplant educator discussions or (2) standard-of-care transplant education provided by dialysis centers. The trial had 3 phases: (1) pre- and postsurveying and dialysis center education (2007-2008), (2) follow-up to determine whether patients restarted or began transplant evaluation (2008-2010), and (3) assessment of participants’ receipt of a renal transplant (2012-2015).
Results:
Compared to patients in standard-of-care dialysis centers, patients who received the intervention were more likely to increase in their stage of readiness for living donor transplantation (odds ratio: 2.50; 95% confidence interval: 1.10-5.66), had greater increases in their transplant knowledge (P < .001), and were more likely to call to restart/begin transplant evaluation (38% vs 24%, P = .006). When analyses were stratified by race, black patients were more likely to take several steps toward transplant in comparison to whites.
Discussion:
The Explore Transplant helps dialysis patients make informed decisions and increases their pursuit of transplant, particularly among black patients.
To reduce racial disparities in transplant, modifiable patient characteristics associated with completion of transplant evaluation and receipt of living donor kidney transplant must be identified.
...From 2004 to 2007, 695 black and white patients were surveyed about 15 less-modifiable and 10 more-modifiable characteristics at evaluation onset; whether they had completed evaluation within 1 year and received living donor kidney transplants by 2010 was determined. Logistic regression and competing risks time-to-event analysis were conducted to determine the variables that predicted evaluation completion and living donor kidney transplant receipt.
Not adjusting for covariates, blacks were less likely than whites to complete evaluation (26.2% versus 51.8%, P<0.001) and receive living donor kidney transplants (8.7% versus 21.9%, P<0.001). More-modifiable variables associated with completing evaluation included more willing to be on the waiting list (odds ratio=3.4, 95% confidence interval=2.1, 5.7), more willing to pursue living donor kidney transplant (odds ratio=2.7, 95% confidence interval=1.8, 4.0), having access to more transplant education resources (odds ratio=2.2, 95% confidence interval=1.5, 3.2), and having greater transplant knowledge (odds ratio=1.8, 95% confidence interval=1.2, 2.7). Patients who started evaluation more willing to pursue living donor kidney transplant (hazard ratio=4.3, 95% confidence interval=2.7, 6.8) and having greater transplant knowledge (hazard ratio=1.2, 95% confidence interval=1.1, 1.3) were more likely to receive living donor kidney transplants.
Because patients who began transplant evaluation with greater transplant knowledge and motivation were ultimately more successful at receiving transplants years later, behavioral and educational interventions may be very successful strategies to reduce or overcome racial disparities in transplant.
Since 2007, the National Living Donor Assistance Center has provided the most financial support to US living donors meeting specific income criteria by reimbursing travel, meal, and lodging expenses. ...In 2019, the National Kidney Registry started providing lost wages, travel, and lodging reimbursement via their Donor Shield program. Donor Shield is automatically provided to donors who participate in kidney paired donation through the National Kidney Registry or who donate at a Donor Shield Direct center, without any income restrictions.
The support donors across the United States received from the Donor Shield program between January 2019 and February 2020 was studied.
During the study period, 326 (25.9%) of the 1260 donors covered by Donor Shield, from 46 programs received reimbursements amounting to a total of $647 384.45, with $472 389.97 (73.0%) covering lost wages. Median reimbursement per donor was $1813.80 (range, $44.0-$165.63). Eighty-one percent of 108 reimbursed donors who were surveyed reported that the lack of these reimbursements would have posed a financial hardship, and 4% said they would have been unable to donate without this support.
Expansion of lost wages reimbursement programs to all donors in the United States would be an important step toward achieving financial neutrality for this unique population and could also help meet the growing demand for transplantable organs by increasing living donation rates.
Despite the best efforts of health care practitioners, medical errors are inevitable. Disclosure of errors to patients is desired by patients and recommended by ethicists and professional ...organizations, but little is known about how patients and physicians think medical errors should be discussed.
To determine patients' and physicians' attitudes about error disclosure.
Thirteen focus groups were organized, including 6 groups of adult patients, 4 groups of academic and community physicians, and 3 groups of both physicians and patients. A total of 52 patients and 46 physicians participated.
Qualitative analysis of focus group transcripts to determine the attitudes of patients and physicians about medical error disclosure; whether physicians disclose the information patients desire; and patients' and physicians' emotional needs when an error occurs and whether these needs are met.
Both patients and physicians had unmet needs following errors. Patients wanted disclosure of all harmful errors and sought information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented. Physicians agreed that harmful errors should be disclosed but "choose their words carefully" when telling patients about errors. Although physicians disclosed the adverse event, they often avoided stating that an error occurred, why the error happened, or how recurrences would be prevented. Patients also desired emotional support from physicians following errors, including an apology. However, physicians worried that an apology might create legal liability. Physicians were also upset when errors happen but were unsure where to seek emotional support.
Physicians may not be providing the information or emotional support that patients seek following harmful medical errors. Physicians should strive to meet patients' desires for an apology and for information on the nature, cause, and prevention of errors. Institutions should also address the emotional needs of practitioners who are involved in medical errors.
The persistent challenges of bridging healthcare disparities for African Americans (AAs) in need of kidney transplantation continue to be unresolved at the national level. This healthcare disparity ...is multifactorial: stemming from limited kidney donors suitable for AAs; inconsistent care coordination and suboptimal risk factor control; social determinants, low socioeconomic status, reduced access to care; and mistrust of clinicians and the healthcare system.
There are numerous opportunities to significantly lessen the disparities in kidney transplantation for AAs through the following measures: the adoption of new care and patient engagement models that include education, enhanced practice-level cultural sensitivity, and timely referral as well as increased research on the impact of the environment on genetic risk, and implementation of new transplantation-related policies. Key Messages: This systematic review describes pretransplant concerns related to access to kidney transplantation, posttransplant complications, and policy interventions to address the challenging issues associated with kidney transplantation in AAs.
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