Given the ongoing desire to make health care more patient-centered and growing evidence supporting the provision of patient-centered care, it is important to have valid tools for measuring ...patient-centered care. The patient-centered clinical method (PCCM) is a conceptual framework for providing patient-centered care. A revision to the PCCM framework led to a corresponding need to enhance the Patient Perception of Patient-Centeredness (PPPC) questionnaire. The original PPPC was aligned with the components of the PCCM conceptual framework and developed to measure patient-centeredness from the patient's perspective. The purpose of this study was to examine the factor structure of a revised version of the PPPC (ie, PPPC-R).
Eleven new items were added to the original 14 items. The modified questionnaire was administered to patients in primary health care teams in Ontario, Canada. The confirmatory factor analysis was conducted on a subset of 381 patients who had seen a family physician.
The initial proposed 4-factor model first tested with a confirmatory factor analysis (CFA) did not fit adequately. Exploratory factor analysis was therefore used as a second step to modify the model and to identify weak items. A 3-factor exploratory model with 18 of the original 25 items was converted into a final hypothetical CFA model that had a good fit (χ
=176.795, P<0.01; CFI=0.991; RMSEA=0.030). The third factor contained only 2 items and so is interpreted with caution.
The validity of the PPPC-R is supported by some congruence between the conceptual framework (the PCCM) and the statistical analysis (CFA), but there is not a 1:1 correspondence. The components of the PCCM represent conceptually what is important when teaching, researching, and providing patient-centered care, whereas the PPPC-R represents patient-centered care as it is experienced by the patient.
Importance Low childhood socioeconomic status (SES) is a social hallmark of aging that contributes to adult health disparities and earlier morbidity and mortality. Childhood perceptions of stress are ...associated with child health outcomes and may contribute to premature biological aging into adulthood. Objective To describe the association of childhood SES and perceived stress with midlife insulin resistance and epigenetic age and to explore whether late adolescent adiposity mediates the observed associations. Design, Setting, and Participants The longitudinal cohort National Heart, Lung, and Blood Institute Growth and Health Study enrolled girls aged 10 years from January 1987 to May 1988, and followed them up to 19 years of age. Participants from Richmond, California, were recruited again at midlife in 2016 to assess insulin resistance and epigenetic age. Analyses were conducted from August 2, 2023, to March 18, 2024. A total of 433 participants were eligible and included in the analyses (specific sample sizes ranged across analyses from 303 to 391). Exposures Childhood levels of SES at 10 years of age (parental educational level and income) and perceived stress at 11 years of age. Main Outcomes and Measures The hypotheses tested were formulated after data collection. Outcomes included the homeostatic model assessment of insulin resistance (HOMA-IR) and the GrimAge and DunedinPACE epigenetic clocks. Waist circumference in late adolescence was tested as a mediator. Results Among the 433 participants, the mean (SD) age was 39.4 (1.2) years; 218 (50.3%) were Black and 215 (49.7%) were White; and 135 (31.2%) had parents with a college degree or higher. Higher parental educational level was associated with lower HOMA-IR (B = −0.22 95% CI, −0.41 to −0.02; P = .03), lower midlife GrimAge (B = −1.76 95% CI, −2.85 to −0.66 years; P = .002), and slower midlife DunedinPACE (B = −0.03 95% CI, −6.29 to −0.002; P = .04). Childhood perceived stress was indirectly associated through late adolescent adiposity with midlife HOMA-IR (B = 0.01 95% CI, 0.001-0.01; P = .02) and midlife GrimAge (B = 0.02 95% CI, 0.003-0.04 years; P = .01). Conclusions and Relevance In this longitudinal cohort study of midlife health and aging, childhood social hallmarks of aging were associated with midlife insulin resistance and epigenetic age (GrimAge and DunedinPACE). Future studies should identify malleable factors that may slow the impact of social hallmarks of aging.
Following exposure to the common cold (i.e., rhinovirus), locally produced nasal cytokines (rather than the infection itself) drive the progression of one’s symptoms (Hendley et al., 1973; Cohen ...et al., 1999). Stress-induced local inflammation exacerbates local cytokine production (e.g., marital hostility; Kiecolt-Glaser et al., 2005). An individual’s ability to effectively manage their emotions is a critical component of positive health and well-being. Here, we evaluated whether one’s self-reported frequency of cognitive reappraisal, an adaptive emotion regulation strategy, predicts nasal cytokine production following experimental rhinovirus exposure. Emotion regulation strategies were assessed at baseline prior to experimental infection. After the baseline assessment, each participant was exposed to a strain of rhinovirus (RV-39) and followed for 5 days in quarantine. Nasal interleukin (IL)-1β, IL-6, and IL-8 and subjective symptoms were assessed at baseline and on each of the 5 days of quarantine. A multilevel analysis of the data for 159 participants with documented infection demonstrated that less frequent use of cognitive reappraisal predicted heightened production of the nasal cytokine composite. Those who self-reported using cognitive reappraisal strategies less frequently displayed elevated nasal IL-6 and IL-8. Among the 63 participants with clinical cold, less frequent use of cognitive reappraisal was associated with heightened production of nasal IL-1β, IL-6, and IL-8. In ancillary analyses, the composite of nasal cytokines was associated with the severity of one’s subjective symptoms across the 5 days. Findings suggest that emotion regulation strategies, particularly cognitive reappraisal, influence illness trajectories during rhinovirus infection.
•Greater use of cognitive reappraisal predicted reduced nasal IL-6 production.•Greater nasal cytokine production predicted more severe symptoms.•Emotion regulation strategies influence illness trajectories during a cold.
Despite widespread advancements in and envisioned uses for artificial intelligence (AI), few examples of successfully implemented AI innovations exist in primary care (PC) settings.ObjectivesTo ...identify priority areas for AI and PC in Ontario, Canada.MethodsA collaborative consultation event engaged multiple stakeholders in a nominal group technique process to generate, discuss and rank ideas for how AI can support Ontario PC.ResultsThe consultation process produced nine ranked priorities: (1) preventative care and risk profiling, (2) patient self-management of condition(s), (3) management and synthesis of information, (4) improved communication between PC and AI stakeholders, (5) data sharing and interoperability, (6-tie) clinical decision support, (6-tie) administrative staff support, (8) practitioner clerical and routine task support and (9) increased mental healthcare capacity and support. Themes emerging from small group discussions about barriers, implementation issues and resources needed to support the priorities included: equity and the digital divide; system capacity and culture; data availability and quality; legal and ethical issues; user-centred design; patient-centredness; and proper evaluation of AI-driven tool implementation.DiscussionFindings provide guidance for future work on AI and PC. There are immediate opportunities to use existing resources to develop and test AI for priority areas at the patient, provider and system level. For larger scale, sustainable innovations, there is a need for longer-term projects that lay foundations around data and interdisciplinary work.ConclusionStudy findings can be used to inform future research and development of AI for PC, and to guide resource planning and allocation.
Maternal and zygotic activities of the homeodomain protein PAL-1 specify the identity and maintain the development of the multipotent C blastomere lineage in the C. elegans embryo. To identify PAL-1 ...regulatory target genes, we used microarrays to compare transcript abundance in wild-type embryos with mutant embryos lacking a C blastomere and to mutant embryos with extra C blastomeres. pal-1-dependent C-lineage expression was verified for select candidate target genes by reporter gene analysis, though many of the target genes are expressed in additional lineages as well. The set of validated target genes includes 12 transcription factors, an uncharacterized wingless ligand and five uncharacterized genes. Phenotypic analysis demonstrates that the identified PAL-1 target genes affect specification, differentiation and morphogenesis of C-lineage cells. In particular, we show that cell fate-specific genes (or tissue identity genes) and a posterior HOX gene are activated in lineage-specific fashion. Transcription of targets is initiated in four temporal phases, which together with their spatial expression patterns leads to a model of the regulatory network specified by PAL-1.
The loss of a spouse is associated with a host of negative health outcomes. While bereaved individuals commonly report somatic symptoms, no investigations exist of the association between ...reactivation of latent Epstein–Barr virus (EBV) and somatic symptoms among this population. Further, how an individual perceives the quality of their lost relationship in retrospect may impact loss outcomes. Among 99 bereaved spouses, elevated EBV antibody titers were associated with somatic symptoms for those who retrospectively reported high or mean levels of relationship satisfaction (RS), but not among those less satisfied. Further, higher RS was associated with greater grief symptoms. This study identifies higher retrospective RS as a possible risk factor for negative physical and mental health outcomes during bereavement.
The onset of the COVID-19 pandemic necessitated a rapid shift in primary health care from predominantly in-person to high volumes of virtual care. The pandemic afforded the opportunity to conduct a ...deep regional examination of virtual care by family physicians in London and Middlesex County, Ontario, Canada that would inform the foundation for virtual care in our region post-pandemic.
(1) to determine volumes of in-person and virtual family physicians visits and characteristics of the family physicians and patients using them during the early COVID-19 pandemic; (2) to determine how virtual visit volumes changed over the pandemic, compared to in-person; and (3) to explore family physicians' experience in virtual visit adoption and implementation.
We conducted a concurrent mixed-methods study of family physicians from March to October 2020. The quantitative component examined mean weekly number of total, in-person and virtual visits using health administrative data. Differences in outcomes according to physician and practice characteristics for pandemic periods were compared to pre-pandemic. The qualitative study employed Constructivist Grounded Theory, conducting semi-structured family physicians interviews; analyzing data iteratively using constant comparative analysis. We mapped themes from the qualitative analysis to quantitative findings.
Initial volumes of patients decreased, driven by fewer in-person visits. Virtual visit volumes increased dramatically; family physicians described using telephone almost entirely. Rural family physicians reported video connectivity issues. By early second wave, total family physician visit volume returned to pre-pandemic volumes. In-person visits increased substantially; family physicians reported this happened because previously scarce personal protective equipment became available. Patients seen during the pandemic were older, sicker, and more materially deprived.
These results can inform the future of virtual family physician care including the importance of continued virtual care compensation, the need for equitable family physician payment models, and the need to attend to equity for vulnerable patients. Given the move to virtual care was primarily a move to telephone care, the modality of care delivery that is acceptable to both family physicians and their patients must be considered.
Concerns about the opportunity costs of social screening initiatives have led some healthcare organizations to consider using social deprivation indices (area-level social risks) as proxies for ...self-reported needs (individual-level social risks). Yet, little is known about the effectiveness of such substitutions across different populations.
This analysis explores how well the highest quartile (cold spot) of three different area-level social risk measures-the Social Deprivation Index, Area Deprivation Index, and Neighborhood Stress Score-corresponds with six individual-level social risks and three risk combinations among a national sample of Medicare Advantage members (N=77,503). Data were derived from area-level measures and cross-sectional survey data collected between October 2019 and February 2020. Agreement between individual and individual-level social risks, sensitivity values, specificity values, positive predictive values, and negative predictive values was calculated for all measures in summer/fall 2022.
Agreement between area and individual-level social risks ranged from 53% to 77%. Sensitivity for each risk and risk category never exceeded 42%; specificity values ranged from 62% to 87%. Positive predictive values ranged from 8% to 70%, and negative predictive values ranged from 48% to 93%. There were modest performance discrepancies across area-level measures.
These findings provide additional evidence that area-level deprivation indices may be inconsistent indicators of individual-level social risks, supporting policy efforts to promote individual-level social screening programs in healthcare settings.
Objective: This study aimed to assess for the prevalence of interpersonal discrimination among undocumented Mexican immigrants residing in high-risk neighborhoods near the California-Mexico border, ...identify relevant vulnerabilities, and determine its association with clinically significant psychological distress after controlling for sociodemographics, immigration characteristics, and history of trauma. Method: Respondent-driven sampling was used in this cross-sectional study to collect and analyze data from clinical interviews with 246 undocumented Mexican immigrants. The 53-item Brief Symptom Inventory was used as the primary outcome measure to assess for clinically significant psychological distress. For all analyses, inferential statistics accounted for design effects and sample weights to produce weighted estimates. Logistic regression was used in the multivariate analyses. Results: In all, 69% of the participants reported interpersonal discrimination due to being undocumented with significant differences observed across sex, educational attainment, and income. Among participants with a history of interpersonal discrimination due to their undocumented status, 52% met criteria for clinically significant psychological distress with significant differences observed across age groups, years living in the United States, and history of trauma. After controlling for relevant covariates, having experienced interpersonal discrimination due to being undocumented was the strongest significant predictor of clinically significant psychological distress, odds ratio = 5.47, 95% confidence interval 2.56, 11.7, p < .001, even beyond history of trauma. Conclusion: Overall, our findings emphasize the need for policies, advocacy, and the development and provision of contextually sensitive interventions to address the high prevalence of interpersonal discrimination and its negative health effects among undocumented Mexican immigrants.
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