To examine whether patient characteristics are associated with communication patterns between oncologists and breast cancer patients.
The study was conducted at 14 practices with 58 oncologists with ...405 newly diagnosed patients with no prior history of breast cancer. The initial consultation between oncologist and patient was audiotaped and a detailed communication analysis performed. Interviews were conducted with patients and physicians immediately before and after consultations.
Disparities were found across all patient demographics. Younger patients asked more questions as did those who were white had more than a high school education and when they reported an income that was high or medium income, compared to low (
p
<
0.01). Patient proactive behavior, such as volunteering information to the physician unasked, was similarly related with all demographic predictors as was physician tendency to ask patients questions. Despite the inherently emotional nature of this encounter, there was surprisingly little overt discussion about how the patient felt about her diagnosis and how she was coping. Both patients and physicians spent time trying to establish an interpersonal relationship with each other, although patients spent more time. Patients differed in the number of relationship building utterances by age, education and income and physicians spent more time engaged in relationship building with white than non-white patients (
p
<
0.01) and more educated and affluent patients (
p
<
0.05).
This study indicates that patient demographic factors, such as race, income level, education and age seem to influence the amount of time physicians spend in almost all communication categories with patients. One recurring difference across most communication categories was race. Racial differences occurred in almost every one of the communication categories examined. White patients had many more utterances in almost every communication category than their non-white counterparts. These differences may mean a less adequate decision-making process for patients who are members of racial or ethnic minorities, patients who are less affluent, older, and have less education.
This study found that providers communicate differently with patients by age, race, education and income. These differences in communication may lead to disparities in patient outcomes. Communication skills training should explicitly train clinicians to recognize these tendencies. Patients with different demographics characteristics may also required education that is tailored to them.
The object of this study is to report on determinants of stunting, defined as low height for age, among children in the occupied Palestinian territories. Using 2006–2007 cross sectional survey data ...collected by the Palestine Central Bureau of Statistics and using multivariate mixed model techniques for logistic regression, the relationships of stunting to characteristics of 9,051 Palestinian children less than 5 years of age living in the Palestinian territories were estimated. These characteristics included demographic and social characteristics of the child, geographic region, type of location (urban, rural, refugee camp) and food insecurity for each governorate. Listed in order of the greater contribution to the explained variation in stunting, children with lower birth weight (
P
< 0.0001), age greater than 12 months (
P
< 0.0001), higher levels of food insecurity (
P
< 0.0001), lower socio-economic status (
P
< 0.0001), mother illiterate (
P
= 0.004), urban areas (
P
= 0.008), and absence of supplementation to breast feeding during the first 4 months of the child’s life (
P
= 0.04) have significantly more stunting. Children living in refugee camps have lower rates of stunting than urban areas; however the difference does not reach statistical significance. The relationship between the child’s gender and stunting is not statistically significant. Lack of food security is directly linked to stunting. The continuing incidence of food insecurity means that the deleterious effects of under-nutrition will continue to affect the children of Palestine. Removing the avoidable causes of food insecurity in the occupied Palestinian territories will alleviate under-nutrition and its deleterious effects.
Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient ...outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients.
One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment.
Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place.
The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs.
ClinicalTrials.gov; No.: NCT01057238 ; URL: www.clinicaltrials.gov.
Objective
Patients with heart failure (HF) have high rates of rehospitalization. Home health care (HHC) patients with HF are not well studied in this regard. The objectives of this study were to ...determine patient, HHC agency, and geographic (i.e., area variation) factors related to 30‐day rehospitalization in a national population of HHC patients with HF, and to describe the extent to which rehospitalizations were potentially avoidable.
Data Sources
Chronic Condition Warehouse data from the Centers for Medicare & Medicaid Services.
Study Design
Retrospective cohort design.
Data Extraction
The 2005 national population of HHC patients was matched with hospital and HHC claims, the Provider of Service file, and the Area Resource File.
Principal Findings
The 30‐day rehospitalization rate was 26 percent with 42 percent of patients having cardiac‐related diagnoses for the rehospitalization. Factors with the strongest association with rehospitalization were consistent between the multilevel model and Cox proportional hazard models: number of prior hospital stays, higher HHC visit intensity category, and dyspnea severity at HHC admission. Substantial numbers of rehospitalizations were judged to be potentially avoidable.
Conclusions
The persistently high rates of rehospitalization have been difficult to address. There are health care‐specific actions and policy implications that are worth examining to improve rehospitalization rates.
Determining the optimal timing and progression of mobility exercise has the potential to affect functional recovery of critically ill adults. This study compared standard care with care delivered ...using a mobility protocol. We examined the effects of exercise on vital signs and inflammatory biomarkers and the effects of the nurse-initiated mobility protocol on outcomes.
Prospective, repeated measures study with a control (standard care) and intervention (protocol) period.
75 heterogeneous subjects admitted to a Medical or Surgical intensive care unit (ICU) were enrolled. In <5% of exercise periods, there was a concerning alteration in respiratory rate or peripheral oxygen saturation; no other adverse events occurred. Findings suggested the use of a protocol with one 20minute episode of exercise daily for 2 or more days reduced ICU length of stay. Duration of exercise was linked to increased IL-10, suggesting brief episodes of low intensity exercise positively altered inflammatory dysregulation in this sample.
A growing body of evidence demonstrates that early, progressive exercise has significant benefits to intubated adults. These results should encourage clinicians to add mobility protocols to the care of ICU adults and lead to future studies to determine optimal “dosing” of exercise in ICU patients.
Objective
Evaluate the effectiveness of a healthy weight intervention designed for children of migrant farmworkers embedded in a 7‐week summer Midwest Migrant Education Program (MEP) for changes in: ...weight; Body Mass Index (BMI); BMI‐percentiles (BMI‐p); muscle strength and muscle flexibility; nutrition knowledge; attitudes; and behaviors.
Design and Sample
This is a two‐group pre‐post quasi‐experimental study. Latino children of migrant farmworkers attending summer MEP in grades one through eight were enrolled (n = 171: comparison n = 33, intervention n = 138).
Measures
Weight, BMI, BMI‐p, muscle strength and flexibility, knowledge, and healthy behaviors.
Intervention
Classroom content included: food variety; increasing fruits and vegetables; healthy breakfasts; more family meals; increasing family time; decreasing TV and electronic game time; increasing physical activity; limiting sugar‐sweetened drinks; portion sizes; and food labels.
Results
Statistically significant were increase in comparison group mean weight, decrease in intervention group BMI‐p, and improvements in muscle flexibility and healthy behavior attitudes. The intervention students showed trends toward healthy BMI. The number of MEP days attended was significantly correlated in four outcomes.
Conclusion
Study findings have the potential to decrease incidence of unhealthy weight in Latino migrant children, reduce rates of premature adult diseases in these children, and a potential to decrease future health care costs.
Despite participation in a cardiac rehabilitation program, there is a downward trajectory of exercise participation during the year following a cardiac event.
The purpose of this study was to test ...the effectiveness of CHANGE (Change Habits by Applying New Goals and Experiences), a lifestyle modification program designed to increase exercise maintenance in the year following a cardiac rehabilitation program. The CHANGE intervention consists of 5 small-group cognitive-behavioral change counseling sessions in which participants are taught self-efficacy enhancement, problem-solving skills, and relapse prevention strategies to address exercise maintenance problems.
Participants (N = 250) were randomly assigned to the CHANGE intervention (supplemental to usual care) or a usual-care-only group. Exercise was measured using portable wristwatch heart rate monitors worn during exercise for 1 year. Cox proportional hazards regression was used to determine differences in exercise over the study year between the study groups.
Participants in the usual-care group were 76% more likely than those in the CHANGE group to stop exercising during the year following a cardiac rehabilitation program (hazard ratio = 1.76, 95% confidence interval = 1.08-2.86, p = .02) when adjusting for the significant covariates race, gender, comorbidity, muscle and joint pain, and baseline motivation. Most participants, however, had less than recommended levels of exercise amount and intensity.
Counseling interventions that use contemporary behavior change strategies, such as the CHANGE intervention, can reduce the number of individuals who do not exercise following cardiac events.
The incidence of breast cancer in the US is known to be higher among white than black women and among women of higher socioeconomic status (SES), but once a woman, either black or white, has the ...disease, she is more likely to have a recurrence and to die of breast cancer if she is of lower socioeconomic status. Explanations for these observed differences are varied and inconsistent making it clear that these reported differentials are not sufficiently understood. In understanding breast cancer in a multicultural setting, delay in diagnosis, follow-up, and treatment are frequently the focus of attention. However these factors do not sufficiently explain the observed differences between blacks and whites. A review of recent literature reveals an increasing focus on the role of SES in breast cancer etiology, and progression; however, the confounding of SES with race/ethnicity (black vs. white) contributes to the insufficient understanding of the effect of these two factors. This report will focus on the interplay between race/ethnicity and SES and their relative effects upon analyses of survival from breast cancer. Findings are based on prospective clinical trial data. SES factors have been associated with most of the known or suspected risk factors for breast cancer incidence and progression. In addition to race/ethnicity, SES is also associated with diet, lifestyle factors, physical characteristics, and tumor characteristics. Without controlling for other risk factors, the ratios of risk for blacks with respect to whites for disease-free survival and overall survival were 1.30 (95% CI: 1.04-1.61) and 1.42 (95% CI: 1.15-1.76), respectively. However, after controlling for patient risk factors, such as the number of positive lymph nodes, tumor diameter, estrogen receptor status and socioeconomic factors, these differences decrease and are not statistically significant. Socioeconomic status is associated both with race/ethnicity and estrogen receptor status. A loglinear analysis demonstrates that the apparent association of race/ethnicity with estrogen receptor status is mediated by socioeconomic status. An implication of this finding is that environmental and lifestyle components rather than genetic factors associated with race may explain the observed differentials between black and white breast cancer patients. Knowledge of environmental factors associated with SES have the potential for providing important clues about the prevention and control of breast cancer.
Do-Not-Resuscitate (DNR) patients tend to receive less medical care after the order is written. To provide a clearer approach, the Ohio Department of Health adopted the Do-Not-Resuscitate law in ...1998, indicating two distinct protocols of DNR orders that allow DNR patients to choose the medical care: DNR Comfort Care (DNRCC), implying DNRCC patients receive only comfort care after the order is written; and DNR Comfort Care-Arrest (DNRCC-Arrest), implying that DNRCC-Arrest patients are eligible to receive aggressive interventions until cardiac or respiratory arrest. The aim of this study was to examine the medical care provided to patients with these two distinct protocols of DNR orders.
Data were collected from August 2002 to December 2005 at a medical intensive care unit in a university-affiliated teaching hospital. In total, 188 DNRCC-Arrest patients, 88 DNRCC patients, and 2,051 non-DNR patients were included. Propensity score matching using multivariate logistic regression was used to balance the confounding variables between the 188 DNRCC-Arrest and 2,051 non-DNR patients, and between the 88 DNRCC and 2,051 non-DNR patients. The daily cost of intensive care unit (ICU) stay, the daily cost of hospital stay, the daily discretionary cost of ICU stay, six aggressive interventions, and three comfort care measures were used to indicate the medical care patients received. The association of each continuous variable and categorical variable with having a DNR order written was analyzed using Student's t-test and the χ2 test, respectively. The six aggressive interventions and three comfort care measures performed before and after the order was initiated were compared using McNemar's test.
DNRCC patients received significantly fewer aggressive interventions and more comfort care after the order was initiated. By contrast, for DNRCC-Arrest patients, the six aggressive interventions provided were not significantly decreased, but the three comfort care measures were significantly increased after the order was initiated. In addition, the three medical costs were not significantly different between DNRCC and non-DNR patients, or between DNRCC-Arrest and non-DNR patients.
When medical care provided to DNR patients is clearly indicated, healthcare professionals will provide the medical care determined by patient/surrogate decision-makers and healthcare professionals, rather than blindly decreasing medical care.
The State of Ohio in the United States has the legislation for two different protocols of do-not-resuscitate orders. The objective of this study was to examine the clinical/demographic factors and ...outcomes associated with the two different do-not-resuscitate orders.
Data were concurrently and retrospectively collected from August 2002 to December 2005. The clinical/demographic factors of do-not-resuscitate patients were compared with those of non-do-not-resuscitate patients, and the clinical/demographic factors of do-not-resuscitate comfort care-arrest patients were compared with those of do-not-resuscitate comfort care patients.
An ICU in a university-affiliated hospital located at Northeast Ohio in the United States.
A sample of 2,440 patients was collected: 389 patients were do-not-resuscitate; and 2,051 patients were non-do-not-resuscitate. Among the 389 do-not-resuscitate patients, 194 were do-not-resuscitate comfort care-arrest patients and 91 were do-not-resuscitate comfort care patients.
None.
The factors associated with do-not-resuscitate were older age, race and ethnicity with white race, more severe clinical illness at admission to the ICU, and longer stay before admission to the ICU. Comparing do-not-resuscitate comfort care-arrest patients with do-not-resuscitate comfort care patients, those with more severe clinical illness, longer ICU stay before making a do-not-resuscitate decision, and being cared for by only one intensivist during ICU stay were significantly associated with do-not-resuscitate comfort care decisions. For 149 do-not-resuscitate patients who eventually survived to hospital discharge and 86 do-not-resuscitate patients who eventually did not, only eight (5.4%) and 23 (26.7%) had the order written within 48 hours before the end of ICU stay, respectively.
Our study showed that some clinical/demographic factors predicted do-not-resuscitate comfort care orders. This study also suggested that Ohio's Do-Not-Resuscitate Law, clearly indicating two different protocols of do-not-resuscitate orders, facilitated early do-not-resuscitate decision.
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