Andrea Altschuler

Effects of Exam-Room Computing on Clinician–Patient Communication: A Longitudinal Qualitative Study

AbstractOBJECTIVE: To evaluate the impact of exam-room computers on communication between clinicians and patients. DESIGN AND METHODS: Longitudinal, qualitative study using video-tapes of regularly scheduled visits from 3 points in time: 1 month before, 1 month after, and 7 months after introduction of computers into the exam room. SETTING: Primary care medical clinic in a large integrated delivery system. PARTICIPANTS: Nine clinicians (6 physicians, 2 physician assistants, and 1 nurse practitioner) and 54 patients. RESULTS: The introduction of computers into the exam room affected the visual, verbal, and postural connection between clinicians and patients. There were variations across the visits in the magnitude and direction of the computer’s effect. We identified 4 domains in which exam-room computing affected clinician-patient communication: visit organization, verbal and nonverbal behavior, computer navigation and mastery, and spatial organization of the exam room. We observed a range of facilitating and inhibiting effects on clinician-patient communication in all 4 domains. For 2 domains, visit organization and verbal and nonverbal behavior, facilitating and inhibiting behaviors observed prior to the introduction of the computer appeared to be amplified when exam-room computing occurred. Likewise, exam-room computing involving navigation and mastery skills and spatial organization of the exam-room created communication challenges and opportunities. In all 4 domains, there was little change observed in exam-room computing behaviors from the point of introduction to 7-month follow-up. CONCLUSIONS: Effective use of computers in the outpatient exam room may be dependent upon clinicians’ baseline skills that are carried forward and are amplified, positively or negatively, in their effects on clinician-patient communication. Computer use behaviors do not appear to change much over the first 7 months. Administrators and educators interested in improving exam-room computer use by clinicians need to better understand clinician skills and previous work habits associated with electronic medical records. More study of the effects of new technologies on the clinical relationship is also needed.

Contentment With Quality of Life Among Breast Cancer Survivors With and Without Contralateral Prophylactic Mastectomy

PURPOSE To understand psychosocial outcomes after prophylactic removal of the contralateral breast in women with unilateral breast cancer. METHODS We mailed surveys to women with contralateral prophylactic mastectomy after breast cancer diagnosis between 1979 and 1999 at six health care delivery systems, and to a smaller random sample of women with breast cancer without the procedure. Measures were modeled on instruments developed to assess contentment with quality of life, body image, sexual satisfaction, breast cancer concern, depression, and health perception. We examined associations between quality of life and the other domains using logistic regression. RESULTS The response rate was 72.6%. Among 519 women who underwent contralateral prophylactic mastectomy, 86.5% were satisfied with their decision; 76.3% reported high contentment with quality of life compared with 75.4% of 61 women who did not undergo the procedure (P = .88). Among all case subjects, less contentment with quality of life was not associated with contralateral prophylactic mastectomy or demographic characteristics, but was associated with poor or fair general health perception (odds ratio [OR], 7.0; 95% CI, 3.4 to 14.1); possible depression (OR, 5.4; 95% CI, 3.1 to 9.2); dissatisfaction with appearance when dressed (OR, 3.5; 95% CI, 2.0 to 6.0); self-consciousness about appearance (OR, 2.0; 95% CI, 1.1 to 3.7); and avoiding thoughts about breast cancer (modest: OR, 2.2; 95% CI, 1.1 to 4.5; highest: OR, 1.7; 95% CI, 0.9 to 3.2). CONCLUSION Most women undergoing contralateral prophylactic mastectomy report satisfaction with their decision and experience psychosocial outcomes similar to breast cancer survivors without the procedure.

Time Trends in Therapies and Outcomes for Adult Inflammatory Bowel Disease, Northern California, 1998–2005

BACKGROUND & AIMS The management of inflammatory bowel disease (IBD) has become increasingly complicated, and it is unknown whether poor outcomes (prolonged steroid use, hospitalizations, and surgery) have declined in the general population. METHODS This multilevel study used computerized clinical data. The study comprised 2892 adults with Crohns disease (CD) and 5895 with ulcerative colitis (UC) who received care at 16 medical centers within an integrated care organization in Northern California between 1998 and 2005. RESULTS Time trends included (1) a shift in gastroenterology-related visits from the gastroenterology division to primary care; (2) increased use of IBD-related drugs, except for a 7% decline in use of 5-aminosalicylate in CD and no change in steroid use for CD; (3) for the prevalence of prolonged steroid exposure (120 days of continuous use), a 36% decline for CD with a 27% increase for UC; (4) declines in the hospitalization rates of 33% for CD and 29% for UC; and (5) for the surgery rate, no significant change for CD with a 50% decline for UC. CONCLUSIONS Declines in prolonged steroid exposure and the hospitalization rate for CD and in the hospitalization and surgery rate for UC are encouraging; however, the increase in prolonged steroid exposure for UC merits concern and further investigation. The variability in care patterns observed in this study suggests lack of standardization of care and the opportunity to identify targets for quality improvement. These findings should stimulate research to quantify the effect of current trends in IBD management.

Gender Differences in Quality of Life Among Long-Term Colorectal Cancer Survivors With Ostomies

PURPOSE/OBJECTIVES To describe how gender shapes the concerns and adaptations of long-term (i.e., more than five years) colorectal cancer survivors with ostomies. DESIGN Qualitative study using content analysis of focus group content. SETTING Oregon, southwestern Washington, and northern California. SAMPLE Four female and four male focus groups (N = 33) selected from 282 quantitative survey participants with health-related quality-of-life (HRQOL) scores in the highest or lowest quartile. METHODS Eight focus groups discussed the challenges of living with an ostomy. Content was recorded, transcribed, and analyzed using directive and summative content analysis. MAIN RESEARCH VARIABLES HRQOL domains of physical, psychological, social, and spiritual well-being. FINDINGS All groups reported avoiding foods that cause gas or rapid transit and discussed how limiting the amount of food eaten controlled the output. All groups discussed physical activities, getting support from friends and family, and the importance of being resilient. Both genders identified challenges with sexuality and intimacy. Coping and adjustment difficulties mostly were discussed by women, with men only discussing these issues to a small extent. Difficulties with sleep primarily were identified by women with low HRQOL. Problems with body image and depression were discussed only by women with low HRQOL. CONCLUSIONS Common issues included diet management, physical activity, social support, and sexuality. Although both genders identified challenges, women described more specific psychological and social issues than men. IMPLICATIONS FOR NURSING Application of these gender-based differences can inform educational interventions for colorectal cancer survivors with ostomies.

Positive, Negative, and Disparate—Women’s Differing Long‐Term Psychosocial Experiences of Bilateral or Contralateral Prophylactic Mastectomy

Abstract:  Because of recent studies showing strong prevention benefit and acceptable psychosocial outcomes, more women may be considering prophylactic mastectomy. A growing literature shows some positive psychosocial outcomes for women with bilateral prophylactic mastectomy, but less is known about women with contralateral prophylactic mastectomy. Several surveys have shown that a large majority of women with prophylactic mastectomy report satisfaction with their decisions to have the procedure when asked in a quantitative, closed‐ended format. We sought to explore the nuances of women’s satisfaction with the procedure using a qualitative, open‐ended format. We included open‐ended questions as part of a mailed survey on psychosocial outcomes of prophylactic mastectomy. The research team coded and analyzed these responses using qualitative methods. We used simple descriptive statistics to compare the demographics of the entire survey sample to those women who answered the open‐ended questions; the responses to the open‐ and closed‐ended satisfaction questions, and the responses of women with bilateral and contralateral prophylactic mastectomy. Seventy‐one percent of women with prophylactic mastectomy responded to the survey and 48% provided open‐ended responses about psychosocial outcomes. Women’s open‐ended responses regarding psychosocial outcomes could be coded into one of three general categories—positive, negative, and disparate. In the subgroup of women with both open‐and closed‐ended responses, over 70% of women providing negative and disparate comments to the open‐ended question simultaneously indicated satisfaction on a closed‐ended question. Negative and disparate open‐ended responses were twice as common among women with bilateral prophylactic mastectomy (52%) than women with contralateral prophylactic mastectomy (26%). These findings suggest that even among women who report general satisfaction with their decision to have prophylactic mastectomy via closed‐ended survey questions, lingering negative psychosocial outcomes can remain, particularly among women with bilateral prophylactic mastectomy. This dichotomy could be an important factor to discuss in counseling women considering the procedure.

Quality of Life After Bilateral Prophylactic Mastectomy

BackgroundBilateral prophylactic mastectomy in women with increased breast cancer risk dramatically reduces breast cancer occurrence but little is known about psychosocial outcomes.MethodsTo examine long-term quality of life after bilateral prophylactic mastectomy, we mailed surveys to 195 women who had the procedure from 1979 to 1999 and to a random sample of 117 women at increased breast cancer risk who did not have the procedure. Measures were modeled on or drawn directly from validated instruments designed to assess quality of life, body image, sexuality, breast cancer concerns, depression, health perception, and demographic characteristics. We used logistic regression to examine associations between quality of life and other domains.ResultsThe response rate was 58%, with 106 women with and 62 women without prophylactic mastectomy returning complete surveys. Among women who underwent bilateral prophylactic mastectomy, 84% were satisfied with their decision to have the procedure; 61% reported high contentment with quality of life compared with an identical 61% of women who did not have the procedure (P = 1.0). Among all subjects, diminished contentment with quality of life was not associated with bilateral prophylactic mastectomy but with dissatisfaction with sex life (adjusted ratio [OR] = 2.5, 95% confidence interval [CI] = 1.0–6.2), possible depression (CES-D > 16, OR = 4.9, CI = 2.0–11.8), and poor or fair general health perception (OR = 8.3, 95% CI = 2.4–29.0).ConclusionsThe majority of women reported satisfaction with bilateral prophylactic mastectomy and experienced psychosocial outcomes similar to women with similarly elevated breast cancer risk who did not undergo prophylactic mastectomy. Bilateral prophylactic mastectomy appears to neither positively nor negatively impact long-term psychosocial outcomes.

Figuring Out Sex in a Reconfigured Body: Experiences of Female Colorectal Cancer Survivors with Ostomies

Colorectal cancer survivors with ostomies can face complex concerns regarding sexuality. We used an anthropological perspective to examine the experiences of 30 female colorectal cancer survivors with ostomies to shed light on the sexual challenges and adaptations made in the wake of cancer surgery and treatment. Participants fell into four categories with regard to their sexual experience post surgery; however, not all women found their altered sexuality to be particularly problematic. This type of phenomenological examination can inform a more patient-centered, less biomedically focused paradigm for assessing and improving the sexual health of cancer survivors.

Surviving colorectal cancer: long-term, persistent ostomy-specific concerns and adaptations.

PURPOSE The purpose of this article was to describe persistent ostomy-specific concerns and adaptations in long-term (>5 years) colorectal cancer survivors with ostomies. SUBJECTS AND SETTINGS Thirty-three colorectal cancer survivors who participated in 8 gender- and health-related quality of life stratified focus groups and 130 colorectal cancer survivors who provided written comments to 2 open-ended questions on ostomy location and pouch problems participated in the study. Data were collected on health maintenance organization members in Oregon, southwestern Washington, and northern California. METHODS Qualitative data were analyzed for the 8 focus groups and written comments from 2 open-ended survey questions. Discussions from the focu s groups were recorded, transcribed, and analyzed using content analysis. Written content from the open-ended questions was derived from a mailed questionnaire on health-related quality of life in survivors with ostomies and analyzed using content analysis. RESULTS Discussions related to persistent ostomy-related issues more than 5 years after formation were common. Persistent ostomy-related issues were focused on clothing restrictions and adaptations, dietary concerns, issues related to ostomy equipment and self-care, and the constant need to find solutions to adjust and readjust to living with an ostomy. CONCLUSIONS Ostomy-specific concerns persist 5 years and more for long-term colorectal cancer survivors after initial ostomy formation. Adaptations tend to be individualized and based on trial and error. Findings underscore the need to develop long-term support mechanisms that survivors can access to promote better coping and adjustment to living with an ostomy.

Gastroenterologists' attitudes and self‐reported practices regarding inflammatory bowel disease

Background: The purpose was to assess organization‐, physician‐, and patient‐based aspects of inflammatory bowel disease (IBD) practice variation within an integrated care delivery system and the extent to which physicians are interested in adopting a chronic care model and/or nurse assistance to manage IBD patients. Methods: As part of an observational cohort study to understand variation in IBD care and outcomes, we conducted semistructured, open‐ended interviews with 17 gastroenterologists and 1 gastroenterology registered nurse at 6 clinics in an integrated care delivery system. Interviews were taperecorded and transcribed. We coded and analyzed transcripts using standard qualitative methods. Results: Physicians reported a range of attitudes and practices regarding IBD. Analysis showed differences in 3 domains and 8 subdomains: 1) patient education and choices, including health education and patient use of complementary and alternative medicine; 2) decisions about diagnosis and treatment, including practice guidelines, conferring with colleagues, using infliximab, and medical hospitalization; and 3) organizational aspects of care, including primary care involvement with IBD and MD attitudes toward ancillary support. Conclusions: Standardized algorithms on care for IBD patients do not exist, but opportunities may exist to improve IBD care by: having initial work‐ups and management of patients in remission in primary care; creating and maintaining opportunities for gastroenterologists to confer with colleagues and acknowledged local experts; and having nurse coordination for medications and labs and/or some type of specialty IBD clinic for high‐need patients. This research highlights the need for more directed comparative efficacy and effectiveness trials that will serve to define preferred treatment strategies.

COMPLICATIONS AMONG COLORECTAL CANCER SURVIVORS: SF-6D PREFERENCE-WEIGHTED QUALITY OF LIFE SCORES

Background:Societal preference-weighted health-related quality of life (HRQOL) scores enable comparing multidimensional health states across diseases and treatments for research and policy. Objective:To assess the effects of living with a permanent intestinal stoma, compared with a major bowel resection, among colorectal cancer (CRC) survivors. Research Design:Cross-sectional multivariate linear regression analysis to explain preference-weighted HRQOL scores. Subjects:In all, 640 CRC survivors (≥5 years) from 3 group model health maintenance organizations; ostomates and nonostomates with colorectal resections for CRC were matched on gender, age (±5 years), time since diagnosis, and tumor site (rectum vs. colon). Measures:SF-6D scoring system was applied to Medical Outcomes Study Short Form-36 version 2 (SF-36v2); City of Hope Quality of Life-Ostomy; and Charlson-Deyo comorbidity index. Methods:Survey of CRC survivors linked to respondents’ clinical data extracted from health maintenance organization files. Results:Response rate was 52%. Ostomates and nonostomates had similar sociodemographic characteristics. Mean SF-6D score was 0.69 for ostomates, compared with 0.73 for nonostomates (P < 0.001), but other factors explained this difference. Complications of initial cancer surgery, and previous year comorbidity burden, and hospital use were negatively associated with SF-6D scores, whereas household income was positively associated. Conclusions:CRC survivors’ SF-6D scores were not associated with living with a permanent ostomy after other factors were taken into account. Surgical complications, comorbidities, and metastatic disease lowered the preference-weighted HRQOL of CRC survivors with and without ostomies. Further research to understand and reduce late complications from CRC surgeries as well as associated depression is warranted.