Dylan M. Smith

Providing Social Support May Be More Beneficial Than Receiving It Results From a Prospective Study of Mortality

This study examines the relative contributions of giving versus receiving support to longevity in a sample of older married adults. Baseline indicators of giving and receiving support were used to predict mortality status over a 5-year period in the Changing Lives of Older Couples sample. Results from logistic regression analyses indicated that mortality was significantly reduced for individuals who reported providing instrumental support to friends, relatives, and neighbors, and individuals who reported providing emotional support to their spouse. Receiving support had no effect on mortality once giving support was taken into consideration. This pattern of findings was obtained after controlling for demographic, personality, health, mental health, and marital-relationship variables. These results have implications for understanding how social contact influences health and longevity.

The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management

AbstractOBJECTIVE: Patients’ self-management practices have substantial consequences on morbidity and mortality in diabetes. While the quality of patient-physician relations has been associated with improved health outcomes and functional status, little is known about the impact of different patient-physician interaction styles on patients’ diabetes self-management. This study assessed the influence of patients’ evaluation of their physicians’ participatory decision-making style, rating of physician communication, and reported understanding of diabetes self-care on their self-reported diabetes management. DESIGN: We surveyed 2,000 patients receiving diabetes care across 25 Veterans’ Affairs facilities. We measured patients’ evaluation of provider participatory decision making with a 4-item scale (Provider Participatory Decision-making Style [PDMstyle]; α=0.96), rating of providers’ communication with a 5-item scale (Provider Communication [PCOM]; α=0.93), understanding of diabetes self-care with an 8-item scale (α=0.90), and patients’ completion of diabetes self-care activities (self-management) in 5 domains (α=0.68). Using multivariable linear regression, we examined self-management with the independent associations of PDMstyle, PCOM, and Understanding. RESULTS: Sixty-six percent of the sample completed the surveys (N=1,314). Higher ratings in PDMstyle and PCOM were each associated with higher self-management assessments (P<.01 in all models). When modeled together, PCOM remained a significant independent predictor of self-management (standardized β: 0.18; P<.001), but PDMstyle became nonsignificant. Adding Understanding to the model diminished the unique effect of PCOM in predicting self-management (standardized β: 0.10; P=.004). Understanding was strongly and independently associated with self-management (standardized β: 0.25; P<.001). CONCLUSION: For these patients, ratings of providers’ communication effectiveness were more important than a participatory decision-making style in predicting diabetes self-management. Reported understanding of self-care behaviors was highly predictive of and attenuated the effect of both PDMstyle and PCOM on self-management, raising the possibility that both provider styles enhance self-management through increased patient understanding or self-confidence.

Misimagining the unimaginable: the disability paradox and health care decision making.

Good decision making often requires accurate predictions about how potential outcomes will make one feel. However, people often mispredict the emotional impact of unfamiliar circumstances. For example, they often overestimate the emotional impact that chronic illnesses and disability will have on their lives. In the present article, the authors look at possible sources of error in both the happiness reports of patients with chronic illness or disability and the happiness predictions of healthy people asked to imagine the same illnesses and disabilities. On balance, the available evidence suggests that, whereas patients misreport their well-being, healthy people also mispredict the emotional impact that chronic illness and disability will have on their lives.

Racial Disparities in Diabetes Care Processes, Outcomes, and Treatment Intensity

Background. Black Americans with diabetes have a higher burden of illness and mortality than do white Americans. However, the extent to which differences in medical care processes and treatment intensity contribute to poorer diabetes outcomes is unknown. Objective. To assess racial disparities in the quality of diabetes care processes, intermediate outcomes, and treatment intensity. Methods. We conducted an observational study of 801 white and 115 black patients who completed the Diabetes Quality Improvement Project survey (response rate = 72%) in 21 Veterans Affairs (VA) facilities using survey data; medical record information on receipt of diabetes services (A1c, low-density lipoprotein [LDL], nephropathy screen, and foot and dilated eye examinations), and intermediate outcomes (glucose control measured by A1c; cholesterol control measured by LDL; and achieved level of blood pressure); and pharmacy data on filled prescriptions. Results. There were no racial differences in receipt of an A1c test or foot examination. Blacks were less likely than whites to have LDL checked in the past 2 years (72% vs. 80%, P <0.05) and to have a dilated eye examination (50% vs. 63%, P <0.01). Even after adjusting for patients’ age, education, income, insulin use, diabetes self-management, duration, severity, comorbidities, and health services utilization, racial disparities in receipt of an LDL test and eye examination persisted. After taking into account the nested structure of the data using a random intercepts model, blacks remained significantly less likely to have LDL testing than whites who received care within the same facility (68% vs. 83%, P <0.01). In contrast, there were no longer differences in receipt of eye examinations, suggesting that black patients were more likely to be receiving care at facilities with overall lower rates of eye examinations. After adjusting for patient characteristics and facility effects, black patients were substantially more likely than whites to have poor cholesterol control (LDL ⩾130) and blood pressure control (BP ⩾140/90 mm Hg) (P <0.01). Among those with poor blood pressure and lipid control, blacks received as intensive treatment as whites for these conditions. Conclusions. We found racial disparities in some diabetes care process and intermediate outcome quality measures, but not in intensity of treatment for those patients with poor control. Disparities in receipt of eye examinations were the result of black patients being more likely to receive care at lower-performing facilities, whereas for other quality measures, racial disparities within facilities were substantial.

Caregiving Behavior Is Associated With Decreased Mortality Risk

Traditional investigations of caregiving link it to increased caregiver morbidity and mortality, but do not disentangle the effects of providing care from those of being continuously exposed to an ailing loved one with serious health problems. We explored this possible confound in a national, longitudinal survey of elderly married individuals (N = 3,376). Results showed that spending at least 14 hr per week providing care to a spouse predicted decreased mortality for the caregiver, independently of behavioral and cognitive limitations of the care recipient (spouse), and of other demographic and health variables. These findings suggest that it may be premature to conclude that health risks for caregivers are due to providing active help. Indeed, under some circumstances, caregivers may actually benefit from providing care.

Effect of Esthetic Outcome After Breast-Conserving Surgery on Psychosocial Functioning and Quality of Life

PURPOSE Although breast-conserving surgery (BCS) is often assumed to result in minimal deformity, many patients report postoperative breast asymmetry. Understanding the effect of asymmetry on psychosocial functioning is essential for patients to make an informed choice for surgery. PATIENTS AND METHODS All women who underwent BCS at the University of Michigan Medical Center (Ann Arbor, MI) during a 4-year period were surveyed using a mailed questionnaire (N = 714; response rate = 79.5%). Women were queried regarding five aspects of psychosocial functioning: quality of life (QOL), depression, fear of recurrence, stigmatization, and perceived change in health status. Postoperative breast asymmetry was assessed using items from the Breast Cancer Treatment and Outcomes Survey. Multiple regression was used to examine the relationship between breast asymmetry and each outcome, controlling for age, time from surgery in years, race, education level, disease stage, surgical treatment, and the occurrence of postoperative complications. RESULTS Women with pronounced breast asymmetry were significantly more likely to feel stigmatized as a result of their breast cancer treatment (odds ratio [OR] = 4.58; 95% CI, 2.77 to 7.55) and less likely to report unchanged or improved health after treatment (OR = 0.43; 95% CI, 0.27 to 0.66). Minimal breast asymmetry was associated with higher QOL scores (86.3 v 82.4, P < .001). Finally, women with pronounced breast asymmetry were more likely to exhibit depressive symptoms (minimal asymmetry, 16.2%; moderate asymmetry, 18.0%; pronounced asymmetry, 33.7%, Wald test = 16.6; P = .002). CONCLUSION Pronounced breast asymmetry after BCS is significantly correlated with poor psychosocial functioning. Identifying patients at risk for postoperative asymmetry at the time of consultation may allow for improved referral for supportive counseling, prosthetics, and reconstruction.

Building a better quality measure: are some patients with 'poor quality' actually getting good care?

Background. National performance measures monitor the proportion of diabetic patients with low-density lipoprotein (LDL) levels ≥130 mg/dL, but such simple intermediate outcomes measure poor control, not necessarily poor care. “Tightly linked” quality measures define good quality either by a good intermediate outcome (LDL <130 mg/dL) or by evidence of appropriate responses to poor control (eg, starting or optimizing medications for high LDL or not doing so in the face of contraindications). Objectives. We examined hyperlipidemia therapy for patients with diabetes to determine the relative accuracy of quality assessment using simple intermediate outcome versus tightly linked quality measures. Research Design. Retrospective longitudinal cohort. Subjects. A total of 1154 diabetic patients with an LDL test done between October 1, 1998, and March 31, 1999, in 2 large VA facilities. M>easures. LDL levels, medication treatment, and explanations for poor quality. Results. Although 27% (307 of 1154) of patients had an LDL ≥130 mg/dL using the simple intermediate outcome measure, only 13% (148 of 1154) were classified as having substandard quality using the tightly linked measure. Among the 159 reclassified to adequate quality, 117 had lipid-lowering medication started or increased within 6 months of an LDL ≥130 mg/dL, 8 were already on high-dose medication, 12 had a repeat LDL <130 mg/dL, and 22 had contraindications to treatment. Conclusion. Simple intermediate outcome measures can be an inaccurate reflection of true quality of care, and many patients classified as having substandard quality by “poor control” might actually be receiving good quality of care.

Communicating Side Effect Risks in a Tamoxifen Prophylaxis Decision Aid: The Debiasing Influence of Pictographs

OBJECTIVE To experimentally test whether using pictographs (image matrices), incremental risk formats, and varied risk denominators would influence perceptions and comprehension of side effect risks in an online decision aid about prophylactic use of tamoxifen to prevent primary breast cancers. METHODS We recruited 631 women with elevated breast cancer risk from two healthcare organizations. Participants saw tailored estimates of the risks of 5 side effects: endometrial cancer, blood clotting, cataracts, hormonal symptoms, and sexual problems. Presentation format was randomly varied in a three factor design: (A) risk information was displayed either in pictographs or numeric text; (B) presentations either reported total risks with and without tamoxifen or highlighted the incremental risk most relevant for decision making; and (C) risk estimates used 100 or 1000 person denominators. Primary outcome measures included risk perceptions and gist knowledge. RESULTS Incremental risk formats consistently lowered perceived risk of side effects but resulted in low knowledge when displayed by numeric text only. Adding pictographs, however, produced significantly higher comprehension levels. CONCLUSIONS Pictographs make risk statistics easier to interpret, reducing biases associated with incremental risk presentations. PRACTICE IMPLICATIONS Including graphs in risk communications is essential to support an informed treatment decision-making process.

The impact of momentary pain and fatigue on physical activity in women with osteoarthritis

OBJECTIVE To examine the daily life patterns of both pain and fatigue symptoms and objective physical activity (using ambulatory monitoring) in women with symptomatic lower extremity osteoarthritis (OA), and to evaluate how momentary symptoms impact physical activity levels. METHODS Sixty women age >or=55 years (40 with knee or hip OA and 20 matched controls) participated in an observational study involving 2 laboratory visits and a 5-day home data collection period. During the home period physical activity levels were assessed continuously, and symptoms were inputted 6 times a day into an enhanced accelerometer at prespecified time points. RESULTS In the OA group as compared with the control group over the 5-day period, average physical activity was significantly lower (P = 0.02) and peak physical activity tended to be lower (P = 0.06). Although pain and fatigue overall were of moderate severity in this cohort, fatigue escalated throughout each day. In a hierarchical linear model, fatigue was most strongly associated with physical activity (beta = -30.1, P < 0.0001). Pain was more weakly associated with physical activity and in the direction opposite to what was hypothesized (beta = 16.9, P = 0.04). CONCLUSION Momentary reports of fatigue negatively predicted physical activity levels and were much more strongly related to physical activity than momentary pain. In order to help women with knee or hip OA manage symptoms and become more physically active, it may be important to emphasize fatigue management.

Coping With Spousal Loss: Potential Buffering Effects of Self-Reported Helping Behavior

The present study examined the role of self-reported helping behavior in attenuating the helpers depression following spousal loss. Using archival data from the Changing Lives of Older Couples sample (N = 289), the study shows that among bereaved participants who had experienced high loss-related grief, helping behavior (providing instrumental support to others) was associated with an accelerated decline in depressive symptoms for the helper from 6 months to 18 months following spousal loss. This relationship between giving help and recovery from depression was independent of support received, as well as measured health, and interpersonal and demographic factors. Implications of these results for theoretical approaches to the study of close relationships and well-being are discussed.