Gary S. Fischer

Patient Knowledge and Physician Predictions of Treatment Preferences After Discussion of Advance Directives

OBJECTIVE: To determine patient knowledge about life-sustaining treatments and physician understanding of patient preferences for proxies and treatments after outpatient discussions about advance directives.DESIGN: Cross-sectional interview-based and questionnaire-based survey.SETTING: Two university general internal medicine practices, two Department of Veterans Affairs general internal medicine practices, and one university-based geriatrics practice, in two different cities.PATIENTS: Fifty-six patients of primary care internists.INTERVENTION: Physicians discussed “advance directives” (ADs) with one randomly selected patient during an outpatient visit.MEASUREMENTS AND MAIN RESULTS: After the discussions, physicians identified the patient’s proxy and predicted the patient’s preferences for treatment in 20 scenarios. Patients provided treatment preferences in the 20 scenarios, the name of their preferred surrogate decision maker, and their understanding of cardiopulmonary resuscitation and mechanical ventilation. Of the 39 patients who discussed resuscitation, 43% were able to identify two important characteristics; 26% identified none; 66% did not know that most patients need mechanical ventilation after undergoing resuscitation. None of the 43 patients who had a discussion about mechanical ventilation had a good understanding of it; 67% did not know that patients generally cannot talk while on ventilators; 46% expressed serious misconceptions about ventilators. There was poor agreement between physicians and their patients regarding treatment preferences in 18 of 20 scenarios (κ −0.04 to 0.31). Physicians correctly identified the proxy 89% of the time (κ 0.78).CONCLUSIONS: Patients leave routine AD discussions with serious misconceptions about life-sustaining treatments. Physicians are unable to predict treatment preferences but do learn about patients’ preferences for surrogate decision makers.

Using the Internet to translate an evidence-based lifestyle intervention into practice.

Despite evidence-based recommendations for addressing obesity in the clinical setting, lifestyle interventions are lacking in practice. The objective of this study was to translate an evidence-based lifestyle program into the clinical setting by adapting it for delivery via the Internet. We adapted the Diabetes Prevention Programs lifestyle curriculum to an online format, comprising 16 weekly and 8 monthly lessons, and conducted a before-and-after pilot study of program implementation and feasibility. The program incorporates behavioral tools such as e-mail prompts for online self-monitoring of diet, physical activity, and weight, and automated weekly progress reports. Electronic counseling provides further support. Physician referral, automated progress reports, and as-needed communication with lifestyle coaches integrate the intervention with clinical care. We enrolled 50 patients from a large academic general internal practice into a pilot program between November 16, 2006 and February 11, 2007. Patients with a body mass index (BMI) =25 kg/m2, at least one weight-related cardiovascular risk factor, and Internet access were eligible if referring physicians felt the lifestyle goals were safe and medically appropriate. Participants were primarily female (76%), with an average age of 51.94 (standard deviation [SD] 10.82), and BMI of 36.43 (SD 6.78). At 12 months of enrollment, 50% of participants had logged in within 30 days. On average, completers (n = 45) lost 4.79 (SD 8.55) kg. Systolic blood pressure dropped 7.33 (SD 11.36) mm Hg, and diastolic blood pressure changed minimally (+0.44 mm Hg; SD 9.27). An Internet-based lifestyle intervention may overcome significant barriers to preventive counseling and facilitate the incorporation of evidence-based lifestyle interventions into primary care.

Living With Diabetes Normalizing the Process of Managing Diabetes

Purpose The purpose of this qualitative study was to explore perceptions of people with diabetes about their experience of living with and managing their diabetes. Methods This study was part of a larger study of patients with diabetes who used a novel computer portal system for access to information about diabetes and to their health care providers for enhanced communication. The research method used for this portion of the study was grounded theory methodology, a particular kind of qualitative research method. Results A central theme generated from the data was “normalizing an identity as a person with diabetes.” The participants described themselves as diabetic; they took on an identity in which having diabetes was central. They struggled with how to become “a person with diabetes” rather than a “diabetic person.” Conclusions For people who are diagnosed with diabetes, there is a struggle to become a person with diabetes rather than a diabetic person and to manage the lifestyle changes that are mandated by this role/identity. One way of dealing or coping with this new identity is to begin to “normalize” these lifestyle changes—to view them as healthy living for all people, those with and without diabetes. This will then have implications for interventions—encouraging healthy lifestyles among people with diabetes rather than emphasizing that people with diabetes are “different from” the general population.

Interest in the Use of Computerized Patient Portals: Role of the Provider–Patient Relationship

BackgroundBioinformatics experts are developing interactive patient portals to help those living with diabetes and other chronic diseases to better manage their conditions. However, little is known about what influences patients’ desires to use this technology.ObjectiveTo discern the impact of the provider–patient relationship on interest in using a web-based patient portal.DesignQualitative analysis of focus groups.ParticipantsTen focus groups involving 39 patients (range 2–7) recruited from four primary care practices.ApproachA qualitative approach was used, which involved reading transcribed texts until a consensus was reached on data interpretation. An intercoder reliability kappa score (0.89) was determined by comparing the provider–patient relationship talk selected by the two coders. A conceptual framework was developed, which involved the development and refinement of a codebook and the application of it to the transcripts.ResultsInterest in the portal was linked to dissatisfaction with the provider–patient relationship, including dissatisfaction with provider communication/responsiveness, the inability to obtain medical information, and logistical problems with the office. Disinterest in the portal was linked to satisfaction with the provider–patient relationship, including provider communication/responsiveness, difficulty in using the portal, and fear of losing relationships and e-mail contact with the provider. No patient identified encrypted e-mail communication through the portal as an advantage.ConclusionsPromoting the use of computerized portals requires patient-based adaptations. These should include ease of use, direct provider e-mail, and reassurances that access and interpersonal relationships will not be lost. Education is needed about privacy concerns regarding traditional e-mail communication.

Objectives for Advance Care Planning

Identifying objectives for advance care planning (ACP) is an important step toward improving care at the end of life. Previous studies of ACP have used many different measures of success. However, there has been no consensus on what should be the objectives for ACP. Lack of attention to specific objectives for ACP may lead to ineffective communication and research. The first step to improving outcomes in ACP is to acknowledge the diversity of objectives that ACP may achieve. Health care providers, patients, and surrogates should identify and agree on common objectives for particular conversations. Various methods, conversations, and forms may be used to achieve these objectives over time. Clarifying objectives from various perspectives is an important step toward achieving the level of understanding necessary to make these difficult decisions. It is time for physicians to reconsider the way in which they think about and discuss ACP with patients. If we are to improve care at the end of life, future patient care, research, and education about ACP should proceed with specific objectives in mind.

Elevator talk: Observational study of inappropriate comments in a public space

OBJECTIVES We conducted a study to determine the type and frequency of inappropriate comments made by hospital employees while riding hospital elevators. METHODS Four observers rode in elevators at five hospitals, listening for any comments made by hospital employees that might be deemed inappropriate. All potentially inappropriate comments were reviewed by the research team and were classified as inappropriate if they met at least one of the following criteria: violated patient confidentiality, raised concerns about the speakers ability or desire to provide high-quality patient care, raised concerns about poor quality of care in the hospital (by persons other than the speaker), or contained derogatory remarks about patients or their families. RESULTS We observed 259 one-way elevator trips offering opportunity for conversation. We overheard a total of 39 inappropriate comments, which took place on 36 rides (13.9% of the trips). The most frequent comments (18) were violations of patients confidentiality. Next most frequent (10 comments) were unprofessional remarks in which clinicians talked about themselves in ways that raised questions about their ability or desire to provide high-quality patient care. Other comments included derogatory statements about the general quality of hospital care (8) and derogatory remarks about patients (5). Physicians were involved in 15 of the comments, nurses in 10, and other hospital employees in the remainder. CONCLUSION Inappropriate comments took place with disturbing frequency in the elevator rides we sampled. These comments did not exclusively involve violations of patient confidentiality, but encompassed a range of discussions that health care employees must be careful to avoid.

Patient Difficulty Using Tablet Computers to Screen in Primary Care

BackgroundPatient-administered computerized questionnaires represent a novel tool to assist primary care physicians in the delivery of preventive health care.ObjectiveThe aim of this study was to assess patient-reported ease of use with a self-administered tablet computer-based questionnaire in routine clinical care.DesignAll patients seen in a university-based primary care practice were asked to provide routine screening information using a touch-screen tablet computer-based questionnaire. Patients reported difficulty using the tablet computer after completion of their first questionnaire.PatientsTen thousand nine hundred ninety-nine patients completed the questionnaire between January 2004 and January 2006.MeasurementsWe calculated rates of reporting difficulty (no difficulty, some difficulty, or a lot of difficulty) using the tablet computers based on patient age, sex, race, educational attainment, marital status, and number of comorbid medical conditions. We constructed multivariable ordered logistic models to identify predictors of increased self-reported difficulty using the computer.ResultsThe majority of patients (84%) reported no difficulty using the tablet computers to complete the questionnaire, with only 3% reporting a lot of difficulty. Significant predictors of reporting more difficulty included increasing age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.05–1.05)]; Asian race (OR 2.3, 95% CI 1.8–2.9); African American race (OR 1.4, 95% CI 1.2–1.6); less than a high school education (OR 3.0, 95% CI 2.6–3.4); and the presence of comorbid medical conditions (1–2: OR 1.3, 95% CI 1.2–1.5; ≥3: OR 1.7 95% CI 1.5–2.1).ConclusionsThe majority of primary care patients reported no difficulty using a self-administered tablet computer-based questionnaire. While computerized questionnaires present opportunities to collect routine screening information from patients, attention must be paid to vulnerable groups.

Comparison of Electronic Physician Prompts versus Waitroom Case-Finding on Clinical Trial Enrollment

BackgroundRecruiting patients into clinical research protocols is challenging. Electronic medical record (EMR) systems capable of prompting clinicians may facilitate enrollment.ObjectiveTo compare an EMR-based clinician prompt versus a wait-room-based case-finding strategy at enrolling patients into a clinical trial.DesignCross-sectional comparison of recruitment data from two trials to treat anxiety disorders in primary care. Both studies utilized similar enrollment criteria, intervention strategies, and the same four practice sites and EMR system.ParticipantsPatients referred by their (primary care physicians) PCPs in response to an EMR prompt (recruited 1/2005–10/2006), and patients enrolled by research assistants stationed in practice waiting rooms (7/2000–4/2002).MeasurementsReferral counts, patients’ baseline sociodemographic and clinical characteristics.ResultsOver a 22-month period, EMR-prompted PCPs referred 794 patients and 176 (22%) met study inclusion criteria and enrolled, compared to 8,095 patients approached by wait room-based recruiters of whom 193 (2.4%) enrolled. Subjects enrolled by EMR-prompted PCPs were more likely to be non-white (23% vs 5%; P < 0.001), male (28% vs 18%; P = 0.03), and have higher anxiety levels than those recruited by wait-room recruiters (P < 0.0001).ConclusionsEMR systems prompting clinicians to refer patients with specific characteristics are an efficient recruitment tool with critical implications for increasing minority participation in clinical research.

Automated Clinical Reminders for Primary Care Providers in the Care of CKD: A Small Cluster-Randomized Controlled Trial

BACKGROUND Primary care physicians (PCPs) care for most non-dialysis-dependent patients with chronic kidney disease (CKD). Studies suggest that PCPs may deliver suboptimal CKD care. One means to improve PCP treatment of CKD is clinical decision support systems (CDSSs). STUDY DESIGN Cluster-randomized controlled trial. SETTING & PARTICIPANTS 30 PCPs in a university-based outpatient general internal medicine practice and their 248 patients with moderate to advanced CKD who had not been referred to a nephrologist. INTERVENTION 2 CKD educational sessions were held for PCPs in both arms. The 15 intervention-arm PCPs also received real-time automated electronic medical record alerts for patients with estimated glomerular filtration rates <45 mL/min/1.73 m(2) recommending renal referral and urine albumin quantification if not done within the prior year. OUTCOMES Primary outcome was referral to a nephrologist; secondary outcomes were albuminuria/proteinuria assessment, CKD documentation, optimal blood pressure (ie, <130/80 mm Hg), and use of renoprotective medications. RESULTS The intervention and control arms did not differ in renal referrals (9.7% vs 16.5%, respectively; between-group difference, -6.8%; 95% CI, -15.5% to 1.8%; P = 0.1) or proteinuria assessments (39.3% vs 30.1%, respectively; between-group difference, 9.2%; 95% CI, -2.7% to 21.1%; P = 0.1). For intervention and control patients without a baseline proteinuria assessment, 27.7% versus 16.3%, respectively, had one at follow-up (P = 0.06). After controlling for clustering, these findings were largely unchanged and no significant differences were apparent between groups. LIMITATIONS Small single-center university-based practice, use of a passive CDSS that required PCPs to trigger the electronic order set. CONCLUSIONS PCPs were willing to partake in a randomized trial of a CDSS to improve outpatient CKD care. Although CDSSs may have potential, larger studies are needed to further explore how best to deploy them to enhance CKD care.

Characterizing pre-dialysis care in the era of eGFR reporting: a cohort study.

BackgroundChronic kidney disease (CKD) is a common disorder associated with increased morbidity and mortality. Primary care physicians (PCPs) care for the majority of pre-dialysis CKD patients; however, PCPs often do not recognize the presence of CKD based on serum creatinine levels. Prior studies suggest that PCPs and nephrologists deliver suboptimal CKD care. One strategy to improve disease awareness and treatment is estimated glomerular filtration rate (eGFR) reporting. We examined PCP and nephrologist CKD practices before and after routine eGFR reporting.MethodsWe conducted a retrospective cohort study of patients with CKD 3b-4 (eGFR < 45) seen at a university-based, outpatient primary care clinic. Using a chi-square or Fishers exact test, we compared co-management rates, renal protective strategies, CKD documentation, and laboratory processes of care in 274 patients and 266 patients seen in a 6-month period prior to and following eGFR implementation, respectively.ResultsCKD co-management increased from 22.6% pre-eGFR to 48.5% post-eGFR (P < 0.0001). eGFR reporting did not improve angiotensin converting enzyme inhibitor or angiotensin receptor blocker use or quantitative urinary testing. However, non-steroidal anti-inflammatory drug avoidance (pre-eGFR 81.8% vs. post- eGFR 90.6%, P = 0.003) and phosphorus and parathyroid hormone testing improved (pre-eGFR vs. post-eGFR: 32.5% vs. 51.5%, P < 0.0001; 12.4% vs. 36.1%, P < 0.0001 respectively).ConclusionsA marked increase in CKD co-management was observed following eGFR implementation. Although some improvements in processes of care were noted, this did not include angiotensin converting enzyme inhibitor or angiotensin receptor blocker use. Overall care remained suboptimal despite eGFR reporting; further strategies are needed to improve PCP and nephrologist CKD care.