Jamie A. Cvengros

The role of depression symptoms in dialysis withdrawal.

Among end-stage renal disease (ESRD) patients on hemodialysis, death from withdrawal from life-sustaining dialysis is increasingly common. The present studys objective was to examine depression as a potential risk factor for hemodialysis withdrawal. Two hundred forty ESRD hemodialysis (133 male and 107 female) patients were followed for an average of 4 years after depression symptom assessment. Of these, 18% withdrew from dialysis. Using multivariate survival analysis and after controlling for the effects of age (p < .001) and clinical variables, the authors found that level of depression symptoms was a unique and significant predictive risk factor for the subsequent decision to withdraw from dialysis (p < .05). The potential impact that depression may have on the decision to withdraw from hemodialysis should be considered by health care providers, patient families, and patients.

Patient and Physician Beliefs About Control over Health: Association of Symmetrical Beliefs with Medication Regimen Adherence

BACKGROUNDPast work suggests that the degree of similarity between patient and physician attitudes may be an important predictor of patient-centered outcomes.OBJECTIVETo examine the extent to which patient and provider symmetry in health locus of control (HLOC) beliefs was associated with objectively derived medication refill adherence in patients with co-morbid diabetes mellitus (DM) and hypertension (HTN).PARTICIPANTSEighteen primary care physicians at the VA Iowa City Medical Center and affiliated clinics; 246 patients of consented providers with co-morbid DM and HTN.DESIGNEstablished patient-physician dyads were classified into three groups according to the similarity of their HLOC scores (assessed in parallel). Data analysis utilized hierarchical linear modeling (HLM) to account for clustering of patients within physicians.MAIN MEASURESObjectively derived medication refill adherence was computed using data from the VA electronic pharmacy record; blood pressure and HgA1c values were considered as secondary outcomes.KEY RESULTSPhysician-patient dyads holding highly similar beliefs regarding the degree of personal control that individual patients have over health outcomes showed significantly higher overall and cardiovascular medication regimen adherence (p = 0.03) and lower diastolic blood pressure (p = 0.02) than in dyads in which the patient held a stronger belief in their own personal control than did their treating physician. Dyads in which patients held a weaker belief in their own personal control than did their treating physician did not differ significantly from symmetrical dyads. The same pattern was observed after adjustment for age, physician sex, and physician years of practice.CONCLUSIONSThese data are the first to demonstrate the importance of attitudinal symmetry on an objective measure of medication adherence and suggest that a brief assessment of patient HLOC may be useful for tailoring the provider’s approach in the clinical encounter or for matching patients to physicians with similar attitudes towards care.

Patient and physician attitudes in the health care context: Attitudinal symmetry predicts patient satisfaction and adherence

Background: There is increasing interest in the role that patient and physician health-related attitudes may play in predicting patient outcomes.Purpose: This study examined the similarity of the attitudes held by patients and their physicians about the patient role in health care delivery and its relationship to patient outcomes.Methods: Participants were 16 primary care physicians from a single academic medical center and 146 patients who had been seen by their respective physician at least twice during the prior 6 months. Physicians and patients completed two measures reflecting healthcare-related attitudes: the Multidimensional Health Locus of Control questionnaire and the Patient-Practitioner Orientation Scale (PPOS). Patients also completed measures of satisfaction and adherence.Results: Analyses were conducted using hierarchical linear modeling with patients clustered within physicians. Degree of symmetry on internal health locus of control was positively associated with both patient adherence, F(2, 131)=3.75, p=.03, and satisfaction, F(2, 133)=7.16, p=.01. Degree of similarity on the Information/Power Sharing subscale of the PPOS was not positively associated with adherence or satisfaction.Conclusions: These data suggest that patients who are more similar in attitude to their physicians as indicated by internal health locus of control scores (but not PPOS scores) are more satisfied with their medical care and more adherent with treatment recommendations than patients who are less internally focused than their physicians.

Health locus of control and depression in chronic kidney disease: a dynamic perspective.

Participants in the present study were 207 patients with chronic kidney disease (CKD) who completed internal HLOC and depression measures at baseline and at an approximately 16-month follow-up period. Regression results indicated that after controlling for baseline level of depression, baseline internal HLOC was not a significant predictor of depression at follow-up. However, increases in internal HLOC over the 16-month follow-up were predictive of depression at follow-up. Furthermore, this relationship was qualified by an interaction between change in internal HLOC and disease progression. These results suggest that changes in internal HLOC over time may be a particularly important determinant of adjustment for individuals whose chronic illness progresses or becomes life threatening.

Patient Preference for and Reports of Provider Behavior: Impact of Symmetry on Patient Outcomes

OBJECTIVE Research has suggested that congruence between patient characteristics and contextual characteristics is a more robust predictor of outcomes than either patient or context characteristics alone. The goal of the present study was to examine the degree of congruence between patient preferences for the clinical encounter and reports of analogous dimensions of provider behavior and the effects of this congruence on patient outcomes. DESIGN Two hundred eighteen patients with diabetes (predominately Type II) completed measures of preference for and ratings of perceived provider behavior in three domains (1) information sharing, (2) behavioral involvement, and (3) socioemotional support. MAIN OUTCOME MEASURES Patient satisfaction, self-reported adherence, and a clinical marker of diabetic control (hemoglobin A1c) were the outcomes of interest. RESULTS Congruence in information sharing and congruence in behavioral involvement were predictive of glycemic control and self-reported adherence, respectively. Congruence in behavioral involvement and congruence in socioemotional support were predictive of greater patient satisfaction. CONCLUSION These findings provide further support for the importance of congruence between patient characteristics and contextual characteristics in predicting patient outcomes.

Impact of a brief dietary self-monitoring intervention on weight change and CPAP adherence in patients with obstructive sleep apnea

OBJECTIVE Weight loss can decrease the severity of obstructive sleep apnea (OSA) in many obese individuals; however, very few studies have investigated the effects of behavioral weight loss interventions for patients with OSA. The aims of this pilot study were to determine the feasibility and initial effects on weight and continuous positive airway pressure (CPAP) use of a brief minimal-contact self-monitoring-based weight loss intervention (SM). An additional aim was to investigate the association between weight loss and CPAP adherence. METHODS Forty obese men and women diagnosed with mild or moderate OSA were randomized to either the SM or an attention-control (AC) condition. SM participants completed daily dietary logs for 6 weeks. Participants were weighed at baseline, post-treatment (6 weeks), and at a 6-week follow up. RESULTS Recruitment and retention were good in this study and attrition rates did not differ significantly by group. Intent to treat repeated measures ANOVA indicated a main effect of time (but not group), such that both groups lost weight over time. Pearson r correlations between weight change and CPAP adherence indicated that among SM participants, 6-week weight loss was correlated with CPAP adherence at post-treatment and follow-up, such that SM participants with greater weight loss at 6 weeks had greater CPAP adherence at 6 and 12 weeks. CONCLUSION This study provides initial support for the beneficial effects of a minimal-contact weight loss intervention for patients with obstructive sleep apnea and highlights a possible association between weight loss and CPAP adherence.

Preferences for a Patient-Centered Role Orientation: Association with Patient-Information-Seeking Behavior and Clinical Markers of Health

BackgroundFew data exist examining how patients’ preferred role orientation (patient-centered or provider-centered) is associated with “patient-centered” behavior and clinical markers of health. PurposeThe purpose of the study is to investigate how patients’ preferred role orientation is associated with information-seeking behavior and clinical markers of health in a chronically ill population. MethodsParticipants were 189 hypertensive patients, at two VA Medical Centers and four community-based clinics, who completed measures of preferred role orientation and medication information seeking. Lab values of patients’ blood pressure, LDL cholesterol, and glycosylated hemoglobin A1c were used as clinical markers. ResultsPreference for a patient-centered role was associated with seeking medication information from various sources (e.g., the internet [OR = 1.14, 95% CI = 1.05–1.23]) and with the number of sources from which patients obtained information (β = .21, p = 0.005). However, patient-centered preferences were also associated with higher systolic blood pressure (β = 0.16, p = 0.04), higher diastolic blood pressure (β = .15, p = 0.04), and higher LDL cholesterol (β = 0.17, p = 0.04). There was no association with glycosylated hemoglobin A1c (β = −0.10, p = 0.36). ConclusionsPatients who preferred a patient-centered role engaged in behavior consistent with their preferences, but had higher blood pressure and less favorable lipid levels. These findings are discussed in terms of the nature and treatment of certain chronic conditions that may explain why a patient-centered role orientation is associated with a less favorable clinical profile in some contexts.

Management of Obstructive Sleep Apnea and Comorbid Insomnia: A Mixed-Methods Evaluation

The purpose of this study was to examine the process of care in an interdisciplinary sleep clinic for patients with obstructive sleep apnea (OSA) and comorbid insomnia. A mixed-methods approach was used to examine clinical and patient-centered measures for 34 patients who received positive-airway pressure for OSA or cognitive-behavior therapy for insomnia. The results revealed baseline-to-follow-up improvements on several self-reported sleep parameters and measures of daytime functioning. Qualitative analyses from patient interviews revealed three themes: conceptual distinctions about each sleep disorder, importance of treating both sleep disorders, and preferences with regard to the sequence of treatment. These findings indicate that patients with OSA and comorbid insomnia encounter unique challenges. A dimensional approach to assessment and treatment is proposed for future research.

The Relationship Between Beliefs About Sleep and Adherence to Behavioral Treatment Combined With Meditation for Insomnia

This study examined beliefs about sleep, as measured by the Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scale, as predictors of adherence to 3 specific insomnia treatment recommendations: restriction of time spent in bed, maintenance of a consistent rise time, and completion of daily meditation practice. Higher DBAS scores predicted poorer adherence to restriction of time spent in bed and to maintenance of a prescribed rise time. DBAS scores were not associated with completion of daily meditation. These preliminary findings suggest that pre-treatment beliefs about sleep may impact patient engagement with behavioral recommendations regarding time in bed and consistent rise time during treatment for insomnia.

Pediatric headache: an examination of process variables in treatment.

The goal of this article is to provide a rational methodological review of studies addressing the treatment of childhood headache. In particular, the goal is to provide a review of process variables that may be associated with the efficacy of behavioral and psychological treatments for childhood headache. A search for studies that examined the efficacy of treatment for headache among children younger than 12 years of age was conducted using Medline from 1966 to 2005. A total of 9 studies were selected for the present systematic review. The findings from this study suggest that although research supports the use of behavioral treatments for headache among this patient population, process variables such as child demographics, as well as treatment characteristics such as time in treatment, may moderate treatment efficacy.