K. Allen Greiner

Knowledge, Attitudes, and Beliefs about End-of-life Care among Inner-City African Americans and Latinos

OBJECTIVE This project explored end-of-life care preferences and barriers among low-income, urban African Americans and Latino/Hispanic Americans (Latinos) to uncover factors that may influence hospice utilization. METHODS Focus groups were conducted separately for African Americans (4 groups, n = 26) and Latinos (4 groups, n = 27). Transcripts were coded and analyzed using consensus and triangulation to identify primary themes. RESULTS Four preference themes and four barriers were identified. Results were largely similar across the two groups. Both preferred having families provide care for loved ones but expressed desire to reduce caretaker burden. Groups emphasized spirituality as the primary means of coping and valued the holistic well-being of the patient and family. Barriers reported were closely tied to access to care. Participants reported low hospice utilization because of lack of awareness of hospice and the prohibitive cost of health care. Latinos were more likely to report language barriers, while African Americans were more likely to report mistrust of the system. CONCLUSIONS African Americans and Latinos in this study were highly receptive to end-of-life care that would provide relief for patients and caregivers and emphasize spirituality and family consensus. Improving awareness of hospice services would likely increase utilization.

Hospice Usage by Minorities in the Last Year of Life: Results from the National Mortality Followback Survey

OBJECTIVES: To examine racial/ethnic variations in rates of hospice use in a national cohort and to identify individual characteristics associated with hospice use.

Using Focus Groups in Community-Based Participatory Research: Challenges and Resolutions

A community-based participatory approach requires that community members be involved in all phases of the research process. We describe three focus group studies with American Indians in Kansas and Missouri, using a newly developed method of conducting and analyzing focus groups with community input (72 focus groups, 519 participants). We conducted two needs assessment studies focused on barriers to breast and colorectal cancer screening and one study focused on Internet use for gathering health information. Community members and researchers collaborated to develop guides for the focus group moderators. Community organizations and our community advisory board conducted recruitment, and we trained and employed community members as moderators, assistant moderators, and analysts. Our community partners also helped with dissemination of research findings to their constituents. The methodologic approach and data from these three studies will allow us to more appropriately address health disparities in the American Indian community, with full community support for our research.

Weight‐Related Perceptions Among Patients and Physicians: How Well do Physicians Judge Patients' Motivation to Lose Weight?

AbstractBACKGROUND: Prior studies suggest that patients and physicians have different perceptions and expectations surrounding weight; however, few studies have directly compared patients’ and physicians’ perspectives. OBJECTIVES: (1) To measure the extent to which obese patients and their physicians have discrepant weight-related perceptions, and (2) to explore patient and physician characteristics that may influence patient-physician discrepancy in motivation to lose weight. DESIGN AND PARTICIPANTS: Four hundred and fifty-six obese patients (302 females; mean age =55.1 years; mean BMI =37.9) and their 28 primary care physicians (22 males, mean age =44.1 years) from nonmetropolitan practices completed an anonymous survey after an office visit. MEASURES: Weight-related perceptions included perceived weight status, health impact of weight, 1-year weight loss expectations, and motivation to lose weight. Correlates included patient and physician sex, age, and BMI; physicians’ reported frequency, perceived patient preference, and confidence for weight counseling; and practice characteristics (e.g., years in practice). RESULTS: Physicians assigned patients to heavier descriptive weight categories and reported a worse health impact than patients perceived for themselves, whereas patients believed they could lose more weight and reported a higher motivation to lose weight than their physicians perceived for patients (P <.001). Physicians who believed patients preferred to discuss weight more often (P=.001) and who saw more patients per week (P=.04) were less likely to underestimate patient motivation. CONCLUSIONS: Patients reported more optimistic weight-related perceptions and expectations than their physicians. Further research is needed to determine how these patient-physician discrepancies may influence weight loss counseling in primary care.

Effect of varying levels of disease management on smoking cessation: a randomized trial.

Context Smoking cessation is difficult and may require repeated or intensive interventions. Contribution In this multicenter trial, 750 primary care patients who smoked at least 10 cigarettes per day were randomly assigned to pharmacotherapy (nicotine patch or bupropion), pharmacotherapy supplemented with up to 2 calls from trained counselors, or pharmacotherapy supplemented with up to 6 counseling calls. Utilization of the interventions, which were offered every 6 months for 2 years, declined over time. Smoking abstinence rates at 2 years were 23%, 24%, and 28% in the 3 groups. Caution Pharmacotherapy was free. Smoking abstinence was self-reported. The Editors Cigarette smoking is a chronic illness characterized by repeated cycles of quit attempts and relapse. Most models for addressing smoking cessation are based on single, short-term interventions lasting only a few weeks or months (1). Although most smokers will not quit after a single intervention, few studies have addressed the chronic nature of nicotine dependence by providing systematic, repetitive treatment opportunities (1). Providing treatment only to smokers who are already prepared to quit further limits the reach of current smoking cessation interventions (2). New models of chronic disease care might provide an alternative approach for expanding the reach and effectiveness of smoking cessation efforts (3). Physicians are in direct contact with approximately 70% of smokers each year (4, 5). Their potential role in promoting smoking cessation has been well delineated and incorporated into current clinical practice guidelines (1). With the development of new, more effective prescription pharmacotherapy for smoking cessation, the role of primary care practices in promoting smoking cessation is now more important than ever. Unfortunately, only half of the smokers who see their physicians are asked about their smoking (6), and even fewer receive advice from their health care provider to quit or receive pharmacotherapy or follow-up (4, 7). Smoking cessation counseling competes with other pressing clinical tasks, and beyond brief advice, many physicians feel they are too busy to routinely and repeatedly counsel participants who smoke (810). To assist primary care physicians in the treatment of rural smokers, we developed KanQuit, a smoking cessation program based on the chronic care model (4), which integrates principles of disease management into the treatment of smokers seen in rural primary care. Our objective was to enroll smokers, regardless of their willingness to quit, into a disease registry and compare cessation rates among smokers who received pharmacotherapy alone or combined with either moderate-intensity or high-intensity disease management that includes counseling and provider feedback. Methods Design Overview We did a randomized, single-blind trial of varying levels of disease management for smoking cessation. We recruited participants who smoked more than 10 cigarettes per day from rural primary care clinics across Kansas and randomly assigned them to receive pharmacotherapy alone, pharmacotherapy supplemented by 1 to 2 counseling calls every 6 months (moderate-intensity disease management), or pharmacotherapy supplemented by up to 6 counseling calls every 6 months (high-intensity disease management). For recipients of moderate-intensity and high-intensity disease management, we faxed periodic progress reports to their physician. We offered all participants free pharmacotherapy (either bupropion or transdermal nicotine patch) every 6 months. We enrolled participants from June 2004 to October 2005 and followed them for 24 months, completing follow-up in December 2007. All participants provided written informed consent. The University of Kansas Medical Centers Human Subjects Committee approved the study. Setting and Participants We conducted our study in 50 rural primary care practices in the Kansas Physicians Engaged in Prevention Research network (11). As part of a rural primary care research experience, trained medical students systematically screened participants, identified smokers, and recruited them for this study, regardless of their interest in quitting (12). We considered smokers eligible if they had a primary care physician who participated in this study; were older than 18 years; smoked more than 10 cigarettes per day for at least 1 year and for at least 25 of the past 30 days; spoke English; and had a telephone. We excluded smokers if they were pregnant or planned to become pregnant, planned to move out of the study area, had signs of dementia or mental illness that would preclude participation, or lived with a smoker already enrolled in the study. Of the 1827 smokers we screened, 61% met criteria for study entry (Figure 1). Of these, we enrolled 67%. Figure 1. Study flow diagram. HDM = high-intensity disease management; MDM = moderate-intensity disease management; PM = pharmacotherapy management. Randomization and Interventions Participant Randomization Randomization occurred at the participant level. A computer-generated random-number table was used to generate allocation cards in blocks of 24, with allocation equally distributed across treatment groups. To conceal allocation, we placed these cards in sequentially numbered, opaque, sealed envelopes. After research assistants verified participant eligibility and completed the baseline assessment, the project director opened the next sequential sealed envelope and determined the participants treatment allocation. One of 9 counselors trained in smoking cessation and motivational interviewing (12) conducted all interventions from a single central site. We assigned participants to counselors without regard to practice site. Pharmacotherapy At baseline, all smokers received a health education mailing that consisted of a welcome letter, information about the use of bupropion and the nicotine patch for smoking cessation, and copies of You Can Quit Smoking: Consumer Guide (13) and When Smokers QuitThe Health Benefits Over Time (14). At baseline and at 6, 12, and 18 months, participants received a mailed offer for free pharmacotherapy that consisted of either a 6-week course of a nicotine patch (21 mg/d) or a 7-week course of sustained-release bupropion (150 mg twice daily). Participants interested in using either medication could return a postage-paid postcard or call a toll-free number. We screened all participants who requested pharmacotherapy for potential contraindications (15). Participants with absolute contraindications for a given drug were ineligible to receive that drug but were offered the option of receiving the other drug. Participants with contraindications to both drugs were not eligible to receive medication from the study but could participate in all other aspects of the intervention. For participants who requested bupropion and those with relative contraindications to the nicotine patch, research staff faxed a prescription request to their primary care physicians. This prescription request delineated any relative contraindications or potential drug interactions. For these participants, their physicians made the final assessment of the appropriateness of the bupropion or the patch. For participants without contraindications to the nicotine patch or on receipt of a faxed, signed prescription, the bupropion or patches were mailed to the participant along with instructions for use. Disease Management In addition to pharmacotherapy, the moderate-intensity and high-intensity disease management groups received educational support, telephone counseling, and periodic progress reports with counseling suggestions faxed to their physician. Every 6 months, they received a KanQuit newsletter that addressed tips on quitting smoking, talking with their physician about smoking, and using pharmacotherapy for cessation. The newsletters were personalized to include study updates, counselor photographs, physician feature stories, and testimonials of participants who had quit smoking. We offered participants assigned to moderate-intensity disease management up to 2 telephone-based counseling sessions every 6 months (1 session to promote a quit attempt and 1 additional follow-up session for those who made a quit attempt). We offered participants assigned to high-intensity disease management up to 6 counseling calls every 6 months to either promote quitting or prevent relapse. We scheduled calls at the participants convenience, and they varied according to the participants quit plan but followed a rough schedule of calls at 1, 3, 6, 9, and 16 weeks after the onset of each 6-month treatment cycle. Counselors used motivational interviewing techniques and followed a semistructured protocol to promote a cessation attempt or, for abstinent smokers, to encourage relapse prevention. During counseling calls, case managers reminded participants about the availability of pharmacotherapy and, for interested participants, provided immediate support for acquiring either the nicotine patch or bupropion, as described previously. We faxed personalized progress reports with suggestions for interventions to the participants physician after the first counseling call (both moderate-intensity and high-intensity disease management participants) and after the last counseling call (high-intensity disease management participants only) during each 6-month cycle. We faxed additional progress reports to the participants physician whenever the moderate-intensity or high-intensity disease management participant set a quit date. Outcomes, Measurements, and Follow-up Research assistants who were blinded to treatment group assignment conducted assessments by telephone at baseline and at 6, 12, 18, and 24 months. Primary Outcome The primary outcome measure was self-reported 7-day abstinence at 24 months, defined as not having smoked a cigarette during the previous 7 days. Although self-reported abstinence has been co

Discussing Weight with Obese Primary Care Patients: Physician and Patient Perceptions

AbstractsObjectiveTo evaluate patient–provider agreement on whether weight and related behaviors were discussed during routine visits.DesignPost-visit survey assessments of patients and providers.ParticipantsObese patients make up the majority of all patients seen in primary care (PC). The patients and physicians were recruited at the time of PC visits.Measurements and Main ResultsPercent patient–physician agreement and patient, provider and practice characteristics associated with agreement. Patients (456) and physicians (30) agreed about whether or not they discussed weight, physical activity (PA), and diet for 61% of office visits. There was disagreement on one of the items (weight, PA, or diet) for 23% of office visits, and for 2 or more of the items for 16% of the visits. Agreement was relatively greater for discussing weight than for discussing diet or physical activity. Physicians reported discussing weight issues more often than did patients. Overall patient–physician agreement was 0.51–0.59 (weighted Kappa statistic). In a multivariate analyses of factors associated with patient–physician agreement, health insurance (odds ratio [OR]=3.67, p value = 0.002), physician description of patient weight status (OR = 2.27, p value = 0.002), patient report of how weight relates to health (OR = 1.70, p value = 0.04), and female patient gender (OR = 1.62, p = value = 0.02) were significantly related to agreement.ConclusionsPatients and providers disagreed about whether or not weight issues were discussed in a large number of primary care encounters in this study. Physicians may be able to improve care for their obese patients by focusing discussions on specific details of diet and physical activity behaviors, and by clarifying that patients perceive weight-related information has been shared.

Quality of diabetes care for adults with developmental disabilities

BACKGROUND Given that individuals with developmental disabilities have a history of difficulty accessing appropriate health care, possess numerous risk factors for diabetes, and frequently have unique needs within the health care setting, it is important to conduct surveillance research to determine the quality of their diabetes care. OBJECTIVE/HYPOTHESIS We assessed the quality of diabetes care for adults with developmental disabilities enrolled in Kansas Medicaid. Developmental disability was defined in accordance with Kansas Medicaid program eligibility and included individuals with intellectual disability, cerebral palsy, autism, and/or seizure disorder. METHODS We identified a retrospective cohort of persons with developmental disabilities who were also diabetic and continuously enrolled in Kansas Medicaid. We tracked their quality of care measures (Hb(A1c)/glucose testing, cholesterol testing, eye examinations, microalbuminaria screening, and primary care visits) across the subsequent 12 months. Quality care measures were evaluated in relation to basic demographic variables and comorbid hypertension using unconditional logistic regression. RESULTS Among 5,960 adults with developmental disability, 666 had diabetes (11.2%). Annual testing rates were Hb(A1c)/glucose testing, 51.7%; cholesterol, 44.3%; eye examinations, 29.3%; and microalbuminaria, 18.5%. Nearly all (93.5%) had contact with a primary care provider during the period. Comorbid hypertension was associated with higher rates of Hb(A1c), cholesterol testing, and primary care visits. Dual eligibility was associated with lower Hb(A1c)/glucose testing and cholesterol testing rates but comparable rates for other measures. Caucasians were more likely to have had an eye examination but less likely to have had their microalbumin checked. CONCLUSIONS Adults with developmental disabilities and diabetes who were enrolled in the Kansas Medicaid Program were screened at lower frequency than published national figures for key quality indicators of diabetes care. These results call for action to find approaches to improve their quality of care. Further work is needed to understand the barriers to appropriate care and incentives that will remedy these gaps. In addition, research is needed to determine the accuracy of diabetes identification, treatment, and monitoring of adults with developmental disabilities.

Understanding smoking cessation in rural communities.

CONTEXT Rural communities are adversely impacted by increased rates of tobacco use. Rural residents may be exposed to unique communal norms and other factors that influence smoking cessation. PURPOSE This study explored facilitating factors and barriers to cessation and the role of rural health care systems in the smoking-cessation process. METHODS Focus groups were conducted with smokers (N = 63) in 7 Midwestern rural communities. Qualitative analysis and thematic coding of transcripts was conducted. FINDINGS Three levels of pertinent themes--intrinsic, health-system resource, and community/social factors--were identified. Intrinsic factors facilitating cessation included willingness to try various cessation methods, beliefs about consequences of continuing smoking (eg, smoking-related illnesses), and benefits of quitting (eg, saving money). Intrinsic barriers included skepticism about resources, low self-efficacy and motivation for smoking cessation, concern about negative consequences of quitting (eg, weight gain), and perceived benefits of continued smoking (eg, enjoyment). Key health-system resource facilitators were pharmacotherapy use and physician visits. Resource barriers included infrequent physician visits, lack of medical/financial resources, limited local smoking-cessation programs, and lack of knowledge of existing resources. In terms of community/social factors, participants acknowledged the negative social impact/image of smoking, but also cited a lack of alternative activities, few public restrictions, stressors, and exposure to other smokers as barriers to cessation. CONCLUSIONS Smokers in rural communities face significant challenges that must be addressed. A multilevel model centered on improving access to health care system resources while addressing intrinsic and community/social factors might enhance smoking-cessation interventions and programs in rural communities.

Colorectal cancer screening, perceived discrimination, and low-income and trust in doctors: a survey of minority patients

BackgroundCompletion of colorectal cancer (CRC) screening testing is lower among low-income and minority groups than the population as a whole. Given the multiple cancer screening health disparities known to exist within the U.S., this study investigated the relationship between perceived discrimination, trust in most doctors, and completion of Fecal Occult Blood Testing (FOBT) among a low-income, minority primary care population in an urban setting.MethodsWe recruited a convenience sample of adults over age 40 (n = 282) from a federally qualified community health center (70% African American). Participants completed a survey which included measures of trust in most doctors, perceived discrimination, demographics and report of cancer screening.ResultsParticipants reported high levels of trust in most doctors, regardless of sex, race, education or income. High trust was associated with low perceived discrimination (p < 0.01). The trend was for older participants to express more trust (p = 0.09) and less perceived discrimination (p < 0.01). Neither trust nor discrimination was associated with race or education. Trust was higher among participants over 50 who were up-to-date on FOBT screening vs. those who were not (31 vs. 29 (median), p < 0.05 by T-test). Among those over 50, up-to-date FOBT screening was nearly associated with high trust (p < 0.06; 95% CI 0.99, 1.28) and low perceived discrimination (p < 0.01; 95% CI 0.76, 0.96). Nevertheless, in multivariate-modeling, age and income explained FOBT completion better than race, trust and discrimination.ConclusionPerceived discrimination was related to income, but not race, suggesting that discrimination is not unique to minorities, but common to those in poverty. Since trust in most doctors trended toward being related to age, FOBT screening could be negatively influenced by low trust and perceived discrimination in health care settings. A failure to address these issues in middle-aged, low income individuals could exacerbate future disparities in CRC screening.

Promoting Healthy Behavior from the Pulpit: Clergy Share Their Perspectives on Effective Health Communication in the African American Church

African Americans continue to suffer disproportionately from health disparities when compared to other ethnicities (ACS 2010; CDC 2007). Research indicates that the church and the pastor in the African American community could be enlisted to increase effectiveness of health programs (Campbell et al. in Health Edu Behav 34(6):864–880, 2007; DeHaven et al. in Am J Public Health 94(6):1030–1036, 2004). The objective of this study was to investigate African American pastors’ perceptions about health promotion in the church and how these perceptions could serve as a guide for improving health communication targeting African Americans. Semi-structured interviews with African American clergy revealed that pastors feel strongly about the intersection of health, religion and spirituality; they also believe that discussing health screening and other health issues more frequently from the pulpit and their own personal experiences will ultimately impact health behavior among congregants. This study suggests that African American clergy see themselves as health promoters in the church and believe this communication (i.e., pastor-endorsed health information materials) will impact health behavior among underserved and minority populations.