Kathryn I. Pollak

Primary care: is there enough time for prevention?

OBJECTIVES We sought to determine the amount of time required for a primary care physician to provide recommended preventive services to an average patient panel. METHODS We used published and estimated times per service to determine the physician time required to provide all services recommended by the US Preventive Services Task Force (USPSTF), at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population. RESULTS To fully satisfy the USPSTF recommendations, 1773 hours of a physicians annual time, or 7.4 hours per working day, is needed for the provision of preventive services. CONCLUSIONS Time constraints limit the ability of physicians to comply with preventive services recommendations.

Hypertension Improvement Project. Randomized Trial of Quality Improvement for Physicians and Lifestyle Modification for Patients

Despite widely publicized hypertension treatment guidelines for physicians and lifestyle recommendations for patients, blood pressure control rates remain low. In community-based primary care clinics, we performed a nested, 2×2 randomized, controlled trial of physician intervention versus control and/or patient intervention versus control. Physician intervention included internet-based training, self-monitoring, and quarterly feedback reports. Patient intervention included 20 weekly group sessions followed by 12 monthly telephone counseling contacts and focused on weight loss, Dietary Approaches to Stop Hypertension dietary pattern, exercise, and reduced sodium intake. The primary outcome was change in systolic blood pressure at 6 months. Eight primary care practices (32 physicians) were randomized to physician intervention or control groups. Within those practices, 574 patients were randomized to patient intervention or control groups. Patient mean age was 60 years, 61% were women, and 37% were black. Blood pressure data were available for 91% of patients at 6 months. The main effect of physician intervention on systolic blood pressure at 6 months, adjusted for baseline pressure, was 0.3 mm Hg (95% CI: −1.5 to 2.2; P=0.72). The main effect of the patient intervention was −2.6 mm Hg (95% CI: −4.4 to −0.7; P=0.01). The interaction of the 2 interventions was significant (P=0.03); the largest impact was observed with the combination of physician and patient intervention (−9.7±12.7 mm Hg). Differences between treatment groups did not persist at 18 months. Combined physician and patient interventions lowers blood pressure; future research should focus on enhancing effectiveness and sustainability of these interventions.

Physician Empathy and Listening: Associations with Patient Satisfaction and Autonomy

Purpose: Motivational Interviewing (MI) is used to help patients change their behaviors. We sought to determine if physician use of specific MI techniques increases patient satisfaction with the physician and perceived autonomy. Methods: We audio-recorded preventive and chronic care encounters between 40 primary care physicians and 320 of their overweight or obese patients. We coded use of MI techniques (eg, empathy, reflective listening). We assessed patient satisfaction and how much the patient felt the physician supported him or her to change. Generalized estimating equation models with logit links were used to examine associations between MI techniques and patient perceived autonomy and satisfaction. Results: Patients whose physicians were rated as more empathic had higher rates of high satisfaction than patients whose physicians were less empathic (29% vs 11%; P = .004). Patients whose physicians made any reflective statements had higher rates of high autonomy support than those whose physicians did not (46% vs 30%; P = .006). Conclusions: When physicians used reflective statements, patients were more likely to perceive high autonomy support. When physicians were empathic, patients were more likely to report high satisfaction with the physician. These results suggest that physician training in MI techniques could potentially improve patient perceptions and outcomes.

Patient–oncologist communication in advanced cancer: predictors of patient perception of prognosis

Goals of workAdvanced cancer patients’ perceptions of prognosis, which are often overly optimistic compared to oncologist estimates, influence treatment preferences. The predictors of patients’ perceptions and the effect of oncologist communication on patient understanding are unclear. This study was designed to identify the communication factors that influence patient–oncologist concordance about chance of cure.Materials and methodsWe analyzed audiorecorded encounters between 51 oncologists and 141 advanced cancer patients with good (n = 69) or poor (n = 72) concordance about chance of cure. Encounters were coded for communication factors that might influence oncologist–patient concordance, including oncologist statements of optimism and pessimism.Main resultsOncologists made more statements of optimism (mean = 3.3 per encounter) than statements of pessimism (mean = 1.2 per encounter). When oncologists made at least one statement of pessimism, patients were more likely to agree with their oncologist’s estimated chance of cure (OR = 2.59, 95%CI = 1.31–5.12). Statements of optimism and uncertainty were not associated with an increased likelihood that patients would agree or disagree with their oncologists about chance of cure.ConclusionsCommunication of pessimistic information to patients with advanced cancer increases the likelihood that patients will report concordant prognostic estimates. Communication of optimistic information does not have any direct effect. The best communication strategy to maximize patient knowledge for informed decision making while remaining sensitive to patients’ emotional needs may be to emphasize optimistic aspects of prognosis while also consciously and clearly communicating pessimistic aspects of prognosis.

Project PREVENT: A Randomized Trial to Reduce Multiple Behavioral Risk Factors for Colon Cancer

Background: This report examines the outcome data for Project PREVENT, a two-site randomized control trial designed to reduce behavioral risk factors for colorectal cancer among individuals who have been diagnosed with adenomatous colon polyps. Methods: The study sample included 1,247 patients with recent diagnosis of adenomatous colorectal polyps. Within 4 weeks following the polypectomy, participants completed a baseline survey by telephone, and were randomized to either Usual Care (UC) or the PREVENT intervention, which was designed to target multiple risk factors. The intervention consisted of a telephone-delivered intervention plus tailored materials, and focused on the six primary behavioral risk factors for colorectal cancer, including red meat consumption, fruit and vegetable intake, multivitamin intake, alcohol, smoking, and physical inactivity. Results: Participation in the PREVENT intervention was associated with a significantly greater reduction in prevalence of multiple risk factors for colorectal cancer compared with UC. Only about one third of UC participants dropped any risk factors during the study period, compared with almost half of the PREVENT participants. PREVENT participants were also significantly more likely to change more than one behavior than UC participants. Conclusions: The PREVENT intervention was effective in helping patients change multiple risk factors. These results provide further support that more comprehensive interventions that move beyond emphasis on a single risk factor are acceptable to patient populations, can result in improvements, and are cost effective.

Sexuality Talk During Adolescent Health Maintenance Visits

IMPORTANCE Physicians may be important sources of sexuality information and preventive services, and one-on-one confidential time during health maintenance visits is recommended to allow discussions of sexual development, behavior, and risk reduction. However, little is known about the occurrence and characteristics of physician-adolescent discussions about sexuality. OBJECTIVE To examine predictors of time spent discussing sexuality, level of adolescent participation, and physician and patient characteristics associated with sexuality discussions during health maintenance visits by early and middle adolescents. DESIGN, SETTING, AND PARTICIPANTS Observational study of audio-recorded conversations between 253 adolescents (mean age, 14.3 years; 53% female; 40% white; 47% African American) and 49 physicians (82% pediatricians; 84% white; 65% female; mean age, 40.9 years; mean [SD] duration in practice, 11.8 [8.7] years) coded for sexuality content at 11 clinics (3 academic and 8 community-based practices) located throughout the Raleigh/Durham, North Carolina, area. MAIN OUTCOMES AND MEASURES Total time per visit during which sexuality issues were discussed. RESULTS One hundred sixty-five (65%) of all visits had some sexual content within it. The average time of sexuality talk was 36 seconds (35% 0 seconds; 30% 1-35 seconds; and 35% ≥ 36 seconds). Ordinal logistic regression (outcome of duration: 0, 1-35, or ≥ 36 seconds), adjusted for clustering of patients within physicians, found that female patients (odds ratio [OR] = 2.58; 95% CI, 1.53-4.36), older patients (OR = 1.37; 95% CI, 1.13-1.65), conversations with explicit confidentiality discussions (OR = 4.33; 95% CI, 2.58-7.28), African American adolescents (OR = 1.58; 95% CI, 1.01-2.48), and longer overall visit (OR = 1.07; 95% CI, 1.03-1.11) were associated with more sexuality talk, and Asian physicians were associated with less sexuality talk (OR = 0.13; 95% CI, 0.08-0.20). In addition, the same significant associations between adolescent, physician, and visit characteristics were significantly associated with greater adolescent participation. CONCLUSIONS AND RELEVANCE Our study may be the first to directly observe sexuality talk between physicians and adolescents. We found that one-third of all adolescents had annual visits without any mention of sexuality issues; when sexuality talk occurred, it was brief. Research is needed to identify successful strategies physicians can use to engage adolescents in discussions about sexuality to help promote healthy sexual development and decision making. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01040975.

What concerns me is... Expression of emotion by advanced cancer patients during outpatient visits.

ObjectiveCancer patients have high levels of distress, yet oncologists often do not recognize patients’ concerns. We sought to describe how patients with advanced cancer verbally express negative emotion to their oncologists.Materials and methodsAs part of the Studying Communication in Oncologist–Patient Encounters Trial, we audio-recorded 415 visits that 281 patients with advanced cancer made to their oncologists at three US cancer centers. Using qualitative methodology, we coded for verbal expressions of negative emotion, identified words patients used to express emotion, and categorized emotions by type and content.ResultsPatients verbally expressed negative emotion in 17% of the visits. The most commonly used words were: “concern,” “scared,” “worried,” “depressed,” and “nervous.” Types of emotion expressed were: anxiety (46%), fear (25%), depression (12%), anger (9%), and other (8%). Topics about which emotion was expressed were: symptoms and functional concerns (66%), medical diagnoses and treatments (54%), social issues (14%), and the health care system (9%). Although all patients had terminal cancer, they expressed negative emotion overtly related to death and dying only 2% of the time.ConclusionsPatients infrequently expressed negative emotion to their oncologists. When they did, they typically expressed anxiety and fear, indicating concern about the future. When patients use emotionally expressive words such as those we described, oncologists should respond empathically, allowing patients to express their distress and concerns more fully.

How Oncologists and Their Patients with Advanced Cancer Communicate about Health-Related Quality of Life

Objective: To describe the content and frequency of communication about health‐related quality of life (HRQOL) during outpatient encounters between oncologists and their patients with advanced cancer.

Adherence to nicotine replacement therapy among pregnant smokers.

INTRODUCTION This secondary analysis examined the association between adherence to nicotine replacement therapy (NRT) and smoking cessation among pregnant smokers enrolled in Baby Steps, an open-label randomized controlled trial testing cognitive-behavioral therapy (CBT) versus CBT plus NRT. METHOD The analysis included only women who received NRT for whom we had complete data (N = 104). Data came from daily calendars created from recordings of counseling sessions and from telephone surveys at baseline and 38 weeks gestation. RESULTS Overall, 29% of the 104 women used NRT for the recommended 6 weeks and 41% used NRT as directed in the first 48 hr after a quit attempt. Ordinal logistic regression modeling indicated that using NRT as directed in the first 48 hr and having made a previous quit attempt were the strongest predictors of longer NRT use. Univariate analyses suggested that primigravid women and women who used NRT longer were more likely to report quitting at 38 weeks gestation. DISCUSSION Findings indicated that adherence to NRT is low among pregnant smokers, but adherence was a predictor of cessation. Future trials should emphasize adherence, particularly more days on NRT, to promote cessation during pregnancy.

Studying communication in oncologist-patient encounters: The SCOPE Trial

Study objective: Most oncologists have not received adequate training in physician-patient communication, and existing effective courses tend to be time and resource intensive. We are developing and testing a tailored CD-ROM educational intervention that includes feedback on oncologists’ own audio-recorded conversations with their advanced cancer patients. In this report, we describe the study methods and identify challenges to implementation and how these were overcome. Study design: A three-phase, randomized, controlled trial. In Phase 1, we audio-recorded oncologist-patient clinic encounters. In Phase 2, oncologists were randomly assigned to a communication CD-ROM intervention or control. Phase 3 consisted of audio-recording all participating oncologists conversing with a new sample of patients, two to 12 months after the intervention, to assess its effectiveness. Setting: Oncology clinics at Duke University Medical Center (DUMC) and the Durham Veterans Affairs Medical Center (DVAMC) in Durham, NC, and the University of Pittsburgh Medical Center (UPMC) in Pittsburgh, PA. Participants: Medical, radiation and gynecological oncologists and their patients with advanced cancer. Intervention: A tailored CD-ROM that contains an interactive educational interface with reference materials and video-clips of model conversations, along with the oncologists’ own Phase 1 audio-recorded conversations. Conclusion: We present challenges and solutions to oncologist recruitment, identifying appropriate patients with advanced cancer, adapting to clinic flow, and developing a self-administered communications intervention.