Rita Gorawara-Bhat

Self-Reported Goals of Older Patients with Type 2 Diabetes Mellitus

Objectives: New diabetes mellitus guidelines from the American Geriatrics Society promote the individualization of treatment goals and plans for patients aged 65 and older. Communicating with older patients about such complex medical decisions presents new challenges for providers. The self‐reported healthcare goals, factors influencing these goals, and self‐care practices of older patients with diabetes mellitus were explored.

Barriers and Facilitators to Shared Decision-making Among African-Americans with Diabetes

ABSTRACTINTRODUCTIONShared decision-making (SDM) between patients and their physicians is associated with improved diabetes health outcomes. African-Americans have less SDM than Whites, which may contribute to diabetes racial disparities. To date, there has been little research on SDM among African-Americans.OBJECTIVEWe explored the barriers and facilitators to SDM among African-Americans with diabetes.METHODSQualitative research design with a phenomenological methodology using in-depth interviews (n = 24) and five focus groups (n = 27). Each interview/focus group was audio-taped and transcribed verbatim, and coding was conducted using an iterative process. Participants: We utilized a purposeful sample of African-American adult patients with diabetes. All patients had insurance and received their care at an academic medical center.RESULTSPatients identified multiple SDM barriers/facilitators, including the patient/provider power imbalance that was perceived to be exacerbated by race. Patient-related factors included health literacy, fear/denial, family experiences and self-efficacy. Reported physician-related barriers/facilitators include patient education, validating patient experiences, medical knowledge, accessibility and availability, and interpersonal skills.DISCUSSIONBarriers/facilitators of SDM exist among African-Americans with diabetes, which can be effectively addressed in the outpatient setting. Primary care physicians, particularly academic internists, may be uniquely situated to address these barriers/facilitators and train future physicians to do so as well.

Fecal bacteriotherapy for ulcerative colitis: patients are ready, are we?

Background: Fecal bacteriotherapy (FB) has been proposed as a safe and effective alternative treatment for a number of gastrointestinal conditions including ulcerative colitis (UC). We performed a qualitative study to explore the attitudes and concerns of adult patients and parents of children with UC regarding FB as a potential treatment. Methods: We conducted six focus groups for adult patients with UC and parents of children with UC or indeterminate colitis. Participants were asked about their perceptions of and interest in FB as a treatment for UC. Sessions were recorded, transcribed, and reviewed to identify domains, themes, and major concepts. Results: The focus groups included 15 adult patients and seven parents of children with colitis. We identified five major domains pertaining to FB: impressions of treatment, benefits, risks, potential mechanisms, and social concerns. All but one participant expressed interest in FB and several wished it were already available. Participants compared FB to probiotics, felt it was “natural,” easier than current therapies, and with donor screening would be safe. Although initial distaste and the “yuck factor” were uniformly mentioned, these concerns were outweighed by perceived benefits. Conclusion: This is the first study to examine important ethical and social issues surrounding FB as a treatment for UC. Given adequate supporting research, donor selection, and screening, adult patients and parents of children with UC will consider FB and are eager for it to become available. These findings have important implications for future microbiome‐based treatments. (Inflamm Bowel Dis 2011;)

How are religion and spirituality related to health? A study of physicians' perspectives.

Background: Despite expansive medical literature regarding spirituality and medicine, little is known about physician beliefs regarding the influence of religion on health. Methods: Semistructured interviews with 21 physicians regarding the intersection of religion, spirituality, and medicine. Interviews were transcribed, coded, and analyzed for emergent themes through an iterative process of qualitative textual analysis. Results: All participants believed religion influences health, but they did not emphasize the influence of religion on outcomes. Instead, they focused on ways that religion provides a paradigm for understanding and making decisions related to illness and a community in which illness is experienced. Religion was described as beneficial when it enables patients to cope with illness but harmful when it leads to psychological conflict or conflict with medical recommendations. Conclusions: Empirical evidence for a “faith-health connection” may have little influence on physicians’ conceptions of and approaches to religion in the patient encounter.

Community and Family Perspectives on Addressing Overweight in Urban, African-American Youth

ObjectiveTo assess weight-related beliefs and concerns of overweight urban, African-American children, their parents, and community leaders before developing a family-based intervention to reduce childhood overweight and diabetes risk.DesignWe conducted 13 focus groups with overweight children and their parents and eight semistructured interviews with community leaders.Participants and SettingFocus group participants (N = 67) from Chicago’s South Side were recruited through flyers in community sites. Interview participants (N = 9) were recruited to sample perspectives from health, fitness, education, civics, and faith leaders.ResultsCommunity leaders felt awareness was higher for acute health conditions than for obesity. Parents were concerned about their children’s health, but felt stressed by competing priorities and constrained by lack of knowledge, parenting skills, time, and financial resources. Parents defined overweight in functional terms, whereas children relied upon physical appearances. Children perceived negative social consequences of overweight. Parents and children expressed interest in family-based interventions to improve nutrition and physical activity and offered suggestions for making programs interesting.ConclusionsThis study provides insights into the perspectives of urban, African-American overweight children, their parents, and community leaders regarding nutrition and physical activity. The specific beliefs of these respondents can become potential leverage points in interventions.

Racism in healthcare: Its relationship to shared decision-making and health disparities: A response to Bradby

Bradby’s (2010) critique of our paper ‘Race and Shared Decision-Making: Perspectives of African-Americans with Diabetes’ (Peek at al., 2010) highlights important questions about racism, patient/provider communication and U.S. health disparities. We address her concerns through the following questions: 1) How can we best conceptualize racism in healthcare? 2) Is there evidence for racism in the current U.S. healthcare system?, 3) How can we disentangle racial discrimination from discrimination based on other social factors?, 4) Is there evidence and/or theoretical model(s) that link institutional racism to population-level health disparities?, 5) Is there evidence and/or theoretical model(s) that link the patient/provider relationship and communication disparities to population-level health disparities?, and 6) Are there potentially effective solutions to address institutional racism, particularly unconscious provider bias?

Palliative Access Through Care at Home: experiences with an urban, geriatric home palliative care program.

The aging of the U.S. population has resulted in a large number of persons with multiple, chronic illnesses and gradual functional decline. Many older adults with these conditions are homebound and have great difficulty accessing medical care. They are also more likely to suffer from unaddressed symptoms and end‐of‐life care needs. Certain groups, such as African‐American patients and patients with dementia, are even less likely to access palliative care and hospice services. Although the informal caregivers attending to such persons may become overwhelmed without adequate support, palliative care, which covers a broad population, is an optimal way to address many of these needs. This article describes a unique, urban, home‐based geriatrics palliative care program (Palliative Access Through Care at Home (PATCH)) designed to address some of these unmet needs. After 1 year of providing service, a mixed‐methods study consisting of chart review, telephone interviews, and face‐to‐face interviews was conducted to assess caregiver expectations of and satisfaction with the program. Caregivers for the elderly, mostly African‐American patients, more than half of whom had dementia, were overall very satisfied with their experience, despite the large amount of time necessary to provide the care that patients required. Themes extracted during qualitative analysis were the desire to remain at home, the need for easy access to a practitioner specializing in geriatrics and palliative medicine, and the challenges of transitions of care. PATCH was able to address many of these needs and provide high levels of caregiver satisfaction.

Perceptions, attitudes, and experiences of hematology/oncology fellows toward incorporating geriatrics in their training

The aging of the U.S. population continues to highlight emerging issues in providing care generally for older adults and specifically for older adults with cancer. The majority of patients with cancer in the U.S. are currently 65 years of age or older; therefore, training and research in geriatrics and geriatric oncology are viewed to be integral in meeting the needs of this vulnerable population. Yet, the ways to develop and integrate best geriatrics training within the context of hematology/oncology fellowship remain unclear. Toward this end, the current study seeks to evaluate the prior and current geriatric experiences and perspectives of hematology/oncology fellows. To gain insight into these experiences, focus groups of hematology/oncology fellows were conducted. Emergent themes included: 1) perceived lack of formal geriatric oncology didactics among fellows; 2) a considerable amount of variability exists in pre-fellowship geriatric experiences; 3) shared desire to participate in a geriatric oncology-based clinic; 4) differences across training levels in confidence in managing older adults with cancer; and 5) identification of specific criteria on how best to approach older adults with cancer in a particular clinical scenario. The present findings will help guide future studies in evaluating geriatrics among hematology/oncology fellows across institutions. They will also have implications in the development of geriatrics curricula and competencies specific to hematology/oncology training.

“One Can Learn From Other People’s Experiences” Latino Adults’ Preferences for Peer-Based Diabetes Interventions

Purpose To assess Latino adults’ preferences for peer-based diabetes self-management interventions and the acceptability of the church setting for these interventions. Methods The authors partnered with 2 predominantly Mexican American churches in Chicago and conducted 6 focus groups with 37 adults who had diabetes or had a family member with diabetes. They assessed participant preferences regarding group education and telephone-based one-to-one peer diabetes self-management interventions. Systematic qualitative methods were used to identify the types of programming preferred by participants in the church setting. Results Participants had a mean (SD) age of 53 (11) years. All participants were Latino, and more than half were born in Mexico (60%). Most participants were female (78%), had finished high school (65%), and had health insurance (57%). Sixty-five percent reported having a diagnosis of diabetes. Many participants believed the group-based and telephone-based one-to-one peer support programs could provide opportunities to share diabetes knowledge. Yet, the majority stated the group education model would offer more opportunity for social interaction and access to people with a range of diabetes experience. Participants noted many concerns regarding the one-to-one intervention, mostly involving the impersonal nature of telephone calls and the inability to form a trusting bond with the telephone partner. However, the telephone-based intervention could be a supplement to the group educational sessions. Participants also stated the church would be a familiar and trusted setting for peer-based diabetes interventions. Conclusions Church-based Latinos with diabetes and their family members were interested in peer-based diabetes self-management interventions; however, they preferred group-based to telephone-based one-to-one peer programs.

Practical Challenges of Individualizing Diabetes Care in Older Patients

i over the age of 65 represent over 40% of patients with type 2 diabetes. Despite their large numbers, how to best care for this group is uncertain because longitudinal trials of various aspects of diabetes care have not routinely included patients over age 65. In addition to the lack of available trial data, treatment decisions are oftentimes more difficult for older patients because of their clinical heterogeneity. For some older diabetes patients who are relatively healthy and functionally independent, the treatment goals developed for the general population may be appropriate because they are likely to benefit from the preventive therapies for diabetes. In contrast, older diabetes patients who have relatively short life expectancies resulting from significant comorbid conditions may not benefit from standard population goals and may find diabetes-related therapies burdensome.