3G
ORAL ABSTRACTS: PATIENT-PROVIDER INTERACTION AND COMMUNICATION
Purpose: Patient honesty with healthcare providers is critical to quality patient care. If providers are not aware of their patients' unhealthy behaviors and concerning symptoms, then providers cannot address these issues, and may even make contraindicated recommendations. Thus, the purpose of this study is to examine the extent to which patients withhold information from their healthcare providers.
Methods: 2,010 people completed an online survey through MTurk, an online resource through Amazon.com that conducts online surveys with adult volunteers for a small monetary reward. The survey asked participants whether they ever avoided telling a healthcare provider any of 19 types of information (Table 1), and if so, the reasons for and conditions of the nondisclosure.
Results: Participants had a mean age of 36 (SD=12.4), 49% had completed college or more, 84% were White, and 60% were female. Across the 19 types of information, 2-46% of participants avoided sharing it with their healthcare provider (Table 1). Multiple regression revealed that females, younger participants, Whites, those with more education, and worse self-rated health were significantly more likely to have avoided sharing with their healthcare provider (p<.049 for all).
Conclusions: The results reveal that it is not uncommon for patients to withhold important information from their healthcare providers. A better understanding of how to make patients comfortable reporting this important, though potentially embarrassing, information is critical to improving the physician-patient relationship and patient care.
Table 1.
Type of information (in order of presentation)
| % who avoided telling healthcare provider the information
|
Didn't understand provider's instructions | 32%
|
Disagreed with provider's recommendation
| 46%
|
Didn't exercise
| 29%
|
Had unhealthy diet
| 25%
|
Took a certain medication
| 16%
|
Did not take prescription medications as instructed
| 23%
|
Took someone else's prescription medication
| 14%
|
Drank alcohol or how much drank
| 17%
|
Smoked or how much smoked
| 15%
|
Were depressed or how depressed
| 23%
|
Had an embarrassing symptom | 16%
|
Had unsafe sex or how much had unsafe sex
| 11%
|
Used recreational drugs or how much used recreational drugs
| 16%
|
Have been abused
| 7%
|
Have been sexually assaulted or raped
| 4%
|
Suicidality or severity of suicidality
| 10%
|
For participants with minor children (N=593):
|
|
Child had an unhealthy diet
| 5%
|
Child has a lot of “screen time”
| 11%
|
Did not use the recommended car seat
| 2%
|
Method: In both studies, college students were asked to take the role of a patient while reading a vignette in which a doctor attempted to diagnose their persistent cough. In Study 1 (N=203) the doctor in the vignette was either portrayed as an Arab or White male, using different surnames. Participants then evaluated the doctor and the visit. To measure their level of implicit bias against people of Arab descent, participants then completed an Implicit Association Test (IAT; Greenwald, Nosek, & Banaji, 2003). In Study 2 (N=61), the doctor was either portrayed as a White female or male. Participants then evaluated the doctor and the visit and completed a measure of their gender bias.
Result: In Study 1, participants who read about a physician with an Arab surname rated him as less thorough (p=.006), lower in physician quality (intelligence, diagnostic ability, and professionalism, alpha=.86, p=.023) and gave him a lower overall grade (p=.006) compared to participants who evaluated a White physician. Participants also expressed less trust in their Arab physician (p=.032), and marginally less satisfaction with his treatment (p=.087). The negative evaluations of the physician with an Arab surname were significantly predicted by participants’ implicit bias against people of Arab descent (p=.03).
In Study 2, relative to female participants, male participants rated the female physician as less thorough (p=.008), lower in physician quality (intelligence, diagnostic ability, and professionalism, alpha=.85, p=.016) and gave her a lower overall grade (p=.015) compared to the male physician. The negative evaluations of the female physician were significantly predicted by participants’ gender bias (p=.04).
Conclusion: A growing number of physicians in the U.S. are racial minorities and/or female. Due to patients’ preexisting biases, minority and female physicians may receive poorer evaluations that could negatively, and erroneously, impact their career and ability to effectively practice medicine.
To explore the effects of personalized prognostic information on physicians’ intentions to communicate prognosis to cancer patients at the end of life, and to identify situational and physician characteristics that moderate these effects.
Method:
A factorial experiment was conducted among a sample of 93 Family Medicine physicians affiliated with residency training programs in northern New England. Participants were presented with a hypothetical case vignette depicting an acutely ill, end-stage gastric cancer patient asking about his prognosis. Participants’ intentions to communicate prognostic information were assessed both before and after provision of an evidence-based, personalized prognostic estimate (78% mortality risk) from a hypothetical clinical prediction model. The emotional state of the hypothetical patient (distressed vs. non-distressed) and ambiguity in the prognostic estimate (ambiguous risk range vs. unambiguous point estimate) were varied between subjects. Other potential determinants of prognostic communication were measured: 1) perceived patient distress, 2) perceived credibility of prognostic models, 3) individual differences in physicians’ objective and subjective numeracy, and 4) individual differences in physicians’ aversion to ambiguity. General linear models were used to assess the effects of personalized prognostic information on the change in prognostic communication intentions, and to identify factors that moderate these effects and influence intentions to communicate available prognostic information.
Result:
Provision of personalized prognostic information significantly increased prognostic communication intentions (p<.001, η2=.39). There were no significant effects of the experimental factors (patient distress, prognostic ambiguity) on change in communication intentions. However, several variables moderated the effects of prognostic information. Greater change in prognostic communication intentions following provision of prognostic information was associated with lower perceptions of patient distress (p=.01, η2p=.08), greater objective numeracy (p=.03, η2p=.06), greater perceived credibility of prognostic models (p=.056, η2p=.045), and lower ambiguity aversion (p=.07, η2p=.04). Similarly, greater intentions to communicate personalized prognostic information were associated with greater subjective numeracy (β=.19, p=.005, η2=.10), lower ambiguity aversion (β=-.08, p=.008, η2=.08), and greater perceived credibility of prognostic models (β=.49, p=.02, η2=.06).
Conclusion:
The provision of personalized prognostic information increases physicians’ intentions to communicate prognosis to a hypothetical cancer patient at the end of life, and several situational and physician characteristics moderate this effect. More research is needed to confirm these findings in actual clinical practice, and to identify and reduce barriers to prognostic communication in end-of-life care.
Purpose: The role of physicians in the observed variability in end-of-life treatment decisions remains under debate. We investigated physician prognostic estimates and treatment recommendations in intracerebral hemorrhage (ICH), a particularly severe type of stroke where early limitations in life-sustaining treatments are common.
Methods: A written survey was mailed to 3727 practicing US neurologists and neurosurgeons consisting of two scenarios of moderate to severe ICH. Selected factors were randomly varied including patient characteristics (age, clinical severity) and presence (versus absence) of a validated prognostic score indicating probability of 90-day functional recovery. All patients were described as being functionally independent at baseline and having no explicit advance directives but a general preference to avoid long-term dependence on machines. Physicians were asked to indicate their predictions of 30-day mortality (free text write-in from 0-100%) and initial treatment recommendations (6-point ordinal scale from 1: comfort only to 6: full treatment, dichotomized as 1-3 vs. 4-6 for analysis). Multilevel marginal regression models were used to investigate predictors of physician-predicted mortality and treatment recommendations.
Results: A total of 816 physicians responded (response rate 22%), with complete data available for 742. Mean age was 52, 32% were neurosurgeons, and 17% were female. Physician predictions of 30-day mortality varied widely (Figure 1). Physician factors associated with mortality prediction included surgical specialty (p<0.001; surgeons more optimistic than non-surgeons), geographic region (p=0.02; West was most optimistic), and number of ICH cases seen in the prior year (p<0.01; 16+ cases more pessimistic than 1-15 cases). Other physician factors including age, race, sex, and personality characteristics (empathy, religious importance, optimism) were not associated with mortality predictions. Treatment recommendations also varied widely (Figure 2), though none of the investigated physician demographic or personality characteristics were associated with treatment recommendations. Providing the results from a validated prognostic score did alter physicians' overall treatment recommendations (p<0.001), though this effect was mostly seen in the younger, moderately severe case (odds ratio for predicting limited treatment 0.22, 95% CI 0.10, 0.50, p<0.001).
Conclusions: Physicians vary substantially in their prognostic estimates and treatment recommendations for ICH. Providing physicians with a formal prognostic score does change their treatment recommendations, though the impact of the prognostic score depends on patient characteristics.
Purpose: Only 38% of adolescent girls and 14% of adolescent boys complete the three-dose human papillomavirus (HPV) vaccine series, despite its excellent safety profile, mounting evidence of effectiveness, and national guidelines for routine administration. Research indicates that improving the implementation of HPV vaccination programs will require healthcare providers to recommend the vaccine more often and more strongly, but little is known empirically about which types of recommendation are most influential. Thus, we sought to investigate the relationship between provider recommendation quality and HPV vaccine decision making by parents of adolescents.
Method: In 2014 to 2015, we conducted a national, online survey of 1,495 U.S. parents who reported on the immunization history of an 11- to 17-year-old adolescent in their households. For parents who had received provider recommendations for HPV vaccination, our survey assessed recommendation quality on three indicators: 1) strength of endorsement (whether the provider said HPV vaccine was very important); 2) urgency (whether the provider recommended vaccinating “today”); and 3) prevention message (whether the provider said HPV vaccine prevents cancer). Using an index of these indicators, we categorized parents as having received no, low-quality, or high-quality provider recommendations. Separate multivariable logistic regression models assessed associations between recommendation quality and HPV vaccination decisions, including initiation (acceptance of ≥1 dose), follow through (acceptance of 3 doses, among initiators), refusal, and delay.
Result: Almost half (48%) of parents reported no provider recommendation for HPV vaccination, while 16% received low-quality recommendations and 36% received high-quality recommendations. Compared to no recommendation, high-quality recommendations were associated with over nine times the odds of HPV vaccine initiation (OR=9.31, 95% CI, 7.10-12.22) and over three times the odds of follow through (OR=3.82, 95% CI, 2.39-6.11). Low-quality recommendations were more modestly associated with initiation (OR=4.13, 95% CI, 2.99-5.70), but not follow through. Parents who received high- versus low-quality recommendations less often reported HPV vaccine refusal or delay.
Conclusion: Our findings provide early evidence to suggest that high-quality recommendations are more effective than low-quality recommendations for encouraging HPV vaccine acceptance and discouraging refusal and delay. Given that only about one-third of parents received high-quality recommendations, interventions are needed to improve provider communication about HPV vaccine so as to support parents' decision making and address the persistent underuse of a powerful tool for cancer prevention.
Methods: We recruited 27 participants and held separate research study sessions for each stakeholder group: physicians (n=7), patients (n=11), family/caregivers (n=4), and a mixed-group of stakeholders (n=5). Sessions were comprised of three activities: 1) participant use of the decision aid with usability tasks, 2) one-on-one semi-structured interviews, and 3) participation in a focus group. Interview and focus group questions elicited stakeholder perceptions of our decision aid, understanding of the information presented, factors impacting decision making, and recommendations for improvement. Audio recordings were transcribed for thematic analysis. Themes were compared, revised, and interpreted within the context of decision aid revisions. Triangulation of data collected from each session and from the three activities was performed to increase comprehensiveness and robustness of data analysis.
Results: All participants felt the decision aid could facilitate this difficult conversation, and found the web-based platform acceptable. There was consensus for: wanting more information on establishing an advance directive; believing that quality of life issues were the most important factors in decision making; desiring information detailing quality of life after mechanical ventilation; and for technical improvements such as navigation and adding a glossary and links to forms. On the other hand: some participants found the information too shocking (“a slap in the face”), while others wanted more explicit and realistic information; and some participants recommended that potentially upsetting information about the likelihood of dying be placed upfront, while others felt it should appear later on in the tool. There were also varying opinions about when the decision aid should be introduced. As expected, those with lower numeracy had difficulty understanding data from pictographs. Additionally, analysis revealed that lived experiences with end-of-life treatments may have influenced participants’ ability to understand the data, and their willingness to incorporate the data into their decision making.
Conclusions: A decision aid designed to inform end-of-life decision making for advanced stage COPD needs to allow for heterogeneity in the level of detail wanted and preferences for the ways in which that information is presented; and consider the impact of lived experience on understanding prognostic information and the informed decision making process.