Patient-clinician Interaction Research Articles

Assessment of Neurocognitive Impairment and Speech Functioning Before Head and Neck Cancer Treatment

Head and neck cancer (HNC) and its treatment may negatively alter neurocognitive and speech functioning. However, the prevalence of neurocognitive impairment among patients with HNC before treatment is poorly studied, and the association between neurocognitive and speech functioning is unknown, which hampers good interpretability of the effect of HNC treatment on neurocognitive and speech function. To document neurocognitive functioning in patients with HNC before treatment and to investigate the association between neurocognitive and speech functioning. Prospective cohort study of newly diagnosed patients with HNC before treatment using a large sample obtained in a nationwide, multicenter setting (Netherlands Quality of Life and Biomedical Cohort Study in Head and Neck Cancer [NET-QUBIC] project). Objective neuropsychological measures of delayed recall, letter fluency, and executive functioning, as well as patient-reported outcome measures on neurocognitive speech and functioning, were collected before treatment. In total, 254 patients with HNC participated (71.7% male), with a mean (SD) age of 62 (10) years. The response rate ranged from 81.9% (208 of 254) to 84.6% (215 of 254). Objective neurocognitive measures indicated that 4.7% (10 of 212) to 15.0% (32 of 214) of patients were initially seen with moderate to severe cognitive impairment. Mild to moderate impairment was found in 12.3% (26 of 212) to 26.2% (56 of 214) of patients. The most altered domains were delayed recall and letter fluency. Seven percent (15 of 208) of the patients reported high levels of everyday neurocognitive failure, and 42.6% (89 of 209) reported speech problems. Objective neurocognitive function was not significantly associated with patient-reported neurocognitive or speech functioning, but the results from patient-reported outcome measures were significantly correlated. Results of this study demonstrate a high prevalence of impaired speech functioning among patients with HNC before treatment, which is in line with previous findings. A novel finding is that neurocognitive impairment is also highly prevalent as objectively measured and as self-perceived. Understanding the reason why patients with HNC are initially seen with neurocognitive impairment before the start of treatment is important because this impairment may complicate patient-clinician interaction and alter treatment adherence and because treatment itself may further worsen cognitive functioning. In addition, low self-perceived neurocognitive and speech functioning before treatment may decrease a patient's confidence in communicative participation and perceived quality of life. Disentangling the associations between objective and patient-reported neurocognitive and speech functions is an important area for future research.

Impact of Patient Gender and Race and Physician Communication on Colorectal Cancer Diagnostic Visits in Primary Care.

Background: Patient gender and race, and physician-patient communication are associated with clinical outcomes. Aim: To understand the role of these factors in the diagnosis of colorectal cancer (CRC) during primary care visits as measured by appropriate outcome. Materials and Methods: Caucasian and African American unannounced standardized patients (USPs) of both genders presented to 207 primary care physicians (PCPs) from community and academic practices in Ohio and Virginia as new patients with CRC symptoms. PCPs were blinded to the diagnosis. Physician subjects consented to audiotaping the encounter. Medical records were obtained. Communication elements were coded by trained observers and appropriate visit outcomes were coded from the medical record and audiofiles, defined as (1) recommendation for colonoscopy/sigmoidoscopy/fecal occult blood test (FOBT) or (2) referral to gastroenterologist. Results: A total of 141 of 367 USP visits (38%) resulted in appropriate clinical outcomes. Patient race was not associated with outcome, but being a male USP was (χ2 = 4.12, p = 0.04). Relational communication was represented as a latent variable with seven indicators (alpha = 0.84) and was independently associated with outcome (beta = 0.15; p = 0.025). After controlling for clustered sampling, relational communication, and race, structural equational modeling indicated that female USPs were less likely to have an appropriate clinical visit outcome (beta = -0.13; p = 0.033). Conclusions: Using a novel and innovative methodology capturing PCP behaviors during real-time clinician-patient interaction, appropriate clinical outcome was independently associated with being male and PCP relational communication factors such as encouraging patient communication, being engaged and expressive in the physician-patient conversation, and appearing friendly and sincere. There are persistent biases in the delivery of health care to female patients and further research into targeted communication skills programs may be warranted.

Tell Me More: Promoting compassionate patient care through conversations with medical students

Tell Me More® (TMM) is a medical student driven project that represents a movement amongst the rising generation of physicians to practice humanistic, patient-centered medicine through a collaborative approach. Students interviewed patients to create individualized posters designed to build rapport and trust between patients and clinicians, remind patients of their special strengths by highlighting their unique interests and qualities, and encourage more personal and compassionate patient-clinician interactions in order to enhance the patient experience. Students asked each patient three questions: 1. “How would your friends describe you?” 2. “What are your strengths?” 3. “What has been most meaningful to you?” and answers were recorded on a large poster, which was displayed prominently in the patient’s room for clinicians and staff to acknowledge. TMM engaged 5 students and 302 patients over 4 hospital settings throughout Northwell Health. Data collection included daily written reflections by students on their experiences, exit interviews with patients to assess the impact of the project on their stay, and staff surveys that addressed provider perception of the program. Descriptive outcomes supported a positive impact on students, patients, staff and clinicians. TMM succeeded in providing a bridge between patients and clinicians and is a cost-effective practice that lends to more personal patient-provider interactions. Bedside posters positively influenced the culture of a hospital organization and reminded providers of the meaning in their work, which literature shows can reduce provider burnout and improve quality of care.

Electronic Cigarettes and Smoking Cessation in the Perioperative Period of Cardiothoracic Surgery: Views of Australian Clinicians.

For patients who smoke, electronic cigarettes may offer a pathway to achieve tobacco abstinence and reduce the risk of postoperative complications. Clinicians have a pivotal role in supporting smoking cessation by patients with lung cancer and coronary artery disease throughout the perioperative period of cardiothoracic surgery. However, the views of Australian cardiothoracic clinicians on electronic cigarettes and smoking cessation are unknown. Semi-structured interviews were conducted with 52 cardiothoracic surgeons, anaesthetists, nurses and physiotherapists in six hospitals in Sydney and thematically analysed. Clinicians’ knowledge about electronic cigarettes and the regulatory environment surrounding them was limited. Clinicians believed that: electronic cigarettes, though unlikely to be safe, were safer than tobacco cigarettes; electronic cigarettes may have a harm reduction role in public health; and electronic cigarettes were a potential smoking cessation tool for the extraordinary circumstances of surgery. The professional role of a clinician and their views about electronic cigarettes as a perioperative smoking cessation aid had an influence on future clinician-patient interactions. Electronic cigarette use is increasing in Australia and clinicians are likely to receive more frequent questions about electronic cigarettes as a cessation aid. Stronger guidance for clinicians is needed on the topic of electronic cigarettes and cardiothoracic surgery.

Learning health systems

Healthcare organizations have invested significant resources into integrating comprehensive electronic health record (EHR) systems into clinical care. EHRs digitize healthcare in ways that allow for repurposing of clinical information to support quality improvement, research, population health, and health system analytics. This has facilitated the development of Learning Health Systems. Learning health systems (LHS) merge healthcare delivery with research, data science, and quality improvement processes. The LHS cycle begins and ends with the clinician-patient interaction, and aspires to provide continuous improvements in quality, outcomes, and health care efficiency. Although, the health sector has been slow to embrace the LHS concept, innovative approaches for improving healthcare, such as a LHS, have shown that better outcomes can be achieved by engaging patients and physicians in communities committed to a common purpose. Here, we explore the mission of a pediatric LHS, such as PEDSnet, which is driven by the distinctive goals of a child's well-being. Its vision is to create a national LHS architecture in which all pediatric institutions can participate. While challenges still exist in the development and adoption of LHS, these challenges are being met with innovative strategies and strong collaborative relationships to reduce system uncertainty while improving patient outcomes.

Improving Medical Communication in Migraine Management: A Modified Delphi Study to Develop a Digital Migraine Tracker.

This study aimed to identify the essential content and amount of information to be collected from people with migraine via a patient-facing smartphone-based migraine tracker for them to share with clinicians during live discussions to assist in optimizing migraine management. The proposed tracker is intended for use in non-interventional research to evaluate disease burden in episodic migraine and chronic migraine patients as assessed by demographic and clinical characteristics and health resource utilization in an integrated delivery network setting. The proposed tracker is not intended for commercial purposes. Epidemiological studies suggest migraine is underdiagnosed and undertreated. Studies of patient-clinician interactions suggest that effective medical communication may help address these issues. Four migraine practice leaders, an epidemiologist with extensive migraine experience, and a measurement expert took part in a modified Delphi panel process to identify data elements that could be collected from people with migraine through a smartphone-based migraine tracker. Importantly, the proposed tracker would not be intended to replace the patient-clinician encounter but to support the encounter through enabling the patient to document migraine symptoms and experiences in a timely and accurate manner for sharing with a clinician as part of a broader face-to-face discussion. The panel reviewed questions derived from the existing migraine diaries in the public domain, those used in clinical trials, and patient-centric surveys assessing the impact of migraine on physical function and other related concepts. Key considerations included identification of the most clinically useful data elements for a shared communication tool for people with migraine under the care of a clinician. The panel also identified numerous functionality requirements for such a tool and provided recommendations on the most effective way to present results to a clinician. The expert panel opined that people with migraine may value the ability to capture a relatively broad range of information for their own migraine-tracking purposes, while clinicians will likely find greater value in a small set of data relevant to the management of migraine. The panel identified the 3 most essential concepts in categories of data for a clinician, for which they coined the term "The 3 Fs": Frequency of days with headache; Frequency of acute medication usage; and Functional impairment. Information on the frequency of days with headache was felt to combine with the information on the frequency of acute medication usage to provide essential insights into current migraine management strategy and its outcomes, and to assist considerations of preventive measures. Functional impairment was treated as an effective surrogate for headache severity and was assessed based on the following: degree of difficulty in performing activities of daily living, impact on absenteeism (taking leave from work or cancelling/avoiding other activities) and presenteeism (performing work or other daily activities, with reduced productivity/capability), and amount of rest required as a result of a migraine attack. The modified Delphi panel process resulted in the selection of 13 questions in 8 categories to elicit sufficient and meaningful data comprising headache occurrence, symptoms, daily/preventive and as-needed/acute medication usage, triggers, ability to concentrate, and functional impairment. The panel also agreed that the tracker should generate 2 distinct reports: one for people with migraine that would include a wider range of data about symptoms and perceived triggers, and a targeted report for the clinician that would place prime emphasis on the 3 Fs for aggregating the results of each headache occurrence and the trend over time. A system that easily captures critical data elements about migraine, with specific feedback displays for patients to share with clinicians during live discussions, may offer some benefit to people with migraine and their clinicians by facilitating more objective communication and optimizing management. The tracker's output may enable people with migraine to track a wide range of data for their own purposes, allowing them to better understand their condition, while a synthesized view of the selected data may support more informed clinical decision-making for the clinician and individualized, evidence-based discussion with the patient. As a result, this shared decision-making tool may enable patients to more accurately convey essential migraine information during live patient-clinician discussions to drive improved management and patient outcomes.

Patient-clinician relationship seems to affect adherence to analgesic use in cancer patients: a cross sectional study in a Taiwanese population.

Objectives Patient satisfaction can provide a measure of service quality and serve as a predictor of health-related behaviors. Little is known about how patients' satisfaction with clinician-patient interactions affects their adherence to taking analgesics. The purposes of this study were to (1) investigate the predictors of patients' satisfaction with clinicians, and (2) examine whether patients' satisfaction with their clinicians can improve adherence to analgesic use. Design A cross-sectional and descriptive design was used. Setting Outpatient oncology clinic at a medical center in Taiwan. Participants A convenience sample (N = 309) was recruited. Main outcome measures The Medical Interview Satisfaction Scale 21 - Chinese Version, Short Version of the Barriers Questionnaire - Taiwan Form, Taiwanese version of the Morisky Medication Adherence Measure, and Interpersonal Physician Trust Scale - Chinese version, and Brief Pain Inventory Chinese Version. Results Variables that could significantly predict patients' satisfaction were patient age and trust in clinicians, which together accounted for 33% of the total variance. Patients' satisfaction with their clinicians significantly predicted patients' adherence to medication use (OR = 3.10, P < 0.05). There was an interactive effect (OR = 0.12, P < 0.05) between patients' satisfaction and barriers to analgesic use. Correlation coefficients between barriers to analgesic use and patients' adherence are -0.52 (P < 0.001) and -0.13 (P = 0.20) in the higher satisfaction and lower satisfaction patients, respectively. Conclusions Patients' satisfaction with their clinicians can have a positive effect on changing analgesics adherence behaviors when patients hold incorrect beliefs about analgesics. Patients' satisfaction has an important role in enhancement of analgesics adherence behaviors.

Tattoos: A summary knowledge for the practising clinician

Tattoos are becoming increasingly common. They have an impact on many aspects of clinician-patient interaction. Therefore, it is necessary for clinicians to have a basic knowledge of pertinent issues relating to tattoos. We provide a brief overview aimed at pointing the practising clinician who interacts with a tattooed person in the right direction. We discuss types of tattoos; their evolving epidemiology; the process of tattooing and variety of pigments used; medical application and relevance of tattoos; complications of tattooing; methods of removing tattoos, the efficacy of these methods and their associated complications; legislative framework guiding tattooing in South Africa and recent significant developments in the industry.

Advance Care Planning in Community: An Evaluation of a Pilot 2-Session, Nurse-Led Workshop.

Engaging patients in advance care planning (ACP) is challenging but crucial to improving the quality of end-of-life care. Group visits and multiple patient-clinician interactions may promote advance directive (AD) completion. Facilitate ACP discussions with patients and caregivers and the creation of notarized AD's at a comprehensive cancer center. Two-session, nurse-led ACP workshops for patients and their family caregivers. The workshop was offered to patients with cancer at a comprehensive cancer center and their family caregivers. Validated 4-question ACP engagement survey, creation of a notarized AD by end of the workshop, and semistructured interviews. Thirty-five patients participated in 10 workshops held March 2017 to February 2018. Median age was 52. Of 35, 24 (68.5%) patients completed pre- and postworkshop evaluation surveys. Mean preworkshop ACP readiness was 3.64 of 5; postworkshop readiness increased to 4.26 of 5 ( P = .001). Of 26, 17 (65.4%) of the patients who attended both workshop sessions had a new notarized AD scanned into the electronic medical record at the completion of the workshop series. Three family caregivers completed and had their own ADs notarized. Patient and family member response was overwhelmingly positive, with participants citing opportunities for group discussion and inclusion of family caregivers as important. The ACP workshop was well received by participants and increased ACP readiness, discussion, and completion. Attendance at the workshop was low and barriers to attending workshops must be explored.

Third-Year Medical Students' Reactions to Surgical Patients in Pain: Doubt, Distress, and Depersonalization

ContextMedical students have limited instruction about how to manage the interpersonal relationships required to care for patients in pain. ObjectivesThe objective of this study was to characterize the experiences of medical students as they encounter pain, suffering, and the emotional experiences of doctoring. MethodsWe used qualitative analysis to explore the content of 341 essays written by third-year medical students who described their experiences with surgical patients in pain. We used an inductive process to develop a coding taxonomy and then characterized the content of these essays related to empathy, patient-clinician interaction, and descriptions of clinical norms. ResultsStudents found it difficult to reconcile patient suffering with the therapeutic objective of treatment. They feared an empathic response to pain might compromise the fortitude and efficiency required to be a doctor and they pursued strategies to distance themselves from these feelings. Students described tension around prescription of pain medications and worried about the side effects of medications used to treat pain. Students felt disillusioned when operations caused suffering without therapeutic benefit or were associated with unexpected complications. Although patients had expressed a desire for intervention, students worried that the burdens of treatment and long-term consequences were beyond patient imagination. ConclusionThese observations about patient-doctor relationships suggest that there is a larger problem among clinicians relating to patient distress and personal processing of the emotional nature of patient care. Efforts to address this problem will require explicit instruction in skills to develop a personal strategy for managing the emotionally challenging aspects of clinical work.

Value-Based Health Care Meets Cost-Effectiveness Analysis.

Value-based health care (VBHC) has recently emerged as a prominent movement within health care. Value-based health care focuses on maximizing outcomes achieved per dollar spent. As such, it bears many similarities to a well-established method, cost-effectiveness analysis (CEA), which provides a framework for comparing the relative value of different diagnostic or treatment interventions. Both approaches address "bang for the health care buck," but although they overlap in many ways, VBHC and CEA differ with regard to their main applications, their perspective, and the types of costs and outcomes they consider. For example, CEA generally considers costs and benefits from the societal or health care sector perspectives, whereas VBHC is intended to adopt the patient perspective. As such, CEA is intended to inform coverage decisions at a group or population level and VBHC is intended to be implemented at the level of clinician-patient interactions. Meanwhile, value-based payment has emerged as a visible component of VBHC and is gaining a foothold in the United States in various forms, particularly bundled payments and accountable care organizations, in an effort to reward high-value care and disincentivize low-value care. Differences aside, as the worlds of VBHC and CEA begin to intersect, each discipline can learn from the other.

Consumer Sleep Technology: An American Academy of Sleep Medicine Position Statement.

Consumer sleep technologies (CSTs) are widespread applications and devices that purport to measure and even improve sleep. Sleep clinicians may frequently encounter CST in practice and, despite lack of validation against gold standard polysomnography, familiarity with these devices has become a patient expectation. This American Academy of Sleep Medicine position statement details the disadvantages and potential benefits of CSTs and provides guidance when approaching patient-generated health data from CSTs in a clinical setting. Given the lack of validation and United States Food and Drug Administration (FDA) clearance, CSTs cannot be utilized for the diagnosis and/or treatment of sleep disorders at this time. However, CSTs may be utilized to enhance the patient-clinician interaction when presented in the context of an appropriate clinical evaluation. The ubiquitous nature of CSTs may further sleep research and practice. However, future validation, access to raw data and algorithms, and FDA oversight are needed.

Effectiveness of interactive mental flexibility groups for patients on acute inpatient psychiatric unit

With the intention of understanding the dynamics of psychiatric interviews, we investigated the usual (DSM/ICD-based) psychiatric assessment process and an alternative assessment process based on a case formulation method. We compared the two different approaches in terms of the clinicians’ practices for offering patients opportunities to reveal their subjective experiences.Using qualitative and quantitative applications of conversation analysis, we compared patient–clinician interaction in five usual psychiatric assessments (AAU) with five assessment interviews based on dialogical sequence analysis (DSA).The frequency of conversational sequences where the patient described his/her problematic experiences was higher in the DSA interviews than in the AAU interviews. In DSA, the clinicians typically facilitated the patient’s subjective experience talk by experience-focused questions and formulations, whereas in AAU, such talk typically occurred in environments where the clinicians’ questions and formulations focused on non-experiential, medical matters.Interaction in DSA was organized to provide for the patient’s experience-focused talk, whereas in AAU, the patient needed to go against the conversational grain to produce such talk.By facilitating patients’ opportunities to uncover subjective experiences, it is possible to promote their individualized care planning in psychiatry.

Engagement Strategies for Self-Monitoring Symptoms of Bipolar Disorder With Mobile and Wearable Technology: Protocol for a Randomized Controlled Trial.

BackgroundMonitoring signs and symptoms in bipolar disorder (BP) is typically based on regular assessments from patient-clinician interactions. Mobile and wearable technology promises to make monitoring symptoms in BP easier, but little is known about how best to engage individuals with BP in monitoring symptoms.ObjectiveThe objective of this study was to provide the rationale and protocol for a randomized controlled trial that investigates engagement strategies for monitoring symptoms of BP, including the strategies of using activity trackers compared with self-reports and reviewing recorded symptoms weekly with an interviewer.MethodsA total of 50 individuals with BP will be recruited from the Prechter Longitudinal Study of Bipolar Disorder at the University of Michigan to participate in a 6-week study. Participants will monitor their symptoms through an activity tracker (Fitbit Alta HR) and a mobile phone app designed for this study. In addition to monitoring symptoms, participants have a 50-50 chance of being assigned to an arm that reviews self-reports and activity information weekly. Statistical tests will be performed to test hypotheses that participants adhere to activity tracking significantly more than self-reporting, prefer activity tracking significantly more than self-reporting, and better adhere to both activity tracking and self-reporting when reviewing collected information weekly.ResultsRecruitment commenced in November 2017. The first group of participants began the study in January 2018.ConclusionsThis study aims to establish strategies to engage individuals with BP in monitoring their symptoms with mobile and wearable technology. Better engagement strategies are expected to aid current efforts in bipolar research and clinical care, from the development of new mobile phone apps to providing the right intervention to the right individual at the right moment.Trial RegistrationClinicalTrials.gov NCT03358238; https://clinicaltrials.gov/ct2/show/NCT03358238 (Archived by WebCite at http://www.webcitation.org/6yebuNfz5)Registered Report IdentifierRR1-10.2196/9899

A Novel Algorithm for Determining the Contextual Characteristics of Movement Behaviors by Combining Accelerometer Features and Wireless Beacons: Development and Implementation.

BackgroundUnfortunately, global efforts to promote “how much” physical activity people should be undertaking have been largely unsuccessful. Given the difficulty of achieving a sustained lifestyle behavior change, many scientists are reexamining their approaches. One such approach is to focus on understanding the context of the lifestyle behavior (ie, where, when, and with whom) with a view to identifying promising intervention targets.ObjectiveThe aim of this study was to develop and implement an innovative algorithm to determine “where” physical activity occurs using proximity sensors coupled with a widely used physical activity monitor.MethodsA total of 19 Bluetooth beacons were placed in fixed locations within a multilevel, mixed-use building. In addition, 4 receiver-mode sensors were fitted to the wrists of a roving technician who moved throughout the building. The experiment was divided into 4 trials with different walking speeds and dwelling times. The data were analyzed using an original and innovative algorithm based on graph generation and Bayesian filters.ResultsLinear regression models revealed significant correlations between beacon-derived location and ground-truth tracking time, with intraclass correlations suggesting a high goodness of fit (R2=.9780). The algorithm reliably predicted indoor location, and the robustness of the algorithm improved with a longer dwelling time (>100 s; error <10%, R2=.9775). Increased error was observed for transitions between areas due to the device sampling rate, currently limited to 0.1 Hz by the manufacturer.ConclusionsThis study shows that our algorithm can accurately predict the location of an individual within an indoor environment. This novel implementation of “context sensing” will facilitate a wealth of new research questions on promoting healthy behavior change, the optimization of patient care, and efficient health care planning (eg, patient-clinician flow, patient-clinician interaction).

The Role of Virtual Rehabilitation in Total and Unicompartmental Knee Arthroplasty.

This study evaluated the use of telerehabilitation during the postoperative period for patients who underwent total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA). Specifically, this study evaluated the following: (1) patient compliance and adherence to the program, (2) time spent performing physical therapy exercises, (3) the usability of the virtual rehabilitation platform, and (4) clinical outcome scores in a selected primary knee arthroplasty cohort. A total of 157 consecutive patients underwent TKA (n = 18) or UKA (n = 139). These patients used a telerehabilitation system with an instructional avatar, three-dimensional motion measurement and analysis software, and real-time televisit capability designed for arthroplasty patients. Compliance was determined by how many times the patients followed prescribed repetitions of exercises. The total time spent performing exercises for each patient was collected. The usability of the virtual rehabilitation platform (on the patient's end) was evaluated using the system usability scale (SUS) questionnaire. The number of in-person and televisits was recorded for each patient. Patient-reported outcomes were collected through the patient and clinician interfaces and included the Knee Society Score (KSS) for pain and functions, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and Boston University Activity Measure for Post-Acute Care (AM-PAC) score. Patients spent an average of 29.5 days partaking in the therapy. TKA and UKA patients had a mean of 3.5 and 3.2 outpatient follow-up visits, each, for in-office therapy with a physical therapist, respectively. This figure exceeded the mean number of real-time virtual patient-clinician visits by 0.8 visits per patient in the TKA cohort and by 1 visit per patient in the UKA cohort. Patients spent on average 26.5 minutes per day conducting an average of 13.5 exercises. By the end of rehabilitation, patients had spent an average of 10.8 hours performing exercises, and of all the exercises performed, approximately 21 exercises were uniquely designed. Mean SUS score in the cohort was 93 points, which was interpreted as being above the 50th percentile point of the scale. Following therapy, KSS pain and function scores improved markedly and the improvements were measured at 368% for TKA and 350% for UKA (pain) and 27% for UKA and 33% for TKA (function). In addition, WOMAC scores improved by 57% and 66% for UKA and TKA patients while the improvement in AM-PAC scores was at 22% and 24%. This telerehabilitation platform encouraged clinician-patient interaction beyond the hospital setting and offers the advantage of cost savings, convenience, at-home monitoring, and coordination of care, all of which are geared to improve adherence and overall patient satisfaction. Additionally, the biometric data can be used to develop custom physical therapy regimens to assure proper rehabilitation, which is lacking in other telerehabilitation applications that use noninteractive videos that can be watched on mobile devices and tablets.

Patient-Clinician Communication About Pain: A Conceptual Model and Narrative Review.

Productive patient-clinician communication is an important component of effective pain management, but we know little about how patients and clinicians actually talk about pain in clinical settings and how it might be improved to produce better patient outcomes. The objective of this review was to create a conceptual model of patient-clinician communication about noncancer pain, review and synthesize empirical research in this area, and identify priorities for future research. A conceptual model was developed that drew on existing pain and health communication research. CINAHL, EMBASE, and PubMed were searched to find studies reporting empirical data on patient-clinician communication about noncancer pain; results were supplemented with manual searches. Studies were categorized and analyzed to identify crosscutting themes and inform model development. The conceptual model comprised the following components: contextual factors, clinical interaction, attitudes and beliefs, and outcomes. Thirty-nine studies met inclusion criteria and were analyzed based on model components. Studies varied widely in quality, methodology, and sample size. Two provisional conclusions were identified: contrary to what is often reported in the literature, discussions about analgesics are most frequently characterized by patient-clinician agreement, and self-presentation during patient-clinician interactions plays an important role in communication about pain and opioids. Published studies on patient-clinician communication about noncancer pain are few and diverse. The conceptual model presented here can help to identify knowledge gaps and guide future research on communication about pain. Investigating the links between communication and pain-related outcomes is an important priority for future research.

Effectiveness and impact of networked communication interventions in young people with mental health conditions: A rapid review.

ObjectiveTo describe the latest evidence of effectiveness and impact of networked communication interventions for young people with mental health conditions.MethodsSearching five databases from 2009 onwards, we included studies of any design investigating two-way communication interventions for the treatment of young people (mean age 12–25) with a chronic mental health disorder. The data were synthesised using narrative summary.ResultsSix studies met the inclusion criteria, covering a range of mental health conditions (depression, psychosis, OCD). Interventions included an online chat room (n = 2), videoconferencing (n = 3) and telephone (n = 1). Where studies compared two groups, equivalence or a statistically significant improvement in symptoms was observed compared to control. Views of patients and clinicians included impact on the patient-clinician interaction. Clinicians did not feel it hindered their diagnostic ability.ConclusionNetworked communication technologies show promise in the treatment of young people with mental health problems but the current available evidence remains limited and the evidence base has not advanced much since the previous inception of this review in 2011.Practice implicationsAlthough the available research is generally positive, robust evidence relating to the provision of care for young persons via these technologies is lacking and healthcare providers should be mindful of this.

Experienced Practitioners' Views on Interpersonal Skills in Telehealth Delivery

Background. As telehealth becomes a larger part of the health care landscape, clinicians are becoming prepared to operate technology-based­ systems for conducting routine care and exchanging information. Less defined are interpersonal skills for telehealth care delivery such as communication and therapeutic relationships that can influence clinical outcomes. Examples include clinician adaptability to the communication process via telehealth, clinician congeniality in communications, and striving to achieve telepresence. The purpose of this study was to describe interpersonal skills for telehealth delivery to assist in the preparation of health professionals. Methods. Aqualitative methods approached was used to build on results from our previously published systematic review. Semi-structured, in-depth interviews were conducted with experienced practitioners or educators (n=6) at multiple regional telehealth centers. Video/audio-recorded sessions were transcribed verbatim and researchers conducted thematic analysis of data until achieving saturation of data. Results. Participants provided their perspectives about interpersonal skills important for quality telehealth delivery based on professional experiences. Analysis of responses across interviews showed strong alignment with the six themes identified previously as non-technical clinician attributes: Preinteractional, Verbal Communication, Non-Verbal Communication, Relational, and Environmental. Also, an additional theme of Management/Operations emerged. Suggested training topics crossed clinical disciplines and ranged from telemedicine etiquette and verbal skills to equipment operation and billing and coding. Each study participant commented on benefits from preparation of telehealth clinicians related to the clinician-patient interaction such as: patient engagement, patient-centered care, patient satisfaction, patient implementation of care plans, effective communication with patients, and quality assessment of telehealth sessions. Conclusions. This study identified interpersonal skills that may be applied in professional education for telehealth delivery from the perspective of experienced practitioners. Further research could explore outcomes from professional preparation for interpersonal skills and patient perspectives.

Education, health literacy, and inequity in access to transplantation: findings from the ATTOM cohort study

BackgroundThe optimal treatment for most people with kidney failure is kidney transplantation, but donor organs are limited. The pathway to living-donor or deceased-donor kidney transplantation entails multiple clinician–patient interactions, likely to require adequate health literacy. The Access to Transplant and Transplant Outcome Measures (ATTOM) study identified inequity in access to transplantation by educational level. We tested the hypothesis that low health literacy promotes inequity by acting as a mediator between reduced education and transplantation. MethodsThe ATTOM cohort study recruited incident dialysis patients aged 18–75 years, who were able to provide informed consent, from all 72 kidney units in the UK from Dec 1, 2011, to Sept 30, 2013]. This mediation analysis concerned the exposure (no educational qualifications vs any), prospective outcomes (time to being added to the deceased-donor transplant waiting list and time to living-donor transplantation, censored at 2 years), the mediator (health literacy as judged by Single Item Literacy Screener, a validated, self-reported health literacy screening measure) and covariates (age, ethnicity, and comorbidity by Charlson index). Effect sizes were calculated for education on health literacy, health literacy on being added to the transplant waiting list and living-donor transplantation, and for education on being added to the waiting list and living-donor transplantation, all adjusted for the covariates. These effect sizes were used to calculate the total effect of education on being added to the transplant list and transplantation and the indirect effect mediated by health literacy. Weibull Accelerated Failure Time models were used. Ethics approval was given by Cambridge Research Ethics Committee. Findings2463 patients were included. The total effect of low educational level was to increase the time to being added to the transplant waiting list by 22% (time to event ratio 1·22, 95% CI 1·02–1·48) and time to living donor transplant by 47% (1·47, 1·04–2·08). The indirect effect mediated by health literacy accounted for 35% and 30%, respectively. InterpretationOur findings show that health literacy mediates a substantial proportion of the effect of low educational level on reduced access to the deceased-donor transplant waiting list and to living donor transplantation. Interventions to improve equity of transplantation should account for the health literacy skills needed for patients to take part in shared decision making. FundingATTOM was funded under National Institute for Health Research Programme Grants for Applied Research (RP-PG-0109-10116).