Patient-physician Discussions Research Articles

Qualitative Analysis of Patient–Physician Discussions Regarding Anticoagulation for Atrial Fibrillation

For patients with atrial fibrillation (AF), the decision to initiate anticoagulation involves the choice between warfarin or a direct oral anticoagulant (DOAC). How physicians engage patients in this decision is unknown. To describe the content of discussions between patients with AF and physicians regarding choice of anticoagulation. This qualitative content analysis included clinical encounters between physicians and anticoagulation-naive patients discussing anticoagulation initiation between 2014 and 2020. Themes identified through content analysis. Of 37 encounters, almost all (34 [92%]) resulted in a prescription for a DOAC. Most (25 [68%]) patients were White; 15 (41%) were female and 22 (59%) were male; and 24 (65%) were aged 65 to 84 years. Twenty-one physicians conducted the included encounters, the majority of whom were cardiologists (14 [67%]) and male (19 [90%]). The analysis revealed 4 major categories and associated subcategories of themes associated with physician discussion of anticoagulation with anticoagulation-naive patients: (1) benefit vs risk of taking anticoagulation-in many cases, this involved an imbalance in completeness of discussion of stroke vs bleeding risk, and physicians often used emotional language; (2) tradeoffs between warfarin and DOACs-physicians typically discussed pros and cons, used persuasive language, and provided mixed signals, telling patients that warfarin and DOACs were basically equivalent, while simultaneously saying warfarin is rat poison; (3) medication costs-physicians often attempted to address patients' questions about out-of-pocket costs but were unable to provide concrete answers, and they often provided free samples or coupons; and (4) DOACs in television commercials-physicians used direct-to-consumer pharmaceutical advertising about DOACs to orient patients to the issue of anticoagulation as well as the advantages of DOACs over warfarin. Patients and physicians also discussed class action lawsuits for DOACs that patients had seen on television. This qualitative analysis of anticoagulation discussions between physicians and patients during clinical encounters found that physicians engaged in persuasive communication to convince patients to accept anticoagulation with a DOAC, yet they were unable to address questions regarding medication costs. For patients who are ultimately unable to afford DOACs, this may lead to unnecessary financial burden or abandoning prescriptions at the pharmacy, placing them at continued risk of stroke.

S1477 Effect of a Detailed Educational Intervention on Pre-Endoscopy Anxiety Levels in Children and Young Adults

Introduction: Invasive medical procedures such as endoscopy are a significant source of anxiety for patients. Published data show that higher levels of pre-endoscopy anxiety are associated with worse clinical outcomes. Studies in adults have shown that pre-endoscopy interventions such as educational videos or brochures are associated with decreased pre-endoscopy anxiety. Similar literature in pediatrics is limited. We sought to evaluate whether an educational video effectively reduces pre-endoscopy anxiety in a pediatric cohort of patients and to identify the most common concerns surrounding endoscopy. Methods: This is a prospective randomized controlled trial of patients ages 8-21 years requiring gastrointestinal endoscopy with their parents participating when appropriate. The intervention group was shown an educational video created by the study investigators. Subjects were asked to report anxiety using a Numerical Rating Scale (NRS) and the State-Trait Anxiety Inventory (STAI, STAI-C). They also reported their anxiety levels surrounding specific components of the procedure. Results: 160 subjects have been recruited and the study remains open. 82 (51%) and 78 (49%) subjects were randomized to the intervention and control group, respectively. Most subjects identified as Hispanic (26%) or African American (15%) and 28% had Medicaid. 35% of subjects had a history of prior endoscopy. Baseline anxiety trait was not significantly different between control and intervention groups. NRS and STAI/STAI-C scores were comparable in intervention and control groups amongst all-comers. However, for the cohort of patients recruited prior to the day of endoscopy, NRS scores were lower in the intervention group (mean score of 3.4 vs 5.6, P = 0.01). Subjects receiving the intervention prior to the day of endoscopy had lower STAI-C state scores than those receiving the intervention the day of endoscopy. Regarding concerns surrounding endoscopy, patients and parents were most worried that some disease might be found, followed by the need for anesthesia. Conclusion: Our results suggest that an educational intervention may attenuate pre-endoscopy anxiety, but that this may be contingent on the timing of delivery. Our results also highlight the factors surrounding endoscopy that are most anxiety-provoking for patients and parents, providing valuable information which may help further define topics that should be addressed not only by educational interventions but also in physician-patient discussions regarding endoscopy.

Patient Understanding of Oncologic Radiology Reports: Is Access to Electronic Medical Records Helpful?

Access to electronic medical record (EMR) patient portals made it easier for patients to quickly acquire the results of their radiology studies. However, there is little research on how well oncology patients understand the findings of radiology reports presented in the online portal without patient-physician discussion. This study assessed oncology patients' confidence and accuracy in interpreting radiology reports either with or without layman translations. A survey based on a radiology report was administered to oncology patients and caregivers. Two versions of the radiological report were randomly distributed, either a standard report or one with layman translations to evaluate participant understanding and accuracy of interpreting radiological results. Among 85 participants, a majority (67.8%) reported wanting patient portal access to radiological reports, yet less than a quarter (21.2%) felt confident in reading and interpreting radiological reports. Univariate binary logistic regression models showed that participants who read the lay report were 8 times more likely to find the radiology report easy to read. This research demonstrated that the inclusion of layman translation of standard radiology reports improves oncology patients' and caregivers' understanding of such reports with statistically significant and clinically meaningful increases in readability.

Treatment of Women With Hepatitis C Diagnosed in Pregnancy: a Co-Located Treatment Approach

The development of direct-acting antiviral (DAA) treatments for hepatitis C virus (HCV) has revolutionized the management of HCV among virtually all patients. However, perhaps the last frontier of HCV treatment is in individuals with HCV during pregnancy for whom there are no specific guidelines for treatment. 1 Kushner T. et al. Ther Adv Infect Dis. 2019; 6: 1-4 Google Scholar Over the past decade, in relation to the increased rates of opioid use among young individuals, a significant increase has been seen in HCV seen among women of childbearing years and in women during pregnancy. 2 Rossi R.M. et al. Obstet Gynecol. 2020; 135: 387-395 Crossref PubMed Scopus (17) Google Scholar Over the past 2 years, the American Association for the Study of Liver Diseases, Centers for Disease Control and Prevention, US Preventative Services Task Force, and, most recently, the American College of Obstetricians and Gynecologists have each recommended screening of all women for HCV during pregnancy. For individuals who screen positive for HCV in pregnancy, per American Association for the Study of Liver Diseases guidelines, “treatment can be considered during pregnancy on an individual basis after a patient-physician discussion about the potential risks and benefits.” 3 American Association for the Study of Liver Diseases. https://www.hcvguidelines.org/unique-populations/pregnancy Google Scholar However, despite these recommendations and a published clinical trial of the use of sofosbuvir/ledipasvir in pregnancy 4 Chappell C.A. et al. Lancet Microbe. 2020; 1: e200-e208 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar (and others currently underway), presently there are no published real-world data regarding HCV treatment during pregnancy in the United States. We describe a case series of women who screened positive for HCV during pregnancy and were referred to our practice for HCV treatment.

Complementary and alternative medicine exposure in oncology (CAMEO) study: A multi-institutional cross-sectional analysis of patients receiving cancer treatment.

e18739 Background: Compared to standard of care treatments, complementary and alternative medicine (CAM) use has been associated with decreased survival in cancer patients. CAM includes a broad range of treatments including vitamins/minerals, herbs/supplements, special diets, and mind/body interventions. An improved understanding of contemporary prevalence, predictors and intended goals of CAM use is needed to improve the cancer patient experience and guide shared decision-making regarding risks and benefits of their use. Methods: A cross-sectional survey of prospectively enrolled adult cancer patients treated at a large regional non-profit cancer center and an NCI-Designated Comprehensive Cancer Center between 2020 and 2021 was collected. Patients receiving cancer treatment were selected for analysis and grouped based on reported CAM use. Differences between CAM users and nonusers were assessed by chi-squared for categorical and two-sample t-test for continuous variables. Predictors of CAM use were identified with univariable and multivariable logistic regression. Results: Of 749 respondents, 83.31% had heard of or been recommended a CAM. Rates of CAM use during cancer treatment were highest for vitamins/minerals (56%), mind/body (52%), herbs/supplements (38%), special diets (30%), and other (12%). In the most common primary cancers, overall rates of CAM use were high (Breast: 84%, prostate: 66%, lung: 79%). Most patients (91%) use CAM in addition to conventional treatments. The intended goal of CAM therapy was most often management of symptoms (42%), treatment of cancer (30%), and mental health (15%). CAM users were younger than non-users (median age 62 years [y] vs 65y, p = 0.03). Females had higher rates of CAM use compared to males (86% vs. 78%, p < 0.01). Patients with incurable cancer had higher rates of CAM use than those with curable cancer (82% vs. 72%, p < 0.01). Predictors of CAM use on multivariable model include female gender (OR 2.5, p < 0.01) and incurable cancer (OR 2.5, p < 0.01). During cancer treatment, patients using CAM used multiple therapies and therapy types, including an average of 3.3 vitamins/minerals, 3.1 herbs/supplements, 2.5 mind/body exercises, and 1.6 special diets. Conclusions: CAM use is common among cancer patients receiving radiation, chemotherapy, and or surgery. Many patients are taking multiple CAM therapies during treatment with one third of patients using CAM with the intended goal of treating their cancer. This data provides details about and predictors of CAM use and provides information to guide patient-physician discussions.

Risk assessment of atherosclerotic cardiovascular diseases before statin therapy initiation: Knowledge, attitude, and practice of physicians in Yemen.

Risk evaluation of atherosclerotic cardiovascular disease (ASCVD) remains the cornerstone of primary prevention. The cardiovascular risk assessment can guide the decision-making on various preventive measures such as initiating or deferring statin therapy. Thus, our study aimed to assess the physicians' knowledge, attitude, and practices regarding atherosclerotic cardiovascular diseases risk assessment. Also, we evaluated the physician-patient discussion and counseling practices before statin therapy initiation in concordance with recommendations from the latest clinical practice guideline. A cross-sectional study was conducted between November 2020 and January 2021. A self-administered questionnaire was distributed to 350 physicians (GPs, residents, specialists, and consultants). Two trained pharmacists distributed the questionnaires in 5 major tertiary governmental hospitals and more than ten private hospitals. Also, private clinics were targeted so that we get a representative sample of physicians at different workplaces. A total of 270 physicians filled the questionnaire out of 350 physicians approached, with 14 being excluded due to high missing data, giving a final response rate of 73%. Participants had suboptimal knowledge and practices with a high positive attitude toward atherosclerotic cardiovascular diseases risk assessment. The knowledge and practices were higher among consultants, participants from the cardiology department, those with experience years of more than nine years, and those who reported following a specific guideline for cholesterol management or using a risk calculator in their practice. Notably, the risk assessment and counseling practices were lower among physicians who reported seeing more patients per day. Physicians had overall low knowledge, suboptimal practices, and a high positive attitude toward cardiovascular risk assessment. Therefore, physicians' training and continuing medical education regarding cholesterol management and primary prevention clinical practice guidelines are recommended. Also, the importance of adherence to clinical practice guidelines and their impact on clinical outcomes should be emphasized.

Sudden cardiac death in cardiomyopathies: acting upon "acceptable" risk in the personalized medicine era.

Patients with cardiomyopathies are confronted with the risk of sudden cardiac death (SCD) throughout their lifetime. Despite the fact that SCD is relatively rare, prognostic stratification is an integral part of physician-patient discussion, with the goal of risk modification and prevention. The current approach is based on a concept of "acceptable risk." However, there are intrinsic problems with an algorithm-based approach to risk management, magnified by the absence of robust evidence underlying clinical decision support tools, which can make high- versus low-risk classifications arbitrary. Strategies aimed at risk reduction range from selecting patients for an implantable cardioverter defibrillator (ICD) to disqualification from competitive sports. These clinical options, especially when implying the use of finite financial resources, are often delivered from the physician's perspective citing decision-making algorithms. When the burden of intervention-related risks or financial costs is deemed higher than an "acceptable risk" of SCD, the patient's perspective may not be appropriately considered. Designating a numeric threshold of "acceptable risk" has ethical implications. One could reasonably ask "acceptable to whom?" In an era when individual choice and autonomy are pillars of the physician-patient relationship, the subjective aspects of perceived risk should be acknowledged and be part of shared decision-making. This is particularly true when the lack of a strong scientific evidence base makes a dichotomous algorithm-driven approach suboptimal for unmitigated translation to clinical practice.

Multiple Sclerosis Progression Discussion Tool Usability and Usefulness in Clinical Practice: Cross-sectional, Web-Based Survey.

BackgroundA digital tool, Multiple Sclerosis Progression Discussion Tool (MSProDiscuss), was developed to facilitate discussions between health care professionals (HCPs) and patients in evaluating early, subtle signs of multiple sclerosis (MS) disease progression.ObjectiveThe aim of this study is to report the findings on the usability and usefulness of MSProDiscuss in a real-world clinical setting.MethodsIn this cross-sectional, web-based survey, HCPs across 34 countries completed an initial individual questionnaire (comprising 7 questions on comprehensibility, usability, and usefulness after using MSProDiscuss during each patient consultation) and a final questionnaire (comprising 13 questions on comprehensibility, usability, usefulness, and integration and adoption into clinical practice to capture the HCPs’ overall experience of using the tool). The responses were provided on a 5-point Likert scale. All analyses were descriptive, and no statistical comparisons were made.ResultsIn total, 301 HCPs tested the tool in 6974 people with MS, of whom 77% (5370/6974) had relapsing-remitting MS, including those suspected to be transitioning to secondary progressive MS. The time taken to complete MSProDiscuss was reported to be in the range of 1 to 4 minutes in 97.3% (6786/6974; initial) to 98.2% (269/274; final) of the cases. In 93.54% (6524/6974; initial) to 97.1% (266/274; final) of the cases, the HCPs agreed (4 or 5 on the Likert scale) that patients were able to comprehend the questions in the tool. The HCPs were willing to use the tool again in the same patient, 90.47% (6310/6974; initial) of the cases. The HCPs reported MSProDiscuss to be useful in discussing MS symptoms and their impact on daily activities (6121/6974, 87.76% initial and 252/274, 92% final) and cognitive function (5482/6974, 78.61% initial and 271/274, 79.2% final), as well as in discussing progression in general (6102/6974, 87.49% initial and 246/274, 89.8% final). While completing the final questionnaire, 94.9% (260/274) of the HCPs agreed that the questions were similar to those asked in regular consultation, and the tool helped to better understand the impact of MS symptoms on daily activities (249/274, 90.9%) and cognitive function (220/274, 80.3%). Overall, 92% (252/274) of the HCPs reported that they would recommend MSProDiscuss to a colleague, and 85.8% (235/274) were willing to integrate it into their clinical practice.ConclusionsMSProDiscuss is a usable and useful tool to facilitate a physician-patient discussion on MS disease progression in daily clinical practice. Most of the HCPs agreed that the tool is easy to use and were willing to integrate MSProDiscuss into their daily clinical practice.

Acceptability of an mHealth breast cancer risk-reduction intervention promoting risk assessment, education, and discussion of risk in the primary care setting.

Breast cancer risk assessment tools and risk reduction strategies have advanced significantly over the past few decades but are underutilized in practice, due in part to limited acceptability by patients and physicians. We implemented a tablet-based Breast Cancer Risk Education Intervention (BreastCARE) tailored towards increasing patients' knowledge about their individual risk of developing breast cancer, increasing patient-physician discussion of breast cancer risk reduction practices, and increasing participation in recommended screening. We surveyed patients and physicians who received the BreastCARE intervention and analyzed their satisfaction and acceptability of the intervention. We compared patient satisfaction measures by race/ethnicity and used multivariable logistic regression models to examine the effect of race/ethnicity on measures of patient satisfaction with the tablet-based risk assessment and with the breast cancer risk report. We also compared measures of physician satisfaction by resident vs. attending/NP status. Finally, we identified patients' and physicians' suggestions for implementation. Overall, both patients and physicians were highly satisfied with BreastCARE, with some variation by patient race/ethnicity and breast cancer risk status. The risk assessment tool and accompanying risk report helped transmit complex information in an efficient way. Patient self-administered risk assessment with a health education component at the point of care is acceptable for both patients and physicians, and represents a novel approach to facilitating health promotion. This risk assessment tool should be made routine in primary care accompanied by results that are easy for the patient to understand and actionable for the clinician.

Physician-patient communication of costs and financial burden of cancer and its treatment: a systematic review of clinical guidelines

BackgroundOptimising the care of individuals with cancer without imposing significant financial burden related to their anticancer treatment is becoming increasingly difficult. The American Society of Clinical Oncology (ASCO) has recommended clinicians discuss costs of cancer care with patients to enhance shared decision-making. We sought information to guide oncologists’ discussions with patients about these costs.MethodsWe searched Medline, EMBASE and clinical practice guideline databases from January 2009 to 1 June 2019 for recommendations about discussing the costs of care and financial burden. Guideline quality was assessed with the AGREE-II instrument.ResultsTwenty-seven guidelines met our eligibility criteria, including 16 from ASCO (59%). 21 of 27 (78%) guidelines included recommendations about discussion or consideration of treatment costs when prescribing, with information about actual costs in four (15%). Recognition of the risk of financial burden or financial toxicity was described in 81% (22/27) of guidelines. However, only nine guidelines (33%) included information about managing the financial burden.ConclusionsCurrent clinical practice guidelines have little information to guide physician-patient discussions about costs of anticancer treatment and management of financial burden. This limits patients’ ability to control costs of treatment, and for the healthcare team to reduce the incidence and severity of financial burden. Current guidelines recommend clinician awareness of price variability and high costs of treatment. Clinicians are recommended to explore cost concerns and address financial worries, especially in high risk groups. Future guidelines should include advice on facilitating cost transparency discussions, with provision of cost information and resources.

"Do you want us to try to resuscitate?": Conversational practices generating patient decisions regarding cardiopulmonary resuscitation

ObjectiveTo explore how physicians elicit patients’ preferences about cardio-pulmonary resuscitation (CPR) during hospital admission interviews. MethodsConversation analysis of 37 audio-recorded CPR patient-physician discussions at admission to a geriatric hospital. ResultsThe most encountered practice is when physicians submit an option to the patient’s validation (“do you want us to resuscitate”). Through it, physicians display presuppositions about the patient’s preference, which is not elicited as an autonomous contribution. Through open elicitors (“what would you wish”), physicians treat patients as knowledgeable about options and autonomous in determining their preference. A third practice is related to patients delivering their preference in anticipation of the request and is encountered only for choices against CPR. These decisions are revealed as informed and autonomous, and the patient as collaborative. ConclusionThe way that physicians elicit patients’ preferences about CPR influences the delivery of autonomous and informed decisions. Our findings point to an asymmetry in ways of initiating talk about the possibility of not attempting CPR, potentially exacerbated by the context of admission interviews. Practice implicationsDecisions about the relevancy life-sustaining interventions need an adequate setting in order to allow for patient participation. Our findings have implications for communication training in regard to involving patients in conversations about goals of care.

Prognostic Modeling of Parkinson's Disease Progression Using Early Longitudinal Patterns of Change.

Predicting Parkinson's disease (PD) progression may enable better adaptive and targeted treatment planning. Develop a prognostic model using multiple, easily acquired longitudinal measures to predict temporal clinical progression from Hoehn and Yahr (H&Y) stage 1 or 2 to stage 3 in early PD. Predictive longitudinal measures of PD progression were identified by the joint modeling method. Measures were extracted by multivariate functional principal component analysis methods and used as covariates in Cox proportional hazards models. The optimal model was developed from the Parkinson's Progression Marker Initiative (PPMI) data set and confirmed with external validation from the Longitudinal and Biomarker Study in PD (LABS-PD) study. The proposed prognostic model with longitudinal information of selected clinical measures showed significant advantages in predicting PD temporal progression in comparison to a model with only baseline information (iAUC=0.812 vs. 0.743). The modeling results allowed the development of a prognostic index for categorizing PD patients into low, mid, and high risk of progression to HY 3 that is offered to facilitate physician-patient discussion on prognosis. Incorporating longitudinal information of multiple clinical measures significantly enhances predictive performance of prognostic models. Furthermore, the proposed prognostic index enables clinicians to classify patients into different risk groups, which could be adaptively updated as new longitudinal information becomes available. Modeling of this type allows clinicians to utilize observational data sets that inform on disease natural history and specifically, for precision medicine, allows the insertion of a patient's clinical data to calculate prognostic estimates at the individual case level. © 2021 International Parkinson and Movement Disorder Society.

Gaps in patient-physician communication at the time of malignant bowel obstruction from recurrent gynecologic cancer: a qualitative study.

We sought to investigate the patient and physician approaches to malignant bowel obstruction (MBO) due to recurrent gynecologic cancer by (1) comparing patient and physician expectations and priorities during a new MBO diagnosis, and (2) highlighting factors that facilitate patient-doctor communication. Patients were interviewed about their experience during an admission for MBO, and physicians were interviewed about their general approach towards MBO. Interviews were analyzed for themes using QDAMiner qualitative analysis software. The analysis utilized the framework analysis and used both predetermined themes and those that emerged from the data. We interviewed 14 patients admitted with MBO from recurrent gynecologic cancer and 15 gynecologic oncologists. We found differences between patients and physicians regarding plans for next chemotherapy treatments, foremost priorities, communication styles, and need for end-of-life discussions. Both patients and physicians felt that patient-physician communication was improved in situations of trust, understanding patient preferences, corroboration of information, and increased time spent with patients during and before the MBO. Gaps in patient-physician communication could be targeted to improve the patient experience and physician counseling during a difficult diagnosis. Our findings emphasize a need for patient-physician discussions to focus on expectations for future cancer-directed treatments, support for patients at home with home health or hospice level support in line with their wishes, and acknowledgement of uncertainty while providing direct information about the MBO diagnosis.

Evaluating Treatment Preferences and Perceptions of a Prosthetic Versus a Transplanted Hand: A Conjoint Analysis-Based Study.

This study used a conjoint analysis-based survey to assess which factors are most influential when considering treatment with a prosthesis or transplant after a unilateral hand amputation. Overall, 469 respondents were recruited using Amazon Mechanical Turk and asked to assume that they experienced a hand amputation. To determine preferences for a prosthetic, respondents chose among 11 pairs of alternatives with variations in the following attributes: appearance, function, maintenance, and learning time. Respondents were then presented with descriptions of the risks and outcomes of hand transplantation. The most compelling reasons for and against a transplant were determined and characteristics predictive of support for a transplant were identified. The most important attributes for a prosthesis were "lifelike appearance" and "myolectric function." For hand transplantation, respondents were most concerned about immunosuppression side effects (n = 323, 69%) and the intense nature of surgery (n = 275, 59%), whereas the most positive benefit was the concept of the transplant being "natural" (n = 339, 72%). When faced with the choice of a hand transplant or a prosthetic, approximately 50% of respondents chose a transplantation. Younger age, previous medical experiences, a perceived "familiarity with medical issues," and the regular attendance of religious services were associated with strong support for a hand transplantation (P < 0.01). When considering a hand prosthesis, respondents are motivated most by appearance and function. Meanwhile, with hand transplantation, the risks of immunosuppression and the intense nature of surgery and recovery are predominant concerns. These findings may help inform patient-physician discussions when considering treatment after unilateral hand amputation.

Treatment-related side effects and views about dosage assessment to sustain quality of life: Results of an advocate-led survey of patients with metastatic breast cancer (MBC).

1005 Background: Metastatic breast cancer (MBC) is generally incurable and the majority of patients with MBC will remain on treatment indefinitely. Patients usually begin each new treatment at the Recommended Starting Dose (RSD) on the FDA-approved label based on results from clinical trials. However, patients’ ability to tolerate the RSD in the real-world may differ from the clinical trial setting. While the importance of patient reported outcomes is recognized, understanding tolerability from the patient’s perspective is lacking and patients’ willingness to discuss individualized doses for MBC therapy has not been evaluated. Methods: Patient advocates from the Patient-Centered Dosing Initiative distributed a confidential online survey to patients with MBC via social media groups, organizational newsletters, and online support forums. The survey was developed by patients and medical oncologists to ascertain the prevalence and impact of patients’ treatment-related side effects, quality of patient-physician communication, management of side effects, and interest in alternative approaches to the RSD when a new treatment is initiated or adverse side effects are experienced. Results: 1,221 patients with MBC completed the survey within 15 days. The median number of lines of MBC therapy was 2.5 (range 1 - ≥5) and 46% (n = 564) of patients received their MBC diagnosis within two years of taking the survey. 86% (n = 1,051) reported experiencing at least one significant treatment-related side effect, and of these, 20% (n = 213) visited the Emergency Room/hospital and 43% (n = 454) missed at least one treatment. 98% (n = 1,026) of patients with side effects discussed them with their doctors and 82% (n = 838) were helped by their physicians. The most common (non-exclusive) mitigation strategies were dosage reductions (66%, n = 556) and prescription medications (59%, n = 494). Of the 556 patients given a dosage reduction, 83% (n = 459) reported feeling better. Notably, 92% (n = 1,127) of patients expressed willingness to discuss alternative dosing options with their physicians based upon their personal characteristics and individual preferences. Conclusions: Given that 86% of patients with MBC experienced at least one significant treatment-related side effect and 83% improved after dosage reduction, innovative dosage-related strategies are warranted to sustain Quality of Life. Patient-physician discussions in which the patient’s physical attributes and circumstances are periodically assessed may determine the right dose for the patient upon treatment initiation and afterwards, and the vast majority of patients would be receptive to such discussions.

Documentation of the patient’s smoking status in common chronic diseases – analysis of medical narrative reports using the ULMFiT based text classification

ABSTRACT Introduction: Smoking cessation is essential part of a successful treatment in many chronic diseases. Our aim was to analyse how actively clinicians discuss and document patients’ smoking status into electronic health records (EHR) and deliver smoking cessation assistance. Methods: We analysed the results using a combination of rule and deep learning-based algorithms. Narrative reports of all adult patients, whose treatment started between years 2010 and 2016 for one of seven common chronic diseases, were followed for two years. Smoking related sentences were first extracted with a rule-based algorithm. Subsequently, pre-trained ULMFiT-based algorithm classified each patient’s smoking status as a current smoker, ex-smoker, or never smoker. A rule-based algorithm was then again used to analyse the physician-patient discussions on smoking cessation among current smokers. Results: A total of 35,650 patients were studied. Of all patients, 60% were found to have a smoking status in EHR and the documentation improved over time. Smoking status was documented more actively among COPD (86%) and sleep apnoea (83%) patients compared to patients with asthma, type 1&2 diabetes, cerebral infarction and ischemic heart disease (range 44-61%). Of the current smokers (N=7,105), 49% had discussed smoking cessation with their physician. The performance of ULMFiT-based classifier was good with F-scores 79-92. Conclusion: Ee found that smoking status was documented in 60% of patients with chronic disease and that the clinician had discussed smoking cessation in 49% of patients who were current smokers. ULMFiT-based classifier showed good/excellent performance and allowed us to efficiently study a large number of patients’ medical narratives.

Parkinson's Disease Is Associated with Increased Complications, Readmission Rates, and Costs of Care after Total Hip Arthroplasty: A Matched-Cohort Analysis

AbstractStudies investigating the impact of Parkinson's disease (PD) on patients undergoing primary total hip arthroplasty (THA) are limited. Therefore, the purpose of this study was to investigate whether PD patients undergoing primary THA are at increased risk of: (1) medical complications; (2) implant-related complications; (3) readmissions; and (4) costs. A query was performed using an administrative claims database. Matched non-PD patients undergoing primary THA served as a control group. Non-PD patients undergoing primary THA served as a matching cohort. The query yielded 39,184 patients (PD = 9,796; control = 29,388). Pearson's chi-square tests, logistic regression analyses, and Welch's t-tests were used to test for significance between the cohorts. Patients who have PD were found to have increased odds (4.64 vs. 1.15%; odds ratio [OR]: 4.19, 95% confidence interval [CI]: 3.60–4.87, p &lt; 0.0001) of medical complications compared with the matched cohort. PD patients had greater odds of implant-related complications (7.12 vs. 3.99; OR: 1.84, p &lt; 0.0001). PD patients also had significantly higher odds of 90-day readmission (19.83 vs. 15.29%; OR: 1.37, 95% CI: 1.29–1.45, p &lt; 0.0001) and incurred greater 90-day costs of care ($20,143 vs. $16,905, p &lt; 0.0001). The results of the study demonstrate that PD is an independent risk factor for medical complications, implant-related complications, readmission rates, and increased costs of care following a primary THA. The findings of this study should be used in risk stratification and should inform physician–patient discussion but should not be arbitrarily used to deny access to care.

Management of Graves’ Hyperthyroidism: More Than a Century of Progression

Context: There are three therapeutic modalities for the management of Graves’ disease (GD), including thyroid surgery, radioactive iodine (RAI), and antithyroid drugs (ATDs). We aimed to briefly review the history of these treatment strategies and their advantages and disadvantages. Evidence Acquisition: We searched PubMed for English language articles using pertinent search terms. Results: Each treatment modality for GD is accompanied by several advantages and disadvantages. Nowadays, ATDs are the most commonly prescribed therapy for GD worldwide. The lack of well-designed, large RCTs comparing three different treatments for hyperthyroidism concerning various short-term and long-term outcomes has led to remarkable uncertainty in the preference of each of these treatments, as is evident in relevant guidelines from different societies. Recently, the efficacy and safety of long-term use of ATDs have been documented. Conclusions: Pros and cons of each therapeutic modality for Graves’ hyperthyroidism should be taken into account during the physician-patient discussion to select the primary treatment. Considering recent data about the long-term efficacy and safety of ATDs, it seems that the appropriate selection of Graves’ patients for long-term ATD therapy can be a new avenue in the treatment and even cure of GD.

Impact of Parkinson's Disease on Complications, Readmission Rates, and Costs of Care following Primary Total Knee Arthroplasty.

Large-scale studies evaluating the effects of Parkinson's disease (PD) on primary total knee arthroplasty (TKA) are limited. The purpose of this study was to determine if PD patients undergoing primary TKA have increased: (1) medical complications; (2) implant-related complications; (3) readmission rates; and (4) costs. A query was performed using an administrative claims database. The study group consisted of all patients undergoing primary TKA who had a history of PD. Matched non-PD patients undergoing primary TKA served as a control group. The query yielded 72,326 patients (PD = 18,082; matching cohort = 54,244). Pearson's chi-square tests, logistic regression analyses, and Welch's t-tests were used to test for significance between the cohorts. Primary TKA patients who had PD were found to have greater incidences and odds of medical complications (4.21 vs. 1.24%; odds ratio [OR]: 3.50, 95% confidence interval [CI]: 3.15-3.89, p < 0.0001) and implant-related complications (5.09 vs. 3.15%; OR: 1.64, 95% CI: 1.51-1.79, p < 0.0001) compared with the matching cohort. Additionally, the rates and odds of 90-day readmission were higher (16.29 vs. 12.66%; OR:1.34, p < 0.0001) and episodes of care costs were significantly greater ($17,105.43 vs. $15,252.34, p < 0.0001) in patients who had PD. Results demonstrate that PD patients undergoing primary TKA had higher incidences of medical and implant-related complications. They also had increased 90-day readmission rates and costs compared with controls. The findings of this study should be used in risk stratification and should inform physician-patient discussion but should not be arbitrarily used to deny access to care.

Nonconscious nonverbal synchrony and patient and physician affect and rapport in cancer treatment discussions with black and white patients.

12116 Background: Clinical communication is poorer with Black patients than with White patients, but most studies are limited to verbal communication. Nonverbal synchrony, the subtle, nonconscious coordination of movement between individuals, has been shown to reflect relationship quality. We investigated nonverbal synchrony’s association with patient and physician affect and rapport in cancer treatment discussions, and if those associations differed by patient race. Methods: We used motion detection software to measure overall synchrony and synchrony based on who is leading in the interaction (similar to leading in dancing) in video recordings of 68 Black patients and 163 White patients discussing treatment with their non-Black physicians. Additionally, naïve observers rated the interaction for six constructs: patient and physician positive and negative affect and patient-physician positive and negative rapport. We examined associations between nonverbal synchrony and the six constructs. Results: In interactions with Black patients, overall synchrony was positively associated with patients’ positive affect and positive patient-physician rapport and negatively associated with patients’ negative affect and negative patient-physician rapport. When the physician was leading, synchrony was positively associated with patients’ positive affect and positive patient-physician rapport and negatively associated with patients’ negative affect and negative patient-physician rapport. When the patient was leading, synchrony was positively associated with patients’ and physicians’ positive affect and positive patient-physician rapport, and negatively associated with patients’ negative affect and negative patient-physician rapport. In interactions with White patients, overall synchrony was positively associated with patient positive affect; when the physician was leading, synchrony was negatively associated with patient negative affect. Conclusions: This is the first study to use an innovative measure of dynamic communication in patient-physician cancer treatment discussions. Nonverbal synchrony was related to patient and physician affect and rapport in interactions with Black patients, but only patient affect in interactions with White patients, suggesting nonverbal synchrony is particularly important in interactions with Black patients. Next steps include investigating associations with patient outcomes (e.g., satisfaction). Findings could contribute to physician training.