Patient-provider Agreement Research Articles

Factors That Predict Magnitude, Timing, and Persistence of Placebo-Like Response in Patients With Irritable Bowel Syndrome

Placebo response impedes the development of novel irritable bowel syndrome (IBS) therapies and the interpretability of randomized clinical trials. This study sought to characterize the magnitude, timing, and durability of IBS symptom relief in patients undergoing a non-drug placebo-like control. One hundred forty-five Rome III-diagnosed patients (80% F, M age = 42 years) were assigned to education/nondirective support delivered over a 10-week acute phase. Treatment response was based on the IBS version of the Clinical Global Improvement Scale completed 2 weeks after treatment ended. Candidate predictors were assessed at baseline (eg, emotion regulation, pain catastrophizing, distress, neuroticism, stress, somatization, gastrointestinal-specific anxiety) or clinically relevant points during treatment (patient-provider relationship, treatment expectancy/credibility). Midtreatment response was associated with lower levels of stress and somatization at baseline and greater patient-provider agreement on treatment tasks (P < .001). Treatment response was associated with baseline gastroenterologist-rated IBS severity, anxiety, ability to reappraise emotions to reduce their impact [cognitive reappraisal], and agreement that provider and patient shared goals from provider perspective (P < .001). The day-to-day ability to reappraise emotions at baseline distinguished rapid from delayed placebo responders (P = .011). Patient beliefs (eg, perceived stress, cognitive reappraisal) impacted the magnitude, timing, and persistence of placebo response measured at midway point of acute phase and 2 weeks after treatment discontinuation. Baseline beliefs that patients could alter the impact of stressful events by rethinking their unpleasantness distinguished rapid vs delayed placebo responders. Collaborative agreement between doctor and patient around shared tasks/goals from the clinician perspective predicted placebo response.

Serial Assessment of Depression and Anxiety by Patients and Providers in Women Receiving Chemotherapy for Early Breast Cancer.

Depression and anxiety are common in patients with breast cancer and associated with worse quality of life and treatment outcomes. Yet, these symptoms are often underrecognized and undermanaged in oncology practice. The objective of this study was to describe depression and anxiety severity and associated patient factors during adjuvant or neoadjuvant chemotherapy in women with early breast cancer using repeated single-item reports. Depression and anxiety were measured from consecutive patients and their clinicians during chemotherapy infusion visits. Associations between psychiatric symptoms and patient characteristics were assessed using Fisher's exact tests for categorical variables and t tests for continuous variables. The joint relationship of covariates significant in unadjusted analyses was evaluated using log-binomial regression. Cohen's kappa was used to assess agreement between patient- and clinician-reported symptoms. In a sample of 256 patients, 26% reported at least moderately severe depression, and 41% reported at least moderately severe anxiety during chemotherapy, representing a near doubling in the prevalence of these symptoms compared with before chemotherapy. Patient-provider agreement was fair (depression: κ = 0.31; anxiety: κ = 0.28). More severe psychiatric symptoms were associated with being unmarried, having worse function, endorsing social activity limitations, using psychotropic medications, and having a mental health provider. In multivariable analysis, social activity limitations were associated with more severe depression (relative risk [RR], 2.17; 95% confidence interval [CI], 1.36-3.45) and anxiety (RR, 1.48; 95% CI, 1.05-2.09). Oncologists frequently underestimate patients' depression and anxiety and should consider incorporating patient-reported outcomes to enhance monitoring of mental health symptoms. In this sample of 256 patients with breast cancer, depression and anxiety, measured using single-item toxicity reports completed by patients and providers, were very common during adjuvant or neoadjuvant chemotherapy. Patient-reported depression and anxiety of at least moderate severity were associated with multiple objective indicators of psychiatric need. Unfortunately, providers underrecognized the severity of their patients' mental health symptoms. The use of patient-reported, single-item toxicity reports can be incorporated into routine oncology practice and provide clinically meaningful information regarding patients' psychological health.

Pharmacy multidisciplinary stewardship program for high-risk patients prescribed opioids in an academic clinic.

To assess observation of the Centers for Disease Control (CDC) Guideline for prescribing opioids for chronic pain within a Pharmacy Controlled Substance Clinic (PCSC) compared to usual care by resident physicians in a Primary Care Internal Medicine (IM) clinic. Single-center, retrospective cohort. IM clinic within a large, academic medical center. Patients receiving stable opioid prescriptions for management of chronic nonmalignant pain (CNCP) were screened. Exclusions included age < 18 years old, aberrant opioid use behaviors, or malignancy-related pain. Both cohorts included 100 eligible patients. Within the PCSC, a pharmacy team provided assistance to resident physicians monitoring patients receiving opioid medications. The primary outcome was application of CDC guidelines: creation of an annual patient provider agreement (PPA); annual urine drug screen (UDS); quarterly review of a prescription drug monitoring program (CURES); and documentation of quarterly evaluation of opioid use. Secondary outcomes included risk factors for opioid-related harms. Respective measures from the control versus the intervention group demonstrated: PPA creation in 28 percent (n = 28) versus 100 percent (n = 100) (p < 0.001); UDS obtained in 59.2 percent (n = 58) versus 90.6 percent (n = 87) (p < 0.001); quarterly CURES review in 26 percent (n = 26) versus 70 percent (n = 70) (p < 0.001); and quarterly evaluation of opioid use in 26 percent (n = 26) versus 37 percent (n = 37) (p = 0.10). Pharmacy-led monitoring of patients prescribed opioids for CNCP in an academic resident clinic improves implementation of CDC guidelines. Similar multidisciplinary team integration may improve opioid prescribing safety in academic primary care settings.

Implementation of a Patient-Provider Agreement to Improve Healthcare Delivery for Patients With Substance Use Disorder in the Inpatient Setting.

ObjectivesInpatient healthcare delivery to people who use drugs is an opportunity to provide acute medical stabilization and offer treatment for underlying substance use disorder (SUD). The process of delivering quality healthcare to people with SUD can present challenges.MethodsWe convened a group of stakeholders to discuss challenges and opportunities for improving healthcare safety and employee satisfaction when providing inpatient care to people with SUD.ResultsWe developed, implemented, and evaluated a “Pain and Addiction Agreement” tool, a document to guide discussions between providers and patients about expectations and policies for inpatient care.ConclusionsIn this article, we share our experience of working closely with stakeholders. We hope that our project can serve as a blueprint motivating other centers to pursue quality improvement initiatives to improve healthcare for people with SUD and support the people who take care of them in the hospital.

Normalizing the use of patient-provider agreement for opioid treatment within a cancer institute.

251 Background: Addressing the opioid epidemic can be challenging in a large academic cancer program and necessitates the need for a multidisciplinary approach for implementation of a successful program. The oncologist has a challenging role caring for patients with preexisting pain conditions, acute cancer-related pain, pain at the end of life and cancer survivors who live with cancer as a chronic condition after treatment. Methods: A structured program was developed to address the mounting pressure from many fronts related to the opioid epidemic including insurance companies, pharmacies, and the Department of Health. In April 2018, the Lifespan Cancer Institute implemented a system wide opioid program including patient education, an electronic patient-provider treatment agreement, and an electronic template for provider documentation. The intent of the program is to implement safe processes to safe guard the patient and their family along with the providers. The patient-provider treatment agreement clearly describes the roles and responsibilities of both groups with a goal of reducing risks by improving education. Our responsibility is to provide optimal management while addressing patient concerns and maintaining patient safety. Results: The opioid program has been well received by both caregivers, patients and families. All are engaged in the embedded education process and fully appreciate the need to use opioids safely. The program has been helpful in managing patient expectations and focusing difficult conversations in cases of potential abuse. In April 2018, only 13% of patients prescribed an opioid had a signed patient-provider treatment agreement. As of April 2019, 75% of patients have a signed agreement. Conclusions: The transitioning of care for the patient with chronic pain after completion of active cancer treatment continues to be a focus of future initiatives. Patient satisfaction remains a top priority as the patient-provider agreement becomes a standard of care for all patients receiving opioids. As oncology healthcare providers, our responsibility is to screen and educate patients on the risk of opioid addiction and diversion while providing compassionate palliative care.

A multicentre evaluation of an opioid patient–provider agreement

The role of the patient–provider agreement (PPA) is to set forth respective roles and responsibilities for opioid therapy with the goal of improving outcomes, reducing risks, and improving patient education....

How does patient-provider communication influence adherence to asthma medications?

ObjectiveTo assess hypothesized pathways through which patient-provider communication impacts asthma medication adherence. MethodsA national sample of 452 adults with asthma reported assessments of patient-provider communication, proximal outcomes (understanding of asthma self-management, patient-provider agreement, trust in the clinician, involvement in care, motivation), and adherence to asthma medications. Structural equation modeling was used to examine hypothesized pathways. ResultsSignificantly positive direct pathways were found between patient-provider communication and all proximal outcomes. Only positive indirect pathways, operating through trust and motivation, were found between patient-provider communication and medication adherence. ConclusionPatient-provider communication influences many desirable proximal outcomes, but only influences adherence through trust and motivation. Practice implicationsTo promote better adherence to asthma medication regimens and, ultimately positive asthma outcomes, healthcare providers can focus on implementing communication strategies that strengthen patients’ trust and increase patient motivation to use asthma medications.

Flibanserin: First agent for female sexual dysfunction

Flibanserin: First agent for female sexual dysfunction

Harnessing the potential of the therapeutic alliance.

Originally developed within psychoanalytic psychotherapy, the therapeutic alliance has emerged as a widely studied pantheoretical change variable. In fact, a Google Scholar search for “therapeutic alliance” and “outcome” returns roughly 135,000 hits. The vast majority of these studies have reported on the relationship between the alliance and psychotherapy outcome. However, a smaller but growing literature has also examined the relationship between the therapeutic alliance and pharmacotherapy adherence and outcome. The therapeutic or working alliance involves an ongoing collaboration between patient and provider encompassing both task- and affectively-oriented features of their relationship. Specifically, it is often defined as: a) the extent of patient-provider agreement on treatment goals; b) collaboration on treatment tasks necessary for goal attainment; and c) the affective bond (e.g., caring, liking, trust) between patient and provider (1). Patient and provider-rated, as well as observer-rated instruments are represented in the alliance-outcome literature.

Physician Estimate of Antiretroviral Adherence in India: Poor Correlation with Patient Self-Report and Viral Load

Adherence to antiretroviral therapy (ART) is critical in maintaining viral suppression and minimizing resistance in HIV-infected patients. We compared physician estimates of their patients' ART adherence with participant's self-reported adherence to determine patient-provider agreement and identify correlates of discordance in three private clinics in Mumbai, India. Between December 2004 and April 2005, 277 persons receiving ART at three private clinics in Mumbai, India, were interviewed regarding adherence to ART using the Adult AIDS Clinical Trials Group questionnaire. Physicians were also asked to assess their patients' adherence. Quantitative HIV-1 RNA level was determined for 200 participants. Agreement between provider estimate of adherence and participant self-report was low, kappa = 0.058 (95% confidence interval [CI] 0.011-0126). Of 200 participants whose viral load was obtained, viral suppression was associated with participant self-reported adherence (odds ratio [OR] 3.08; 95% CI 1.65-5.74; p < 0.05), but not with provider estimated adherence (OR 1.2; 95% CI 0.67-2.14; p = 0.54). Cost of ART was positively associated with physician underestimation of participant adherence and older age was negatively associated. No independent correlates of physician overestimation of participant adherence were found. There was poor agreement between physician estimate of adherence and patient self-report. Providers should avoid using their own assessment of patient ART adherence. Instead, providers should rely on effective and validated measures, especially when viral load or drug level monitoring are not readily available.

Anticoagulation clinic workflow analysis

To evaluate a workflow model and define factors affecting patient visit length in an anticoagulation clinic primarily treating an urban patient population. Workflow analysis. Anticoagulation clinic in Memphis, TN, between November 2005 and April 2006. 240 and 246 patient visits were assessed pre- and postintervention, respectively. For 7 weeks, pharmacists documented factors affecting visit length and problems addressed during the visit, which were classified as anticoagulation or non-anticoagulation related. Following data analysis, changes were made to address inefficiencies in the clinic workflow. Postintervention data were collected for 7 weeks to assess the impact of these interventions. Patient visit length and factors affecting patient visit length. Factors affecting visit length were overbooking, pharmacist preceptor availability, attending physician availability, and repeat venipuncture. To target these inefficiencies, changes were made to the clinic schedule and workflow and a patient-provider agreement was implemented. These interventions decreased the frequency of the visit length factors significantly. As a result, pharmacist providers addressed significantly more total problems (anticoagulation problems plus nonanticoagulation problems) without an increase in visit length. Periodically evaluating workflow efficiency and making changes, if indicated, is important. In this study, we identified areas for improvement in anticoagulation clinic efficiency and implemented specifically targeted interventions. The resolution of workflow issues created a more streamlined patient visit. This provided more time for pharmacists to address important health issues specific to our indigent patient population. Other clinicians can apply this model to their practice setting to evaluate and make improvements to workflow efficiency as a means of providing highquality patient care.

Discussing Weight with Obese Primary Care Patients: Physician and Patient Perceptions

To evaluate patient-provider agreement on whether weight and related behaviors were discussed during routine visits. Post-visit survey assessments of patients and providers. Obese patients make up the majority of all patients seen in primary care (PC). The patients and physicians were recruited at the time of PC visits. Percent patient-physician agreement and patient, provider and practice characteristics associated with agreement. Patients (456) and physicians (30) agreed about whether or not they discussed weight, physical activity (PA), and diet for 61% of office visits. There was disagreement on one of the items (weight, PA, or diet) for 23% of office visits, and for 2 or more of the items for 16% of the visits. Agreement was relatively greater for discussing weight than for discussing diet or physical activity. Physicians reported discussing weight issues more often than did patients. Overall patient-physician agreement was 0.51-0.59 (weighted Kappa statistic). In a multivariate analyses of factors associated with patient-physician agreement, health insurance (odds ratio [OR]=3.67, p value = 0.002), physician description of patient weight status (OR = 2.27, p value = 0.002), patient report of how weight relates to health (OR = 1.70, p value = 0.04), and female patient gender (OR = 1.62, p = value = 0.02) were significantly related to agreement. Patients and providers disagreed about whether or not weight issues were discussed in a large number of primary care encounters in this study. Physicians may be able to improve care for their obese patients by focusing discussions on specific details of diet and physical activity behaviors, and by clarifying that patients perceive weight-related information has been shared.

Renal Provider Recognition of Symptoms in Patients on Maintenance Hemodialysis

Although several studies have found that the burden of symptoms in patients who are on maintenance hemodialysis is substantial, little is known about renal providers' awareness of these symptoms. The aim of this study was to assess renal provider recognition of symptoms and their severity in hemodialysis patients. The Dialysis Symptom Index, a 30-item measure of symptoms and their severity, was administered to patients during a routine hemodialysis session. Immediately after surveying patients, the renal provider who evaluated the patient completed the Dialysis Symptom Index to report the symptoms that he or she believed were present in that patient. Sensitivity, specificity, and positive and negative predictive values of provider reports of symptoms were calculated using patient reports as the reference standard. Patient-provider agreement on the presence and severity of symptoms was assessed using the kappa statistic. Surveys were completed by 75 patients and 18 providers. For 27 of 30 symptoms, the sensitivity of provider responses was <50%, and provider responses for 25 symptoms were characterized by positive predictive values of <75%. kappa scores for 25 symptoms including those pertaining to pain, sexual dysfunction, sleep disturbance, and psychologic distress were <0.20, indicating poor provider recognition of these symptoms. Providers underestimated the severity of 19 of 30 symptoms. Renal providers are largely unaware of the presence and severity of symptoms in patients who are on maintenance hemodialysis. Implementation of a standardized symptom assessment process may improve provider recognition of symptoms and promote use of symptom-alleviating treatments.

The Importance of Establishing Regimen Concordance in Preventing Medication Errors in Anticoagulant Care

Miscommunication between patients and providers can have serious consequences, especially where medications are concerned. We examined whether regimen discordance between patient and provider, a possible result of miscommunication, contributes to unsafe medication management. We studied 220 patients taking warfarin in an anticoagulation clinic to characterize two medication assessment methods. We measured (1) adherence by asking patients to report any missed doses and (2) concordance between patients' and providers' reports of warfarin regimens. We categorized patients as having regimen adherence if they missed no doses, and concordance if there was patient–provider agreement in weekly dosage. We characterized anticoagulant outcomes as unsafe if international normalized ratio (INR) values were <2.0 (at risk for thrombosis) or >4.0 (at risk for hemorrhage), and explored relationships among adherence, concordance, and anticoagulant outcomes. One hundred fifty-five patients (71%) reported no missed doses during the prior 30 days. Poor adherence was associated with underanticoagulation (AOR 2.33, 1.56–3.45), but not overanticoagulation (AOR 1.36, 0.69–2.66). One hundred ten patients (50%) reported regimens discordant with clinicians' report. There was no relationship between patients' reports of adherence and concordance. Among adherent patients, discordance was associated with underanticoagulation (AOR 1.67, 1.00–2.78) and overanticoagulation (AOR 3.44, 1.32–9.09). Discordance regarding warfarin regimens is common and places patients at risk for adverse events. To promote safe and effective care, clinicians should separately determine adherence and regimen concordance during routine medication assessments. Systems need to be developed to ensure concordance in medication regimens.

When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make?

For patients with chronic illnesses, it is hypothesized that effective patient-provider collaboration contributes to improved patient self-care by promoting greater agreement on patient-specific treatment goals and strategies. However, this hypothesis has not been tested in actual encounters of patients with their own physicians. To assess the extent to which patients with type 2 diabetes agree with their primary care providers (PCPs) on diabetes treatment goals and strategies, the factors that predict agreement, and whether greater agreement is associated with better patient self-management of diabetes. One hundred twenty-seven pairs of patients and their PCPs in two health systems were surveyed about their top 3 diabetes treatment goals (desired outcomes) and strategies to meet those goals. Using several measures to evaluate agreement, we explored whether patient characteristics, such as education and attitudes toward treatment, and patient-provider interaction styles, such as shared decision making, were associated with greater agreement on treatment goals and strategies. We then examined whether agreement was associated with higher patient assessments of their diabetes care self-efficacy and self-management. Overall, agreement on top treatment goals and strategies was low (all kappa were less than 0.40). In multivariable analyses, however, patients with more education, greater belief in the efficacy of their diabetes treatment, and who shared in treatment decision making with their providers were more likely to agree with their providers on treatment goals or strategies. Similarly, physician reports of having discussed more content areas of diabetes self-care were associated with greater agreement on treatment strategies. In turn, greater agreement on treatment goals and strategies was associated both with higher patient diabetes care self-efficacy and assessments of their diabetes self-management. Although patients and their PCPs in general had poor agreement on goals and strategies for managing diabetes, agreement was associated with higher patient self-efficacy and assessments of their diabetes self-management. This supports the hypothesis that enhancing patient-provider agreement on both overall treatment goals and specific strategies to meet these goals may lead to improved patient outcomes.

Patient-Provider Agreement on Guidelines for Preparation for Breast Cancer Treatment

Abstract Guidelines for preparing cancer patients for threatening medical procedures were developed and refined and their perceived relevance and importance rated by three concerned groups—84 breast cancer patients, 64 doctors, and 140 nurses and nurse oncologists. All three groups indicated strong support for the guidelines. Patients and nurses rated more of the guidelines as essential aspects of good quality care than did doctors. Items in which a significant discrepancy existed included the importance of (a) consistent information, (b) involvement of others in preparation, and (c) assistance to the patient in coping with treatment for breast cancer: Doctors, compared with patients and nurses, underrated the importance of some aspects of preparation. These issues should be given more prominence in undergraduate and specialist medical training, as well as in continuing medical education.

Patient-Provider Agreement on Guidelines for Preparation for Breast Cancer Treatment

Guidelines for preparing cancer patients for threatening medical procedures were developed and refined and their perceived relevance and importance rated by three concerned groups—84 breast cancer patients, 64 doctors, and 140 nurses and nurse oncologists. All three groups indicated strong support for the guidelines. Patients and nurses rated more of the guidelines as essential aspects of good quality care than did doctors. Items in which a significant discrepancy existed included the importance of (a) consistent information, (b) involvement of others in preparation, and (c) assistance to the patient in coping with treatment for breast cancer: Doctors, compared with patients and nurses, underrated the importance of some aspects of preparation. These issues should be given more prominence in undergraduate and specialist medical training, as well as in continuing medical education.

Title Change

The correct title for the SPECIAL COMMUNICATION published in the July 27 issue ofThe Journal(242:344-346, 1979) is as follows: "Patient-Provider Agreement About Problems: Influence on Outcome of Care."