Uninformed Patients Research Articles

The Importance of Collaboration Elevating Cardio-Oncology Care

The Importance of Collaboration Elevating Cardio-Oncology Care

The ABCs of a gynaecological teaching associate (GTA) programme

Gynaecological/Male Urogenital Teaching Associate (GTA/MUTA) methodology is considered the gold standard of invasive genital examination technique. Lay persons are trained in the technique of invasive genital examinations and patient-centred, trauma informed communication, and autonomously instruct learners on how to comfortably perform this examination using their own bodies as a teaching tool. GTAs/MUTAs function simultaneously as an autonomous instructor and a simulated patient during the exam. GTAs and MUTAs instruct clinical invasive examination techniques in a structured educational setting with a predetermined curriculum on which they have been trained, while letting learners perform these exam techniques on their bodies. Existing alternatives to GTA/MUTA education include the use of anesthetized patients, cadavers, plastic anatomical models (task trainers) and/or voluntary examinations on peers. There are unique benefits to the GTA/MUTA programme from both an institutional and learner perspective. Learner’s benefits unique to GTA/MUTA education include decreased learner anxiety [1], immediate feedback on examination technique with regard to patient’s physical comfort, and the opportunity to practise patient communication skills while performing such examinations. Institutional benefits unique to GTA/MUTA methodology are that after the initial setup cost, funds are saved removing the need for faculty to perform the examination instruction. Learner proficiency is higher compared to learners taught by physicians [1], and increased proficiency saves time and cost associated with learners being taken off clinical rotation to receive supplemental genital examination technique instruction. The use of simultaneous patient-instructors also introduces ‘elements of sensitivity and humanism’ to the examination [2] by having students learn to involve their patient and incorporate their perspective with regard to comfort and patient education information. By learning this examination from GTAs/MUTAs, a new model of physician patient relationship is taught, with GTAs/MUTAs functioning as informed collaborators rather than docile, uninformed patients [3]. In order to implement such a programme in an institution, among the first tasks is to obtain funding. This funding can be sought from grants or via institutional funds. Institutions may even choose to grow their GTA/MUTA programme to contract with outside institutions where this clinical examination instruction is needed. Other preparatory steps include establishing a curriculum, observing an established GTA/MUTA programme session to assess the format, and recruitment and training of GTAs and MUTAs. Once the programme is established, a clinical skills training day may be implemented. Implementing such a programme improves the learners’ experience and provides them with an increased understanding of sound technique that will benefit their patients in the long term. 1. Theroux R, Pearce C. Graduate students’ experiences with standardized patients as adjuncts for teaching pelvic examinations. Journal of the American Academy of Nurse Practitioners. 2006;18(9):429–35. 2. Kretzschmar RM. Evolution of the Gynecology Teaching Associate: an education specialist. American Journal of obstetrics and gynecology. 1978;131(4):367–73. 3. Underman K. Feeling Medicine: How the Pelvic Exam Shapes Medical Training. New York, New York University Press; 2020.

Pushy Patients Or Pushy Providers? Effect Of Patient Knowledge On Antibiotic Prescribing In Tanzania.

Antimicrobial resistance is one of the most serious threats to global health, but little progress has been made in reversing its spread. Inappropriate use of antibiotics in humans is a major driver of antimicrobial resistance, and rates are high and growing in lower- and middle-income countries. Antibiotics are thought to be subject to supplier-induced demand, whereby providers prescribe them to patients who do not know they are unnecessary. We conducted a randomized field experiment in 227 private health facilities in Tanzania, with standardized patients presenting uncomplicated upper respiratory tract infection symptoms. Standardized patients were randomly assigned to express knowledge (informed) or not (uninformed) that antibiotics were not required to treat them. There was a very high rate of inappropriate antibiotic prescription, with 86.0percent of informed standardized patients and 94.8percent of uninformed standardized patients prescribed an antibiotic, for an adjusted difference of 7.8percentage points between the groups. This small effect suggests that broader health systems factors are at play and that interventions should be aimed at systems, health facilities, and providers.

Palliative Care education in Armenia: perspectives of first-year Armenian physician\xa0residents

BackgroundDue to developing demographic changes, including an aging society and the increasing prevalence of non-communicable diseases, Palliative Care is increasingly highlighted as a universal healthcare need. The need for Palliative Care in Armenia is set against the context of an underdeveloped healthcare system. Further, the absence of palliative medicine within medical education, particularly undergraduate education in Armenia presents a major barrier to improving care. This research aimed to assess the perception of young Armenian physicians’ understanding of Palliative Care, its perceived status in Armenia and the experience and influence of any engaged Palliative Care education.MethodsTwenty Armenian first-year residents with different specializations were interviewed July and September 2016 regarding: understanding/knowledge, experiences, perceived competence, and expectations of Palliative Care and Palliative Care education. The transcripts from these semi-structured interviews were analyzed using Qualitative Content Analysis.ResultsParticipants perceived that Armenia’s health care system lacked sufficient Palliative Care and Palliative Care education. Although elements of Palliative Care were included in different specialty teaching, this provided just a partial understanding of typical Palliative Care patients/symptoms, approaches to holistic care, and crucially key communication skills. Challenges noted by participants in caring for Palliative Care patients included emotional difficulties, communication of diagnosis/prognosis, uninformed patients and concerns for patients, families, and physicians. Self-confidence in caring for patients with incurable illness varied. Participants hoped for increasing availability and accessibility of Palliative Care, and extension of clinical education in Palliative Care at all levels (undergraduate, postgraduate, specialization).ConclusionsAbsence of training has resulted in misconceptions and ignorance of common concepts and practices in Palliative Care. Palliative Care education needs to be systematically developed and integrated into clinical training within Armenia. This research may provide a rallying call for changes within the core curricula in Armenia and may also encourage collaborative development in associated countries of the Caucasus region.

The impact on quality of life from informing diagnosis in patients with cancer: a systematic review and meta-analysis

BackgroundThe aim of this study was to assess the impact on quality of life from informing patients with cancer of their diagnosis and disease status.MethodWe searched the follow databases, PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), PsycINFO, WEB OF SCIENCE, Embase, CBM (Chinese Biomedical Literature database), WANFANG database (Chinese Medicine Premier), and CNKI (China National Knowledge Infrastructure), using the following terms: neoplasm, cancer, tumor, tumor, carcinoma, disclosure, truth telling, breaking bad news, knowledge, knowing, awareness, quality of life, QOL. Pairs of reviewers independently screened documents and extracted the data, and the meta-analysis was performed using Revman 5.0 software.ResultsEleven thousand seven hundred forty records retrieved from the databases and 23 studies were included in the final analysis. A meta-analysis revealed that there were no differences in either the general quality of life and symptoms of fatigue, pain, dyspnea, insomnia, appetite loss, and diarrhea, between informed and uniformed cancer patients (P > 0.05). There were also no differences found between the patient groups in physical function, role function, cognitive activity, and emotional function (P > 0.05). In terms of vitality, patients who were completely informed about their diagnosis showed higher vitality than uniformed patients. Uninformed patients seemed to have lower social function scores. Between partly informed and uninformed cancer patients, no differences were found in their general quality of life, function domains, and disease-related symptoms (P > 0.05).ConclusionInforming cancer patients of their diagnosis may not have a detrimental effect on their quality of life.Trial registrationCRD42017060073.

Impact of the disclosure of diagnosis on posttraumatic stress and growth and quality of life in Chinese patients with hepatocellular carcinoma.

To evaluate the impact of disclosure/nondisclosure of cancer diagnosis on patients' posttraumatic stress symptoms (PTSS), posttraumatic growth (PTG), and quality of life (QOL). Patients with primary hepatocellular carcinoma (HCC) who were admitted for potentially curative treatments in a teaching hospital were recruited. Patients were interviewed at admission regarding their QOL and their attitude towards disclosure of diagnosis. They were interviewed again for QOL, PTSS, and PTG at discharge and at 1month after discharge. There were 300 patients recruited, 88.3% of whom preferred disclosure of cancer diagnosis. In fact, 162 patients (54.0%) received disclosure of their cancer diagnosis before discharge (disclosed group). However, for the 138 patients whose diagnoses were concealed by their families (uninformed group), 116 patients (84.1%) had learned of their diagnosis of HCC independently within 1month after discharge. Comparing the scores at 1month after discharge with scores at discharge showed that the PTSS score significantly declined for patients in the disclosed group and the PTG score significantly decreased for the uninformed patients at 1month after discharge (p < 0.001 for both comparisons). Additionally, compared with the uninformed group, patients in the disclosed group had lower scores for PTSS (p < 0.001), higher scores for PTG (p < 0.001), better emotional functioning (p < 0.001), and better global QOL (p = 0.006) at 1month after discharge. Our findings indicate that concealing the diagnosis of cancer from patients is unlikely to succeed. Additionally, disclosure of diagnosis is beneficial for HCC patients in reducing PTSS and improving PTG and QOL.

An Opinion Survey of Orthopaedic and Traumatology Surgeons Working in Outpatient Care (Society, Laws and Patients).

The German health care system is well accepted, but efficiency, costs and patient satisfaction are sometimes criticised. Opinions and models prevail, and empirical data are rarely presented, although quantitative data are a precondition to assess the acceptance of the health care system. To determine the appraisal of the patient-doctor relationship, economic situation and cooperation with clinical institutions, a 37 item was developed where participants indicated their agreement with a statement on a four point Likert scale. This questionnaire was answered by 525 German orthopaedic and/or traumatology surgeons, representing 7.7% of all German specialists working in outpatient care. 75% of all respondents felt challenged by demanding patients and a need for justification; what was less pronounced was the feeling of being exploited as physicians. Restrictions in medical treatment from budgeting expenses were seen by 74%. More than 90% considered that it was impossible to finance their medical practice expenses by conservative medical treatment only. The respondents felt similarly critical about the current cooperation with hospitals - only 19% were not interested in closer cooperation and 96% advocated higher fees for this cooperation. 74% confirmed that hospitals are taking over outpatient tasks, whereas only 35% agreed that more clinical patient care can be provided by outpatient providers, especially due to legal restrictions. Practitioning orthopaedic and traumatology surgeons feel exploited by uninformed patients, misallocation of reimbursement funds and legal restrictions, as well as unilateral substitution of outpatient care by hospitals. They do not consider that the current structures are sustainable for long term patient care.

Importance of medical information for health-care utilisation in China: a cross-sectional study

BackgroundIncreasing concerns have arisen about provider misbehaviour in the Chinese health system, such as unnecessary care, with the potential consequence of an increase of health-care expenditure. This study aims to investigate the effect of medical information on health-care utilisation and expenditure in China based on the supplier-induced demand hypothesis. MethodsData were derived from the China Labour-force Dynamics Survey (CLDS) done in 2014 using a multistage stratified cluster-random sampling method in 29 provinces in China. Providing information about health-care provision to some patients but not others, we identified 806 informed patients and 22 788 uninformed patients as our analytical sample. Using the coarsened exact matching method to control for confounding factors, we identified the impact of health-care information provision in China on proportion of patients who were outpatients and expenditure in the past 2 weeks as well as proportion of patients who were inpatients and expenditure in the past year. All study procedures were approved by the Health Science Center Ethics Committee at Xi'an Jiaotong University, Shaanxi, China (approval number: 2015-644) and all patients gave written informed consent. FindingsAfter coarsened exact matching, although the outpatient rate of uninformed patients seemed to be 0·6% higher than that of informed patients (4·3% [95% CI 3·9–4·8] vs 3·7% [2·3–5·1]), and the inpatient rate of uninformed patients seemed to be 1·1% lower than that of informed patients (4·3% [3·7–4·6] vs 5·3% [3·6–6·9]), none of these effects were significant. Uninformed patients paid 680 CNY more per outpatient visit than did informed patients (1126 CNY [95% CI 885–1368] vs 446 CNY [248–643]), accounting for 56·7% of the average outpatient expenditure of uninformed patients. However, uninformed patients paid 2061 CNY less per inpatient visit than informed patients did (15 584 CNY [9% CI 12 052–19 115] vs 17 645 CNY [488430 406]). InterpretationThe medical information has limited effect on outpatient and inpatient health-care utilisation in the health-care market in China. However, our results highlight the need for policies to address the large outpatient care expenses attributable to medical information asymmetry in the health-care market in China. Creating incentives for providers to provide less health-care services that could be avoided in the process of outpatient services may work well to reduce health-care costs, improve the governance of public hospitals, and institute a stronger regulatory system. FundingChina Medical Board (15–277), Research Program of Shaanxi Soft Science (2015KRM117), the National high-level talents special support plan (thousands of people plan), Shaanxi provincial youth star of science and technology in 2016 and the Basic Scientific Research Funding of Xi'an Jiaotong University (SK2015007), China Scholarship Council (201706280307 and 201806280021), the US PEPPER Center Scholar Award (P30AG021342), National Institutes of Health/National Institute on Aging (R03AG048920 and K01AG053408).

Patient Characteristics that Influence the Advocacy Role of Nurses in Ghana: A Qualitative Study

Study background: Several factors influence nurses to advocate for patients in the course of their work including particular patient characteristics. These characteristics however, are under reported in Ghana. Methods: The objective of the study was to determine the patient characteristics that influence the advocacy role of nurses. Ethical approval was obtained from the appropriate bodies and the study employed a qualitative exploratory descriptive design. A sample size of 15 nurses working in a regional hospital in Ghana was used and the participants voluntarily consented to participate in the study. Data was collected using a semi-structured interview guide and analyzed using content analysis. Results: The participants advocated for patients who were neglected, vulnerable, uninformed, intimidated and dissatisfied. They advocated for those whose relatives failed to provide them with food, drugs and care. The participants also advocated for unconscious patients, children and apathetic patients. Their advocacy was also sometimes geared towards the protection of patients from paternalism, the profit-oriented health system and the complexity of the health system. Additionally, they advocated for the poor, uninformed and anxious patients and those who were dissatisfied with their care. Conclusion: The characteristics of patients that elicit nurses’ advocacy roles are diverse and may be context specific. The study provides an insight into patient characteristics which elicit nurses’ advocacy. Findings could be useful in enhancing the advocacy role of nurses to improve quality of care, patient satisfaction and patient autonomy.

Building COPD care on shaky ground: a mixed methods study from Swedish primary care professional perspective

BackgroundChronic obstructive pulmonary disease (COPD) is a public health problem. Interprofessional collaboration and health promotion interventions such as exercise training, education, and behaviour change are cost effective, have a good effect on health status, and are recommended in COPD treatment guidelines. There is a gap between the guidelines and the healthcare available to people with COPD.The aim of this study was to increase the understanding of what shapes the provision of primary care services to people with COPD and what healthcare is offered to them from the perspective of healthcare professionals and managers.MethodsThe study was conducted in primary care in a Swedish county council during January to June 2015. A qualitatively driven mixed methods design was applied. Qualitative and quantitative findings were merged into a joint analysis. Interviews for the qualitative component were performed with healthcare professionals (n = 14) from two primary care centres and analysed with qualitative content analysis. Two questionnaires were used for the quantitative component; one was answered by senior managers or COPD nurses at primary care centres (n = 26) in the county council and the other was answered by healthcare professionals (n = 18) at two primary care centres. The questionnaire data were analysed with descriptive statistics.ResultsThe analysis gave rise to the overarching theme building COPD care on shaky ground. This represents professionals driven to build a supportive COPD care on ‘shaky’ organisational ground in a fragmented and non-compliant healthcare organisation. The shaky ground is further represented by uninformed patients with a complex disease, which is surrounded with shame. The professionals are autonomous and pragmatic, used to taking responsibility for their work, and with limited involvement of the management. They wish to provide high quality COPD care with interprofessional collaboration, but they lack competence and are hindered by inadequate routines and lack of resources.ConclusionsThere is a gap between COPD treatment guidelines and the healthcare that is provided in primary care. To facilitate implementation of the guidelines several actions are needed, such as further training for professionals, additional resources, and improved organisational structure for interprofessional collaboration and patient education.

Trainee Involvement in Patient Care: A Necessity and Reality in Teaching Hospitals.

Trainee Involvement in Patient Care: A Necessity and Reality in Teaching Hospitals.

Dispensing physicians, asymmetric information supplier-induced demand: evidence from the Swiss Health Survey.

In this paper, we apply a two-part model to estimate the effect of health literacy on the demand for physician visits under different institutional settings. Using a constructed measure of health information, we find evidence for supplier-induced demand in some parts of Switzerland. While the level of health information is uncorrelated with the likelihood of visiting a physician (contact decision), the conditional number of visits (frequency decision) depends on the individual's information status and the regulation of physician drug dispensing. In cantons with a drug prescription scheme, we do not find a significant difference in the number of visits between well-informed individuals and people with relatively little health literacy. In contrast, the existence of self-dispensing general practitioner and specialists is associated with a gap in demand that is strongly related to health literacy: Compared to cantons with prescription schemes, uninformed patients exhibit a higher number of outpatient visits in the cantons that (partly) allow the dispensation of drugs by physicians. However, patients with a high level of health information seem to be rather unaffected by physician drug dispensing. As a consequence, we observe an information-related gap in the number of outpatient contacts that only prevails in areas where doctors are entitled to sell drugs themselves. These findings suggest that self-dispensing doctors succeed in inducing demand that affects the number of physician-patient contacts. Health literacy, on the other hand, tends to counter these incentives.

The relevance of educating doctors, pharmacists and older patients about potentially inappropriate medications.

Providing appropriate pharmacotherapy to older people can be difficult since older people are more at risk of developing adverse drug reactions due to age-related physiological changes. The use of potentially inappropriate medications (PIMs) among older people is common throughout the globe, and is a cause for concern due to their clinical, humanistic and economic implications. Nevertheless, it appears that doctors and pharmacists have limited knowledge regarding PIMs. Moreover, uninformed older patients may use PIMs without considering their potential negative consequences. There is a need, therefore, to educate doctors, pharmacists and older patients about PIMs. Geriatric pharmacotherapy education with an emphasis on appropriate prescribing, and PIMs, should be included in the medical and pharmacy teachings at the undergraduate, postgraduate and continuing education levels. Moreover, older patients should be informed about PIMs and the possible risks that they may pose.

Health Care Adherence and Personalized Medicine

Non-adherence in health care results when a patient does not initiate or continue care that a provider has recommended. Previous research identifies non-adherence as a major source of waste in US health care, totaling approximately 2.3% of GDP, and has proposed a plethora of interventions to raise adherence. However, health economics provides little explicit analyses of the important dynamic demand behavior that drives non-adherence, and it is often casually attributed to uninformed patients. We argue that whereas providers may be more informed about the population-wide effects of treatments, patients are more informed about the individual-specific value of treatment. We interpret a patient’s decision to adhere to a treatment regime as an optimal stopping problem in which patients learn the value of a treatment through treatment experience. We derive strong positive and normative implications resulting from interpreting non-adherence as an optimal stopping problem. Our positive analysis derives an “adherence survival function,” depicting the share of patients still on treatment as a function of time, and predicts how various observable factors alter adherence. Our normative analysis derives the efficiency effects of non-adherence and the conditions under which adherence is too high or low. We consider the efficiency implications of this analysis for common adherence interventions. We argue that personalized medicine is intimately linked to adherence issues. It replaces the learning through treatment experience with a diagnostic test, and thereby speeds up the learning process and cuts over-adherence and raises under-adherence. We assess the quantitative implications of our analysis by calibrating the degree of over- and under-adherence for one of the largest US drug categories: cholesterol-reducing drugs. Contrary to frequent normative claims of under-adherence, our estimates suggest the efficiency loss from over-adherence is over 80% larger than from under-adherence, even though only 43% of patients fully adhere.

Striving for good nursing care: nurses' experiences of do not resuscitate orders within oncology and hematology care.

Within oncology and hematology care, patients are sometimes considered to have such a poor prognosis that they can receive a do not resuscitate order from the physician responsible, stipulating that neither basic nor advanced coronary pulmonary rescue be performed in the event of a cardiac arrest. Studies on do not resuscitate decisions within oncology and hematology units, focusing on the specific role of the nurse in relation to these decisions, are scarce. The aim of this study was to investigate hematology and oncology nurses' experiences and perceptions of do not resuscitate orders, in order to achieve a deeper understanding of the nurses' specific role in these decisions. A qualitative, descriptive methodology with individual semi-structured interviews was used. A total of 15 nurses from eight hematology/oncology wards in four hospitals in Sweden were interviewed individually. In accordance with national regulations, an ethical review was not required for this study. The research followed international guidelines for empirical research, as outlined in the Helsinki Declaration. The nurses strived for good nursing care through balancing harms and goods and observing integrity and quality of life as important values. Experienced hindrances for good care were unclear and poorly documented decisions, uninformed patients and relatives, and disagreements among the caregivers and family. The nurses expressed a need for an ongoing discussion on do not resuscitate decisions, including all concerned parties. In order to provide good nursing care, nurses need clear and well-documented do not resuscitate orders, and patients and relatives need to be well informed and included in the decisions. To increase the understanding for each other's opinions within the medical team, regular ethical discussions are required.

Pharmacists’ responsibilities providing informed consent

Recently, I was asked to be an expert witness for a case involving a patient who experienced an adverse drug reaction and sued the prescriber and pharmacist for not warning them of their risks. This caused me to reflect on my own practice and my responsibilities to counsel and educate patients about their medications so that they can make informed decisions. Recently, I was asked to be an expert witness for a case involving a patient who experienced an adverse drug reaction and sued the prescriber and pharmacist for not warning them of their risks. This caused me to reflect on my own practice and my responsibilities to counsel and educate patients about their medications so that they can make informed decisions. Case 1: A pharmacist received a prescription for sulfamethoxazole/trimethoprim 800 mg/160 mg twice daily for 10 days. Before filling the prescription, the pharmacist reviewed his records and saw that the patient had an allergy to sulfa antibiotics, but he was not sure about the type or severity of the reaction. The pharmacist called the prescrib- er, who told the pharmacist that she was aware of the allergy but believed the antibiotic was the patient’s best option. The pharmacist made a note to talk with the patient about the allergy.■Pharmacists should fully inform patients about their treatment.■Pharmacists should document patient care activities and seek out complete medical histories. ■Pharmacists should fully inform patients about their treatment.■Pharmacists should document patient care activities and seek out complete medical histories. Case 2: A pharmacist was providing medication therapy management services for a new patient, an older man with dementia whose daughter held his power of attorney. The daughter noted that her father’s past medical history was significant for atrial fibrillation, coronary artery disease, hyertension, and hyperlipidemia and that her father had recently moved from another state. The pharmacist saw that the patient and his daughter did not maintain very good medical histories. The patient had not yet established a relationship with a lowith his daughter’s physician next week. The pharmacist noted that the patient took simvastatin 80 mg and extended- release diltiazem 180 mg every day. These cases represent real dilemmas pharmacists face in informed consent and duty to warn. For my recent work as an expert witness, I reviewed the literature regarding informed consent and found an interesting article.1.Wick J.Y. Zanni G.R. Informed consent: what every pharmacist should know.J Am Pharm Assoc. 2001; 41: 523-527Scopus (2) Google Scholar ■From 30% to 50% of patients do not use medication as prescribed because they lack information.■Pharmacists have a professional obligation to counsel patients so that they are informed comanagers of their drug therapy.■Informed consent is an interactive process with patients through which the pharmacist ensures that they fully understand their medications.■Informed consent requires pharmacists to be knowledgeable about treatment risks and benefits and standards of care.■Obstacles to informed consent occur when communication barriers exist between pharmacists and other health care providers and/or between pharmacists and patients.■Uninformed pharmacists result in uninformed patients and failure to meet informed consent guidelines. In the first case, the pharmacist has a responsibility to seek more information about the patient’s previous allergic reaction. After obtaining that information, the pharmacist must communicate with the prescriber to ensure that she has the same information. If the prescriber still wants the patient to receive the antibiotic, then the pharmacist has a responsibility to inform the patient of the risks. As pharmacists, we must both follow prescribers’ orders and fully inform patients about their treatment. Informed patients have the right to refuse treatment even if it is in their best interest. Pharmacists need to routinely document patient care, including recommendations, education, and follow-up. In the second case, a pharmacist with incomplete information was presented with two potential problems—a dosage issue with simvastatin and a drug-drug interaction between simvastatin and diltiazem. This pharmacist was not filling prescriptions, but rather providing a professional service. The patient and caregiver provided incomplete medical histories, so the pharmacist was not able to assess their medications properly. The pharmacist should, if possible, obtain a complete medical history from previous health care providers, including when medications were started, reasons for current doses, and any monitoring data. If that information is not available, then the pharmacist should address the potential problems with the patient and caregiver and send a written work-up to the new physician. Again, the pharmacist should fully document this information in the patient chart. Pharmacists may not always have complete medical histories, but that does not preclude them from informing their patients and other providers of potential drug therapy problems. Not only is this consistent with good patient care—it is the right thing to do.

Disparities in the Quality and Provision of Kidney Transplant Education

Introduction: The nephrologist is often the first provider to educate ESRD patients about kidney transplant (KT). Disparities in the quality and provision of KT education might contribute to disparities in access to transplant (ATT). The goals of this study were to (1) describe nephrologists' attitudes and practices regarding KT education, (2) characterize the provision of KT education by nephrologists nationally and, (3) analyze associations between KT education and ATT. Methods: We surveyed 906 nephrologists regarding KT education attitudes and practices. We then analyzed the provision of transplant education among all incident ESRD patients in the United States between 2005 and 2007 as captured in the United States Renal Data System (USRDS). Results: Most survey respondents (81%) felt the ideal time to spend on transplant education was >20mins, but only 43% reported actually doing so. Spending >20mins was associated with covering more topics, having one-on-one and repeated conversations, involving families in discussions, and initiating discussions at CKD-stage 4. Nationally, 30.1% of ESRD patients were not informed about transplant at ESRD-onset, for reasons reported by providers as follows: 42.1% unassessed, 30.4% medically unfit, 16.9% unsuitable due to age, 3.1% psychologically unfit, and 1.5% declined counsel. Patients at for-profit centers were 20% more likely to be unassessed. This finding was supported by survey data; nephrologists at for-profit centers were significantly less likely to spend >20mins on KT education (RR=0.89, 95%CI:0.80-0.99) or involve families (RR=0.57, 95%CI:0.38-0.87). Furthermore, they reported that fewer of their patients received transplant counseling (RR=0.58, 95%CI:0.37-0.96), initiated transplant discussions (RR=0.58, 95%CI:0.38-0.88), or were eligible for transplantation (RR=0.45, 95%CI:0.30-0.68). In the national sample, uninformed patients had a 53% lower rate of ATT, a disparity that persisted in the subgroup of uninformed patients who were simply unassessed (Figure 1).[Figure 1]Conclusions: Disparities in ATT may be partially explained by disparities in the quality and provision of KT education; dialysis centers should ensure this critical intervention is offered to patients in an equitable and timely manner.

Disparities in the Quality and Provision of Kidney Transplant Education

Introduction: The nephrologist is often the first provider to educate ESRD patients about kidney transplant (KT). Disparities in the quality and provision of KT education might contribute to disparities in access to transplant (ATT). The goals of this study were to (1) describe nephrologists’ attitudes and practices regarding KT education, (2) characterize the provision of KT education by nephrologists nationally and, (3) analyze associations between KT education and ATT. Methods: We surveyed 906 nephrologists regarding KT education attitudes and practices. We then analyzed the provision of transplant education among all incident ESRD patients in the United States between 2005 and 2007 as captured in the United States Renal Data System (USRDS). Results: Most survey respondents (81%) felt the ideal time to spend on transplant education was >20mins, but only 43% reported actually doing so. Spending >20mins was associated with covering more topics, having one-on-one and repeated conversations, involving families in discussions, and initiating discussions at CKD-stage 4. Nationally, 30.1% of ESRD patients were not informed about transplant at ESRD-onset, for reasons reported by providers as follows: 42.1% unassessed, 30.4% medically unfit, 16.9% unsuitable due to age, 3.1% psychologically unfit, and 1.5% declined counsel. Patients at for-profit centers were 20% more likely to be unassessed. This finding was supported by survey data; nephrologists at for-profit centers were significantly less likely to spend >20mins on KT education (RR=0.89, 95%CI:0.80-0.99) or involve families (RR=0.57, 95%CI:0.38-0.87). Furthermore, they reported that fewer of their patients received transplant counseling (RR=0.58, 95%CI:0.37-0.96), initiated transplant discussions (RR=0.58, 95%CI:0.38-0.88), or were eligible for transplantation (RR=0.45, 95%CI:0.30-0.68). In the national sample, uninformed patients had a 53% lower rate of ATT, a disparity that persisted in the subgroup of uninformed patients who were simply unassessed (Figure 1).[Figure 1]Conclusions: Disparities in ATT may be partially explained by disparities in the quality and provision of KT education; dialysis centers should ensure this critical intervention is offered to patients in an equitable and timely manner.

Disparities in Provision of Transplant Information Affect Access to Kidney Transplantation

Recently Centers for Medicare and Medicaid Services (CMS) began asking providers on Form-2728 whether they informed patients about transplantation, and if not, to select a reason. The goals of this study were to describe national transplant education practices and analyze associations between practices and access to transplantation (ATT), based on United States Renal Data System (USRDS) data from 2005 to 2007. Multinomial logistic regression was used to examine factors associated with not being informed about transplantation, and modified Poisson regression to examine associations between not being informed and ATT (all models adjusted for demographics/comorbidities). Of 236,079 incident end-stage renal disease (ESRD) patients, 30.1% were not informed at time of 2728 filing, for reasons reported by providers as follows: 42.1% unassessed, 30.4% medically unfit, 16.9% unsuitable due to age, 3.1% psychologically unfit and 1.5% declined counsel. Older, obese, uninsured, Medicaid-insured and patients at for-profit centers were more likely to be unassessed. Women were more likely to be reported as unsuitable due to age, medically unfit and declined, and African Americans as psychologically unfit. Uninformed patients had a 53% lower rate of ATT, a disparity persisting in the subgroup of uninformed patients who were unassessed. Disparities in ATT may be partially explained by disparities in provision of transplant information; dialysis centers should ensure this critical intervention is offered equitably.

Sociocognitive Factors Associated with Nonadherence to Medication After Hospital Discharge

Poor adherence to prescribed medication is a well-known problem and continues to be a major challenge in all medical specialties. Unlike previous studies that have mainly focused on nonadherence behaviors in specific diseases, this study sought to examine socio-cognitive factors associated with nonadherence behavior in a sample of a general clinical population. A questionnaire investigating socio-demographic and cognitive factors and a telephone follow-up interview were administered to 84 patients recruited in a General Medicine Unit before their discharge. Half of the participants were informed about that follow-up procedure. One month after hospital discharge, 42% of uninformed patients reported nonadherence behaviors, as against 21% of informed patients. Middle-aged patients and short-term treatments were associated significantly more often with nonadherence. Among cognitive factors, patients’ perceived risks and benefits of nonadherence, personal susceptibility to diseases, subjective health value, and reported memory failures were significantly associated with adherence. We conclude that a patient's perception may be more important than medication load, illness severity, and complexity of regimen in influencing medication adherence, and that a telephone call follow-up helps in monitoring medication adherence after hospital discharge.