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Weiner S.J.,University of Illinois at Chicago | Weiner S.J.,Center for the Management of Complex Chronic Care | Weiner S.J.,Jesse Brown Medical Center | Schwartz A.,University of Illinois at Chicago | And 7 more authors.
Journal of General Internal Medicine | Year: 2013

BACKGROUND: Despite wide-spread endorsement of patient-centered communication (PCC) in health care, there has been little evidence that it leads to positive change in health outcomes. The lack of correlation may be due either to an overestimation of the value of PCC or to a measurement problem. If PCC measures do not capture elements of the interaction that determine whether the resulting care plan is patient-centered, they will confound efforts to link PCC to outcomes. OBJECTIVE: To evaluate whether one widely used measure of PCC, the Roter Interaction Analysis System (RIAS), captures patient-centered care planning. DESIGN: RIAS was employed in the coding of unannounced standardized patient (USP) encounters that were scripted so that the failure to address patient contextual factors would result in an ineffective plan of care. The design enabled an assessment of whether RIAS can differentiate between communication behavior that does and does not result in a care plan that takes into account a patient's circumstances and needs. PARTICIPANTS: Eight actors role playing four scripted cases (one African American and one Caucasian for each case) in 399 visits to 111 internal medicine attending physicians. MAIN MEASURES: RIAS measures included composites for physician utterance types and (in separate models) two different previously applied RIAS patient-centeredness summary composites. The gold standard comparison measure was whether the physician's treatment plan, as abstracted from the visit note, successfully addressed the patient's problem. Mixed effects regression models were used to evaluate the relationship between RIAS measures and USP measured performance, controlling for a variety of design features. KEY RESULTS: None of the RIAS measures of PCC differentiated encounters in which care planning was patient-centered from care planning in which it was not. CONCLUSIONS: RIAS, which codes each utterance during a visit into mutually exclusive and exhaustive categories, does not differentiate between conversations leading to and not leading to care plans that accommodate patients' circumstances and needs. © 2012 Society of General Internal Medicine. Source

Friedman N.C.,Edward Hines Medical Center | Hassan A.,Edward Hines Medical Center | Grady E.,Christiana Care Health System | Matsuoka D.T.,DTM | Jacobson A.F.,General Electric
Journal of Nuclear Medicine | Year: 2014

Although iodinated radiopharmaceuticals usually contain a small quantity of unbound iodine, it is difficult to establish the degree to which thyroid activity on scintigraphic images reflects uptake of free radioiodine. The objective of the present study was to examine the effectiveness of thyroid blockade in subjects undergoing 123Imeta- iodobenzylguanidine (mIBG) imaging and to estimate the relative contribution of bound and unbound radioiodine to imaging findings. Methods: All subjects were participants in prospective trials of 123I-mIBG cardiac imaging in which pretreatment with thyroid blockade was optional unless locally required. In a pilot project, 15 subjects (6 blocked) had thyroid uptakemeasured at 4 h using a probe system. Fifteen-minute (early) and 4-h (late) anterior planar chest images that included the thyroid region were visually scored for thyroid uptake (scale of 0-4) in another group of 152 subjects (98 blocked). Quantitative analysisbased on thyroid regions of interestwas performed on anterior planar images from a further sample of 669 subjects (442 blocked). For all 3 investigations, quantitative comparisons of thyroid uptake were made between the blocked and nonblocked subjects. Results: There was no statistical difference between probe uptake of the 6blockedand9 nonblocked subjects.However, in the second series, mean visual score on the late imageswas significantly lower for blocked than nonblocked subjects (P<0.001). In the region-of-interest analyses, net thyroidcountswere significantlyhigheronthelateimagesofnonblocked subjects (P < 0.0001), and compared with early images, 87% of subjects who received blockade showed decreased or unchanged counts whereas 75% of nonblocked subjects had increased net thyroid activity. In nonblocked subjects, an estimated 79%of thyroid counts on late images could be attributed to unbound 123I. Conclusion: On the basis of 3 different methods for assessing thyroid uptake of 123I, use of thyroid blockade pretreatment in 123I-mIBG imaging prevents increase of thyroid activity over time because of uptake of unbound 123I. In most subjects, there is a low level of 123I-mIBG thyroid activity that probably represents specific uptake in sympathetic nerve terminals. Copyright © 2014 by the Society of Nuclear Medicine and Molecular Imaging, Inc. Source

Weiner S.J.,University of Illinois at Chicago | Weiner S.J.,Center for Management of Complex Chronic Care | Kelly B.,Center for Management of Complex Chronic Care | Kelly B.,University of Illinois at Chicago | And 11 more authors.
Medical Decision Making | Year: 2014

Background and Objective. Adapting best evidence to the care of the individual patient has been characterized as "contextualizing care" or "patient-centered decision making" (PCDM). PCDM incorporates clinically relevant, patient-specific circumstances and behaviors, that is, the patient's context, into formulating a contextually appropriate plan of care. The objective was to develop a method for analyzing physician-patient interactions to ascertain whether decision making is patient centered. Methods. Patients carried concealed audio recorders during encounters with their physicians. Recordings and medical records were reviewed for clues that contextual factors, such as an inability to pay for a medication or competing responsibilities, might undermine an otherwise appropriate care plan, rendering it ineffective. Iteratively, the team refined a coding process to achieve high interrater agreement in determining (a) whether the clinician explored the clues - termed "contextual red flags" - for possible underlying contextual factors affecting care, (b) whether the presence of contextual factors was confirmed and, if so, (c) whether they were addressed in the final care plan. Results. A medical record data extraction instrument was developed to identify contextual red flags such as missed appointments or loss of control of a treatable chronic condition which signal that contextual factors may be affecting care. Interrater agreement (Cohen's kappa) for coding whether the clinician explored contextual red flags, whether a contextual factor was identified, and whether the factors were addressed in the care plan was 88% (0.76, P < 0.001), 94% (0.88, P < 0.001), and 85% (0.69, P < 0.001) respectively. Conclusions. PCDM can be assessed with high interrater agreement using a protocol that examines whether essential contextual information (when present) is addressed in the plan of care. © The Author(s) 2013. Source

Garcia S.,University of Minnesota | Rider J.E.,University of Minnesota | Moritz T.E.,VA Cooperative Studies Program | Pierpont G.,University of Minnesota | And 9 more authors.
Catheterization and Cardiovascular Interventions | Year: 2011

Background: Abdominal aortic operations have the highest perioperative cardiac risk. To test the impact of preoperative coronary artery revascularization (PR) in this high-risk subset, a post hoc analysis was performed in patients undergoing aortic surgery within the Coronary Artery Revascularization Prophylaxis (CARP) trial. Methods: The study cohort was a subset of 109 CARP patients with myocardial ischemia on nuclear imaging randomized to a strategy of PR (N = 52) or no PR (N = 57) before their scheduled abdominal aortic vascular operation. The clinical indications for vascular surgery were an expanding aneurysm (N = 62) or severe claudication (N = 47). The composite end-point of death and nonfatal myocardial infarction (MI) was determined by an intention-to-treat analysis following randomization. Results: The median time (Interquartiles) from randomization to vascular surgery was 56 (40, 81) days in patients assigned to PR and 19 (10, 43) days in patients assigned to no PR (P < 0.001). At 2.7 years following randomization, the probability of remaining free of death and nonfatal MI was 0.65 with PR and 0.55 with no PR [unadjusted P = 0.08, odds ratio = 1.67, 95% confidence interval (0.93, 2.99)]. Using a Cox proportional hazard model, predictors of the composite of death and nonfatal MI (odds ratio; 95% confidence interval) were no PR (1.90; 1.06-3.43; P = 0.03) and anterior ischemia on preoperative imaging (1.79; 0.99-3.23; P = 0.07). Conclusions: In patients with an abnormal cardiac imaging before abdominal aortic vascular surgery, PR was associated with a reduced risk of death and nonfatal MI while anterior ischemia was an identifier of poor outcome independent of the revascularization status. Copyright © 2010 Wiley-Liss, Inc. Source

Guihan M.,Edward Hines Medical Center | Bombardier C.H.,University of Washington
Journal of Spinal Cord Medicine | Year: 2012

Context/objective: Pressure ulcers (PrUs) are a serious, costly and potentially life-long complication of spinal cord injury (SCI). Co-morbid conditions increase PrU risk, adding to the health behavior challenges faced by people with SCI. Little is known about medical co-morbidities, health beliefs, risk, protective behaviors, and readiness to improve skin care behaviors in people with SCI. This study describes the potentially modifiable medical and behavioral risk factors among veterans with SCI and severe (Stage III /IV) PrUs. Design: Cross-sectional observational design. Setting: 6 VA SCI Centers. Participants: Convenience sample from a larger intervention study of 148 veterans hospitalized for PrUs. Interventions: Not applicable. Outcome measures: Knowledge, PrU risk, skin protective behaviors, health beliefs, and practices, health locus of control, skin worsening. Results: Most ulcers were stage IV (73%) and about half had 2+ PrUs. Participants reported a mean of 6.7 co-morbid conditions (respiratory, gastrointestinal, renal disease/urinary tract infection, autonomic dysreflexia, diabetes, bowel/bladder incontinence). Potential intervention opportunities include proactive assistance with management of multiple chronic conditions, substance abuse, nutrition, adherence to skin protective behaviors, readiness to change, and access to resources. Overall knowledge about PrUs was low, especially for how to prevent PrUs and what to do if skin breakdown occurs. Conclusion: Future research should address whether comprehensive models that include patient self-management, decision support and health care system, and proactive behavior change assistance for patients help reduce PrU incidence and recurrence in persons with SCI. Trial Registration: http://clinicaltrials.gov/ct2/show/NCT00105859. © The Academy of Spinal Cord Injury Professionals, Inc. 2012. Source

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