Does the Quality of Behavior Change Counseling in Routine HIV Care Vary According to Topic and Demand?

HIV clinicians face increasing time constraints. Our objective was to describe the prevalence and quality of behavior change counseling within routine HIV visits and to explore whether clinicians may provide lower quality counseling when facing increased counseling demands. We audio-recorded and transcribed encounters between 205 patients and 12 clinicians at an urban HIV primary care clinic. We identified and coded episodes of behavior change counseling to determine clinicians' consistency with motivational interviewing (MI) and used multi-level regression to evaluate counseling quality changes with each additional topic. Clinician counseling for at least one behavior was indicated in 92% of visits (mean 2.5/visit). Behavioral topics included antiretroviral medication adherence (80%, n = 163), appointment adherence (54%, n = 110), drug use (46%, n = 95), tobacco use (45%, n = 93), unsafe sex (43%, n = 89), weight management (39%, n = 80), and alcohol use (35%, n = 71). Clinician counseling was most MI-consistent when discussing drug and tobacco use and least consistent for medication and appointment adherence, unsafe sex, and alcohol use. In multilevel analyses, clinician counseling was significantly less MI-consistent (ß = - 0.14, 95% CI - 0.29 to - 0.001) with each additional behavior change counseling need. This suggests that HIV ambulatory care be restructured to allocate increased time for patients with greater need for behavior change.

Unlicensed Transdermal Medications in Feline Patients: Three Case Reports.

In veterinary clinical practice, conventional pharmacological treatments such as commercial capsules, tablets, or oral liquids may be difficult to administer to feline patients. Noncompliance, which is estimated to account for the majority of treatment failures, may potentially be overcome with alternative, customized treat- ment options such as topically applied, permeation-enhancing (transdermal) unlicensed medications. These medications allow for the percutaneous absorption of drugs into and through the animal's skin, bypassing the first-pass metabolism, potentially allowing for greater bioavailability, and thus decreasing dosage to achieve therapeutic effects. In these case reports, the efficacy of two unlicensed transdermal medications is demonstrated by the successful treatment of three feline patients, refractory to conventional pharmacotherapy. In case 1, the veterinary physician prescribed gabapentin 10 mg/0.1 mL topical Lipoderm, a permeation-enhancing base, to be applied three times a day inside the cat's ear, in order to manage the unconscious fits following a road traffic accident. In cases 2 and 3, two cats were prescribed fluoxetine 40-mg/g topical Lipoderm, to be applied once a day, in order to manage the inappropriate behavior (urination and defecation). Following three months of transdermal treatment, the quality of life of the three cats and their owners increased considerably, as demonstrated by the results of the validated, Health Related Quality of Life questionnaires employed before treatment (retrospectively) and after treatment. Permeation-enhancing (transdermal) medications are a promising dosage form in veterinary pharmacotherapy. The benefits and versatility of these alternative, customized treatment options are worth considering in current therapeutics.

Experiences and expectations of patients living with HIV on their engagement with care in Western Kenya.

PURPOSE: In resource-limited HIV care settings, effective and innovative interventions that respond to the existing challenges along the HIV care continuum are urgently needed to realize the benefits of antiretroviral therapy (ART). Initiating effective ART adherence dialog in an environment that promotes patient engagement in care is key. It is therefore critical to enhance our understanding about how patients living with HIV in these regions conceptualize and experience patient engagement. This study explores HIV patients' perceptions, experiences and expectations of their engagement in care. MATERIALS AND METHODS: We sampled 86 patients from three Academic Model for Providing Access to Healthcare (AMPATHplus) sites, one urban and two rural. We conducted 24 in-depth interviews and eight focus group discussions in either Swahili or English. Audio recordings of the interviews were transcribed, and then translated into English. We performed content analysis after thematic coding. RESULTS: Patients living with HIV in Kenya desire active engagement with care. However, their engagement was inconsistent and varied depending on the provider. Patients had a sense of how provider's interpersonal behaviors influenced their level of engagement. These included various aspects of provider-patient communication and relationship dynamics. Patients also highlighted relational boundaries that influenced the level and kind of information they shared with their providers. Aspects of their psychological, social or economic wellbeing were often viewed as personal and not discussed with their clinicians. Patients identified factors that would promote or impede their engagement with care including those related to patients themselves, providers, and the healthcare system. CONCLUSION: Patients living with HIV desired more active engagement in their care. In addition, they desired clinicians to engage in more social behaviors to promote patient engagement. To address existing patient engagement barriers, HIV care systems in the region should apply contextualized patient-centered interventions.

The Perspective of HIV Providers in Western Kenya on Provider-Patient Relationships.

Enhancing effective adherence dialogue with HIV patients in an environment that promotes good provider-patient relationships, is key to optimizing the benefits of antiretroviral therapy (ART). The study examines the perspectives of HIV providers in western Kenya on provider-patient relationships. Sixty healthcare providers were sampled using convenience sampling methods from three Academic Model for Providing Access to Healthcare (AMPATH) sites (one urban and two rural). In-depth interviews conducted in either Swahili or English were audio recorded, transcribed, and translated into English. Content analysis was performed after thematic coding. Providers perceived that they had good relationships with most patients, and tended to identify negative patient attributes as the source of poor provider-patient relationships. Providers preferred patients who adhered to treatment guidelines. They did not like patients who challenged their authority, and did not see it as their responsibility to find more effective ways of interacting with patients who they found difficult. Structural barriers to collaborative physician-patient relationships included noncontinuity of relationships, lack of specific appointment times, high provider-patient ratio, and management of provider fatigue and job dissatisfaction. There is need for HIV care programs to identify culturally appropriate interventions to enhance better provider-patient relationship.

Comparison of Electronic Health Record-Based and Claims-Based Diabetes Care Quality Measures: Causes of Discrepancies.

OBJECTIVE: To investigate magnitude and sources of discrepancy in quality metrics using claims versus electronic health record (EHR) data. STUDY DESIGN: Assessment of proportions of HbA1c and LDL testing for people ascertained as diabetic from the respective sources. Qualitative interviews and review of EHRs of discrepant cases. DATA COLLECTION/EXTRACTION: Claims submitted to Rhode Island Medicaid by three practice sites in 2013; program-coded EHR extraction; manual review of selected EHRs. PRINCIPAL FINDINGS: Of 21,030 adult Medicaid beneficiaries attributed to a primary care patient at a site by claims or EHR data, concordance on assignment ranged from 0.30 to 0.41. Of patients with concordant assignment, the ratio of patients ascertained as diabetic by EHR versus claims ranged from 1.06 to 1.14. For patients with concordant assignment and diagnosis, the ratio based on EHR versus claims ranged from 1.08 to 18.34 for HbA1c testing, and from 1.29 to 14.18 for lipid testing. Manual record review of 264 patients discrepant on diagnosis or testing identified problems such as misuse of ICD-9 codes, failure to submit claims, and others. CONCLUSIONS: Claims data underestimate performance on these metrics compared to EHR documentation, by varying amounts. Use of claims data for these metrics is problematic.

"Our lab is the community": Defining essential supporting infrastructure in engagement research.

INTRODUCTION: Effective patient engagement is central to patient-centered outcomes research. A well-designed infrastructure supports and facilitates patient engagement, enabling study development and implementation. We sought to understand infrastructure needs from recipients of Patient-Centered Outcomes Research Institute (PCORI) pilot grant awards. METHODS: We surveyed recipients of PCORI pilot project awards on self-perceived strengths in engagement infrastructure through PCORI's Ways of Engaging-Engagement Activity Tool survey, and interviewed leaders of 8 projects who volunteered as exemplars. Descriptive statistics summarized the survey findings. We conducted a thematic analysis of the interview transcripts. RESULTS: Of the 50 surveyed pilots, 22 answered the engagement infrastructure questions (44% response rate). Survey and interview findings emphasized the importance of committed institutional leadership, ongoing relationships with stakeholder organizations, and infrastructure funding through Clinical and Translational Science Awards, PCORI, and institutional discretionary funds. CONCLUSIONS: These findings highlight the importance of and how to improve upon existing institutional infrastructure.

Health-Needs Assessment for West African Immigrants in Greater Providence, RI.

African immigrants in the United States may experience barriers to health-care access and effectiveness. This mixed-methods study used paper-based surveys of people (N=101) in the target population from Nigeria, Ghana, and Liberia, recruited through convenience and snowball sampling. Semi-structured interviews were conducted with 3 clergy members who pastor churches with large Nigerian, Ghanaian, and Liberian populations, respectively; and five physicians and a clinical pharmacist who serve African immigrants. RESULTS: Length of stay in the United States was associated with the health status of refugee children. Undocumented immigration status was associated with lack of health insurance. Cardiovascular diseases, uterine fibroids and stress-related disorders were the most prevalent reported conditions. Regardless of English fluency, many immigrants are unfamiliar with medical terminology. CONCLUSION: African immigrants in the state of Rhode Island need more health education and resources to navigate the US health-care system. [Full article available at http://rimed.org/rimedicaljournal-2017-01.asp].

How does decision complexity affect shared decision making? An analysis of patient-provider antiretroviral initiation dialogue.

OBJECTIVES: This study analyzed patient-provider dialogue regarding anti-retroviral therapy (ART) initiation, assessing the degree to which shared decision making (SDM) occurred. METHODS: We analyzed 24 audio-recorded dialogues between 14 HIV providers and their patients regarding ART initiation. We coded transcribed dialogues for seven SDM elements. We stratified dialogues into three levels of decision complexity (basic, intermediate, complex) based on patient CD4 counts and evaluated SDM criteria fulfillment at each level of decision complexity. RESULTS: There were five basic, twelve intermediate, and seven complex decisions in our sample. While only two met the defined criteria for SDM, the mean number of SDM elements present increased with each level of decision complexity. Discussion of the clinical issue requiring the decision occurred most frequently (88%), while discussion of pros/cons (13%), patient's understanding (21%), and decision alternatives (29%) occurred least frequently. CONCLUSION/PRACTICE IMPLICATIONS: While few dialogues met the defined SDM criteria, providers are having conversations that respond to decision complexity. Clinicians should be aware that discussion of pros/cons, alternatives, and uncertainties are frequently skipped, even when these elements are clearly relevant, as in complex decisions. In addition, rhetorical questions to assess patient preferences and understanding are insufficient to fully engage patients in SDM.

Experimental Evaluation of Three Designs of Electrodynamic Flexural Transducers.

Three designs for electrodynamic flexural transducers (EDFT) for air-coupled ultrasonics are presented and compared. An all-metal housing was used for robustness, which makes the designs more suitable for industrial applications. The housing is designed such that there is a thin metal plate at the front, with a fundamental flexural vibration mode at ∼50 kHz. By using a flexural resonance mode, good coupling to the load medium was achieved without the use of matching layers. The front radiating plate is actuated electrodynamically by a spiral coil inside the transducer, which produces an induced magnetic field when an AC current is applied to it. The transducers operate without the use of piezoelectric materials, which can simplify manufacturing and prolong the lifetime of the transducers, as well as open up possibilities for high-temperature applications. The results show that different designs perform best for the generation and reception of ultrasound. All three designs produced large acoustic pressure outputs, with a recorded sound pressure level (SPL) above 120 dB at a 40 cm distance from the highest output transducer. The sensitivity of the transducers was low, however, with single shot signal-to-noise ratio ( SNR ) ≃ 15 dB in transmit-receive mode, with transmitter and receiver 40 cm apart.

Assessing Problematic Substance Use in HIV Care: Which Questions Elicit Accurate Patient Disclosures?

BACKGROUND: Substance use is associated with higher rates of antiretroviral non-adherence and poor HIV outcomes. This study examined how HIV care providers assess substance use, and which questions elicit accurate patient disclosures. METHODS: We conducted a conversation analysis of audio-recorded encounters between 56 providers and 162 patients living with HIV (PLWH) reporting active substance use in post-encounter interviews (cocaine or heroin use in the past 30 days, > 4 days intoxicated in past 30 days, or AUDIT score ≥ 8). We assessed the frequency of substance use discussion, characterized the types of questions used by providers, and determined the frequency of accurate patient disclosure by question type. RESULTS: In 55 reports of active substance use, providers already knew about the use (n = 16) or patients disclosed unpromptednn = 39). Among the remaining 155 instances of substance use in which providers had the opportunity to elicit disclosure, 78 reports (50 %) of substance use were not discussed. Of the remaining 77 reports in which the provider asked about substance use, 55 (71 %) patients disclosed and 22 (29 %) did not disclose. Questions were classified as: open-ended (n = 18, "How's the drinking going?"); normalizing (n = 14, "When was the last time you used?"); closed-ended (n = 36, "Have you used any cocaine?"); leading towards non-use (n = 9, "Have you been clean?"). Accurate disclosure followed 100 % of open-ended and normalizing questions, 58 % of closed-ended questions, and 22 % of leading questions. After adjusting for drug type, closed-ended questions were 41 % less likely (p < 0.001), and 'leading' questions 78 % less likely (p = 0.016) than broad and normalizing questions to elicit disclosures. CONCLUSION: Providers in this sample missed almost half of the opportunities to identify and discuss substance use with PLWH. Providers can increase the probability of patient disclosure by using open-ended or normalizing questions that ask about the "last time" that the patient used drugs or alcohol.

Parallel strip waveguide for ultrasonic flow measurement in harsh environments.

Wetted ultrasonic transit time flow meters typically consist of one or more pairs of transducers, containing piezoelectric elements, which alternate between transmitting and detecting an ultrasonic pulse. Typical piezoelectric materials and the adhesives used to attach the piezoelectric element in such devices can be damaged by hostile environments, such as extreme temperature, potentially limiting possible applications of ultrasonic flow measurement techniques. We have investigated a design for a flow meter with an integrated thermal buffer waveguide consisting of five parallel stainless steel strips. These, in addition to thermal protection, may function as a transducer array, with the possibility of steering the emitted field. Because the buffer strips used in the transducer assembly are thin, one might expect Lamb-like guided waves to propagate along it. However, the finite width of the strips has a significant effect on the propagation characteristics of the guided waves. In this work, the effect of the waveguide's small rectangular cross-section has been studied. Additionally, we have examined the effect of thermal gradients on the average sound speed and dispersion characteristics of such strip waveguides. We also suggest modifications to the plate geometry, which can alter both the frequency content and the shape of the transmitted pulse, potentially giving a better signal to use in flow measurement.

Patient-provider concordance with behavioral change goals drives measures of motivational interviewing consistency.

OBJECTIVE: Motivational Interviewing (MI) consistent talk by a counselor is thought to produce "change talk" in clients. However, it is possible that client resistance to behavior change can produce MI inconsistent counselor behavior. METHODS: We applied a coding scheme which identifies all of the behavioral counseling about a given issue during a visit ("episodes"), assesses patient concordance with the behavioral goal, and labels providers' counseling style as facilitative or directive, to a corpus of routine outpatient visits by people with HIV. Using a different data set of comparable encounters, we applied the concepts of episode and concordance, and coded using the Motivational Interviewing Treatment Integrity system. RESULTS: Patient concordance/discordance was not observed to change during any episode. Provider directiveness was strongly associated with patient discordance in the first study, and MI inconsistency was strongly associated with discordance in the second. CONCLUSION: Observations that MI-consistent behavior by medical providers is associated with patient change talk or outcomes should be evaluated cautiously, as patient resistance may provoke MI-inconsistency. PRACTICE IMPLICATIONS: Counseling episodes in routine medical visits are typically too brief for client talk to evolve toward change. Providers with limited training may have particular difficulty maintaining MI consistency with resistant clients.

Allocating HIV treatment to the adherent: a qualitative study of patient perceptions of their HIV care in the Dominican Republic.

BACKGROUND: The Dominican Republic (DR) has provided free antiretrovirals (ARVs) since 2004. Little is known about adherence to ARV regimens in the DR. METHODS: We audio-recorded 53 HIV care visits at a hospital-based clinic in the DR, conducted post-visit interviews with each patient, and observed clinic policies and practices. RESULTS: Scaled measures showed uniformly positive patient ratings of physician care and strong motivation for ARV adherence. However, it is clinic policy to suspend ARV treatment for patients believed to be non-adherent. This policy limited our study population, preventing us from talking to patients struggling with medication adherence. Clinical interactions featured little or no psychosocial content and patients did not consider physicians responsible for adherence counseling or problem solving. DISCUSSION: Patients excluded from treatment may be those facing the greatest barriers to adherence, such as mental health and substance use disorders, and may be at risk of transmitting the virus.

Motivational interviewing by HIV care providers is associated with patient intentions to reduce unsafe sexual behavior.

OBJECTIVE: Motivational interviewing (MI) can promote behavior change, but HIV care providers rarely have training in MI. Little is known about the use of MI-consistent behavior among untrained providers. This study examines the prevalence of such behaviors and their association with patient intentions to reduce high-risk sexual behavior. METHODS: Audio-recorded visits between HIV-infected patients and their healthcare providers were searched for counseling dialog regarding sexual behavior. The association of providers' MI-consistence with patients' statements about behavior change was assessed. RESULTS: Of 417 total encounters, 27 met inclusion criteria. The odds of patient commitment to change were higher when providers used more reflections (p=0.017), used more MI consistent utterances (p=0.044), demonstrated more empathy (p=0.049), and spent more time discussing sexual behavior (p=0.023). Patients gave more statements in favor of change (change talk) when providers used more reflections (p<0.001) and more empathy (p<0.001), even after adjusting for length of relevant dialog. CONCLUSION: Untrained HIV providers do not consistently use MI techniques when counseling patients about sexual risk reduction. However, when they do, their patients are more likely to express intentions to reduce sexual risk behavior. PRACTICE IMPLICATIONS: MI holds promise as one strategy to reduce transmission of HIV and other sexually transmitted infections.

The association of visit length and measures of patient-centered communication in HIV care: a mixed methods study.

OBJECTIVE: Patient centered clinical communication may be associated with longer encounters. METHODS: We used the General Medical Interaction Analysis System (GMIAS) to code transcripts of routine outpatient visits in HIV care, and create 5 measures of patient-centeredness. We defined visit length as number of utterances. To better understand properties of encounters reflected in these measures, we conducted a qualitative analysis of the 15 longest and 15 shortest visits. RESULTS: All 5 measures were significantly associated with visit length (p<0.05, rank order correlations 0.21-0.44). In multivariate regressions, association of patient centeredness with visit length was attenuated for 4 measures, and increased for 1; two were no longer statistically significant (p>0.05). Black and Hispanic race were associated with shorter visits compared with White race. Some of the longest visits featured content that could be considered extraneous to appropriate care. CONCLUSION: Patient centeredness is weakly related to visit length, but may reflect inefficient use of time in long encounters. PRACTICE IMPLICATIONS: Efforts to make visits more patient centered should focus on improving dialogue quality and efficient use of time, not on making visits longer. Shorter visits for Black and Hispanic patients could contribute to health disparities related to race and ethnicity.

Provider-focused intervention increases adherence-related dialogue but does not improve antiretroviral therapy adherence in persons with HIV.

BACKGROUND: Physicians' limited knowledge of patients' antiretroviral adherence may reduce their ability to perform effective adherence counseling. METHODS: We conducted a randomized, cross-over study of an intervention to improve physicians' knowledge of patients' antiretroviral adherence. The intervention was a report given to the physician before a routine office visit that included data on Medication Event Monitoring System and self-reported data on antiretroviral adherence, patients' beliefs about antiretroviral therapy, reasons for missed doses, alcohol and drug use, and depression. We audio recorded 1 intervention and 1 control visit for each patient to analyze differences in adherence-related dialogue. RESULTS: One hundred fifty-six patients were randomized, and 106 completed all 5 study visits. Paired audio recorded visits were available for 58 patients. Using a linear regression model that adjusted for site and baseline Medication Event Monitoring System adherence, adherence after intervention visits did not differ significantly from control visits (2.0% higher, P = 0.31, 95% confidence interval: -1.95% to 5.9%). There was a trend toward more total adherence-related utterances (median of 76 vs. 49.5, P = 0.07) and a significant increase in utterances about the current regimen (median of 51.5 vs. 32.5, P = 0.0002) in intervention compared with control visits. However, less than 10% of adherence-related utterances were classified as "problem solving" in content, and one third of physicians' problem-solving utterances were directive in nature. CONCLUSIONS: Receipt of a detailed report before clinic visits containing data about adherence and other factors did not improve patients' antiretroviral adherence. Analyses of patient-provider dialogue suggests that providers who care for persons with HIV may benefit from training in adherence counseling techniques.