Factors Related to Disclosure and Nondisclosure of Dietary Supplements in Primary Care, Integrative Medicine, and Naturopathic Medicine.

BACKGROUND: Patients infrequently disclose use of dietary supplements to providers. Little is known about factors that motivate patients to disclose supplement use. The study aimed to identify reported factors motivating patients' disclosure and nondisclosure of dietary supplement use and explore differences based on type of supplement and provider practice. METHODS: Mixed methods study combining qualitative content analysis of semi-structured interviews with statistical analyses to assess differences in identified factors by provider practice type and supplement type. Seventy-eight English-speaking patients who reported taking 466 dietary supplements in the previous 30 days were recruited from primary care and Complementary and Alternative Medicine (CAM), and Integrative Medicine (IM) offices in Southern California. RESULTS: We identified nine themes related to disclosure and nine related to nondisclosure of dietary supplement use. Major themes were features of the office visit, circumstances in patient health and medical care, and provider/patient characteristics. The most commonly raised theme promoting disclosure of supplement use was provider inquiry. Patients associate disclosure with having concerns about a supplement but also with annual physical exams and some routine topics of discussion, including self-care, lab results, and new medication prescriptions. Themes related to nondisclosure included lack of provider inquiry, features of the office visit, such as supplements being unrelated to the visit purpose, and patients' convictions that supplements are safe or not important to discuss. Themes did not vary by supplement type. Primary care patients were more likely than CAM/IM patients to attribute nondisclosure to convictions that supplements were beneficial, not worth mentioning, or equivalent to food (p ≤ 0.001). CONCLUSIONS: When providers fail to ask directly about dietary supplement use, disclosure is often an impromptu decision that is driven by the content of provider-patient interactions. Ensuring disclosure of dietary supplement use to prevent potential drug-supplement interactions or adverse health outcomes likely requires consistent, proactive provider queries about supplement use.

Stakeholder views regarding a planned primary care office-based interactive multimedia suicide prevention tool.

OBJECTIVES: Nearly half of all men who die by suicide visit a primary care clinician (PCC) in the month before death, yet few disclose suicide thoughts. We solicited stakeholders' views to guide development of a tailored multimedia program to activate middle-aged men experiencing suicide thoughts to engage with PCCs. METHODS: We conducted semi-structured interviews with 44 adults self-identifying as: suicide attempt survivor; family member/loved one of person(s) who attempted or died by suicide; PCC; non-PCC office staff; health administrator; and/or prevention advocate. We coded recorded interview transcripts and identified relevant themes using grounded theory. RESULTS: Two thematic groupings emerged, informing program design: structure and delivery (including belief the program could be effective and desire for use of plain language and media over text); and informational and motivational content (including concerns about PCC preparedness; fear that disclosing suicide thoughts would necessitate hospitalization; and influence of male identity and masculinity, respectively, in care-seeking for and interpreting suicide thoughts). CONCLUSION: Stakeholder input informed the design of a primary care tailored multimedia suicide prevention tool. PRACTICE IMPLICATIONS: In revealing a previously unreported barrier to disclosing suicide thoughts to PCCs (fear of hospitalization), and underscoring known barriers, the findings may suggest additional suicide prevention approaches.

Patients' Experience With Opioid Tapering: A Conceptual Model With Recommendations for Clinicians.

Clinical guidelines discourage prescribing opioids for chronic pain, but give minimal advice about how to discuss opioid tapering with patients. We conducted focus groups and interviews involving 21 adults with chronic back or neck pain in different stages of opioid tapering. Transcripts were qualitatively analyzed to characterize patients' tapering experiences, build a conceptual model of these experiences, and identify strategies for promoting productive discussions of opioid tapering. Analyses revealed 3 major themes. First, owing to dynamic changes in patients' social relationships, emotional state, and health status, patients' pain and their perceived need for opioids fluctuate daily; this finding may conflict with recommendations to taper by a certain amount each month. Second, tapering requires substantial patient effort across multiple domains of patients' everyday lives; patients discuss this effort superficially, if at all, with clinicians. Third, patients use a variety of strategies to manage the tapering process (eg, keeping an opioid stash, timing opioid consumption based on planned activities). Recommendations for promoting productive tapering discussions include understanding the social and emotional dynamics likely to impact patients' tapering, addressing patient fears, focusing on patients' best interests, providing anticipatory guidance about tapering, and developing an individualized tapering plan that can be adjusted based on patient response. Perspective: This study used interview and focus group data to characterize patients' experiences with opioid tapering and identify communication strategies that are likely to foster productive, patient-centered discussions of opioid tapering. Findings will inform further research on tapering and help primary care clinicians to address this important, often challenging topic.

The Art of Analgesia: A Pilot Study of Art Museum Tours to Decrease Pain and Social Disconnection Among Individuals with Chronic Pain.

OBJECTIVE: This mixed-methods study examines the feasibility of art museum tours (Art Rx) as an intervention for individuals with chronic pain. METHODS: Art Rx provided 1-hour docent-led tours in an art museum to individuals with chronic pain. Survey data were collected pre-tour, immediately post-tour, and at three weeks post-tour. Pain intensity and unpleasantness were measured with a 0-10 numerical rating scale. Social disconnection was measured with a 12-item social disconnection scale. Participants also reported percent pain relief during the tour and program satisfaction in the post-tour survey. Change in pain and social disconnection was analyzed with paired t tests, bias-corrected and accelerated bootstrap confidence intervals (BCa CIs), and Cohen's d. Thematic analysis of semistructured interviews with participants explored the feasibility and perceived impact of the program. RESULTS: Fifty-four individuals participated in this study (mean age [SD] = 59 [14.5] years, 64.8% female), and 14 were interviewed. Fifty-seven percent of participants reported pain relief during the tour, with an average pain relief (SD) of 47% (34.61%). Participants reported decreased social disconnection and pain unpleasantness pre- to post-tour (3.65, BCa 95% CI = 1.70-5.73, P < 0.001, d = 0.37; and 0.49, BCa 95% CI = 0.06-0.90, P = 0.016, d = 0.20, respectively). Participants indicated high satisfaction with the program. Interviewees remarked on the isolating impact of chronic pain and how negative experiences with the health care system often compounded this sense of isolation. Participants experienced Art Rx as a positive and inclusive experience, with potential lasting benefit. CONCLUSIONS: Art museum tours for individuals with chronic pain are feasible, and participants reported positive effects on perceived social disconnection and pain.

Perspectives of Chinese American smoker and nonsmoker household pairs about the creating smokefree living together program.

BACKGROUND: Chinese men smoke at high rates, and this puts household members at risk for tobacco-related diseases. Culturally responsive interventions that provide education and support are needed to promote smokefree living and reduce smoke exposure, particularly for US immigrants who experience changes in smokefree social norms. This qualitative study examines perspectives of Chinese American smoker and nonsmoker household pairs in the Creating Smokefree Living Together program. METHODS: Four focus groups were conducted with 30 Chinese American participants (15 smokers and 15 nonsmokers) who, in household pairs, completed smokefree education interventions of either brief or moderate intensity. Nearly three-quarters of the smokers continued to smoke after the intervention at the time of focus group participation. All smokers were male, and most household nonsmokers were female spouses. All participants had limited English proficiency. Focus group meetings were recorded, and the recordings were translated and transcribed. Transcripts and field notes were thematically analyzed. RESULTS: The following themes, shared by smokers and nonsmokers across interventions, were identified: 1) there was a preference for dyadic and group interventions because of the support offered, 2) increased knowledge of the health harms of smoke exposure within a pair improved the nonsmoker's support for smokefree living, 3) learning communication strategies improved household relationships and assertiveness for smokefree environments, 4) biochemical feedback was useful but had short-term effects, and 5) project magnets provided cues to action. CONCLUSIONS: Involving household partners is critical to smokefree interventions. Simple reminders at home appear to be more powerful than personal biochemical feedback of smoke exposure for sustaining motivation and engagement in ongoing behavioral changes within the household. Cancer 2018;124:1599-606. © 2018 American Cancer Society.

Barriers to Career Flexibility in Academic Medicine: A Qualitative Analysis of Reasons for the Underutilization of Family-Friendly Policies, and Implications for Institutional Change and Department Chair Leadership.

PURPOSE: Academic medical and biomedical professionals need workplace flexibility to manage the demands of work and family roles and meet their commitments to both, but often fail to use the very programs and benefits that provide flexibility. This study investigated the reasons for faculty underutilization of work-life programs. METHOD: As part of a National Institutes of Health-funded study, in 2010 the authors investigated attitudes of clinical and/or research biomedical faculty at the University of California, Davis, toward work-life policies, and the rationale behind their individual decisions regarding use of flexibility policies. The analysis used verbatim responses from 213 of 472 faculty (448 unstructured comments) to a series of open-ended survey questions. Questions elicited faculty members' self-reports of policy use, attitudes, and evaluations of the policies, and their perceptions of barriers that limited full benefit utilization. Data were coded and analyzed using a grounded theory approach. RESULTS: Faculty described how their utilization of workplace flexibility benefits was inhibited by organizational influences: the absence of reliable information about program eligibility and benefits, workplace norms and cultures that stigmatized program participation, influence of uninformed/unsupportive department heads, and concerns about how participation might burden coworkers, damage collegial relationships, or adversely affect workflow and grant funding. CONCLUSIONS: Understanding underuse of work-life programs is essential to maximize employee productivity and satisfaction, minimize turnover, and provide equal opportunities for career advancement to all faculty. The findings are discussed in relation to specific policy recommendations, implications for institutional change, and department chair leadership.

Social Environmental Influences on Smoking and Cessation: Qualitative Perspectives Among Chinese-Speaking Smokers and Nonsmokers in California.

This qualitative study examines the social environmental influences on smoking and cessation from the perspectives of Chinese smokers and household nonsmokers in California. Seven focus groups were conducted with 63 participants. Three culturally influenced levels of potential intervention emerged from constant comparative analysis. At the individual level, participants focused more on irritating odor than health harms of exposure and had inaccurate beliefs about harms of smoking and cessation. At the relational level, peers kept smokers connected to pro-smoking norms. There was conflict in the home about smoking and failed cessation, but smokers recognized the benefits of cessation for family harmony and children's health. Physicians encouraged cessation but this tended to be insufficient to prompt action unless a smoker felt ill. At the societal level, participants recognized changes in social acceptability and environmental regulation of smoking upon immigration. Better implementation of smokefree policies, plus culturally nuanced strategies for equipping both nonsmokers and smokers to become smokefree, are needed.

Characterizing internet health information seeking strategies by socioeconomic status: a mixed methods approach.

BACKGROUND: The Internet is valuable for those with limited access to health care services because of its low cost and wealth of information. Our objectives were to investigate how the Internet is used to obtain health-related information and how individuals with differing socioeconomic resources navigate it when presented with a health decision. METHODS: Study participants were recruited from public settings and social service agencies. Participants listened to one of two clinical scenarios - consistent with influenza or bacterial meningitis - and then conducted an Internet search. Screen-capture video software captured the Internet search. Participant Internet search strategies were analyzed and coded for pre- and post-Internet search guess at diagnosis and information seeking patterns. Individuals who did not have a college degree and were recruited from locations offering social services were categorized as "lower socioeconomic status" (SES); the remainder was categorized as "higher SES." Participants were 78 Internet health information seekers, ranging from 21-35 years of age, who experienced barriers to accessing health care services. RESULTS: Lower-SES individuals were more likely to use an intuitive, rather than deliberative, approach to Internet health information seeking. Lower- and higher-SES participants did not differ in the tendency to make diagnostic guesses based on Internet searches. Lower-SES participants were more likely than their higher-SES counterparts to narrow the scope of their search. CONCLUSIONS: Our findings suggest that individuals with different levels of socioeconomic status vary in the heuristics and search patterns they rely upon to direct their searches. The influence and use of credible information in the process of making a decision is associated with education and prior experiences with healthcare services. Those with limited resources may be disadvantaged when turning to the Internet to make a health decision.

Provider Recommendations in the Face of Scientific Uncertainty: An Analysis of Audio-Recorded Discussions about Vitamin D.

BACKGROUND: Little is known about how providers communicate recommendations when scientific uncertainty exists. OBJECTIVES: To compare provider recommendations to those in the scientific literature, with a focus on whether uncertainty was communicated. DESIGN: Qualitative (inductive systematic content analysis) and quantitative analysis of previously collected audio-recorded provider-patient office visits. PARTICIPANTS: Sixty-one providers and a socio-economically diverse convenience sample of 603 of their patients from outpatient community- and academic-based primary care, integrative medicine, and complementary and alternative medicine provider offices in Southern California. MAIN MEASURES: Comparison of provider information-giving about vitamin D to professional guidelines and scientific information for which conflicting recommendations or insufficient scientific evidence exists; certainty with which information was conveyed. RESULTS: Ninety-two (15.3 %) of 603 visit discussions touched upon issues related to vitamin D testing, management and benefits. Vitamin D deficiency screening was discussed with 23 (25 %) patients, the definition of vitamin D deficiency with 21 (22.8 %), the optimal range for vitamin D levels with 26 (28.3 %), vitamin D supplementation dosing with 50 (54.3 %), and benefits of supplementation with 46 (50 %). For each of the professional guidelines/scientific information examined, providers conveyed information that deviated from professional guidelines and the existing scientific evidence. Of 166 statements made about vitamin D in this study, providers conveyed 160 (96.4 %) with certainty, without mention of any equivocal or contradictory evidence in the scientific literature. No uncertainty was mentioned when vitamin D dosing was discussed, even when recommended dosing was higher than guideline recommendations. CONCLUSIONS AND RELEVANCE: Providers convey the vast majority of information and recommendations about vitamin D with certainty, even though the scientific literature contains inconsistent recommendations and declarations of inadequate evidence. Not communicating uncertainty blurs the contrast between evidence-based recommendations and those without evidence. Providers should explore best practices for involving patients in decision-making by acknowledging the uncertainty behind their recommendations.

Training Primary Care Physicians to Employ Self-Efficacy-Enhancing Interviewing Techniques: Randomized Controlled Trial of a Standardized Patient Intervention.

BACKGROUND: Primary care providers (PCPs) have few tools for enhancing patient self-efficacy, a key mediator of myriad health-influencing behaviors. OBJECTIVE: To examine whether brief standardized patient instructor (SPI)-delivered training increases PCPs' use of self-efficacy-enhancing interviewing techniques (SEE IT). DESIGN: Randomized controlled trial. PARTICIPANTS: Fifty-two family physicians and general internists from 12 primary care offices drawn from two health systems in Northern California. INTERVENTIONS: Experimental arm PCPs received training in the use of SEE IT training during three outpatient SPI visits scheduled over a 1-month period. Control arm PCPs received a single SPI visit, during which they viewed a diabetes treatment video. All intervention visits (experimental and control) were timed to last 20 min. SPIs portrayed patients struggling with self-care of depression and diabetes in the first 7 min, then delivered the appropriate intervention content during the remaining 13 min. MAIN MEASURES: The primary outcome was provider use of SEE IT (a count of ten behaviors), coded from three audio-recorded standardized patient visits at 1-3 months, again involving depression and diabetes self-care. Two five-point scales measured physician responses to training: Value (7 items: quality, helpfulness, understandability, relevance, feasibility, planned use, care impact), and Hassle (2 items: personal hassle, flow disruption). KEY RESULTS: Pre-intervention, study PCPs used a mean of 0.7 behaviors/visit, with no significant between-arm difference (P = 0.23). Post-intervention, experimental arm PCPs used more of the behaviors than controls (mean 2.7 vs. 1.0 per visit; adjusted difference 1.7, 95 % CI 1.1-2.2; P < 0.001). Experimental arm PCPs had higher training Value scores than controls (mean difference 1.05, 95 % CI 0.68-1.42; P < 0.001), and similarly low Hassle scores. CONCLUSIONS: Primary care physicians receiving brief SPI-delivered training increased their use of SEE IT and found the training to be of value. Whether patients visiting SEE IT-trained physicians experience improved health behaviors and outcomes warrants study. CLINICALTRIALS. GOV IDENTIFIER: NCT01618552.

Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial.

IMPORTANCE: Low-value diagnostic tests have been included on primary care specialty societies' "Choosing Wisely" Top Five lists. OBJECTIVE: To evaluate the effectiveness of a standardized patient (SP)-based intervention designed to enhance primary care physician (PCP) patient-centeredness and skill in handling patient requests for low-value diagnostic tests. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial of 61 general internal medicine or family medicine residents at 2 residency-affiliated primary care clinics at an academic medical center in California. INTERVENTIONS: Two simulated visits with SP instructors portraying patients requesting inappropriate spinal magnetic resonance imaging for low back pain or screening dual-energy x-ray absorptiometry. The SP instructors provided personalized feedback to residents regarding use of 6 patient-centered techniques to address patient concerns without ordering low-value tests. Control group physicians received SP visits without feedback and were emailed relevant clinical guidelines. MAIN OUTCOMES AND MEASURES: The primary outcome was whether resident PCPs ordered SP-requested low-value tests during up to 3 unannounced SP clinic visits over 3 to 12 months follow-up, with patients requesting spinal magnetic resonance imaging, screening dual-energy x-ray absorptiometry, or headache neuroimaging. Secondary outcomes included PCP patient-centeredness and use of targeted techniques (both coded from visit audiorecordings), and SP satisfaction with the visit (0-10 scale). RESULTS: Of 61 randomized resident PCPs (31 control group and 30 intervention group), 59 had encounters with 155 SPs during follow-up. Compared with control PCPs, intervention PCPs had similar patient-centeredness (Measure of Patient-Centered Communication, 43.9 [95% CI, 42.0 to 45.7] vs 43.7 [95% CI, 41.8 to 45.6], adjusted mean difference, -0.2 [95% CI, -2.9 to 2.5]; P = .90) and used a similar number of targeted techniques (5.4 [95% CI, 4.9 to 5.8] vs 5.4 [95% CI, 4.9 to 5.8] on a 0-9 scale, adjusted mean difference, 0 [95% CI, -0.7 to 0.6]; P = .96). Residents ordered low-value tests in 41 SP encounters (26.5% [95% CI, 19.7%-34.1%]) with no significant difference in the odds of test ordering in intervention PCPs relative to control group PCPs (adjusted odds ratio, 1.07 [95% CI, 0.49-2.32]). Rates of test ordering among intervention and control PCPs were similar for all 3 SP cases. The SPs rated visit satisfaction higher among intervention than control PCPs (8.5 [95% CI, 8.1-8.8] vs 7.8 [95% CI, 7.5-8.2], adjusted mean difference, 0.6 [95% CI, 0.1-1.1]). CONCLUSIONS AND RELEVANCE: An SP-based intervention did not improve the patient-centeredness of SP encounters, use of targeted interactional techniques, or rates of low-value test ordering, although SPs were more satisfied with intervention than control residents. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01808664.

Patient Admission Preferences and Perceptions.

INTRODUCTION: Understanding patient perceptions and preferences of hospital care is important to improve patients' hospitalization experiences and satisfaction. The objective of this study was to investigate patient preferences and perceptions of hospital care, specifically differences between intensive care unit (ICU) and hospital floor admissions. METHODS: This was a cross-sectional survey of emergency department (ED) patients who were presented with a hypothetical scenario of a patient with mild traumatic brain injury (TBI). We surveyed their preferences and perceptions of hospital care related to this scenario. A closed-ended questionnaire provided quantitative data on patient preferences and perceptions of hospital care and an open-ended questionnaire evaluated factors that may not have been captured with the closed-ended questionnaire. RESULTS: Out of 302 study patients, the ability for family and friends to visit (83%), nurse availability (80%), and physician availability (79%) were the factors most commonly rated "very important," while the cost of hospitalization (62%) and length of hospitalization (59%) were the factors least commonly rated "very important." When asked to choose between the ICU and the floor if they were the patient in the scenario, 33 patients (10.9%) choose the ICU, 133 chose the floor (44.0%), and 136 (45.0%) had no preference. CONCLUSION: Based on a hypothetical scenario of mild TBI, the majority of patients preferred admission to the floor or had no preference compared to admission to the ICU. Humanistic factors such as the availability of doctors and nurses and the ability to interact with family appear to have a greater priority than systematic factors of hospitalization, such as length and cost of hospitalization or length of time in the ED waiting for an in-patient bed.

Resident Self-Assessment and Learning Goal Development: Evaluation of Resident-Reported Competence and Future Goals.

OBJECTIVE: To determine incidence of learning goals by competency area and to assess which goals fall into competency areas with lower self-assessment scores. METHODS: Cross-sectional analysis of existing deidentified American Academy of Pediatrics' PediaLink individualized learning plan data for the academic year 2009-2010. Residents self-assessed competencies in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas and wrote learning goals. Textual responses for goals were mapped to 6 ACGME competency areas, future practice, or personal attributes. Adjusted mean differences and associations were estimated using multiple linear and logistic regression. RESULTS: A total of 2254 residents reported 6078 goals. Residents self-assessed their systems-based practice (51.8) and medical knowledge (53.0) competencies lowest and professionalism (68.9) and interpersonal and communication skills (62.2) highest. Residents were most likely to identify goals involving medical knowledge (70.5%) and patient care (50.5%) and least likely to write goals on systems-based practice (11.0%) and professionalism (6.9%). In logistic regression analysis adjusting for postgraduate year (PGY), gender, and degree type (MD/DO), resident-reported goal area showed no association with the learner's relative self-assessment score for that competency area. In the conditional logistic regression analysis, with each learner serving as his or her own control, senior residents (PGY2/3+s) who rated themselves relatively lower in a competency area were more likely to write a learning goal in that area than were PGY1s. CONCLUSIONS: Senior residents appear to develop better skills and/or motivation to explicitly turn self-assessed learning gaps into learning goals, suggesting that individualized learning plans may help improve self-regulated learning during residency.

Characterizing the Processes for Navigating Internet Health Information Using Real-Time Observations: A Mixed-Methods Approach.

BACKGROUND: Little is known about the processes people use to find health-related information on the Internet or the individual characteristics that shape selection of information-seeking approaches. OBJECTIVE: Our aim was to describe the processes by which users navigate the Internet for information about a hypothetical acute illness and to identify individual characteristics predictive of their information-seeking strategies. METHODS: Study participants were recruited from public settings and agencies. Interested individuals were screened for eligibility using an online questionnaire. Participants listened to one of two clinical scenarios­consistent with influenza or bacterial meningitis­and then conducted an Internet search. Screen-capture video software captured Internet search mouse clicks and keystrokes. Each step of the search was coded as hypothesis testing (etiology), evidence gathering (symptoms), or action/treatment seeking (behavior). The coded steps were used to form a step-by-step pattern of each participant's information-seeking process. A total of 78 Internet health information seekers ranging from 21-35 years of age and who experienced barriers to accessing health care services participated. RESULTS: We identified 27 unique patterns of information seeking, which were grouped into four overarching classifications based on the number of steps taken during the search, whether a pattern consisted of developing a hypothesis and exploring symptoms before ending the search or searching an action/treatment, and whether a pattern ended with action/treatment seeking. Applying dual-processing theory, we categorized the four overarching pattern classifications as either System 1 (41%, 32/78), unconscious, rapid, automatic, and high capacity processing; or System 2 (59%, 46/78), conscious, slow, and deliberative processing. Using multivariate regression, we found that System 2 processing was associated with higher education and younger age. CONCLUSIONS: We identified and classified two approaches to processing Internet health information. System 2 processing, a methodical approach, most resembles the strategies for information processing that have been found in other studies to be associated with higher-quality decisions. We conclude that the quality of Internet health-information seeking could be improved through consumer education on methodical Internet navigation strategies and the incorporation of decision aids into health information websites.

Organizing for Quality Improvement in Health Care: An Example From Childhood Obesity Prevention.

Children in rural areas face higher rates of obesity than children in urban areas, and their clinicians face challenges with preventing and managing obesity and translation of evidence into practice. We evaluated how the quality improvement (QI) intervention, Healthy Eating Active Living TeleHealth Community of Practice (HEALTH COP), at 7 rural California clinics addressed these challenges. Focus group interviews with QI team members assessed their experiences and factors related to adoption of key changes. Key challenges were clinician and staff buy-in, changing ingrained clinical practices, and motivating patient and families. Facilitators were top-down organizational requirements for QI, linkages to local QI resources, involvement of clinical champions, alignment with existing practices, incorporating a learning system connecting similar clinics, and clear and consistent communication channels. Evaluations of QI interventions should include not only measurement of effectiveness but also identification of factors associated with change and interactions with organizational processes and contexts.

e-Patients Perceptions of Using Personal Health Records for Self-management Support of Chronic Illness.

Chronic illness self-management is largely moving from healthcare professionals and into the hands of the patient. One tool that has been promoted to facilitate self-management support of chronic illness by policymakers, health advocates, providers, and consumers is the personal health record. Little is known about how consumers effectively use personal health records for self-management support and for productive patient-provider interactions. The purpose of this study was to learn from chronically ill engaged, experienced, and educated (e-patient) adults how and why they use personal health records for self-management support and productive patient-provider interactions. Eighteen purposively selected consumers were interviewed in two communities. Qualitative description methods were used, and we used a grounded theory approach to analyzing interview data, which was digitally recorded and transcribed verbatim. We identified four major thematic categories that capture the perceptions of the chronically ill using personal health records: (1) patient engagement and health self-management, (2) access to and control over personal health data, (3) promotion of productive communication, and (4) opportunities for training and education. Knowledge gained from the e-patient personal health record users suggest that making improvements to the portal system and providing education to consumers and providers will increase the utility among the experienced users and encourage new users to embrace adoption and use.

A cross-sectional study of provider and patient characteristics associated with outpatient disclosures of dietary supplement use.

OBJECTIVE: Explore patterns in patients' disclosures of supplement use and identify provider and patient characteristics associated with disclosures. METHODS: Cross-sectional study of 61 outpatient primary care, integrative medicine, and complementary medicine providers, and 603 of their patients. Primary outcomes were supplement disclosures (based on audio recorded office visits, post-visit patient surveys and medical record abstractions for the day of the visits). RESULTS: Seventy-nine percent of 603 patients reported on a post-visit survey that they took a total of 2107 dietary supplements. Of those taking supplements, 232 patients (48.6%) discussed at least one supplement with their provider on the day of their office visit. However, patients disclosed only 714 (33.9%) of the 2107 supplements they were taking. Patients more frequently disclosed supplement use when they saw providers who attributed greater importance to asking about supplements. Patient characteristics such as patient activation, number of medical conditions, and use of prescription medications were not associated with disclosure of supplement use. CONCLUSIONS: Provider rating of the importance of asking about supplements is a major factor prompting patients' disclosures of supplement use. PRACTICE IMPLICATIONS: Provider-targeted interventions to encourage provider awareness about potential supplement-drug interactions are needed to increase disclosures about dietary supplement use.

The eHealth Enhanced Chronic Care Model: a theory derivation approach.

BACKGROUND: Chronic illnesses are significant to individuals and costly to society. When systematically implemented, the well-established and tested Chronic Care Model (CCM) is shown to improve health outcomes for people with chronic conditions. Since the development of the original CCM, tremendous information management, communication, and technology advancements have been established. An opportunity exists to improve the time-honored CCM with clinically efficacious eHealth tools. OBJECTIVE: The first goal of this paper was to review research on eHealth tools that support self-management of chronic disease using the CCM. The second goal was to present a revised model, the eHealth Enhanced Chronic Care Model (eCCM), to show how eHealth tools can be used to increase efficiency of how patients manage their own chronic illnesses. METHODS: Using Theory Derivation processes, we identified a "parent theory", the Chronic Care Model, and conducted a thorough review of the literature using CINAHL, Medline, OVID, EMBASE PsychINFO, Science Direct, as well as government reports, industry reports, legislation using search terms "CCM or Chronic Care Model" AND "eHealth" or the specific identified components of eHealth. Additionally, "Chronic Illness Self-management support" AND "Technology" AND several identified eHealth tools were also used as search terms. We then used a review of the literature and specific components of the CCM to create the eCCM. RESULTS: We identified 260 papers at the intersection of technology, chronic disease self-management support, the CCM, and eHealth and organized a high-quality subset (n=95) using the components of CCM, self-management support, delivery system design, clinical decision support, and clinical information systems. In general, results showed that eHealth tools make important contributions to chronic care and the CCM but that the model requires modification in several key areas. Specifically, (1) eHealth education is critical for self-care, (2) eHealth support needs to be placed within the context of community and enhanced with the benefits of the eCommunity or virtual communities, and (3) a complete feedback loop is needed to assure productive technology-based interactions between the patient and provider. CONCLUSIONS: The revised model, eCCM, offers insight into the role of eHealth tools in self-management support for people with chronic conditions. Additional research and testing of the eCCM are the logical next steps.

Impact of patient requests on provider-perceived visit difficulty in primary care.

BACKGROUND: "Difficult visits" are common in primary care and may contribute to primary care provider (PCP) career dissatisfaction and burnout. Patient requests occur in approximately half of primary care visits and may be a source of clinician-patient miscommunication or conflict, contributing to perceived visit difficulty. OBJECTIVE: We aimed to determine associations between types of patient requests and PCP-perceived visit difficulty. DESIGN: This was an observational study, nested in a multicenter randomized trial of depression engagement interventions. SUBJECTS: We included 824 patient visits within 135 PCP practices in Northern California occurring from June 2010 to March 2012. MAIN MEASURES: PCP-perceived visit difficulty was quantified using a three-item scale (relative visit difficulty, amount of effort required, and amount of time required; Cronbach's α = 0.81). Using linear regression, the difficulty scale (score range 0-2 from least to most difficult) was modeled as a function of: patient requests for diagnostics tests, pain medications, and specialist referrals; PCP perception of likely depression or likely substance abuse; patient sociodemographics, comorbidity, depression; PCP characteristics and practice setting. RESULTS: Patients requested diagnostic tests, pain medications, and specialist referrals in 37.2, 20.0 and 30.0 % of visits, respectively. After adjustment for patient medical and psychiatric complexity, perceived difficulty was significantly higher when patients requested diagnostic tests [parameter estimate (PE) 0.11, (95 % CI: 0.03, 0.20)] but not when patients requested pain medications [PE -0.04 (95 % CI: -0.15, 0.08)] or referrals [PE 0.04 (95 % CI: -0.07, 0.25)]. CONCLUSIONS: PCP-perceived visit difficulty is associated with patient requests for diagnostic tests, but not requests for pain medications or specialist referrals. In this era of "choosing wisely," PCPs may be challenged to respond to diagnostic test requests in an evidence-based manner, while maintaining the provider-patient relationship and PCP career satisfaction.