Healthcare professionals' perceptions on barriers and facilitators to DMARD use in rheumatoid arthritis.

BACKGROUND: Disease-modifying anti-rheumatic drugs (DMARDs) are the cornerstone of rheumatoid arthritis (RA) treatment. However, the full benefits of DMARDs are often not realized because many patients are sub-optimally adherent to their medication. In order to optimize adherence, it is essential that healthcare professionals (HCPs) understand patients' barriers and facilitators for medication use. Insight in these barriers and facilitators may foster the dialogue about adequate medication use between HCPs and patients. What HCPs perceive as barriers and facilitators has, so far, scarcely been investigated. This study aimed to identify the perceptions of HCPs on patients' barriers and facilitators that might influence their adherence. METHODS: This qualitative study was performed using semi structured in-depth interviews with HCPs. An interview guide was used, based on an adjusted version of the Theoretical Domains Framework (TDF). Thematic analysis was conducted to identify factors that influence barriers and facilitators to DMARD use according to HCPs. RESULTS: Fifteen HCPs (5 rheumatologists, 5 nurses and 5 pharmacists) were interviewed. They mentioned a variety of factors that, according to their perceptions, influence DMARD adherence in patients with RA. Besides therapy-related factors, such as (onset of) medication effectiveness and side-effects, most variation was found within patient-related factors and reflected patients' beliefs, ways of coping, and (self-management) skills toward medication and their condition. In addition, factors related to the condition (e.g., level of disease activity), healthcare team and system (e.g., trust in HCP), and social and economic context (e.g. support, work shifts) were reported. CONCLUSIONS: This study provided insights in HCPs' perceptions of the barriers and facilitators to DMARD use patients with RA. Most factors that were mentioned were patient-related and potentially modifiable. When physicians understand patients' perceptions on medication use, adherence to DMARDs can probably be optimized in patients with RA leading to more effectiveness of treatment outcomes.

Continuity of care experienced by patients in a multi-institutional pancreatic care network: a pilot study.

BACKGROUND: Over the past decades, health care services for pancreatic surgery were reorganized. Volume norms were applied with the result that only a limited number of expert centers perform pancreatic surgery. As a result of this centralization of pancreatic surgery, the patient journey of patients with pancreatic tumors has become multi-institutional. To illustrate, patients are referred to a center of expertise for pancreatic surgery whereas other parts of pancreatic care, such as chemotherapy, take place in local hospitals. This fragmentation of health care services could affect continuity of care (COC). The aim of this study was to assess COC perceived by patients in a pancreatic care network and investigate correlations with patient-and care-related characteristics. METHODS: This is a pilot study in which patients with (pre) malignant pancreatic tumors discussed in a multidisciplinary tumor board in a Dutch tertiary hospital were asked to participate. Patients were asked to fill out the Nijmegen Continuity of Care-questionnaire (NCQ) (5-point Likert scale). Additionally, their patient-and care-related data were retrieved from medical records. Correlations of NCQ score and patient-and care-related characteristics were calculated with Spearman's correlation coefficient. RESULTS: In total, 44 patients were included (92% response rate). Pancreatic cancer was the predominant diagnosis (32%). Forty percent received a repetition of diagnostic investigations in the tertiary hospital. Mean scores for personal continuity were 3.55 ± 0.74 for GP, 3.29 ± 0.91 for the specialist and 3.43 ± 0.65 for collaboration between GPs and specialists. Overall COC was scored with a mean 3.38 ± 0.72. No significant correlations were observed between NCQ score and certain patient-or care-related characteristics. CONCLUSION: Continuity of care perceived by patients with pancreatic tumors was scored as moderate. This outcome supports the need to improve continuity of care within multi-institutional pancreatic care networks.

Ranking facilitators and barriers of medication adherence by patients with inflammatory arthritis: a maximum difference scaling exercise.

INTRODUCTION: Facilitators and barriers of adherence to disease-modifying anti-rheumatic drugs (DMARDs) have been identified by patients with inflammatory arthritis earlier. However, the relative importance from the patients' perspective of these factors is unknown. Knowledge on this ranking might guide the development of interventions and may facilitate targeted communication on adherence. This study aims to examine 1) the relative importance patients attach to facilitators and barriers for DMARDs adherence, and 2) the relationship between patient characteristics and ranking of these factors. METHODS: One hundred twenty-eight outpatients with inflammatory arthritis; (60% female, mean age 62 years (SD = 12), median disease duration 15 years, IQR (7, 23) participated in a Maximum Difference scaling exercise and ranked 35 items based upon previously identified facilitators and barriers to medication adherence. Hierarchical Bayes estimation was used to compute mean Rescaled Probability Scores (RPS; 0-100) (i.e. relative importance score). Kendall's coefficient of concordance was used to examine a possible association between patients' characteristics (i.e. age, sex and educational level) and ranking of the items. RESULTS: The three most important items ranked by patients were: Reduction of symptoms formulated as "Arthritis medications help to reduce my symptoms" (RPS = 7.30, CI 7.17-7.44), maintaining independence formulated as "I can maintain my independence as much as possible" (RPS = 6.76, CI 6.54-6.97) and Shared decision making formulated as "I can decide -together with my physician- about my arthritis medications" (RPS = 6.48, CI 6.24-6.72). No associations between patient characteristics and ranking of factors were found. CONCLUSIONS: Reducing symptoms, maintaining independency and shared decision making are patients' most important factors for DMARDs adherence. This knowledge might guide the development of interventions and may facilitate communication between health professionals and their patients on medication adherence.

Referral to cancer genetic counseling: do migrant status and patients' educational background matter?

Participation rates in cancer genetic counseling differ among populations, as patients with a lower educational background and migrant patients seem to have poorer access to it. We conducted a study to determine the present-day educational level and migrant status of counselees referred to cancer genetic counseling. We assessed personal characteristics and demographics of 731 newly referred counselees. Descriptive statistics were used to describe these characteristics. The results show that about 40% of the counselees had a high educational level and 89% were Dutch natives. Compared to the Dutch population, we found a significant difference in educational level (p = < 0.01) and migrant status (p = < 0.001). This suggests disparities in cancer genetic counseling and as a result of that, suboptimal care for vulnerable groups. Limited health literacy is likely to pose a particular challenge to cancer genetic counseling for counselees with a lower education or a migrant background. Our study points to considerable scope for improvement in referring vulnerable groups of patients for cancer genetic counseling.

Breast cancer genetic counseling among Dutch patients from Turkish and Moroccan descent: participation determinants and perspectives of patients and healthcare professionals.

Lower participation rates in cancer genetic counseling are observed among different ethnic minorities. The goal of our study is to gain insight into determinants of Turkish and Moroccan patients' participation in breast cancer genetic counseling and DNA testing, from the point of view of healthcare professionals and patients. Questionnaire-based telephone interviews about awareness, perceptions, and reasons for (non-) participation in cancer genetic counseling were conducted with 78 Dutch breast cancer patients from Turkish and Moroccan descent. The interviews were held in Arabic, Berber, Turkish, or Dutch by bilingual research assistants. Additionally, 14 breast cancer patients participated in one of two focus group meetings, and two focus groups were held with 11 healthcare professionals. SPSS and QSR Nvivo were used to examine the quantitative and qualitative data, respectively. Half of the total group of patients (N = 78) and 79% of patients eligible for genetic counseling and testing (N = 33) were aware of the possibility of genetic counseling. The most important determinants for nonparticipation in genetic counseling were experienced difficulties in patient-doctor communication, cultural factors (e.g., social norms), limited health literacy, limited knowledge of the family cancer history, and anxiety about cancer. Religious beliefs and knowing personal and family members' breast cancer risks were motives to obtain genetic counseling. Despite the fact that our study showed that Moroccan and Turkish women reported several personal motives to obtain genetic counseling and testing (GCT), patients and healthcare professionals experience significant language and health literacy difficulties, which make it harder to fully access health care such as genetic counseling and testing.

How do medical specialists value their own intercultural communication behaviour? A reflective practice study.

BACKGROUND: Intercultural communication behaviour of doctors with patients requires specific intercultural communication skills, which do not seem structurally implemented in medical education. It is unclear what motivates doctors to apply intercultural communication skills. We investigated how purposefully medical specialists think they practise intercultural communication and how they reflect on their own communication behaviour. METHODS: Using reflective practice, 17 medical specialists independently watched two fragments of videotapes of their own outpatient consultations: one with a native patient and one with a non-native patient. They were asked to reflect on their own communication and on challenges they experience in intercultural communication. The interviews were open coded and analysed using thematic network analysis. RESULTS: The participants experienced only little differences in their communication with native and non-native patients. They mainly mentioned generic communication skills, such as listening and checking if the patient understood. Many participants experienced their communication with non-native patients positively. The participants mentioned critical incidences of intercultural communication: language barriers, cultural differences, the presence of an interpreter, the role of the family and the atmosphere. CONCLUSION: Despite extensive experience in intercultural communication, the participants of this study noticed hardly any differences between their own communication behaviour with native and non-native patients. This could mean that they are unaware that consultations with non-native patients might cause them to communicate differently than with native patients. The reason for this could be that medical specialists lack the skills to reflect on the process of the communication. The participants focused on their generic communication skills rather than on specific intercultural communication skills, which could either indicate their lack of awareness, or demonstrate that practicing generic communication is more important than applying specific intercultural communication. They mentioned well-known critical incidences of ICC: language barriers, cultural differences, the presence of an interpreter, the role of the family and the atmosphere. Nevertheless, they showed a remarkably enthusiastic attitude overall was noteworthy. A strategy to make doctors more aware of their intercultural communication behaviour could be a combination of experiential learning and ICC training, for example a module with reflective practice.

Migrant breast cancer patients and their participation in genetic counseling: results from a registry-based study.

Certain ethnic groups seem to have less access to cancer genetic counseling. Our study was to investigate the participation in cancer genetic counseling among migrant breast cancer patients of Turkish and Moroccan origin. Hospital medical records of Turkish and Moroccan and of a comparative group of non-Turkish/Moroccan newly diagnosed breast cancer patients were studied. All women were diagnosed between 2007 and 2012. Eligibility for genetic counseling was assessed with a checklist. A total of 156 Turkish/Moroccan patients were identified, and 321 patients were assigned to the comparative group. About one third (35%) of the Turkish/Moroccan patients fulfilled criteria for breast cancer genetic counseling, compared to 21% of the comparative group (P = 0.001); this was largely due to a relatively young age at diagnosis in the migrant group (26% <40 years vs 5% in the comparative group, P = 0.0001). Uptake of genetic counseling among eligible patients was 47% in the migrant group and 56% in the comparative group; differences in uptake were seen among the patients diagnosed before 40 years of age (48% in the migrant group vs 81% in the comparative group; P = 0.021). When adjusted for age at diagnosis, ethnicity was associated with discussing referral to genetic counseling and its actual uptake. The Turkish/Moroccan ethnicity appears to be associated with a lower uptake of genetic counseling, mainly caused by the lower uptake in the young age-group. The major barrier to participation in genetic counseling seems to lie within the referral process.

Communication at an online infertility expert forum: provider responses to patients' emotional and informational cues.

Online patient-provider communication has become increasingly popular in fertility care. However, it is not known to what extent patients express cues or concerns and how providers respond. In this study, we investigated cues and responses that occur in online patient-provider communication at an infertility-specific expert forum. We extracted 106 threads from the multidisciplinary expert forum of two Dutch IVF clinics. We performed the following analyses: (1) thematic analysis of patients' questions; and (2) rating patients' emotional and informational cues and subsequent professionals' responses using an adaptation of the validated Medical Interview Aural Rating Scale. Frequencies of themes, frequencies of cues and responses, and sequences (what cue is followed by what response) were extracted. Sixty-five infertile patients and 19 providers participated. The most common themes included medication and lifestyle. Patients gave more informational than emotional cues (106 versus 64). Responses to informational cues were mostly adequate (61%). The most common response to emotional cues was empathic acknowledgment (72%). Results indicate that an online expert forum could have a positive effect on patient outcomes, which should guide future research. Offering infertile patients an expert forum to communicate with providers can be a promising supplement to usual care in both providing information and addressing patients' concerns.

The influence of dispositional optimism on post-visit anxiety and risk perception accuracy among breast cancer genetic counselees.

OBJECTIVE: Much is unknown about the influence of dispositional optimism and affective communication on genetic counselling outcomes. This study investigated the influence of counselees' optimism on the counselees' risk perception accuracy and anxiety, while taking into account the affective communication during the first consultation for breast cancer genetic counselling. METHODS: Counselees completed questionnaires measuring optimism, anxiety and the perceived risk that hereditary breast cancer runs in the family before, and anxiety and perceived risk after the first consultation. Consultations were videotaped. The duration of eye contact was measured, and verbal communication was rated using the Roter Interaction Analysis System. RESULTS: Less-optimistic counselees were more anxious post-visit (ß = -.29; p = .00). Counsellors uttered fewer reassuring statements if counselees were more anxious (ß = -.84; p = .00) but uttered more reassurance if counselees were less optimistic (ß = -.76; p = .01). Counsellors expressed less empathy if counselees perceived their risk as high (ß = -1.51; p = .04). An increase in the expression of reassurance was related to less post-visit anxiety (ß = -.35; p = .03). More empathy was related to a greater overestimation of risk (ß = .92; p = .01). CONCLUSIONS: Identification of a lack of optimism as a risk factor for high anxiety levels enables the adaptation of affective communication to improve genetic counselling outcomes. Because reassurance was related to less anxiety, beneficial adaptation is attainable by increasing counsellors' reassurance, if possible. Because of a lack of optimally adapted communication in this study, further research is needed to clarify how to increase counsellors' ability to adapt to counselees.

[Shared Medical Appointments: experiences of patients and care givers]. / 'Gezamenlijk Medisch Consult': samen naar de dokter. Ervaringen van patiënten en zorgverleners.

OBJECTIVE: To examine the characteristics of patients participating in a shared medical appointment (SMA); to what extent SMAs fulfil patients' needs; to evaluate if patients are better informed after an SMA and how they evaluate meeting other patients at an SMA, and how health professionals experience SMAs. DESIGN: Descriptive. METHOD: Fourteen multidisciplinary teams participated in the study. The Dutch Institute for Healthcare Improvement (CBO) trained them in how to conduct an SMA. The experiences of patients participating in an SMA were compared with the experiences of patients who visited the doctor individually. Patients completed questionnaires before and after the SMA (n = 83) or the individual visit (n = 158). RESULTS: Patients who participated in an SMA did not differ significantly from the regular patient population in either demographic characteristics or in their experience of health and care uptake. Patients participated in an SMA primarily to share experiences with fellow patients, to learn from others and to obtain more information. Both patients and health professionals (n = 53) reported that patients received more information during an SMA. Patients valued the contact with their fellow patients. SMA offered care givers a different experience and opportunities to learn. CONCLUSION: For patients and health professionals, SMAs seem indeed to have added value. More research is needed to understand the working mechanism and the long-term effects of participation in SMAs.

Communication in cancer genetic counselling: does it reflect counselees' previsit needs and preferences?

This study sought to describe counsellor-counselee interaction during initial cancer genetic counselling consultations and to examine whether the communication reflects counselees' previsit needs. A total of 130 consecutive counselees, referred mainly for breast or colon cancer, completed a questionnaire before their first appointment at a genetic clinic. Their visit was videotaped. Counselee and counsellor verbal communications were analysed and initiative to discuss 11 genetics-specific conversational topics was assessed. The content of the visit appeared relatively standard. Overall, counselees had a stronger psychosocial focus than counsellors. Counsellors directed the communication more and initiated the discussion of most of the topics assessed. Counselees did not appear to communicate readily in a manner that reflected their previsit needs. Counsellors provided more psychosocial information to counselees in higher need for emotional support, yet did not enquire more about counselees' specific concerns. New counselees may be helped by receiving more information on the counselling procedure prior to their visit, and may be advised to prepare the visit more thoroughly so as to help them verbalise more their queries during the visit.

Effects of gynaecological education on interpersonal communication skills.

OBJECTIVE: To investigate the effects of an experimental communication course on how gynaecologists handle psychosocial issues in gynaecological consultation. DESIGN: Pre-post testing. Multilevel analysis was used to take into account the similarity among encounters with the same gynaecologist. SAMPLE: Eighteen gynaecologists (13 consultants and 5 junior doctors) from five different hospitals participated. All gynaecologists videotaped consecutive outpatient encounters before and after attending an intensive training course. MAIN OUTCOME MEASURES: The communicative performance of the gynaecologists at pre-and post measurement. RESULTS: The gynaecologists recorded a total of 526 outpatient encounters, 272 before and 254 after the training. As a result of the training, gynaecologists' sensitivity to psychosocial aspects of their patients increased. At post measurement, the gynaecologists gave more signs of agreement, became less directive, asked fewer medical questions and more psychosocial questions. No difference was found in the duration of the outpatient visits. With the trained gynaecologists, patients asked more questions and provided more psychosocial information. CONCLUSIONS: Junior doctors and clinically experienced gynaecologists can be taught to handle psychosocial issues without lengthening the visit.

Physician reimbursement and the medical encounter: an observational study in Dutch pediatrics.

Pediatrician reimbursement is shifting from fee-for-service to a fixed salary. In the Netherlands, as physicians working on a fee-for-service basis have a financial interest in talking less and in carrying out more diagnostic tests and investigations, it may be questioned whether this will influence the structure and content of medical visits. With use of 302 videotaped outpatient encounters with either salaried or fee-for-service pediatricians, differences were examined in visit length, number of requests for diagnostic tests and investigations (laboratory test, endoscopy, and radiography), pediatrician-parent communication behaviors, and patient satisfaction. This investigation was carried out by means of bivariate and multilevel analysis. The results showed that the visits with salaried pediatricians lasted almost 4 minutes longer. This surplus time was not spent on social talk or on a more elaborate history taking but was used to provide more information and advice. In addition, salaried pediatricians engaged in more empathic behavior toward the patient, thereby facilitating a therapeutic relationship. No differences were found in the number of diagnostic tests and investigations or in patient satisfaction. It may be concluded that history taking and social talk took place in a fixed part of the visit. Salaried pediatricians spent more time on exchanging information with their patients and paid more attention to patient concerns and emotions. As the reimbursement shift is not likely to diminish the number of diagnostic tests and investigations and will increase the length of the medical visits, overall financial benefits may be limited.

Effects of continuing paediatric education in interpersonal communication skills.

UNLABELLED: Paediatric care places great demands on interpersonal communication skills, especially as regards the handling of psychosocial issues. Recent shifts in paediatric morbidity and increases in patient empowerment furthermore emphasize the need for continuing paediatric education in communication skills. It is, however, debatable, whether after residency paediatric education can influence paediatrician performance. This study evaluated the effects of a 5-day experiential communication training by means of a pretest/post-test control group design. A total of 21 consulting paediatricians (10 experimental, 11 control group paediatricians) videotaped two series of consecutive outpatient encounters. Compared with the untrained control group, trained paediatricians asked more psychosocial questions and looked at the patients and their parents more often. In addition, they gave patients and parents more room to talk. No difference was found in the length of the outpatient visits. CONCLUSION: Paediatric education after residency influences paediatricians' verbal and nonverbal communication skills positively, especially as regards handling psychosocial issues. On the basis of these findings, it appears worthwhile to encourage continuing paediatric education in interpersonal communication skills.

Gender differences in gynecologist communication.

The intimate nature of gynecological health problems requires the physician's specific attention. On the basis of previous findings in primary care, female gynecologists are expected to communicate more affectively than men. This study addressed gender differences in gynecologist communication behavior by comparing videotapes of real-life outpatient encounters with female (N = 107) and male (N = 196) gynecologists by means of bivariate and multilevel analysis. Only a few gender differences were found: female gynecologists performed longer physical examinations, showed more global attentiveness, and asked fewer medical questions. Either the duration of the medical education or the type of statistical analysis may account for this lack of gender differences.

Communication during gynecological out-patient encounters.

The intimate nature of women's health problems presented during gynecological encounters places great demands on gynecologists' communicative behavior. The present study examined what patients expect from their gynecologist, how gynecologists and patients actually communicate during out-patient encounters, and what factors shape the structure and process of the encounter. Twenty-one gynecologists (13 consultants and eight residents) videotaped 303 consecutive out-patient encounters. Multilevel analysis was used to take into account the similarity among encounters with the same gynecologist. The results showed that gynecological patients expected foremost to receive clear and understandable information. One-third of the patients expected support and understanding. Psychosocial issues were hardly ever the topic of conversation. The length of the out-patient visits increased in the presence of patients' partner, with the type of problem presented, and with the frequency with which the patient disagreed with the gynecologist. The visit was also longer when gynecologists provided more medical information and asked more psychosocial questions. Although gynecological encounters focus almost exclusively on medical issues, talking about non-somatic aspects does not seem to prolong the visit as much as the presence of the patient's partner or whether or not the gynecologist and patient had met before. In view of patients' affective needs, it would be worthwhile to examine whether gynecologists can be taught to handle patients' psychosocial needs as well.

Children's contributions to pediatric outpatient encounters.

OBJECTIVE: Generally, increasing attention is being paid to the quality of doctor-patient communication. However, children's contributions have been, until now, primarily ignored in communication research, although there are indications that considering their views increases satisfaction and compliance. In the present study, we examined how children contributed to communication during outpatient pediatric encounters and what factors were associated with children's contributions. PATIENTS: Twenty-one consulting pediatricians videotaped a total of 302 consecutive outpatient encounters. DESIGN: Multilevel analysis was used to take into account the similarity among encounters with the same pediatrician. RESULTS: Children's contributions to the outpatient encounters were limited to 4%. Pediatricians directed one out of every four statements to the child. Although pediatricians asked children a lot of medical questions (26%), only a small part of the medical information (13%) was directed at the children. Apart from social talk and laughter, the amount of pediatrician-child communication increased with children's age. Communication with children suffering from disorders of the nervous system seemed to differ from that with children suffering from other diseases. Allowing children more room in the medical visit did not seem to increase the duration of the visit. CONCLUSIONS: Although recent legislation requires children to be adequately informed, in pediatric outpatient encounters information still tends to be directed primarily at the parents. Children do get the opportunity to talk about social and psychosocial issues. Pediatricians may need to acquire similar communication skills to discuss medical-technical issues with the children.

[Improved prognosis of functional abdominal complaints by attending to psychic factors]. / Betere prognose van functionele buikklachten door aandacht voor psychische factoren.

OBJECTIVE: To determine the assessment by physicians of psychic factors in patients with functional abdominal complaints, and the relationship between the assessment and the evolution of the abdominal complaints. DESIGN: Prospective, descriptive. SETTING: Outpatient Clinic Internal Medicine, University Hospital Nijmegen, the Netherlands. METHODS: 120 patients with functional abdominal complaints were asked to indicate by questionnaires the severity and meaning of their complaints prior to and at the end of the visits to their internist. Internists were asked how they rated the somatic and non-somatic complaint dimensions in their patients. RESULTS: Overall, internists perceived the severity and details of the abdominal complaints correctly. Prognostically unfavourable complaint-related cognitions and emotions were perceived less correctly. During the outpatient consulting period, patients' anxiety and somatic attributions diminished, especially when the internist had perceived these aspects correctly. Six months after the first outpatient visit the abdominal complaints of these reassured patients had improved, compared with patients with persistent somatic attributions; the latter made more frequent use of health care services at follow-up (GP visits, drug use). CONCLUSION: Systematic exploration of somatic and non-somatic complaint dimensions by physicians could be an important tool in improving the prognosis and diminishing the medical consumption in patients with functional abdominal complaints.

Persisting improvement in complaint-related cognitions initiated during medical consultations in functional abdominal complaints.

BACKGROUND: Previously it was shown that during a series of out-patient consultations dysfunctional complaint-related cognitions and anxiety diminished significantly in patients with functional abdominal complaints (IBS). The aim of the present study was to assess the maintenance of positive changes initiated during medical consultations in the patients' complaint-related cognitions and anxiety, as well as the influence of these cognitions on the severity of the complaints, 6 months after the first visit to the out-patient clinic. METHODS: One hundred and five consecutive patients with IBS referred by their general practitioners to the out-patient clinic for internal medicine completed questionnaires about their complaints and their complaint-related cognitions and anxiety before the first and after the last out-patient visit and again at follow-up, 6 months after the first out-patient consultation. RESULTS: Positive changes in the patients' complaint-related cognitions during the consulting period were found to persist during the follow-up period. Improvement in abdominal complaints at follow-up was found to be related to the level of the patients' state anxiety, fear of cancer, and catastrophizing cognitions at the last out-patient visit. CONCLUSIONS: Medical consultations can bring about long-lasting positive changes in prognostically unfavourable cognitions and anxiety. These changes appear to be related to a better outcome of IBS.