United Ostomy Associations of America's Ostomy and Continent Diversion Patient Bill of Rights: An Examination of Best-in-Practice Care for Ostomy Patients.

PURPOSE: The purpose of this study was to examine best practices through utilization of United Ostomy Associations of America's (UOAA's) Ostomy and Continent Diversion Patient Bill of Rights (PBOR) from the perspective of patients and clinicians. DESIGN: Cross-sectional, comparative design. SUBJECTS AND SETTING: The sample comprised 412 patients with ostomies (colostomy, ileostomy, urostomy) and continent diversions (such as J-pouch) and 195 clinicians (physicians, nurses, nurse assistants) residing in the United States. All patients underwent surgery within the United States. Almost half of participants (n = 196/412; 47.6%) had surgery within 5 years of data collection. METHODS: Participants were recruited between 2019 and 2020. Patient data were collected from UOAA's national conference and affiliated ostomy support groups. Clinician data were collected at the 2019 National WOCN Society Conference and through affiliated nursing and medical professional societies. Participants completed a self-administered online or printed survey; items focused on the Ostomy and Continent Diversion PBOR and standards of ostomy care. RESULTS: Among clinicians familiar with the PBOR, 54% (n = 58/106) reported UOAA's PBOR was being used to inform ostomy care. When analyzing the full sample of both clinicians and patients, we found that less than 13% (n = 25/195) of clinicians and 5% (n = 20/412) of patients reported that all 16 of the recommended standards of care outlined in the PBOR were incorporated into ostomy care. Analysis also revealed differences between patients' and clinicians' reports of provision of 14 of the 16 PBOR components. They include a discussion on emotional impact of the ostomy surgery, instructions on troubleshooting potential difficulties with the ostomy, provision of educational materials, and providing information for ordering supplies. CONCLUSIONS: Study findings showed discrepancies between the PBOR standards of care being provided by clinicians versus the care patients reported they received. Findings also indicated variability in the consistency of delivering all components of the PBOR. We assert that further awareness and wider utilization of the PBOR in every health care setting in the United States are needed to provide best care to patients living with an ostomy.

Marginalization in the Medical Encounter: Ostomy Patients Experience of Perceived Stigmatizing Sentiments from Medical Clinicians.

Introduction: Ostomy stigma negatively impacts the health of people with an ostomy and contributes to a lower quality of life and health outcomes. Objective: To assess whether participants experience perceived stigmatizing sentiments (SS) from medical clinicians at the time of their ostomy procedure. Methods: Using a nonprobability sample of 312 persons with an ostomy, we conducted a retrospective descriptive study. We measured SS as patients' self-reports of verbal and non-verbal communication from clinicians that were perceived to be negative and may contribute to ostomy stigma. We used thematic analyses to analyze open-ended written comments. Results: Findings indicate that ostomy patients experience stigmatizing sentiments from their medical clinician before and after surgery. Sixteen percent of patients reported a SS, such as clinicians stating feelings of disgust, showing visible signs of disgust, or treating patients negatively regarding the ostomy. Conclusion: The perceived treatment that this patient cohort experienced in healthcare likely contributes to ostomy stigmatization and may impact ostomy patients' psychosocial adjustment. Future research should examine the specific consequences of perceived stigmatizing sentiments from medical clinicians.

Childhood Adversity and Intimate Partner Violence in Adulthood: The Mediating Influence of PTSD in a Sample of Women Prisoners.

Although past research documents strong linkages between adverse childhood experiences (ACEs), posttraumatic stress disorder (PTSD), and adult intimate partner violence (IPV) in the lives of women prisoners, researchers have often neglected to consider the potential mediating role of PTSD in the relationships between ACEs and adult IPV. Using data from a stratified random sample of all incarcerated women in Oklahoma (N = 334), we explore the relationships between ACEs, PTSD symptomology, and adult IPV utilizing a feminist life course theoretical framework. Results indicate that PTSD symptomology fully mediates the relationship between ACEs and adult IPV, suggesting that PTSD may be central to understanding pathways to adult IPV as well as offending and incarceration for women. Implications and suggestions for policy and future research are offered.

Peoples' Experiences With Pouches (PEWP) Study: Ostomate-Provider Interactions.

BACKGROUND: Minimal research focuses on interactions between providers and new ostomy patients. Studies show that provider communication is important for patient health outcomes. OBJECTIVE: The purpose of this study was to investigate ostomy patients' perceptions of provider communication following surgery and whether interactions adequately prepare ostomy patients to care for their new appliance. METHOD: Using a nonprobability national sample of 381 ostomy patients, we conducted a retrospective quantitative study. We measured adequacy of provider communication from self-reports from ostomy patients. RESULTS: The results show that almost half of the sample (49%) reported receiving inadequate communication from providers. We also found a relationship between ostomy patients' educational level and their perceptions of receiving adequate communication. Notably, patients with lower educational attainment reported receiving adequate communication up to 4 times more than patients with higher educational attainment. CONCLUSION: Our results suggest that not only do ostomy patients need better communication from providers following their surgery but also patients with higher educational attainment appear to expect more information from providers than patients with lower educational attainment.

A Prospective Examination of Racial Microaggressions in the Medical Encounter.

Disparities in healthcare and health outcomes between whites and non-whites continue to plague the US healthcare system. A large literature suggests that people of color face obstacles at various points in the healthcare system. This article examines one such obstacle: whether patients of color experience microaggressions from physicians during primary care medical visits. A majority of microaggression studies are qualitative and retrospective in nature. In the current study, we use a prospective approach to broaden how microaggressions are measured, as well as understand differential treatment of racial minorities within healthcare. Using data derived from audio recordings of medical visits (n = 224), we utilize a quantitative measure to examine microaggressions in the medical encounter. We find that when race status differences are present between patient and physician, patients of color are more likely to experience microaggressions from their physician. The results suggest that medical encounters differ depending on characteristics of the parties involved. These differences may not only perpetuate the differential treatment of people of color but also contribute to health disparities for people of color.

Patient-Centered Care: An Examination of Provider-Patient Communication Over Time.

OBJECTIVE: To examine the quality of provider communication over time considering the increasing emphasis on patient-centered care (PCC). Patient-centered care has been shown to have a positive impact on health outcomes, care experiences, quality-of-life, as well as decreased costs. Given this emphasis, we expect that provider-patient communication has improved over time. DATA SOURCE: We collected primary data by self-report surveys between summer 2017 and fall 2018. STUDY DESIGN: We use a quantitative retrospective cohort study of a national sample of 353 patients who had an ostomy surgery. DATA EXTRACTION METHOD: We measure provider communication from open-ended self-reports from patients of the number of stated inadequacies in their care. PRINCIPAL FINDINGS: Results show that the time since patients had their surgery is related to higher quality provider communication. That is, patients who had their surgery further back in time reported higher quality provider communication compared with patients who had their surgery performed more recently. CONCLUSION: Results suggest that the quality of provider communication has not improved even with an emphasis on PCC.

Age-related differences in doctor-patient interaction and patient satisfaction.

Background. Relatively little is known about patient characteristics associated with doctor-patient interaction style and satisfaction with the medical visit. Objective. The primary study objectives are to assess: whether doctors interact in a more or less patient-centered style with elderly patients and whether patient age moderates the relationship between interaction style and satisfaction, that is, whether elderly patients are more or less satisfied with patient-centered medical encounters. Methods. We collected pre- and post-visit questionnaire data from 177 patients at a large family medicine clinic. We audiotaped the encounters between doctors and patients. Patient-centered interaction style was measured from coding from the audiotapes of the doctor-patient interactions. Patient satisfaction was measured using the Patient Satisfaction Questionnaire. Results. We found physicians were more likely to have patient-centered encounters with patients over age 65. We also found patient age moderated the association between interaction style and patient satisfaction: older patients were more satisfied with patient-centered encounters. Conclusion. Patient age is associated with style of interaction, which is, in turn, associated with patient satisfaction. Understanding the factors and processes by which doctors and patients interact has the potential to improve many facets of health care delivery.

Socio-environmental factors associated with pubertal development in female adolescents: the role of prepubertal tobacco and alcohol use.

PURPOSE: Alcohol administered to laboratory animals has been shown to suppress puberty-related hormones and delay puberty by interfering with ovarian development and function. The effects of early substance use on human pubertal development are relatively unexplored. METHODS: This cross-sectional study of 3,106 female adolescents, aged 11-21 years, evaluated the association between prepubertal alcohol and tobacco use and the onset of puberty. Ages at initial breast development, body hair growth, and menarche were self-reported. Prepubertal alcohol and tobacco use were defined as the age at first use before the age of pubertal development and accompanied by regular use. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox proportional hazard models. Logistic regression was used to estimate the association between substance use and delayed puberty, defined as lack of breast development by the age of 13 years. RESULTS: Unadjusted models indicated prepubertal tobacco use was associated with a longer time required for breast development (HR = 0.74; 95% CI, 0.65-0.85) and body hair growth (HR = 0.81; 95% CI, 0.71-0.93). Prepubertal alcohol use was associated with late breast development (HR = 0.71; 95% CI, 0.57-0.88). The direction of the observed associations remained consistent after adjusting for covariates, but the magnitude of effects were attenuated and the upper bound of the 95% CIs exceeded the null value. Girls who used alcohol before puberty had four times the odds of having delayed puberty (OR = 3.99; 95% CI, 1.94-8.21) as compared with nonusers. CONCLUSION: The results of this study suggest that the endocrine-disrupting effects of alcohol and tobacco use may alter the timing of pubertal development. These cross-sectional findings warrant further investigation.

Provider-patient communication about antidepressants among veterans with mental health conditions.

BACKGROUND: Little is known about provider-patient communication regarding antidepressants in primary care settings. OBJECTIVE: The purpose of the study was to describe the extent to which veterans and their providers discuss anti-depressants during primary care visits, and to examine how patient characteristics are related to elements of this communication. METHODS: This study is a secondary analysis conducted of a data set of audiotaped clinic visits and previsit interviews with 253 adult male veterans seen in primary care. The study patients who were provided an initial antidepressant prescription or continued on an antidepressant on the day of the audiotaped visit and who had a diagnosis of depression, posttraumatic stress disorder, or bipolar disorder were included in the current analysis. Audiotapes were coded using a reliable instrument. Descriptive and bivariate statistics were calculated. RESULTS: Forty veterans (mean [SD] age, 58.9 [10.4] years) were eligible for study. Of these 40 veterans with a documented prescription for an antidepressant, 62.5% (n = 25) discussed these medications with their provider during the visits. If antidepressants were discussed, the provider initiated the discussion 68.0% (n = 17) of the time. Only 2 patients asked questions about their antidepressants. Thirty-two of the 40 veterans were continued users of anti-depressants; 8 began their antidepressant on the date of the audiotaped visit. Providers asked 15.6% of veterans (n = 5) on continued therapy how well their antidepressants were working and 6.3% of veterans (n = 2) on continued therapy about adverse effects. Among continued users of antidepressants, 18.8% (n = 6) expressed a complaint about their antidepressant and 21.9% (n = 7) of patients expressed an adherence problem. CONCLUSIONS: To detect and prevent problems with antidepressant therapy, primary care clinics should consider having nonphysician health care personnel ask patients taking antidepressant medication at least one open-ended question about how the antidepressant is working, another about possible adverse effects or barriers to use, and a third about adherence.

Lifestyle discussions during doctor-older patient interactions: the role of time in the medical encounter.

CONTEXT: Although physician influence can be especially powerful with older adults, relatively little is known about how primary care physicians (PCPs) interact with their patients regarding lifestyle issues. OBJECTIVE: To document the length of time that PCPs discuss lifestyle issues with their older patients and to examine patient, physician, and contextual correlates. DESIGN: Descriptive and multivariate analysis of videotapes of physician-patient encounters. SETTING: Medical encounters from 3 primary care ambulatory settings. PATIENTS: There were 116 ongoing medical encounters with patients aged 65 years or older. MAIN OUTCOME MEASURES: Total time spent in physical activity (PA) discussions and total time spent discussing PA, nutrition, and smoking during the medical encounter. RESULTS: Very little time was spent in lifestyle discussions. On average, PA was discussed for less than a minute (58.28 seconds) and nutrition for slightly less than 90 seconds (83.11 seconds). Only about 10% of the average 17-minute, 22-second encounter was spent on physical activity, nutrition, or smoking topics. Physician supportiveness score (beta = 8.92, P

Opportunities for administrators to promote disease management.

Studies of disease management (DM) have shown that patients who participate in such programs achieve better health status and make fewer emergency room visits. Private and government payers have recently increased their efforts to promote DM initiatives through financial incentives to healthcare providers. This article explores opportunities for administrators of health services organizations (HSO) to promote DM in the current political and economic environment. Our survey of professionals (DM leaders, physicians, and DM nurses) in six DM programs reveals these professionals' assessments of the key players and resources that they deem important to their respective DM programs. They view DM programs as heavily dependent on the support of physicians, nurses, and health plan leaders but relatively less so on the support of HSO administrators- a situation that may suggest opportunities for administrators to take on greater leadership in moving the HSO toward developing DM programs. Survey results also indicate a strong need for the integration of resources such as communication systems, electronic medical records, and DM reporting. Taken collectively, these needs suggest a number of strategies for the administrator to play a larger role in supporting the adoption and effective implementation of DM. In the article, we propose that DM programs can benefit substantially from an administrator who can demonstrate a thorough knowledge of DM-related government and private-payer initiatives and who has the ability to provide leadership to develop and implement viable DM programs. Valued contributions that the administrator should bring to the table include support of standardized DM processes, use of practice guidelines, and provision of pertinent information systems.

Do unmet expectations for specific tests, referrals, and new medications reduce patients' satisfaction?

BACKGROUND: Patient-centered care requires clinicians to recognize and act on patients' expectations. However, relatively little is known about the specific expectations patients bring to the primary care visit. OBJECTIVE: To describe the nature and prevalence of patients' specific expectations for tests, referrals, and new medications, and to examine the relationship between fulfillment of these expectations and patient satisfaction. DESIGN: Prospective cohort study. SETTING: VA general medicine clinic. PATIENTS/PARTICIPANTS: Two hundred fifty-three adult male outpatients seeing their primary care provider for a scheduled visit. MEASUREMENTS AND MAIN RESULTS: Fifty-six percent of patients reported at least 1 expectation for a test, referral, or new medication. Thirty-one percent had 1 expectation, while 25% had 2 or more expectations. Expectations were evenly distributed among tests, referrals, and new medications (37%, 30%, and 33%, respectively). Half of the patients who expressed an expectation did not receive one or more of the desired tests, referrals, or new medications. Nevertheless, satisfaction was very high (median of 1.5 for visit-specific satisfaction on a 1 to 5 scale, with 1 representing "excellent"). Satisfaction was not related to whether expectations were met or unmet, except that patients who did not receive desired medications reported lower satisfaction. CONCLUSIONS: Patients' expectations are varied and often vague. Clinicians trying to implement the values of patient-centered care must be prepared to elicit, identify, and address many expectations.

Examining localized patterns of air quality perception in Texas: a spatial and statistical analysis.

Environmental and human health issues associated with outdoor air pollution, such as ozone, sulfur dioxide, and other pollutants in metropolitan regions, are an area of growing concern for both policy officials and the general public. Increasing attention from the news media, new health data, and public debate over the effectiveness of clean air regulations have raised the importance of air quality in the public consciousness. While public perceptions of air quality have been studied thoroughly dating back to the 1960s, little empirical research has been conducted to explain the spatial aspects of these perceptions, particularly at the local level. Although recent studies suggest characteristics of local setting are important in shaping perceptions of air quality, the roles of proximity, neighborhood characteristics, and location have not been clarified. This study seeks to improve understanding of the major factors shaping public perceptions of air quality by examining the spatial pattern of local risk perception, the role of socioeconomic characteristics in forming these perceptions, and the relationship between perceived and scientifically measured air pollution. First, we map the spatial pattern of local air quality perceptions using Geographic Information Systems (GIS) across the Dallas and Houston metropolitan areas. Next, we explain these perceptions through local contextual factors using both bivariate correlations and multivariate regression analysis. Results indicate that perceptions of air quality in the study areas are not significantly correlated with air quality based on readings of air monitoring stations. Instead, perceptions appear to be influenced by setting (urban vs. rural), state identification, access to information, and socioeconomic characteristics such as age, race, and political identification. We discuss the implications of the findings and provide direction on how further research can provide a deeper understanding of the local contextual factors influencing public perceptions.