A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction.
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ABSTRACT:
SUBMITTER: Morgan DJ
PROVIDER: S-EPMC5570540 | biostudies-other | 2017 May
REPOSITORIES: biostudies-other
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Project description:BackgroundPatient engagement is a priority for health care quality improvement and health system design, but many organizations struggle to engage patients meaningfully. We describe patient engagement activities and success factors that influence organizational decision-making in Ontario's patient medical homes.MethodsFrom March to May 2018, we conducted an online survey focused on practice-level patient engagement that targeted primary care organization leaders at all Ontario family health teams, community health centres, nurse practitioner-led clinics and Aboriginal Health Access Centres. We asked questions from the Measuring Organizational Readiness for Engagement (MORE) and Public and Patient Engagement Evaluation Tool (PPEET) questionnaires. We used factor and mediation analysis to identify organizational conditions and activities that are associated with the outcomes of patient engagement, affecting board decisions, program-level decisions and the formation of collaborative partnerships.ResultsWe achieved a 53% response rate (n = 149/283); after removing missing data, our final sample size was 141 respondents. Most respondents perceived that their organization's patient engagement activities and resources were insufficient. Processes that had a direct effect on outcomes (β = 0.7, p < 0.0001) included planning, training and supporting employees; identifying, recruiting and supporting relevant patients; and using leaders. Structures - including an organizational mission and vision for patient engagement, and policies, procedures, job positions, training programs and organizational culture that reflect that mission - indirectly affected outcomes, mediated by the aforementioned processes (β = 0.7, p < 0.0001).InterpretationBased on the perceptions of primary care leaders, organizational structures and processes are related to successful patient engagement. Organizations that seek to improve patient engagement should assess their commitment and follow-through with associated resources and activities.
| S-EPMC8687489 | biostudies-literature
Project description:BackgroundPrimary care clinicians (PCCs) are typically the first practitioners to detect cognitive impairment in their patients, including those with Alzheimer's disease or related dementias (ADRD). However, conversations around cognitive changes can be challenging for patients, family members, and clinicians to initiate, with all groups reporting barriers to open dialogue. With the expanding array of evidence-based interventions for ADRD, from multidomain care management to novel biotherapeutics for early-stage AD, incorporating conversations about brain health into routine healthcare should become a standard of care. We conducted a systematic review to identify barriers to and facilitators of brain health conversations in primary care settings.MethodsWe systematically searched PubMed, Scopus, Web of Science, and the Cochrane Library for qualitative or quantitative studies conducted in the US between January 2000 and October 2022 that evaluated perceptions of cognition and provider-patient brain health conversations prior to formal screening for, or diagnosis of, mild cognitive impairment or ADRD. We assessed the quality of the included studies using the Mixed Methods Appraisal Tool.ResultsIn total, 5547 unique abstracts were screened and 22 articles describing 19 studies were included. The studies explored perceptions of cognition among laypersons or clinicians, or provider-patient interactions in the context of a patient's cognitive concerns. We identified 4 main themes: (1) PCCs are hesitant to discuss brain health and cognitive concerns; (2) patients are hesitant to raise cognitive concerns; (3) evidence to guide clinicians in developing treatment plans that address cognitive decline is often poorly communicated; and (4) social and cultural context influence perceptions of brain health and cognition, and therefore affect clinical engagement.ConclusionsEarly conversations about brain health between PCCs and their patients are rare, and effective tools, processes, and strategies are needed to make these vital conversations routine.
| S-EPMC10626639 | biostudies-literature
Project description:BackgroundEfforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.ObjectiveTo examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.DesignSecondary analysis from the Quality Improvement in Depression Study dataset.ParticipantsThe participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study.MeasurementsPrimary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden.ResultsClinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45).ConclusionsClinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.
| S-EPMC2585690 | biostudies-literature
Project description:Scientific advances in health care have been disproportionately distributed across social strata. Disease burden is also disproportionately distributed, with marginalized groups having the highest risk of poor health outcomes. Social determinants are thought to influence health care delivery and the management of chronic diseases among marginalized groups, but the current conceptualization of social determinants lacks a critical focus on the experiences of people within their environment. The purpose of this article was to integrate the literature on marginalization and situate the concept in the framework of social determinants of health. We demonstrate that social position links marginalization and social determinants of health. This perspective provides a critical lens to assess the societal power dynamics that influence the construction of the socio-environmental factors affecting health. Linking marginalization with social determinants of health can improve our understanding of the inequities in health care delivery and the disparities in chronic disease burden among vulnerable groups.
| S-EPMC6342665 | biostudies-literature
Project description:BackgroundStrategies to optimize antibiotic prescribing at discharge are not well understood.MethodsIn fall 2019, we surveyed 39 Michigan hospitals on their antibiotic stewardship strategies. The association of reported strategies with discharge antibiotic overuse (unnecessary, excess, suboptimal fluoroquinolones) for community-acquired pneumonia (CAP) and urinary tract infection (UTI) was evaluated in 2 ways: (1) all strategies assumed equal weight and (2) strategies were weighted based on the ROAD (Reducing Overuse of Antibiotics at Discharge) Home Framework (ie, Tier 1-Critical infrastructure, Tier 2-Broad inpatient interventions, Tier 3-Discharge-specific strategies) with Tier 3 strategies receiving the highest weight.ResultsBetween 1 July 2017 and 30 July 2019, 39 hospitals with 20 444 patients (56.5% CAP; 43.5% UTI) were included. Survey response was 100%. Hospitals reported a median (interquartile range [IQR]) 12 (9-14) of 34 possible stewardship strategies. On analyses of individual stewardship strategies, the Tier 3 intervention, review of antibiotics prior to discharge, was the only strategy consistently associated with lower antibiotic overuse at discharge (adjusted incident rate ratio [aIRR] 0.543, 95% confidence interval [CI]: .335-.878). On multivariable analysis, weighting by ROAD Home tier predicted antibiotic overuse at discharge for both CAP and UTI. For diseases combined, having more weighted strategies was associated with lower antibiotic overuse at discharge (aIRR 0.957, 95% CI: .927-.987, per weighted intervention); discharge-specific stewardship strategies were associated with a 12.4% relative decrease in antibiotic overuse days at discharge.ConclusionsThe more stewardship strategies a hospital reported, the lower its antibiotic overuse at discharge. However, Tier 3, or discharge-specific strategies, appeared to have the largest effect on antibiotic prescribing at discharge.
| S-EPMC9390953 | biostudies-literature
Project description:Gerontologists have argued that the growing human capital of the aging population can be better marshaled as a resource for families, communities, and society at large. Additionally, this active, purposeful engagement can produce positive outcomes for older adults themselves. In this manuscript, we propose that existing conceptual frameworks articulating antecedents and outcomes of productive engagement, including working, volunteering, and caregiving can be improved using a system dynamics (SD) approach. Through a series of five unstructured group model-building sessions, experts from gerontology and systems science developed a qualitative SD model of the productive engagement of older adults. The model illustrates the reciprocal and dynamic nature of the stocks of human capital of older adults, social capital of older adults, and family resources; the engagement of older adults in productive activities; and the social and organizational variables that affect the flow and depletion of these stocks. Given this is the first attempt to develop a SD model for productive engagement in later life, the model is preliminary and heuristic. However, it offers a new approach to advancing theory and research on productive engagement in later life. Further, it can guide the development of mathematical models to estimate the effects of changes in any part of this system.
| S-EPMC6177040 | biostudies-literature
Project description:Connecting the nonlinear and often counterintuitive physiological effects of multiple environmental drivers to the emergent impacts on ecosystems is a fundamental challenge. Unfortunately, the disconnect between the way "stressors" (e.g., warming) is considered in organismal (physiological) and ecological (community) contexts continues to hamper progress. Environmental drivers typically elicit biphasic physiological responses, where performance declines at levels above and below some optimum. It is also well understood that species exhibit highly variable response surfaces to these changes so that the optimum level of any environmental driver can vary among interacting species. Thus, species interactions are unlikely to go unaltered under environmental change. However, while these nonlinear, species-specific physiological relationships between environment and performance appear to be general, rarely are they incorporated into predictions of ecological tipping points. Instead, most ecosystem-level studies focus on varying levels of "stress" and frequently assume that any deviation from "normal" environmental conditions has similar effects, albeit with different magnitudes, on all of the species within a community. We consider a framework that realigns the positive and negative physiological effects of changes in climatic and nonclimatic drivers with indirect ecological responses. Using a series of simple models based on direct physiological responses to temperature and ocean pCO 2, we explore how variation in environment-performance relationships among primary producers and consumers translates into community-level effects via trophic interactions. These models show that even in the absence of direct mortality, mismatched responses resulting from often subtle changes in the physical environment can lead to substantial ecosystem-level change.
| S-EPMC5551099 | biostudies-other
Project description:Listeria monocytogenes strain:medical patient | isolate:medical patient Genome sequencing
| PRJNA814010 | ENA
Project description:ObjectiveTo understand public attitudes about and recommendations to address antibiotic overuse by employing public deliberation (a method for eliciting informed input on value-laden issues).Data sources/study settingParticipants in 24 Community Deliberation groups (CD; n = 263), four Citizens' Panel groups (CP; n = 96), and a control group (n = 348). Data were collected in 2012 in four U.S.LocationsStudy designUsing mixed methods, we analyzed quantitative and qualitative data from a randomized control trial.Data collection/extraction methodsUsing pre/postdeliberation surveys, we compared CD and CP participant attitude changes regarding antibiotic use to the control group. We analyzed deliberation transcripts using qualitative techniques to provide context for survey results.Principal findingsCompared to control group participants, CD and CP participants had a larger postdeliberation shift in attitudes toward support of government limits on when doctors can prescribe antibiotics. Participants described unawareness about antibiotic overuse and called for education. When discussing prescription limits, participants debated tensions between preserving patient/doctor autonomy and protecting society from antibiotic-related harms. Participants saw patient, physician, and government roles in antibiotic stewardship policies/programs.ConclusionWhen informed about individual and social consequences of antibiotic overuse, patients may be more receptive to antibiotic prescription limits. Community-physician-government partnerships are needed to create solutions.
| S-EPMC6863223 | biostudies-literature
Project description:ObjectiveThe aim of this study was to examine whether lag sequential analysis could be used to describe eye gaze orientation between clinicians and patients in the medical encounter. This topic is particularly important as new technologies are implemented into multiuser health care settings in which trust is critical and nonverbal cues are integral to achieving trust. This analysis method could lead to design guidelines for technologies and more effective assessments of interventions.BackgroundNonverbal communication patterns are important aspects of clinician-patient interactions and may affect patient outcomes.MethodThe eye gaze behaviors of clinicians and patients in 110 videotaped medical encounters were analyzed using the lag sequential method to identify significant behavior sequences. Lag sequential analysis included both event-based lag and time-based lag.ResultsResults from event-based lag analysis showed that the patient's gaze followed that of the clinician, whereas the clinician's gaze did not follow the patient's. Time-based sequential analysis showed that responses from the patient usually occurred within 2 s after the initial behavior of the clinician.ConclusionOur data suggest that the clinician's gaze significantly affects the medical encounter but that the converse is not true.ApplicationFindings from this research have implications for the design of clinical work systems and modeling interactions. Similar research methods could be used to identify different behavior patterns in clinical settings (physical layout, technology, etc.) to facilitate and evaluate clinical work system designs.
| S-EPMC3211102 | biostudies-literature