Patients’ attitudes about the use of placebo treatments: telephone survey

Objective To examine the attitudes of US patients about the use of placebo treatments in medical care. Design: One time telephone surveys. Setting: Northern California. Participants 853 members of Kaiser Permanente Northern California, aged 18-75, who had been seen by a primary care provider for a chronic health problem at least once in the prior six months. Results The response rate was 53.4% (853/1598) of all members who were eligible to participate, and 73.2% (853/1165) of all who could be reached by telephone. Most respondents (50-84%) judged it acceptable for doctors to recommend placebo treatments under conditions that varied according to doctors’ level of certainty about the benefits and safety of the treatment, the purpose of the treatment, and the transparency with which the treatment was described to patients. Only 21.9% of respondents judged that it was never acceptable for doctors to recommend placebo treatments. Respondents valued honesty by physicians regarding the use of placebos and believed that non-transparent use could undermine the relationship between patients and physicians. Conclusions: Most patients in this survey seemed favorable to the idea of placebo treatments and valued honesty and transparency in this context, suggesting that physicians should consider engaging with patients to discuss their values and attitudes about the appropriateness of using treatments aimed at promoting placebo responses in the context of clinical decision making

Local services and amenities, neighborhood social capital, and health

Recent work on health and place has examined the impact of the environment on health. At the local level, research has followed several strands, such as contextual effects of neighborhoods, the impact of differential access to services and amenities, effects of a neighborhood's collective efficacy, and the relationship between social capital and health. Of these four approaches, social capital has generated the most debate; some scholars discuss social capital as a key epidemiological variable, while others discount or dismiss its utility. We undertook this research to assess whether the concept of social capital could increase our understanding of the impact of neighborhoods on residents' health. We utilized key informant interviews and focus groups to understand ways in which residents of diverse neighborhoods in one large California city perceived that their local communities were affecting health. We argue in this paper that using the term "social capital" to discuss social resources and their mobilization in a particular neighborhood highlights the ways in which social resources can vary in relation to economic resources, and that residents of neighborhoods with differing levels of services and amenities face different issues when mobilizing to improve their neighborhoods. Additionally, the projects that people invest in vary by neighborhood socioeconomic status. We draw on the paired concepts of "bridging" and "bonding" social capital, and discuss that while stores of bonding social capital may be more uniform across neighborhoods of varying SES, bridging social capital tends to be found in greater amounts in neighborhoods of higher SES which allows them greater success when mobilizing to improve their neighborhoods.Social capital Neighborhoods Services and amenities Health disparities

Partnering With Patient Advisors in the PORTAL Clinical Data Research Network

Background/Aims: PORTAL, composed of Kaiser Permanente, Group Health Cooperative, Health Partners and Denver Health, is a PCORnet network focusing start-up efforts on identifying what matters most for patients with obesity, colorectal cancer and congenital heart disease (three cohorts) and building capacity to conduct patient-centered research to address those priorities. This presentation will describe the Patient Engagement Council (PEC) and an associated Online Advisor group guiding PORTAL’s development. Methods: The PEC is composed of 10 patients representing each of the cohorts as well as three representatives from cohort-specific advocacy organizations. PEC members attend an in-person meeting for orientation/team-building and subsequently offer guidance through 10 webinars, emails and conference calls. PORTAL seeks PEC members’ input about how to engage patients in research, identify research questions and methods that matter to patients, and facilitate communication between PORTAL and broader audiences. Eighteen online advisors are being recruited to help PORTAL establish three cohort-specific online Smart Patients communities –– where patients and caregivers learn from each other about the latest science, treatments and patient concerns. Online advisors work with Smart Patients to identify key topics and develop early content for the online communities’ discussion boards. Results: Eligible members were identified within each health system through clinical and operational liaisons and were then interviewed by PORTAL staff. Selected candidates were invited to join as PEC members or online advisors. All of the PEC members have been recruited, completed the orientation, and participated in the first webinar focused on cohort-specific survey questions/modes of survey administration. The successes and challenges of recruitment, hosting in-person and online meetings, and PEC contributions to PORTAL’s start-up phase will be presented. Prior to the conference, all 18 online advisors will have been recruited and completed their work setting up online communities. The benefits and challenges of engaging online advisors will be presented and the online communities will be described. Discussion: This presentation of the process and initial outcomes of engaging patients in the development of a large multisite network will have broad significance as a model for engaging patients in research network development

Partnering With Patient Advisors in the PORTAL Clinical Data Research Network

Background/Aims: PORTAL, composed of Kaiser Permanente, Group Health Cooperative, Health Partners and Denver Health, is a PCORnet network focusing start-up efforts on identifying what matters most for patients with obesity, colorectal cancer and congenital heart disease (three cohorts) and building capacity to conduct patient-centered research to address those priorities. This presentation will describe the Patient Engagement Council (PEC) and an associated Online Advisor group guiding PORTAL’s development. Methods: The PEC is composed of 10 patients representing each of the cohorts as well as three representatives from cohort-specific advocacy organizations. PEC members attend an in-person meeting for orientation/team-building and subsequently offer guidance through 10 webinars, emails and conference calls. PORTAL seeks PEC members’ input about how to engage patients in research, identify research questions and methods that matter to patients, and facilitate communication between PORTAL and broader audiences. Eighteen online advisors are being recruited to help PORTAL establish three cohort-specific online Smart Patients communities –– where patients and caregivers learn from each other about the latest science, treatments and patient concerns. Online advisors work with Smart Patients to identify key topics and develop early content for the online communities’ discussion boards. Results: Eligible members were identified within each health system through clinical and operational liaisons and were then interviewed by PORTAL staff. Selected candidates were invited to join as PEC members or online advisors. All of the PEC members have been recruited, completed the orientation, and participated in the first webinar focused on cohort-specific survey questions/modes of survey administration. The successes and challenges of recruitment, hosting in-person and online meetings, and PEC contributions to PORTAL’s start-up phase will be presented. Prior to the conference, all 18 online advisors will have been recruited and completed their work setting up online communities. The benefits and challenges of engaging online advisors will be presented and the online communities will be described. Discussion: This presentation of the process and initial outcomes of engaging patients in the development of a large multisite network will have broad significance as a model for engaging patients in research network development

Shared Decision Making and the Experience of Partnership in Primary Care

PURPOSE Communication has been researched either as a set of behaviors or as a facet of the patient-physician relationship, often leading to conflicting results. To determine the relationship between these perspectives, we examined shared decision making (SDM) and the subjective experience of partnership for patients and physicians in primary care. METHODS From a convenience sample of experienced primary care physicians in 3 clinics, we recruited a stratified sample of 18 English- or Spanish-speaking patients. Direct observation of visits was followed by videotape-triggered stimulated recall sessions with patients and physicians. We coded decision moments for objective evidence of SDM, using a structured instrument. We classified patients’ and physicians’ subjective experience of partnership as positive or negative by a consensus analysis of stimulated recall sessions. We combined results from these 2 analyses to generate 4 archetypes of engagements and used grounded theory to identify themes associated with each archetype. RESULTS The 18 visits yielded 125 decisions, 62 (50%) of which demonstrated SDM. Eighty-two decisions were discussed in stimulated recall and available for combined analysis, resulting in 4 archetypes of engagement in decision making: full engagement (SDM present, subjective experience positive)—22%; simulated engagement (SDM present, subjective experience negative)—38%; assumed engagement (SDM absent, subjective experience positive)—21%; and nonengagement (SDM absent, subjective experience negative)—19%. Thematic analysis revealed that both relationship factors (eg, trust, power) and communication behavior influenced subjective experience of partnership. CONCLUSIONS Combining direct observation and assessment of the subjective experience of partnership suggests that communication behavior does not ensure an experience of collaboration, and a positive subjective experience of partnership does not reflect full communication. Attempts to enhance patient-physician partnership must attend to both effective communication style and affective relationship dynamics

Sex and Racial/Ethnic Disparities in Outcomes After Acute Myocardial Infarction

Background Previous studies have documented sex and racial/ethnic disparities in outcomes after acute myocardial infarction (AMI), but the explanation of these disparities remains limited. In a setting that controls for access to medical care, we evaluated whether sex and racial/ethnic disparities in prognosis after AMI persist after consideration of socioeconomic background, personal medical history, and medical management. Methods We conducted a prospective cohort study of the members (20 263 men and 10 061 women) of an integrated health care delivery system in northern California who had experienced an AMI between January 1, 1995, and December 31, 2002, and were followed up for a median of 3.5 years (maximum, 8 years). Main outcome measures included AMI recurrence and all-cause mortality. Results In age-adjusted analyses relative to white men, black men (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.26-1.65), black women (HR, 1.47; 95% CI, 1.26-1.72), and Asian women (HR, 1.37; 95% CI, 1.13-1.65) were at increased risk of AMI recurrence. However, multivariate adjustment for sociodemographic background, comorbidities, medication use, angiography, and revascularization procedures effectively removed the excess risk of AMI recurrence in these 3 groups. Similarly, the increased age-adjusted risk of all-cause mortality seen in black men (HR, 1.55; 95% CI, 1.37-1.75) and black women (HR, 1.45; 95% CI, 1.27-1.66) was greatly attenuated in black men and reversed in black women after full multivariate adjustment. Conclusion In a population with equal access to medical care, comprehensive consideration of social, personal, and medical factors could explain sex and racial/ethnic disparities in prognosis after AMI

Effectiveness and reach of the FLU-FIT program in an integrated health care system: a multisite randomized trial.

ObjectivesWe tested the effectiveness of offering home fecal immunochemical tests (FITs) during influenza vaccination clinics to increase colorectal cancer screening (CRCS).MethodsIn a clinical trial at Kaiser Permanente Northern California influenza clinics in Redwood City, Richmond, South San Francisco, Union City, and Fresno, we randomly assigned influenza clinic dates to intervention (FIT offered) or control (FIT not offered) and compared subsequent CRCS activity.ResultsClinic staff provided FITs to 53.9% (1805/3351) of intervention patients aged 50 to 75 years. In the intent-to-treat analysis, 26.9% (900/3351) and 11.7% (336/2884) of intervention and control patients completed an FIT, respectively, within 90 days of vaccination (P ≤ .001). The adjusted odds ratio for completing FIT in the intervention versus the control arm was 2.75 (95% confidence interval = 2.40, 3.16). In the per protocol analysis, 35.4% (648/1830) of patients given FIT and 13.3% (588/4405) of patients not given FIT completed FIT within 90 days of vaccination (P ≤ .001).ConclusionsThis intervention may increase CRCS among those not reached by other forms of CRCS outreach. Future research should include the extent to which these programs can be disseminated and implemented nationally

Increasing Minority Enrollment Onto Clinical Trials: Practical Strategies and Challenges Emerge From the NRG Oncology Accrual Workshop

Racial and ethnic diversity has historically been difficult to achieve in National Cancer Institute-sponsored clinical trials, even while as many as 80% of those trials have faced difficulty in meeting overall recruitment targets. In an attempt to address these issues, NRG Oncology recently convened a comprehensive workshop titled Clinical Trials Enrollment: Challenges and Opportunities. Discussants at the workshop included representatives of the three legacy groups of the NRG (ie, Gynecologic Oncology Group, National Surgical Adjuvant Breast and Bowel Program, and Radiation Therapy Oncology Group), a minority-based community clinical oncology program, a large integrated health care system, the leadership of the National Cancer Institute, and a large patient advocacy group. This article summarizes the concepts discussed at the workshop, which included: needs assessments, infrastructural support, training of investigators and research staff, specific clinical trial recruitment strategies (both system and community based), and development and mentoring of young investigators. Many new, more specific tactics, including use of diverse cancer care settings, direct-to-consumer communication, and the need for centralized information technology such as the use of software to match trials to special populations, are presented. It was concluded that new, innovative trial designs and the realities of limited funding would require the adoption of effective and efficient recruiting strategies, specialized training, and stakeholder engagement. US clinical research programs must generate and embrace new ideas and pilot test novel recruitment strategies if they are to maintain their historic role as world leaders in cancer care innovation and delivery

Effectiveness and reach of the FLU-FIT program in an integrated health care system: a multisite randomized trial.

ObjectivesWe tested the effectiveness of offering home fecal immunochemical tests (FITs) during influenza vaccination clinics to increase colorectal cancer screening (CRCS).MethodsIn a clinical trial at Kaiser Permanente Northern California influenza clinics in Redwood City, Richmond, South San Francisco, Union City, and Fresno, we randomly assigned influenza clinic dates to intervention (FIT offered) or control (FIT not offered) and compared subsequent CRCS activity.ResultsClinic staff provided FITs to 53.9% (1805/3351) of intervention patients aged 50 to 75 years. In the intent-to-treat analysis, 26.9% (900/3351) and 11.7% (336/2884) of intervention and control patients completed an FIT, respectively, within 90 days of vaccination (P ≤ .001). The adjusted odds ratio for completing FIT in the intervention versus the control arm was 2.75 (95% confidence interval = 2.40, 3.16). In the per protocol analysis, 35.4% (648/1830) of patients given FIT and 13.3% (588/4405) of patients not given FIT completed FIT within 90 days of vaccination (P ≤ .001).ConclusionsThis intervention may increase CRCS among those not reached by other forms of CRCS outreach. Future research should include the extent to which these programs can be disseminated and implemented nationally