Patient and provider characteristics associated with communication about opioids: An observational study

Objective Our objective is to examine the relationship of patient and provider characteristics and communication with chronic non-cancer pain and opioid management in primary care. Method We conducted an observational study using audio-recorded primary care appointments (up to 3/patient) and self-reported assessments of primary care providers (PCPs) and patients. We coded visit transcripts for 1) opioid and pain management talk and 2) mental health and opioid safety talk. Results Eight PCPs and 30 patients had complete data for 78 clinic visits. PCPs and patients engaged in more opioid and pain management talk when patients reported greater pain catastrophizing and PCPs reported higher psychosocial orientation. PCPs and patients engaged in talk about mental health and opioid safety when patients reported greater anxiety, higher working alliance with their PCP, and when PCPs reported higher burnout. PCPs’ negative attitudes about opioids were associated with fewer discussions about mental health and opioid safety. Conclusions Our results should facilitate design of interventions that improve communication and, ultimately, pain outcomes for patients. Practice Implications Clinicians can use our results to increase patient engagement in discussions about opioid use and pain management or mental health and safety discussions

Physicians Use of Inclusive Sexual Orientation Language During Teenage Annual Visits

Purpose: Physicians are encouraged to use inclusive language regarding sexuality in order to help all adolescent patients feel accepted. Non-inclusive language by physicians may influence relationships with adolescent patients, especially those with still-developing sexual identities. The aim of this study was to identify patterns of physicians' use of inclusive and non-inclusive language when discussing sexuality. Method: A total of 393 conversations between 393 adolescents and 49 physicians from 11 clinics located throughout the Raleigh-Durham, North Carolina, area were audio recorded. Conversations were coded for the use of inclusive talk (language use that avoids the use of specific gender, sex, or sexual orientation language), direct non-inclusive talk (language use that assumes the teenager is heterosexual or exclusively engages in heterosexual sexual activity), and indirect non-inclusive talk (language use that frames talk heterosexually but does not pre-identify the adolescent as heterosexual). Results: Nearly two-thirds (63%, 245) of the visits contained some sexuality talk. Inclusive talk rarely occurred (3.3%) while non-inclusive language was predominant (48.1% direct and 48.6% indirect). There were no significant differences in language use by gender, age, adolescent race, or visit length. These non-significant findings suggest that all adolescents regardless of race, gender, or age are receiving non-inclusive sexuality talk from their providers. Conclusion: Physicians are missing opportunities to create safe environments for teenagers to discuss sexuality. The examples of inclusive talk from this study may provide potentially useful ways to teach providers how to begin sexuality discussions, focusing on sexual attraction or asking about friends' sexual behavior, and maintain these discussions.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140157/1/lgbt.2014.0035.pd

“I’m Not Gonna Pull the Rug out from under You”: Patient-Provider Communication about Opioid Tapering

In response to increases in harms associated with prescription opioids, opioid prescribing has come under greater scrutiny, leading many healthcare organizations and providers to consider or mandate opioid dose reductions (tapering) for patients with chronic pain. Communicating about tapering can be difficult, particularly for patients on long-term opioids who perceive benefits and are using their medications as prescribed. Given the importance of effective patient-provider communication for pain management and recent health system-level initiatives and provider practices to taper opioids, this study used qualitative methods to understand communication processes related to opioid tapering, to identify best practices and opportunities for improvement. Up to 3 clinic visits per patient were audio-recorded, and individual interviews were conducted with patients and their providers. Four major themes emerged: 1) Explaining—Patients needed to understand individualized reasons for tapering, beyond general, population-level concerns such as addiction potential; 2) Negotiating—Patients needed to have input, even if it was simply the rate of tapering; 3) Managing difficult conversations—When patients and providers did not reach a shared understanding, difficulties and misunderstandings arose; 4) Non-abandonment—Patients needed to know that their providers would not abandon them throughout the tapering process

Quality of Life in Partners of Young and Old Breast Cancer Survivors

Background: Partners of breast cancer survivors experience the effects of a spouse's cancer years after treatment. Partners of younger survivors (YP) may experience greater problems than partners of older survivors (OP), just as younger survivors experience greater problems than their older counterparts. Objectives: To 1) compare quality of life (QoL) in YP and OP, and 2) determine contributing factors to each group's QoL. Methods: Cross-sectional data were collected from YP (n=227) and OP (n=281) through self-report. MANOVA was used to determine differences between YP and OP on QoL while controlling for covariates. Multiple regression analyses were conducted to determine what contributes to each group's QoL. Results: YP reported better physical function (effect size (ES)= -0.57), lower marital satisfaction (ES=0.39), and lower overall QoL (ES=0.43) than partners of older survivors. Predictors of QoL also differed between partner groups. For YP, overall QoL was predicted by greater physical functioning, fewer depressive symptoms, higher marital satisfaction, higher parenting satisfaction, and more personal resources. R2= .47; F(5, 195)= 35.05; p<.001. For OP, overall QoL was predicted by fewer depressive symptoms, higher parenting satisfaction, higher spirituality, and greater social support from the breast cancer survivor spouse. R2= .33; F(4, 244)= 29.80; p<.001. Conclusions: OP reported greater QoL than YP. Common factors contributing to QoL between YP and OP were fewer depressive symptoms and higher parenting satisfaction. Implications for Practice: Partners of breast cancer survivors may need support coping with their spouse’s/partner’s cancer. Partners of younger survivors may require more support than partners of older survivors.This study was coordinated by the ECOG-ACRIN Cancer Research Group (Robert L. Comis, MD and Mitchell D. Schnall, MD, PhD, Group Co-Chairs) and supported in part by Public Health Service Grants CA189828, CA180795, CA37403, CA35199, CA17145 and CA49883, and from the National Cancer Institute, National Institutes of Health and the Department of Health and Human Services. Its content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute. Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Numbers K05CA175048, T32CA117865-11, and R25CA117865. Its content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, including the National Cancer Institute or the National Institute of Nursing Research

Addressing Personal Barriers to Advance Care Planning: Qualitative Investigation of a Mindfulness-Based Intervention for Adults with Cancer and Their Family Caregivers

Objective Advance care planning (ACP) increases quality of life and satisfaction with care for those with cancer and their families, yet these important conversations often do not occur. Barriers include patients’ and families’ emotional responses to cancer, such as anxiety and sadness, which can lead to avoidance of discussing illness-related topics such as ACP. Interventions that address psychological barriers to ACP are needed. The purpose of this study was to explore the effects of a mindfulness intervention designed to cultivate patient and caregiver emotional and relational capacity to respond to the challenges of cancer with greater ease, potentially decreasing psychological barriers to ACP and enhancing ACP engagement. Method The Mindfully Optimizing Delivery of End-of-Life (MODEL) Care intervention provided 12 hours of experiential training to two cohorts of six to seven adults with advanced-stage cancer and their family caregivers (n = 13 dyads). Training included mindfulness practices, mindful communication skills development, and information about ACP. Patient and caregiver experiences of the MODEL Care program were assessed using semistructured interviews administered immediately postintervention and open-ended survey questions delivered immediately and at 4 weeks postintervention. Responses were analyzed using qualitative methods. Result Four salient themes were identified. Patients and caregivers reported the intervention (1) enhanced adaptive coping practices, (2) lowered emotional reactivity, (3) strengthened relationships, and (4) improved communication, including communication about their disease. Significance of results The MODEL Care intervention enhanced patient and caregiver capacity to respond to the emotional challenges that often accompany advanced cancer and decreased patient and caregiver psychological barriers to ACP

Sexuality talk during adolescent health maintenance visits

IMPORTANCE: Physicians may be important sources of sexuality information and preventive services, and one-on-one confidential time during health maintenance visits is recommended to allow discussions of sexual development, behavior, and risk reduction. However, little is known about the occurrence and characteristics of physician-adolescent discussions about sexuality. OBJECTIVE: To examine predictors of time spent discussing sexuality, level of adolescent participation, and physician and patient characteristics associated with sexuality discussions during health maintenance visits by early and middle adolescents. DESIGN, SETTING, AND PARTICIPANTS: Observational study of audio-recorded conversations between 253 adolescents (mean age, 14.3 years; 53% female; 40% white; 47% African American) and 49 physicians (82% pediatricians; 84% white; 65% female; mean age, 40.9 years; mean [SD] duration in practice, 11.8 [8.7] years) coded for sexuality content at 11 clinics (3 academic and 8 community-based practices) located throughout the Raleigh/Durham, North Carolina, area. MAIN OUTCOMES AND MEASURES: Total time per visit during which sexuality issues were discussed. RESULTS One hundred sixty-five (65%) of all visits had some sexual content within it. The average time of sexuality talk was 36 seconds (35% 0 seconds; 30% 1-35 seconds; and 35% ≥ 36 seconds). Ordinal logistic regression (outcome of duration: 0, 1-35, or ≥ 36 seconds), adjusted for clustering of patients within physicians, found that female patients (odds ratio [OR] = 2.58; 95% CI, 1.53-4.36), older patients (OR = 1.37; 95% CI, 1.13-1.65), conversations with explicit confidentiality discussions (OR = 4.33; 95% CI, 2.58-7.28), African American adolescents (OR = 1.58; 95% CI, 1.01-2.48), and longer overall visit (OR = 1.07; 95% CI, 1.03-1.11) were associated with more sexuality talk, and Asian physicians were associated with less sexuality talk (OR = 0.13; 95% CI, 0.08-0.20). In addition, the same significant associations between adolescent, physician, and visit characteristics were significantly associated with greater adolescent participation. CONCLUSIONS AND RELEVANCE: Our study may be the first to directly observe sexuality talk between physicians and adolescents. We found that one-third of all adolescents had annual visits without any mention of sexuality issues; when sexuality talk occurred, it was brief. Research is needed to identify successful strategies physicians can use to engage adolescents in discussions about sexuality to help promote healthy sexual development and decision making. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01040975

Dyadic and mediation analyses of coping with cardiovascular disease

AbstractThe purpose of this study was to investigate the relationship between attachment security and health outcomes of cardiac patients and their spouses. Dyadic coping and relationship quality were proposed to mediate this relationship. Participants were 72 couples in which one member of the couple was participating in cardiac rehabilitation. Results showed that participants with higher attachment avoidance perceived their general and mental health worse and were less likely to exercise. Patients with higher attachment avoidance perceived their partner as less supportive and this was negatively associated with their general and mental health. Spouses’ positive support and marital happiness partially mediated the relationship between their attachment anxiety and mental health. Patients with spouses with higher attachment anxiety exercised more; whereas spouses of patients with higher attachment anxiety exercised less

Mindfulness Training Supports Quality of Life and Advance Care Planning in Adults With Metastatic Cancer and Their Caregivers: Results of a Pilot Study

Background: Emotional distress often causes patients with cancer and their family caregivers (FCGs) to avoid end-of-life discussions and advance care planning (ACP), which may undermine quality of life (QoL). Most ACP interventions fail to address emotional barriers that impede timely ACP. Aim: We assessed feasibility, acceptability, and preliminary effects of a mindfulness-based intervention to facilitate ACP for adults with advanced-stage cancer and their FCGs. Design: A single-arm pilot was conducted to assess the impact of a 6-week group mindfulness intervention on ACP behaviors (patients only), QoL, family communication, avoidant coping, distress, and other outcomes from baseline (T1) to post-intervention (T2) and 1 month later (T3). Participants: Eligible patients had advanced-stage solid malignancies, limited ACP engagement, and an FCG willing to participate. Thirteen dyads (N = 26 participants) enrolled at an academic cancer center in the United States. Results: Of eligible patients, 59.1% enrolled. Attendance (70.8% across 6 sessions) and retention (84.6% for patients; 92.3% for FCGs) through T3 were acceptable. Over 90% of completers reported high intervention satisfaction. From T1 to T3, patient engagement more than doubled in each of 3 ACP behaviors assessed. Patients reported large significant decreases in distress at T2 and T3. Family caregivers reported large significant improvements in QoL and family communication at T2 and T3. Both patients and FCGs reported notable reductions in sleep disturbance and avoidant coping at T3. Conclusions: The mindfulness intervention was feasible and acceptable and supported improvements in ACP and associated outcomes for patients and FCGs. A randomized trial of mindfulness training for ACP is warranted

The social and behavioral influences (SBI) study: study design and rationale for studying the effects of race and activation on cancer pain management

Background Racial disparities exist in the care provided to advanced cancer patients. This article describes an investigation designed to advance the science of healthcare disparities by isolating the effects of patient race and patient activation on physician behavior using novel standardized patient (SP) methodology. Methods/design The Social and Behavioral Influences (SBI) Study is a National Cancer Institute sponsored trial conducted in Western New York State, Northern/Central Indiana, and lower Michigan. The trial uses an incomplete randomized block design, randomizing physicians to see patients who are either black or white and who are “typical” or “activated” (e.g., ask questions, express opinions, ask for clarification, etc.). The study will enroll 91 physicians. Discussion The SBI study addresses important gaps in our knowledge about racial disparities and methods to reduce them in patients with advanced cancer by using standardized patient methodology. This study is innovative in aims, design, and methodology and will point the way to interventions that can reduce racial disparities and discrimination and draw links between implicit attitudes and physician behaviors