A Mixed Methods Study of Endometriosis: Patient Experience and Provider Awareness

Endometriosis is a serious yet understudied medical condition impacting hundreds of millions of women around the world. We used a mixed methods approach to better understand provider’s perceptions of the disease, as well as patient’s experiences with the disease. The study consisted of two parts. The first was a quantitative analysis of providers, in which participants completed a brief survey to assess their perception of the prevalence of endometriosis. Fifty-three providers completed surveys. Analysis of the survey data included calculating means and frequencies of each item, as well as determining providers’ prevalence estimates of endometriosis and whether this estimate varied by sub-specialty, number of years in practice, and gender. All quantitative analyses were conducted using SPSS. Survey results indicated that only six of the 53 providers accurately identified the prevalence of endometriosis. The second part of the study involved in-depth, qualitative interviews with both providers and patients. Four providers and 12 patients participated in the interview process. For the provider and patient interviews, code books were created and used to analyze the responses to identify recurring themes. Emergent themes in the provider interviews included, limited training about endometriosis, the difficulty of making a diagnosis, referral process, patient-provider dynamic, and the importance of multidisciplinary collaboration. Emergent themes from patients included, the mental aspect of the disease, lack of confidence in the healthcare system, concerns about fertility, self-advocacy, quality of life, being adverse to hormonal therapies, feelings of dismissiveness by providers, the financial impact of the disease, limited treatment options, and lack of awareness. Findings of this study highlighted some of the major issues which currently contribute to its public health burden, and can allow clinicians to foster change in their current practice with the aim of increasing awareness, issuing more timely and accurate diagnoses, and a call to action for investment and funding for research that will move the field forward and ultimately improve patient outcomes

Bringing the Patient\u27s Voice into Teamwork Assessment Using the Jefferson Teamwork Observation Guide (JTOG)

Purpose: To test the feasibility of using the Jefferson Teamwork Observation Guide (JTOG) as a mobile application with diverse patients to gather perceptions of team-based care delivery. Background: A validated tool assessing IPE core competencies is a significant gap in the literature (IOM, 2015). Little research has demonstrated links between effective teamwork and improved patient outcomes. In 2015, a research team validated the JTOG tool to assess team function. This JTOG was then converted to a mobile application, and individual, patient, and caregiver versions were developed, allowing for 360° evaluation. Description of Intervention or Program: A research team piloted the Patient JTOG mobile application, asking patients to participate in a survey consisting of one open-ended and ten Likert scale questions. Items were tied to the domains of interprofessional collaborative practice – communication, values/ethics, teamwork, and roles/responsibilities (IPEC, 2011) – and one patient-centeredness (PC) domain. Results: Four hundred and forty three patients completed the JTOG, ranging in age from 18-90+. Of the diverse patient population, 52% were female and 39% male. Eighty-seven percent of patients responded “strongly agree” to a question about the importance of teamwork in healthcare. Teams received a mean score from 3.51 to 3.60 out of 4.0 for the eight IPE competency questions. Overall satisfaction with the teams evaluated was 3.83. Items were subjected to a principal axis factor analysis with varimax rotation and a screen plot inspection was used to determine the number of factors to extract. A Cronbach’s alpha was 0.93. Conclusion: Our study confirms the feasibility of using the Patient JTOG app to elicit patient perceptions of teams in inpatient and outpatient settings. By completing this survey, patients provided real-time feedback and summary reports were sent to care teams to improve team functioning. A full validation study of the Patient JTOG is now underway, and a multi-institutional study is planned to assess its use in other healthcare institutions. Relevance to interprofessional education or practice: Assessment strategies must incorporate the voice of the patient as we move forward in developing new tools to assess team function, identify behaviors consistent with effective teamwork, and demonstrate the impact of collaborative practice on patient outcomes. Learning Objectives: Two to three measurable learning objectives relevant to the conference goals. 1) Describe a new mobile tool for gathering patient feedback on patient-centered team based care 2) Apply lessons learned for 360° competency-based assessment of interprofessional education and collaborative practic

Overcoming Obesity: A Mixed Methods Study of the Impact of Primary Care Physician Counseling on Low-Income African American Women Who Successfully Lost Weight.

Purpose: Low-income, African American women are disproportionately impacted by obesity. Little is known about the interactions between low-income, African American women who successfully lost weight and their primary care physicians (PCPs). Design: Mixed methods, positive deviance study. Setting: Urban university-based family medicine practice. Participants: The positive deviance group comprised low-income, African American women who were obese, lost 10% body weight, and maintained this loss for 6 months. Measures: The PCP- and patient-reported weight-related variables collected through the electronic medical record (EMR), surveys, and interviews. Analysis: Logistic regression of quantitative variables. Qualitative analysis using modified grounded theory. Results: The EMR documentation by PCPs of dietary counseling and a weight-related medical problem were significant predictors of positive deviant group membership. Qualitative analyses of interviews revealed 5 major themes: framing obesity in the context of other health problems provided motivation; having a full discussion around weight management was important; an ongoing relationship with the physician was valuable; celebrating small successes was beneficial; and advice was helpful but self-motivation was necessary. Conclusion: The PCP counseling may be an important factor in promoting weight loss in low-income, African American women. Patients may benefit from their PCPs drawing connections between obesity and weight-related medical conditions and enhancing intrinsic motivation for weight loss

An Examination of the Cumulative Effect Model of Adverse Childhood Experiences: Are All ACEs Created Equal?

Adverse childhood experiences have been linked to a wide variety of physical and mental/behavioral health outcomes later in life by many studies since a major research effort by Dr. Vincent Felitti in 1998. The majority of this research has used a cumulative model of the ACEs of participants, or what is known as an ACE score, and has linked a higher ACE score to an increased likelihood of negative health outcomes later in life. Other predictive models involving health conditions such as the LACE hospital readmission model and Charlson Comorbidity Index weight different factors of their models in the predictive assessments. The purpose of this Capstone project is to demonstrate that the cumulative ACE model may require revision in its assumption that all ACEs contribute equally to an ACE score, and that different ACEs may contribute more or less significantly than others. To accomplish this goal, the Behavioral Risk Factor Surveillance System (BRFSS) data from 2009 to 2012 was coded in a way that allowed for binary logistic regressions to be performed on single, 2 combination, and 3 combinations compared to those with no ACEs to create odds ratios of having angina/coronary artery disease or a smoking habit later in life. These odds ratios were then grouped in frequencies to show that different combinations varied widely in their odds ratio compared to the generic ACE score. Further research into this is necessary, especially if specific weights are to be created in order to revise the model, but it helps demonstrate that the cumulative effects model may be incorrect in assuming that all ACEs contribute equally

The Influence of Protective Factors on Perceived Impact of Adverse Childhood Experiences

Adverse Childhood Experiences (ACES) have been linked to long-term negative health outcomes, substance abuse, and illegal activity. However, many individuals overcome these traumatic events and become healthy, successful, stable adults. Research has found that internal cognitive processes and personal attributes such as resilience, centrality, and the perceived impact of the ACE influence these divergent paths. Interpersonally, there is evidence that positive relationships during childhood and adolescence serve as protective factors (which reduce the negative effects of traumatic events). My study’s aim is to find if there is an association between the external influences of protective factors and the internal perception of the impact of ACES. I recoded, merged, and analyzed data from three separate data sets (N = 456) containing survey responses on ACES, perceived impact of the ACE, valence of the ACE, and presence of protective factors to identify if there is a statistically significant correlation between protective factors and the perceived impact of ACES. To the best of my knowledge, this is the first study to assess the correlations between the perception of the ACE (magnitude and valence) and the presence or absence of protective factors. Statistically significant bivariate correlations were found between higher ACE scores and increased perception of magnitude of the ACE, higher ACE scores and decreased perception of valence of the ACE, presence of protective factors and decreased ACE scores, presence of protective factors and decreased perception of magnitude of the ACE, and presence of protective factors and increased perception of positive valence of the ACE. Unique to our study, we identified that perception of the valence of the ACE, ranging from very negative to very positive, has a positive correlation to the identified protective factors when controlling for ACE score

Learning From Past Mistakes – Opioids, Cannabis and the Treatment of Chronic Non-Cancer Pain Conditions

Background. Finding effective treatments for chronic pain is a major public health challenge. In the 1980s and 1990s, claims of opioid effectiveness without addiction for Chronic Non-Cancer Pain (CNCP) conditions were rooted in uncritical citation of faulty science by the pharmaceutical industry and physicians. The national public heath impact of the ‘opioid epidemic’ is well known. In the 2000s, Medical Cannabis has proliferated as a physician-prescribed treatment for CNCP conditions in the face of uncertain evidence. Some are questioning: has the medical community ‘repeated past mistakes’ in chronic pain management? We approach this question with a comparative analysis of quality of evidence for opioids and cannabis for CNCP conditions during their periods of liberalization. Method. We identified the ‘liberalization periods’ for Opioids as 1989-1999, and Medical Cannabis as 1998–2008 and conducted a literature search for Randomized Control Trials (RCTs) in these time periods. We then conducted modified GRADE criteria evaluations (Cochrane Collaborative tool for assessing Quality of Evidence) for each body of evidence, and contextualized our findings. Results. Opioids: Very Low quality evidence; concerns regarding publication bias, handling of dropouts and outcome data, vague method descriptions and indirectness of population and intervention. Cannabis: Low - Very Low quality evidence; concerns regarding publication bias, potential issues with blinding and indirectness of population. Conclusions & Discussion. It is important to consider several factors, including differences in scientific rigor in each time period and DEA schedule I classification of marijuana being a barrier to conducting studies. Still, there is a striking parallel of prescribing practices outpacing evidence quality. Policy Implications. Rescheduling Marijuana from Schedule I, reinforcing quality and rigor standards for clinical trials, and better integration of evidence interpretation and synthesis into medical school curricula are all warranted

“What Happened?” Exploring the Complexities of Clinical Inertia in the Treatment of People with Type 2 Diabetes

The diabetes epidemic in the US affects over 29 million individuals every day. Type 2 diabetes accounts for 95% of those cases. Each year approximately $245 billion is spent on caring for individuals with diabetes. Yet, 33-49% of patients with diabetes do not meet the target for glycemic control. There are many reasons that can be cited as to the cause for the lack of glycemic control in almost half of patients with diabetes however one possible explanation is the phenomenon of clinical inertia. Clinical inertia in the treatment of type 2 diabetes is the failure of a healthcare provider to escalate pharmacotherapy when glycemic control (HbA1