Implementing an innovative consent form: the PREDICT experience

<p>Abstract</p> <p>Background</p> <p>In the setting of coronary angiography, generic consent forms permit highly variable communication between patients and physicians. Even with the existence of multiple risk models, clinicians have been unable to readily access them and thus provide patients with vague estimations regarding risks of the procedure.</p> <p>Methods</p> <p>We created a web-based vehicle, PREDICT, for embedding patient-specific estimates of risk from validated multivariable models into individualized consent documents at the point-of-care. Beginning August 2006, outpatients undergoing coronary angiography at the Mid America Heart Institute received individualized consent documents generated by PREDICT. In February 2007 this approach was expanded to all patients undergoing coronary angiography within the four Kansas City hospitals of the Saint Luke's Health System. Qualitative research methods were used to identify the implementation challenges and successes with incorporating PREDICT-enhanced consent documents into routine clinical care from multiple perspectives: administration, information systems, nurses, physicians, and patients.</p> <p>Results</p> <p>Most clinicians found usefulness in the tool (providing clarity and educational value for patients) and satisfaction with the altered processes of care, although a few cardiologists cited delayed patient flow and excessive patient questions. The responses from administration and patients were uniformly positive. The key barrier was related to informatics.</p> <p>Conclusion</p> <p>This preliminary experience suggests that successful change in clinical processes and organizational culture can be accomplished through multidisciplinary collaboration. A randomized trial of PREDICT consent, leveraging the accumulated knowledge from this first experience, is needed to further evaluate its impact on medical decision-making, patient compliance, and clinical outcomes.</p

A theoretical framework to describe communication processes during medical disability assessment interviews

BACKGROUND: Research in different fields of medicine suggests that communication is important in physician-patient encounters and influences satisfaction with these encounters. It is argued that this also applies to the non-curative tasks that physicians perform, such as sickness certification and medical disability assessments. However, there is no conceptualised theoretical framework that can be used to describe intentions with regard to communication behaviour, communication behaviour itself, and satisfaction with communication behaviour in a medical disability assessment context. OBJECTIVE: The objective of this paper is to describe the conceptualization of a model for the communication behaviour of physicians performing medical disability assessments in a social insurance context and of their claimants, in face-to-face encounters during medical disability assessment interviews and the preparation thereof. CONCEPTUALIzATION: The behavioural model, based on the Theory of Planned Behaviour (TPB), is conceptualised for the communication behaviour of social insurance physicians and claimants separately, but also combined during the assessment interview. Other important concepts in the model are the evaluation of communication behaviour (satisfaction), intentions, attitudes, skills, and barriers for communication. CONCLUSION: The conceptualization of the TPB-based behavioural model will help to provide insight into the communication behaviour of social insurance physicians and claimants during disability assessment interviews. After empirical testing of the relationships in the model, it can be used in other studies to obtain more insight into communication behaviour in non-curative medicine, and it could help social insurance physicians to adapt their communication behaviour to their task when performing disability assessment

The affinity of GXXXG motifs in transmembrane helix-helix interactions is modulated by long-range communication

Sequence motifs are responsible for ensuring the proper assembly of transmembrane (TM) helices in the lipid bilayer. To understand the mechanism by which the affinity of a common TM-TM interactive motif is controlled at the sequence level, we compared two well characterized GXXXG motif-containing homodimers, those formed by human erythrocyte protein glycophorin A (GpA, high-affinity dimer) and those formed by bacteriophage M13 major coat protein (MCP, low affinity dimer). In both constructs, the GXXXG motif is necessary for TM-TM association. Although the remaining interfacial residues (underlined) in GpA ((LI) under bar XXG (V) under bar XXG (V) under bar XX (T) under bar) differ from those in MCP ( (VV) under bar XXG (A) under bar XXG (I) under bar XX (F) under bar), molecular modeling performed here indicated that GpA and MCP dimers possess the same overall fold. Thus, we could introduce GpA interfacial residues, alone and in combination, into the MCP sequence to help decrypt the determinants of dimer affinity. Using both in vivo TOXCAT assays and SDS-PAGE gel migration rates of synthetic peptides derived from TM regions of the proteins, we found that the most distal interfacial sites, 12 residues apart (and similar to18 Angstrom in structural space), work in concert to control TM-TM affinity synergistically.X119594sciescopu

Self-association of the transmembrane domain of an anthrax toxin receptor

Protective antigen (PA), lethal factor (LF) and edema factor (EF) are secreted individually by Bacillus anthracis. These components of anthrax toxin must then assemble into complexes to intoxicate mammalian cells. Toxin assembly it-vitiates when molecules of PA bind mammalian receptors ANTXR1/2 and are cleaved by surface proteases into 20 kDa and 63 kDa fragments. After PA(20) dissociates, receptor-bound PA(63) homo-oligomerizes into heptamers. Oligomeric PA(63) binds EF and LF and these complexes are internalized into an acidic compartment where the two enzymatic components are translocated across the membrane by a channel formed by heptameric PA(63). Since oligomerization of PA(63) is required to bind and translocate the enzymatic components, we sought to determine whether interactions between toxin receptors could facilitate the assembly process. In the present work, we performed a co-immunoprecipitation experiment to demonstrate that ANTXR1 is oligomeric in mammalian cells. Computer modeling predicted the self-association of the ANTXR1 transmembrane domain and we detected oligomerization of ANTXR1 transmembrane domain peptides in the membrane-mimetic environment of SDS micelles using fluorescence resonance energy transfer. Furthermore, the ANTXR1 transmembrane domain mediated oligomerization of a reporter protein construct in a bacterial membrane. In both assays, mutations that disrupted the interaction were consistent with the interaction being mediated through an asymmetric binding interface. Mutations that impaired self-association of the transmembrane domain reduced the rate of PA(63) heptamer formation on the mammalian cell surface. Our findings indicate that ANTXR1 transmembrane domains self-associate and that these interactions may stabilize intermediate oligomerization states of ANTXR1-PA(63) complexes. (c) 2006 Elsevier Ltd. All rights reserved.X1120sciescopu

Perceptions of Benefit and Risk of Patients Undergoing First-time Elective Percutaneous Coronary Revascularization

OBJECTIVE: To assess reasons why patients undergo elective percutaneous coronary revascularization (PCR), patient expectations of the benefits of PCR, and their understanding of the risks associated with PCR. We hypothesized that patients overestimate the benefits and underestimate the risks associated with PCR. DESIGN: A prospective, semistructured questionnaire. PARTICIPANTS: Patients undergoing their first elective PCR. MAIN RESULTS: Fifty-two consecutive patients with a mean age of 64.3 years (range 39-87) completed the interview. Although 30 (57%) patients cited relief of symptoms as at least 1 reason to have PCR, 32 (62%) patients cited either an abnormal diagnostic test result (i.e., exercise stress test or catheterization) or “pathophysiologic” problem (i.e., “I have a blockage”), with 17 patients (33%) citing these reasons alone as indications for PCR. Thirty-nine (75%) patients believed PCR would prevent a future myocardial infarction, and 37 (71%) patients felt PCR would prolong their life. Regarding the potential complications, only 24 patients (46%) could recall at least 1 possible complication. However, on a Deber questionnaire, the majority of patients (67%) stated that they should determine either mostly alone or equally with a physician how acceptable the risks of the procedure are for themselves. CONCLUSIONS: The majority of patients had unrealistic expectatations about the long-term benefits of elective PCR and was not aware of the potential risks, even though they expressed a strong interest in participating in the decision to have PCR. More work is needed to define the optimal strategy to educate patients about the benefits and risks of elective PCR, and whether such education will affect patient decision making

Impoverished Diabetic Patients Whose Doctors Facilitate Their Participation in Medical Decision Making Are More Satisfied with Their Care

OBJECTIVE: Greater participation in medical decision making is generally advocated for patients, and often advocated for those with diabetes. Although some studies suggest that diabetic patients prefer to participate less in decision making than do healthy patients, the empirical relationship between such participation and diabetic patients' satisfaction with their care is currently unknown. We sought to characterize the relationship between aspects of diabetic patients' participation in medical decision making and their satisfaction with care. DESIGN: Cross-sectional observational study. SETTING: A general medical county hospital–affiliated clinic. PARTICIPANTS: One hundred ninety-eight patients with type 2 diabetes. MAIN MEASURES: Interviews conducted prior to the doctor visit assessed patients' desire to participate in medical decision making, baseline satisfaction (using a standardized measure), and sociodemographic and clinical characteristics. Postvisit interviews of those patients assessed their visit satisfaction and perception of their doctor's facilitation of patient involvement in care. A discrepancy score was computed for each subject to reflect the difference between the previsit stated desire regarding participation and the postvisit report of their experience of participation. RESULTS: Overall, patients reported low postvisit satisfaction relative to national standards (mean of 70 on a 98-point scale). Patients perceived a high level of facilitation of participation (mean 88 on a 100-point scale). Facilitation of participation and the discrepancy score both independently predicted greater visit satisfaction. In particular, a 13-point (1 SD) increase in the perceived facilitation score resulted in a 12-point (0.87 SD) increase in patient satisfaction, and a 1.22 point increase (1 SD) in the discrepancy score (the extent to which the patient was allowed more participation than, at previsit, he or she desired) resulted in a 6-point (0.5 SD) increase in the satisfaction score, even after controlling for initial desire to participate. For women, but not for men, physician facilitation of participation was a positive predictor of satisfaction; for men, but not women, desire to participate was a significant positive predictor of visit satisfaction. CONCLUSION: Clinicians may feel reassured that encouraging even initially reluctant patients with diabetes to participate in medical decision making may be associated with increased patient satisfaction. Greater patient participation has the potential to improve diabetic self-care because of the likely positive effect of patient satisfaction on adherence to treatment. Further research to assess the prospective effects of enhancing physician facilitation of patient participation is likely to yield important information for the effective treatment of chronically ill patients