Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Wilson IB, Eggly S, Cooper LA, Roter D, Sankar A, Moore R. Patient-Provider Communication Differs for Black Compared to White HIV-Infected Patients. AIDS Behav. 2010 Jan 12. [Epub ahead of print]
(Race/Cross-Culture, HIV/AIDS, United States)
Poor patient-provider interactions may play a role in explaining racial disparities in the quality and outcomes of HIV care in the United States. We analyzed 354 patient-provider encounters coded with the Roter Interaction Analysis System across four HIV care sites in the United States to explore possible racial differences in patient-provider communication. Providers were more verbally dominant in conversations with black as compared to white patients. This was largely due to black patients' talking less than white patients. There was no association between race and other measures of communication. Black and white patients rated their providers' communication similarly. Efforts to more effectively engage patients in the medical dialogue may lead to improved patient-provider relationships, self-management, and outcomes among black people living with HIV/AIDS.
Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Wilson I, Eggly S, Cooper LA, Roter D, Sankar A, Moore R. Differences in patient-provider communication for Hispanic compared to non-Hispanic white patients in HIV care. J Gen Intern Med. 2010 Jul;25(7):682-7. Epub 2010 Mar 18.
(Race/Cross-Culture, HIV/AIDS. United States)
BACKGROUND: Hispanic Americans with HIV/AIDS experience lower quality care and worse outcomes than non-Hispanic whites. While deficits in patient-provider communication may contribute to these disparities, no studies to date have used audio recordings to examine the communication patterns of Hispanic vs. non-Hispanic white patients with their health care providers. OBJECTIVE: To explore differences in patient-provider communication for English-speaking, HIV-infected Hispanic and non-Hispanic white patients. DESIGN: Cross-sectional analysis. SETTING: Two HIV care sites in the United States (New York and Portland) participating in the Enhancing Communication and HIV Outcomes (ECHO) study. SUBJECTS: Nineteen HIV providers and 113 of their patients. MEASUREMENTS: Patient interviews, provider questionnaires, and audio-recorded, routine, patient-provider encounters coded with the Roter Interaction Analysis System (RIAS). RESULTS: Providers were mostly non-Hispanic white (68%) and female (63%). Patients were Hispanic (51%), and non-Hispanic white (49%); 20% were female. Visits with Hispanic patients were less patient-centered (0.75 vs. 0.90, p = 0.009), with less psychosocial talk (80 vs. 118 statements, p < 0.001). This pattern was consistent among Hispanics who spoke English very well and those with less English proficiency. There was no association between patient race/ethnicity and visit length, patients' or providers' emotional tone, or the total number of patient or provider statements categorized as socioemotional, question-asking, information-giving, or patient activating. Hispanic patients gave higher ratings than whites (AOR 3.05 Hispanic vs. white highest rating of providers' interpersonal style, 95% CI 1.20-7.74). CONCLUSION: In this exploratory study, we found less psychosocial talk in patient-provider encounters with Hispanic compared to white patients. The fact that Hispanic patients rated their visits more positively than whites raises the possibility that these differences in patient-provider interactions may reflect differences in patient preferences and communication style rather than "deficits" in communication. If these findings are replicated in future studies, efforts should be undertaken to understand the reasons underlying them and their impact on the quality and equity of care.
Kinsman H, Roter D, Berkenblit G, Saha S, Korthuis PT, Wilson I, Eggly S, Sankar A, Sharp V, Cohn J, Moore RD, Beach MC. "We'll do this together": the role of the first person plural in fostering partnership in patient-physician relationships. J Gen Intern Med. 2010 Mar;25(3):186-93. Epub 2009 Dec 22.
(Communication Skills, HIV/AIDS, United States)
BACKGROUND: Partnership is integral to therapeutic relationships, yet few studies have examined partnership-fostering communication behaviors in the clinic setting. We conducted this study to better understand how statements in which physicians use the first person plural might foster partnership between patient and provider. METHODS: We audio-recorded encounters between 45 HIV providers and 418 patients in the Enhancing Communication and HIV Outcomes (ECHO) Study. We used the Roter Interaction Analysis System (RIAS) to code for statements made by the physician that used the first person plural to refer to themselves and their patient. Using multiple logistic regression, we examined the associations between the occurrence of one or more first person plural statements with patient ratings of provider communication. To better understand the meaning of first person plural statements, we conducted a qualitative analysis. MAIN RESULTS: Providers were mostly white (69%) and Asian (24%); 57% were female. Patients were black (60%), white (25%), and Hispanic (15%); 33% were female. One or more first person plural statements occurred in 92/418 (22%) of encounters. In adjusted analyses, encounters with first person plural statements were associated with younger patient age (OR 0.97, 95% CI 0.94-0.99), higher patient depression scores (highest tertile compared to lowest tertile: OR 1.89, 95% CI 1.01-3.51), the patient not being on anti-retroviral therapy (OR 0.53, 95% CI 0.29-0.93), and older provider age (OR 1.05, 95% CI 1.00-1.09). After adjustment, patients were less likely to highly rate their provider's communication style if first person plural statements were used (AOR 0.57, 95% CI 0.33-0.96). There were 167 first person plural statements made by physicians in the 418 encounters. Qualitative analysis revealed that many first person plural features had at least one negative feature such as being overtly persuasive ("That's going to be our goal"), indirect ("What can we do to improve your diet?"), or ambiguous ("Let's see what we can do"), although there were also positive statements that involved patients in the health-care process, contributed to a mutual understanding, and addressed the patients' goals. CONCLUSIONS: Contrary to our hypotheses, use of first person plural was not associated with higher ratings of provider communication, probably because some of these statements were overtly persuasive, indirect, or ambiguous. Physicians should become aware of benefits and pitfalls of using the first person plural with patients. Further research is needed to determine the most effective methods through which providers can build alliances with patients.
Korthuis PT, Saha S, Chander G, McCarty D, Moore RD, Cohn JA, Sharp VL, Beach MC. Substance use and the quality of patient-provider communication in HIV clinics. AIDS Behav. 2011 May;15(4):832-41.
(HIV, United States)
The objective of this study was to estimate the influence of substance use on the quality of patient-provider communication during HIV clinic encounters. Patients were surveyed about unhealthy alcohol and illicit drug use and rated provider communication quality. Audio-recorded encounters were coded for specific communication behaviors. Patients with vs. without unhealthy alcohol use rated the quality of their provider's communication lower; illicit drug user ratings were comparable to non-users. Visit length was shorter, with fewer activating/engaging and psychosocial counseling statements for those with vs. without unhealthy alcohol use. Providers and patients exhibited favorable communication behaviors in encounters with illicit drug users vs. non-users, demonstrating greater evidence of patient-provider engagement. The quality of patient-provider communication was worse for HIV-infected patients with unhealthy alcohol use but similar or better for illicit drug users compared with non-users. Interventions should be developed that encourage providers to actively engage patients with unhealthy alcohol use.
Kumar R, Korthuis PT, Saha S, Chander G, Sharp V, Cohn J, Moore R, Beach MC. Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors. J Gen Intern Med. 2010 Jun;25(6):517-23. Epub 2010 Feb 24.
(Decision-making, HIV/AIDS, United States)
BACKGROUND: A preference for shared decision-making among patients with HIV has been associated with better health outcomes. One possible explanation for this association is that patients who prefer a more active role in decision-making are more engaged in the communication process during encounters with their providers. Little is known, however, about patient and provider characteristics or communication behaviors associated with patient decision-making preferences in HIV settings. OBJECTIVE: We examined patient and provider characteristics and patient-provider communication behaviors associated with the decision-making role preferences of patients with HIV. DESIGN: Cross-sectional analysis of patient and provider questionnaires and audio recorded clinical encounters from four sites. PARTICIPANTS: A total of 45 providers and 434 of their patients with HIV. MEASURES: Patients were asked how they prefer to be involved in the decision-making process (doctor makes all/most decisions, patients and doctors share decisions, or patients make decisions alone). Measures of provider and patient communication behaviors were coded from audio recordings using the Roter Interaction Analysis System. MAIN RESULTS: Overall, 72% of patients preferred to share decisions with their provider, 23% wanted their provider to make decisions, and 5% wanted to make decisions themselves. Compared to patients who preferred to share decisions with their provider, patients who preferred their provider make decisions were less likely to be above the age of 60 (ARR 0.09, 95% CI 0.01-0.89) and perceive high quality provider communication about decision-making (ARR 0.41, 95% CI 0.23-0.73), and more likely to have depressive symptoms (ARR 1.92, 95% CI 1.07-3.44). There was no significant association between patient preferences and measures of provider or patient communication behavior. CONCLUSION: Observed measures of patient and provider communication behavior were similar across all patient decision-making role preferences, indicating that it may be difficult for providers to determine these preferences based solely on communication behavior. Engaging patients in open discussion about decision-making preferences may be a more effective approach.
Ratanawongsa N, Korthuis PT, Saha S, Roter D, Moore RD, Sharp VL, Beach MC. Clinician Stress and Patient-Clinician Communication in HIV Care. J Gen Intern Med. 2012 Jul 21. [Epub ahead of print]
(HIV, Communication Skills, Physician Satisfaction, United States)
BACKGROUND: Clinician stress is common, but few studies have examined its relationship with communication behaviors. OBJECTIVE: To investigate associations between clinician stress and patient-clinician communication in primary HIV care. DESIGN: Observational study. PARTICIPANTS: Thirty-three primary HIV clinicians and 350 HIV-infected adult, English-speaking patients at three U.S. HIV specialty clinic sites. MAIN MEASURES: Clinicians completed the Perceived Stress Scale, and we categorized scores in tertiles. Audio-recordings of patient-clinician encounters were coded using the Roter Interaction Analysis System. Patients rated the quality of their clinician's communication and overall quality of medical care. We used regression with generalized estimating equations to examine associations between clinician stress and communication outcomes, controlling for clinician gender, clinic site, and visit length. KEY RESULTS: Among the 33 clinicians, 70 % were physicians, 64 % were women, 67 % were non-Hispanic white, and the mean stress score was 3.9 (SD 2.4, range 0-8). Among the 350 patients, 34 % were women, 55 % were African American, 23 % were non-Hispanic white, 16 % were Hispanic, and 30 % had been with their clinicians > 5 years. Verbal dominance was higher for moderate-stress clinicians (ratio = 1.93, p<0.01) and high-stress clinicians (ratio = 1.76, p = 0.01), compared with low-stress clinicians (ratio 1.45). More medical information was offered by moderate-stress clinicians (145.5 statements, p<0.01) and high-stress clinicians (125.9 statements, p = 0.02), compared with low-stress clinicians (97.8 statements). High-stress clinicians offered less psychosocial information (17.1 vs. 19.3, p = 0.02), and patients of high-stress clinicians rated their quality of care as excellent less frequently than patients of low-stress clinicians (49.5 % vs. 66.9 %, p = 0.01). However, moderate-stress clinicians offered more partnering statements (27.7 vs. 18.2, p = 0.04) and positive affect (3.88 vs. 3.78 score, p = 0.02) than low-stress clinicians, and their patients' ratings did not differ. CONCLUSIONS: Although higher stress was associated with verbal dominance and lower patient ratings, moderate stress was associated with some positive communication behaviors. Prospective mixed methods studies should examine the complex relationships across the continuum of clinician well-being and health communication.
Resources by Subject Area
Following are abstracts of RIAS studies through 2012, listed by subject area. Click on the subject name below to go directly to that section.
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