Publications by authors named "Richard Street"

155 Publications

Pediatric Oncologists' Experiences Returning and Incorporating Genomic Sequencing Results into Cancer Care.

J Pers Med 2021 Jun 18;11(6). Epub 2021 Jun 18.

Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA.

Pediatric oncologists' perspectives around returning and incorporating tumor and germline genomic sequencing (GS) results into cancer care are not well-described. To inform optimization of cancer genomics communication, we assessed oncologists' experiences with return of genomic results (ROR), including their preparation/readiness for ROR, collaboration with genetic counselors (GCs) during ROR, and perceived challenges. The BASIC3 study paired pediatric oncologists with GCs to return results to patients' families. We thematically analyzed 24 interviews with 12 oncologists at two post-ROR time points. Oncologists found pre-ROR meetings with GCs and geneticists essential to interpreting patients' reports and communicating results to families. Most oncologists took a collaborative ROR approach where they discussed tumor findings and GCs discussed germline findings. Oncologists perceived many roles for GCs during ROR, including answering families' questions and describing information in lay language. Challenges identified included conveying uncertain information in accessible language, limits of oncologists' genetics expertise, and navigating families' emotional responses. Oncologists emphasized how GCs' and geneticists' support was essential to ROR, especially for germline findings. GS can be successfully integrated into cancer care, but to account for the GC shortage, alternative ROR models and access to genetics resources will be needed to better support families and avoid burdening oncologists.
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http://dx.doi.org/10.3390/jpm11060570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8235493PMC
June 2021

Information giving, managing, and understanding in clinical encounters.

Authors:
Richard L Street

Patient Educ Couns 2021 08;104(8):1831-1833

Department of Communication, Texas A&M University, College Station, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Houston VA Center for Innovations in Quality, Effectiveness and Safety, USA. Electronic address:

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http://dx.doi.org/10.1016/j.pec.2021.05.027DOI Listing
August 2021

How Communication "Failed" or "Saved the Day": Counterfactual Accounts of Medical Errors.

J Patient Exp 2020 Dec 26;7(6):1247-1254. Epub 2020 May 26.

Meyers Primary Care Institute, a Joint Endeavor of the University of Massachusetts Medical School, Reliant Medical Group and Fallon Health, Worcester, MA, USA.

Communication breakdowns among clinicians, patients, and family members can lead to medical errors, yet effective communication may prevent such mistakes. This investigation examined patients' and family members' experiences where they believed communication failures contributed to medical errors or where effective communication prevented a medical error ("close calls"). The study conducted a thematic analysis of open-ended responses to an online survey of patients' and family members' past experiences with medical errors or close calls. Of the 93 respondents, 56 (60%) provided stories of medical errors, and the remaining described close calls. Two predominant themes emerged in medical error stories that were attributed to health care providers-information inadequacy (eg, delayed, inaccurate) and not listening to or being dismissive of a patient's or family member's concerns. In stories of close calls, a patient's or family member's proactive communication (eg, being assertive, persistent) most often "saved the day." The findings highlight the importance of encouraging active patient/family involvement in a patient's medical care to prevent errors and of improving systems to provide meaningful information in a timely manner.
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http://dx.doi.org/10.1177/2374373520925270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786716PMC
December 2020

Shared Decisions: A Qualitative Study on Clinician and Patient Perspectives on Statin Therapy and Statin-Associated Side Effects.

J Am Heart Assoc 2020 11 10;9(22):e017915. Epub 2020 Nov 10.

Health Policy, Quality and Informatics Program Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety Houston TX.

Background Despite guideline recommendations and clinical trial data suggesting benefit, statin therapy use in patients with atherosclerotic cardiovascular disease remains suboptimal. The aim of this study was to understand clinician and patient views on statin therapy, statin-associated side effects (SASEs), SASE management, and communication around statin risks and benefits. Methods and Results We conducted qualitative interviews of patients with atherosclerotic cardiovascular disease who had SASEs (n=17) and clinicians who regularly prescribe statins (n=20). We used directed content analysis, facilitated by Atlas.ti software, to develop and revise codebooks for clinician and patient interviews. The most relevant codes were "pile sorted" into 5 main topic domains: (1) SASEs vary in severity, duration, and time of onset; (2) communication practices by clinicians around statins and SASEs are variable and impacted by clinician time limitations and patient preconceived notions of SASEs; (3) although a "trial and error" approach to managing SASEs may be effective in allowing clinicians to keep patients with atherosclerotic cardiovascular disease on a statin, it can be frustrating for patients; (4) outside sources, such as the media, internet, social networks, and social circles, influence patients' perceptions and often impact the risk benefit discussion; and (5) a decision aid would be beneficial in facilitating clinician decision-making around SASEs and discussion of SASEs with the patients. Conclusions Statin use among patients with atherosclerotic cardiovascular disease remains suboptimal because of various patient- and clinician-related factors. The development of a decision aid to facilitate discussion of SASEs, clinician decision-making, and SASE management may improve statin use in this high-risk population.
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http://dx.doi.org/10.1161/JAHA.120.017915DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763718PMC
November 2020

Factors affecting cancer patients' electronic communication with providers: Implications for COVID-19 induced transitions to telehealth.

Patient Educ Couns 2020 Sep 28. Epub 2020 Sep 28.

Department of Communication, Texas A&M University, College Station, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA.

Objective: Because of the pandemic, electronic communication between patients and clinicians has taken on increasing significance in the delivery of cancer care. The study explored personal, clinical, and technology factors predicting cancer survivors' electronic communication with clinicians.

Methods: Data for this investigation came from the Health Information National Trends Survey (HINTS5, Cycle 2) that included 593 respondents who previously or currently had cancer. Multivariate regression analyses were used to predict electronic communication with clinicians. Predictors included demographic variables and health status, technology use (online health information-seeking behavior, tracking of health-related data such as using a Fitbit), and quality of past communication experiences with clinicians.

Results: In this pre COVID-19 sample, 42 % respondents (N = 252) did not engage in any type of electronic communication (e.g., emailing, texting, data sharing) with providers. In multivariate analyses, predictors of more electronic communication with clinicians included frequency of seeking health-related information online (ß = .267, p < .001) and better communication experiences with clinicians (ß = .028, p = .034), while no demographic variable showed significance. The technology use variables (online health information seeking, health tracking) were significantly higher predictors of electronic communication with clinicians (ΔR = .142, p < .001) than was past experiences with clinicians (ΔR = .029, p = .016).

Conclusions: Access and past experience with interactive media technologies are strong predictors of cancer patients' electronic communication than with clinicians. Adoption of telehealth technology likely depends as much on patients' relationships with technology as it does their relationships with clinicians.

Practice Implications: Since Covid-19, cancer care providers have turned to telehealth provide patients with needed cancer care services. Enhancing patients' digital competence and experience with electronic communication will help them more easily navigate telehealth care. Providers can leverage their relationship with patients to facilitate more effective use of telehealth services.
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http://dx.doi.org/10.1016/j.pec.2020.09.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521379PMC
September 2020

Characterizing patient-oncologist communication in genomic tumor testing: The 21-gene recurrence score as an exemplar.

Patient Educ Couns 2021 02 3;104(2):250-256. Epub 2020 Sep 3.

Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, MI, USA.

Objective: Women with early-stage, ER + breast cancer are recommend to receive genomic profiling tests, such as the 21-gene Recurrence Score (RS) test, to guide treatment decisions. We examined test- and treatment-related information discussed and the associations between RS categories and aspects of communication during patient-oncologist clinical encounters.

Methods: As part of a larger trial, clinical encounters (N = 46) were audiorecorded and coded for 1) RS- and treatment-related information, 2) shared decision making, 3) patient active participation, and 4) oncologist patient-centered communication. We examined differences by RS category using mixed models, adjusting for nesting within oncologist.

Results: Patients with a high RS were more likely to receive a chemotherapy recommendation (p < .01), hear about the risks/side effects of chemotherapy (p < .01), and offer their preferences (p = .02) than those with intermediate or low RS. Elements of shared decision making increased with RS. Oncologist patient-centered communication (M = 4.09/5, SD = .25) and patient active participation (M = 3.5/4, SD = 1.0) were high across RS.

Conclusion: Findings suggest that disease severity, rather than clinical uncertainty, impact treatment recommendations and shared decision making.

Practice Implications: Oncologists adjust test- and treatment-related information and shared decision making by disease severity. This information provides a framework to inform decision making in complex cancer and genomics settings.
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http://dx.doi.org/10.1016/j.pec.2020.08.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854933PMC
February 2021

The Communicative Ecology of Chinese Patients' Experiences with Health Care.

J Health Commun 2020 06 27;25(6):463-473. Epub 2020 Jul 27.

Department of Communication, Texas A&M University , College Station, Texas, USA.

Patient satisfaction and trust are important intermediate outcomes along pathways linking clinician-patient communication to improve well-being, but they are difficult to achieve in Chinese health care. Problematic physician-patient interactions, questionable health-care organizational practices, and media coverage of medical scandals may have contributed to this problem. Nevertheless, there isscant literature documenting reasons underlying dissatisfaction with Chinese health care. Using Street's ecological model of communication in medical encounters as a conceptual framework, this study explores how media and organizational factors affect Chinese patients' satisfaction and trust both directly and as mediated by the quality of patients' past communication experiences with clinicians. A survey was conducted among 257 Ob-gyn patients in a top-tier hospital in Sichuan, China. The results show that several organizational and media factors, along with patients' experiences with physician communication, predict patient satisfaction and trust. Perceptions of physician communication mediated some of the relationships between organizational and media factors with outcomes. Theoretical and practical implications are discussed, particularly with respect to improving health-care services in China.
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http://dx.doi.org/10.1080/10810730.2020.1789245DOI Listing
June 2020

Question Prompt List to Support Patient-Provider Communication in the Use of the 21-Gene Recurrence Test: Feasibility, Acceptability, and Outcomes.

JCO Oncol Pract 2020 10 28;16(10):e1085-e1097. Epub 2020 May 28.

Georgetown Lombardi Comprehensive Cancer Center, Washington, DC.

Purpose: The 21-gene recurrence score (RS) assay is used to guide breast cancer treatment decisions but can be poorly understood by patients. We examined the effects of a question prompt list (QPL) on knowledge, distress, and decisional conflict related to genomic testing and treatment in early-stage breast cancer.

Methods: We describe the feasibility and acceptability of the QPL and the impact of the QPL on knowledge, distress, and decisional conflict before and after the receipt of the QPL (MEND 2, N = 65). We also compared distress and decisional conflict between women who received the QPL (MEND 2, N = 65) and a comparable group of women who did not receive the QPL who participated in an earlier observational study within the same clinics (MEND 1, N = 136).

Results: MEND 2 participants indicated high acceptability and feasibility using the QPL. Knowledge increased post-QPL ( < .01) but did not decrease distress. Decisional conflict was lower among women in MEND 2 compared with those in MEND 1 ( < .01), with no statistically significant differences in distress.

Conclusion: The findings suggest that the QPL is feasible, acceptable, can improve knowledge and decrease decisional conflict in the large group of women deciding treatment while integrating RS test results.
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http://dx.doi.org/10.1200/JOP.19.00661DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7564130PMC
October 2020

Reply to: Outcomes and Patient Goals: Comment on "Chronic Disease Decision Making and 'What Matters Most'".

J Am Geriatr Soc 2020 07 11;68(7):1615-1616. Epub 2020 May 11.

Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.

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http://dx.doi.org/10.1111/jgs.16505DOI Listing
July 2020

Empowering Older Adults to Discuss Advance Care Planning During Clinical Visits: The PREPARE Randomized Trial.

J Am Geriatr Soc 2020 06 10;68(6):1210-1217. Epub 2020 Mar 10.

Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.

Background/objectives: A patient-directed, online program (PREPARE for Your Care [PREPARE]; prepareforyourcare.org) has been shown to increase advance care planning (ACP) documentation. However, the mechanisms underlying PREPARE are unknown. Our objectives were to compare the efficacy of PREPARE plus an easy-to-read advance directive (AD) vs an AD alone to increase active patient participation in ACP discussions during clinic visits and to examine effects of active patient participation on ACP documentation.

Design: Audio recordings of postintervention primary care visits from two randomized trials (2013-2016).

Setting: Seven primary care clinics at a veterans affair and safety-net hospital in San Francisco, CA.

Participants: English- and Spanish-speaking adults, aged 55 years and older, with two or more chronic/serious conditions.

Intervention: PREPARE plus an easy-to-read AD or an AD alone.

Measurements: The primary outcome was the number of active patient participation utterances about ACP (eg, asking questions, stating preferences) measured by the validated Active Patient Participation Coding Scheme. We examined differences in utterances by study arm using mixed effects negative binomial models and utterances as a mediator of PREPARE's effect on documentation using adjusted logistic regression. Models were adjusted for health literacy, prior care planning, and clinician.

Results: Among 393 participants, the mean (SD) age was 66 (8.1) years, 120 (30.5%) had limited health literacy, and 99 (25.2%) were Spanish speaking. PREPARE plus the AD resulted in 41% more active patient participation in ACP discussions compared with the AD alone (mean [SD] = 10.1 [16.8] vs 6.6 [13.4] utterances; incidence rate ratio = 1.41; 95% confidence interval = 1.00-1.98). For every additional utterance, participants had 15% higher odds of ACP documentation, and active patient participation accounted for 16% of PREPARE's effect on documentation.

Conclusions: The PREPARE program and easy-to-read AD empowered patients to actively participate in ACP discussions during clinical visits more than the AD alone. Increased activation was associated with increased ACP documentation. Therefore, PREPARE may mitigate barriers to ACP among English- and Spanish-speaking older adults.

Trial Registration: ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941. J Am Geriatr Soc 68:1210-1217, 2020.
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http://dx.doi.org/10.1111/jgs.16405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787080PMC
June 2020

Chronic Disease Decision Making and "What Matters Most".

J Am Geriatr Soc 2020 03 11;68(3):474-477. Epub 2020 Feb 11.

Department of Medicine, Yale School of Medicine, New Haven, Connecticut.

The increasing use of the question, "What matters most to you?" is a welcome development in the effort to provide patient-centered care. However, it is difficult for clinicians to translate answers to this question into treatment plans for chronic conditions, including recognizing when to consider options other than clinical practice guideline (CPG)-directed therapy. Goal elicitation is most helpful when a patient has different treatment options with clearly identifiable trade-offs. In the face of trade-offs, goal elicitation helps patients to prioritize among potentially competing outcomes. While decision aids (DAs) focus on trade-offs by delineating options and outcomes, the robust outcome data necessary to create DAs for older patients with multimorbidity are often lacking and even mild cognitive impairment makes the use of DAs difficult. The challenges for providing chronic disease care to older patients who are at risk for adverse events from CPG-directed therapy because of multimorbidity and/or frailty are to organize the complexity of individual combinations of diseases, conditions, and syndromes into common sets of trade-offs and to identify those goals or priorities that will directly inform a plan of care. J Am Geriatr Soc 68:474-477, 2020.
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http://dx.doi.org/10.1111/jgs.16371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197748PMC
March 2020

Weight-related genomic information and provider communication approach: looking through the lens of patient race.

Per Med 2019 09 25;16(5):387-397. Epub 2019 Sep 25.

Social and Behavioral Research Branch, National Human Genome Research Institute 31 Center Drive, B1B36, Bethesda, MD 20892, USA.

This report explores the process of weight-related genomic information provision considering patient race as an important potential moderator of patient response. Health beliefs and perceived stigma were assessed following provision of genomic (versus behavioral) information by a virtual reality-based physician using either a supportive or directive communication style. Participants included 168 women with overweight. Genomic explanations, combined with supportive communication, resulted in some improved health behavior-related and interpersonal outcomes for white patients, but not black participants. Black participants, on average, did not have diminished outcomes when provided with genomic information. Genomic communications may elicit more positive interpersonal responses than behavioral explanations among both majority and minority populations, but these effects may be moderated by patient race.
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http://dx.doi.org/10.2217/pme-2018-0148DOI Listing
September 2019

Pediatric clinician perspectives on communicating diagnostic uncertainty.

Int J Qual Health Care 2019 Nov;31(9):G107-G112

Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2450 Holcombe Blvd, Suite 01Y, Houston, TX, USA.

Objective: Diagnosis often evolves over time, involves uncertainty, and is vulnerable to errors. We examined pediatric clinicians' perspectives on communicating diagnostic uncertainty to patients' parents and how this occurs.

Design: We conducted semi-structured interviews, which were audiotaped, transcribed, and analyzed using content analysis. Two researchers independently coded transcripts and then discussed discrepancies to reach consensus.

Setting: A purposive sample of pediatric clinicians at two large academic medical institutions in Texas.

Participants: Twenty pediatric clinicians participated: 18 physicians, 2 nurse practitioners; 7 males, 13 females; 7 inpatient, 11 outpatient, and 2 practicing in mixed settings; with 0-16 years' experience post-residency.

Intervention(s): None.

Main Outcome Measure(s): Pediatric clinician perspectives on communication of diagnostic uncertainty.

Results: Pediatric clinicians commonly experienced diagnostic uncertainty and most were comfortable seeking help and discussing with colleagues. However, when communicating uncertainty to parents, clinicians used multiple considerations to adjust the degree to which they communicated. Considerations included parent characteristics (education, socioeconomic status, emotional response, and culture) and strength of parent-clinician relationships. Communication content included setting expectations, explaining the diagnostic process, discussing most relevant differentials, and providing reassurance. Responses to certain parent characteristics, however, were variable. For example, some clinicians were more open to discussing diagnostic uncertainty with more educated parents- others were less.

Conclusions: While pediatric clinicians are comfortable discussing diagnostic uncertainty with colleagues, how they communicate uncertainty to parents appears variable. Parent characteristics and parent-clinician relationships affect extent of communication and content discussed. Development and implementation of optimal strategies for managing and communicating diagnostic uncertainty can improve the diagnostic process.
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http://dx.doi.org/10.1093/intqhc/mzz061DOI Listing
November 2019

Metadata and Table Caption Correction: What Do Patients Say About Doctors Online? A Systematic Review of Studies on Patient Online Reviews.

J Med Internet Res 2019 Jul 18;21(7):e14823. Epub 2019 Jul 18.

Department of Communication, Texas A&M University, College Station, TX, United States.

[This corrects the article DOI: 10.2196/12521.].
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http://dx.doi.org/10.2196/14823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6670278PMC
July 2019

Mapping diverse measures of patient-centered communication onto the conceptual domains of patient-centered care.

Authors:
Richard L Street

Patient Educ Couns 2019 07;102(7):1225-1227

Department of Communication, Texas A&M University, College Station, TX, United States; Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Houston VA Center for Innovations in Quality, Effectiveness and Safety, United States. Electronic address:

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http://dx.doi.org/10.1016/j.pec.2019.05.011DOI Listing
July 2019

Individualized decision aid for diverse women with lupus nephritis (IDEA-WON): A randomized controlled trial.

PLoS Med 2019 05 8;16(5):e1002800. Epub 2019 May 8.

University of California at San Francisco (UCSF), San Francisco, California, United States of America.

Background: Treatment decision-making regarding immunosuppressive therapy is challenging for individuals with lupus. We assessed the effectiveness of a decision aid for immunosuppressive therapy in lupus nephritis.

Methods And Findings: In a United States multicenter, open-label, randomized controlled trial (RCT), adult women with lupus nephritis, mostly from racial/ethnic minority backgrounds with low socioeconomic status (SES), seen in in- or outpatient settings, were randomized to an individualized, culturally tailored, computerized decision aid versus American College of Rheumatology (ACR) lupus pamphlet (1:1 ratio), using computer-generated randomization. We hypothesized that the co-primary outcomes of decisional conflict and informed choice regarding immunosuppressive medications would improve more in the decision aid group. Of 301 randomized women, 298 were analyzed; 47% were African-American, 26% Hispanic, and 15% white. Mean age (standard deviation [SD]) was 37 (12) years, 57% had annual income of <$40,000, and 36% had a high school education or less. Compared with the provision of the ACR lupus pamphlet (n = 147), participants randomized to the decision aid (n = 151) had (1) a clinically meaningful and statistically significant reduction in decisional conflict, 21.8 (standard error [SE], 2.5) versus 12.7 (SE, 2.0; p = 0.005) and (2) no difference in informed choice in the main analysis, 41% versus 31% (p = 0.08), but clinically meaningful and statistically significant difference in sensitivity analysis (net values for immunosuppressives positive [in favor] versus negative [against]), 50% versus 35% (p = 0.006). Unresolved decisional conflict was lower in the decision aid versus pamphlet groups, 22% versus 44% (p < 0.001). Significantly more patients in the decision aid versus pamphlet group rated information to be excellent for understanding lupus nephritis (49% versus 33%), risk factors (43% versus 27%), medication options (50% versus 33%; p ≤ 0.003 for all); and the ease of use of materials was higher in the decision aid versus pamphlet groups (51% versus 38%; p = 0.006). Key study limitations were the exclusion of men, short follow-up, and the lack of clinical outcomes, including medication adherence.

Conclusions: An individualized decision aid was more effective than usual care in reducing decisional conflict for choice of immunosuppressive medications in women with lupus nephritis.

Trial Registration: Clinicaltrials.gov, NCT02319525.
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http://dx.doi.org/10.1371/journal.pmed.1002800DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6505936PMC
May 2019

What Do Patients Say About Doctors Online? A Systematic Review of Studies on Patient Online Reviews.

J Med Internet Res 2019 04 8;21(4):e12521. Epub 2019 Apr 8.

Department of Communication, Texas A&M University, College Station, TX, United States.

Background: The number of patient online reviews (PORs) has grown significantly, and PORs have played an increasingly important role in patients' choice of health care providers.

Objective: The objective of our study was to systematically review studies on PORs, summarize the major findings and study characteristics, identify literature gaps, and make recommendations for future research.

Methods: A major database search was completed in January 2019. Studies were included if they (1) focused on PORs of physicians and hospitals, (2) reported qualitative or quantitative results from analysis of PORs, and (3) peer-reviewed empirical studies. Study characteristics and major findings were synthesized using predesigned tables.

Results: A total of 63 studies (69 articles) that met the above criteria were included in the review. Most studies (n=48) were conducted in the United States, including Puerto Rico, and the remaining were from Europe, Australia, and China. Earlier studies (published before 2010) used content analysis with small sample sizes; more recent studies retrieved and analyzed larger datasets using machine learning technologies. The number of PORs ranged from fewer than 200 to over 700,000. About 90% of the studies were focused on clinicians, typically specialists such as surgeons; 27% covered health care organizations, typically hospitals; and some studied both. A majority of PORs were positive and patients' comments on their providers were favorable. Although most studies were descriptive, some compared PORs with traditional surveys of patient experience and found a high degree of correlation and some compared PORs with clinical outcomes but found a low level of correlation.

Conclusions: PORs contain valuable information that can generate insights into quality of care and patient-provider relationship, but it has not been systematically used for studies of health care quality. With the advancement of machine learning and data analysis tools, we anticipate more research on PORs based on testable hypotheses and rigorous analytic methods.

Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42018085057; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=85057 (Archived by WebCite at http://www.webcitation.org/76ddvTZ1C).
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http://dx.doi.org/10.2196/12521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6475821PMC
April 2019

The Role of Text Messages in Patient-Physician Communication about the Influenza Vaccine.

J Mob Technol Med 2018 Sep;7(2):55-59

Department of Medicine, Baylor College of Medicine, Houston, TX, U.S.A.

Background: Racial and ethnic minorities face disparities in receiving the influenza vaccination. A text message intervention could deliver personalized and timely messages to counsel patients on asking their physician for the vaccination.

Aims: We assessed whether patients would be receptive to influenza vaccination text messages.

Methods: Participants were recruited from a sample of low-income, racial and ethnic minority primary care patients. Participants completed a self-administered survey. Descriptive statistics were used to analyze the data.

Results: There were 274 patients who participated and answered the questions of interest, of whom 70% were racial and ethnic minorities and 85% owned a cell phone. Thirty-six percent reported they had never received an influenza vaccination recommendation from their physician. However, 84% would be comfortable asking their physician for the influenza vaccination. Of cell phone-owning participants who would be comfortable asking their physician about the influenza vaccination, 80% would also be comfortable receiving a text message reminder.

Conclusion: Text messages may be an acceptable channel to prompt patients to discuss the annual influenza vaccination with their physicians. Text messaging is a feasible tool to engage patients in their health and improve annual influenza vaccination rates among low-income, racial and ethnic minority patients.
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http://dx.doi.org/10.7309/jmtm.7.2.8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347375PMC
September 2018

Agents of empathy: How medical interpreters bridge sociocultural gaps in genomic sequencing disclosures with Spanish-speaking families.

Patient Educ Couns 2019 05 10;102(5):895-901. Epub 2018 Dec 10.

Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, USA. Electronic address:

Objectives: To describe how linguistic tools used by interpreters during return of genomic sequencing results may have impacted communication with Spanish-speaking families, and to discuss the implications for the role of medical interpreters.

Methods: Using discourse analysis, we identified and categorized the various ways hospital-based interpreters adapted clinicians' language in 37 audio-recorded sessions in which Spanish-speaking parents participating in a clinical trial received their child's genomic sequencing results from English-speaking clinicians.

Results: We found that interpreters adapted clinicians' statements using five empathic linguistic tools: contextualization, encouragement, checking comprehension, endearment, and softening. Interpreters used an average of four linguistic tools per session, with contextualization and encouragement being the most frequently used.

Conclusions: Interpreters used empathic linguistic tools to alter clinicians' statements when communicating genomic information to Spanish-speaking families. Our findings demonstrate the critical role of interpreters as cultural mediators and facilitators of understanding for Spanish-speaking families.

Practice Implications: This study expands upon the definition of clinical empathy in interpreter-mediated sessions. Our findings suggest that revisions of standards of medical interpretation practice may be warranted regarding interpreters' ability to adapt clinicians' language in a culturally sensitive manner during interpretation.
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http://dx.doi.org/10.1016/j.pec.2018.12.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197396PMC
May 2019

Cancer survivors' experiences with breakdowns in patient-centered communication.

Psychooncology 2019 02 28;28(2):423-429. Epub 2018 Dec 28.

Meyers Primary Care Institute, University of Massachusetts Medical School, Reliant Medical Group and Fallon Health, Worcester, Massachusetts, USA.

Objective: This study analyzed cancer survivors' communication experiences that fell short of being patient-centered. Patients' descriptions of communication "breakdowns" were analyzed according to domain (eg, information exchange, fostering relationships, and managing emotions), whether it was a breakdown of commission (what was communicated) or omission (what should have been communicated) and whether it involved a clinician or the health care organization.

Methods: Cancer survivors (from an online panel of patients) completed the Patients Assessment of Communication Experience measure. Ratings less than "excellent" elicited a prompt asking where communication fell short. Communication breakdowns were categorized as one of commission/omission, if it involved a clinician/health care system, and within which communication domain. Thematic analysis explored how communication breakdowns affected respondents' cancer care experiences.

Results: Overall communication was rated as less than excellent by 153 respondents, of which 79 identified a specific communication breakdown. Over half (n = 43, 54%) were problems of omission, mostly attributed to interaction with health care organizations (n = 25). Breakdowns of commission (n = 36, 46%) occurred primarily within clinical encounters (n = 32). Most breakdowns were problems of information exchange (49%) or fostering relationships (27%). Three overarching themes emerged-emotional fallout from unmet information needs, inattention to patient perspective, and uncertainty about navigation and team communication.

Conclusions: Patient-centered communication breakdowns create distress that worsens patients' cancer care experiences. Communication skills training for clinicians should address listening, perspective taking, and assessing/satisfying patients' information and emotional needs. Health care organizations should enhance processes to provide timely, useful information to patients.
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http://dx.doi.org/10.1002/pon.4963DOI Listing
February 2019

Exome sequencing disclosures in pediatric cancer care: Patterns of communication among oncologists, genetic counselors, and parents.

Patient Educ Couns 2019 04 12;102(4):680-686. Epub 2018 Nov 12.

Department of Medicine, Baylor College of Medicine, 6620 Main St., Houston, TX 77030, United States; Department of Communication, Texas A&M University, TAMU 4234, College Station, TX 77843, United States; Center for Innovation in Healthcare Quality, Effectiveness, & Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2450 Holcombe Blvd., Suite 01Y, Houston, TX 77021, United States. Electronic address:

Objective: To examine communication patterns and behaviors during disclosure of exome sequencing (ES) results to parents of pediatric cancer patients, and describe common themes in parental communication.

Methods: Using mixed methods, we analyzed transcripts of sessions where parents of pediatric cancer patients received ES results from an oncologist and genetic counselor. Seventy-six transcripts were analyzed for frequency of clinician information-giving, partnering-supportive talk, and active parent participation. A subset of 40 transcripts were analyzed using thematic content analysis.

Results: Disclosures consisted mostly of clinician talk (84% of total talk), which was focused on providing information (62% of clinicians' utterances) with occasional partnering-supportive talk (7% of clinicians' utterances). Most parents assumed a passive, listening role (16% of total talk). Themes in parental communication included expressing relief and the significance of an answer, concern about sharing results and responsibility for inheritance, and seeking clarification of health implications of results.

Conclusion: Our finding of low levels of active parent participation during ES disclosures highlights the need to improve patient/parent engagement and understanding in a genetic setting.

Practice Implications: Clinician communication strategies that could encourage parent participation and understanding include checking for parent understanding, partnership-building, and tailoring ES discussions to address parent concerns and preferences.
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http://dx.doi.org/10.1016/j.pec.2018.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6440863PMC
April 2019

Development and Evaluation of a Physician-Targeted Video to Promote HIV Screening.

Health Promot Pract 2019 11 25;20(6):922-931. Epub 2018 Jun 25.

Baylor College of Medicine, Houston, TX, USA.

Despite national recommendations, routine opt-out HIV testing has not been widely adopted by physicians. Guided by previous research on physician barriers to HIV testing, we developed a physician-targeted video to promote routine opt-out HIV screening. The objective of this study was to evaluate this video intervention. From June to July 2016, physicians in two primary care clinics completed an online survey prior to and after watching the video. Survey items assessed acceptability of the video and HIV testing knowledge, attitudes, and intention to screen. Descriptive statistics were generated to analyze data. Of the 53 participants, 90% liked or strongly liked the video. Pre- to postvideo, significant improvements were seen in the knowledge of national HIV screening recommendations (45.3% to 67.9%; = .010) and of the proportion of unaware Houstonians living with HIV (22.6% to 75.5%; < .001). Participant beliefs about the likelihood of patients accepting HIV testing increased from 47.2% to 84.9% pre- to postvideo ( < .001). Intention to screen did not change; participants had high intentions pre- and postvideo. Our study found that a video is an acceptable HIV testing promotion medium for physicians. Our video improved physician HIV testing knowledge and attitudes, overcoming key barriers to HIV testing.
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http://dx.doi.org/10.1177/1524839918783742DOI Listing
November 2019

Communication about geriatric assessment domains in advanced cancer settings: "Missed opportunities".

J Geriatr Oncol 2019 01 6;10(1):68-73. Epub 2018 Jun 6.

Department of Medicine, Hematology/Oncology, Wilmot Cancer Center, University of Rochester. 601 Elmwood Avenue, Box, 704, Rochester, NY, USA.

Objectives: Older patients with advanced cancer often have age-related health issues (e.g., memory impairment) that influence their cancer treatment decisions. Communication about these age-related concerns can potentially lead to further assessment and subsequent clinical interventions to improve treatment decision-making and patients' quality of life. Yet, little is known about the communication of age-related concerns between oncologists, patients, and caregivers.

Materials And Methods: This study is a secondary analysis of data from the Values and Options in Cancer Care (VOICE) study. Audio-recorded and transcribed outpatient clinical oncology encounters with 37 patients with advanced cancer ≥60 years of age were content-analyzed. Two trained coders used a structured coding scheme based on pre-specified geriatric assessment (GA) domains to examine the transcripts for the frequency and quality of communication about age-related concerns. Atlas.ti version 6 was used for all analyses.

Results: The median age of the patients was 66 years (range = 60-90 years); patients were mostly female (26/37), married (22/37), and White (36/37). Out of 37 audio-recorded visits, 31 had at least one mention of an age-related concern with a total of 70 mentions. Oncologists initiated communication about age-related concerns half of the time (53%). When age-related concerns were mentioned, half of the time (50%) the oncologist did not implement further evidence-based interventions to address the age-related concern (e.g., conduct a cognitive screen for a memory concern).

Conclusion: Interventions are needed to improve the frequency and quality of the communication about age-related concerns to improve the care of older adults with cancer.
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http://dx.doi.org/10.1016/j.jgo.2018.05.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281774PMC
January 2019

Factors affecting the communication experiences of newly diagnosed colorectal cancer patients.

Patient Educ Couns 2018 09 27;101(9):1585-1593. Epub 2018 Apr 27.

Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States; Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States.

Objective: This study assessed patient-centered communication (PCC) among newly diagnosed colorectal cancer patients. PCC, a key part of patient-centered care, contributes directly and indirectly to health-related quality of life, satisfaction with care, and other outcomes.

Methods: We conducted a survey of patients in North Carolina, using a theoretically-based and validated measure that provides an overall PCC score and subscale scores for six PCC functions.

Results: A total of 501 patients participated. The highest scores were for the PCC functions of Fostering Healing Relationships, Exchanging Information, and Making Decisions. The lowest scores were for the functions of Managing Uncertainty and Enabling Self-Management, yet these were functions respondents rated as most important. Respondents who thought about more than one health professional (versus oncologist) reported better communication. PCC also varied by treatment type, mental and physical health status, age, race, and education.

Conclusion: Most patients reported good communication overall, however patients in poor physical health and mental health reported worse communication. The quality of communication varied across the PCC functions.

Practice Implications: Health professionals need to use a PCC approach that builds trust, respects the patient, provides salient information that patients can understand, provides emotional support, and facilitates the patient's engagement in care.
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http://dx.doi.org/10.1016/j.pec.2018.04.016DOI Listing
September 2018

Parent-Provider Communication of HPV Vaccine Hesitancy.

Pediatrics 2018 06 15;141(6). Epub 2018 May 15.

Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas;

: media-1vid110.1542/5754332185001PEDS-VA_2017-2312 OBJECTIVES: To prevent human papillomavirus (HPV)-related cancers, providers must effectively communicate with HPV vaccine-hesitant parents. Here, we developed a typology characterizing parent-provider communication around HPV vaccine hesitancy.

Methods: We audio-recorded 43 visits with unvaccinated adolescents at 6 pediatric clinics in Dallas, Texas in which parents were undecided about HPV vaccination. We qualitatively coded how parents verbally expressed hesitancy (assertive response, asking a question, or expressing concern) and whether providers responded with acquiescence (agree to defer vaccination) and/or persistence (continue discussion). We described the frequency of parent and provider communication codes and same-day vaccination.

Results: Among the 43 visits, 37 parents expressed hesitancy ≥1 times in many ways. Assertive responses were most common (27 visits), followed by questions (16 visits), and concerns (12 visits). When the first expression of hesitancy was a question or concern, 71% and 75% of adolescents, respectively, received same-day vaccinations, whereas 33% of adolescents who received an initial assertive response were vaccinated. Providers responded with only persistence in 18 visits, a mix of acquiescence and persistence in 13 visits, and only acquiescence in 6 visits. When providers only used persistence, 17 of 18 adolescents were vaccinated; when providers responded with only acquiescence, no adolescents received the vaccine.

Conclusions: Our exploratory analysis reveals that providers engaging hesitant parents and addressing their concerns can lead to same-day HPV vaccination. Data reveal that even parents making assertive statements are amenable to influence by providers. Our findings reveal an important missed opportunity when providers simply acquiesce to parental hesitation.
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http://dx.doi.org/10.1542/peds.2017-2312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005174PMC
June 2018

Portero versus portador: Spanish interpretation of genomic terminology during whole exome sequencing results disclosure.

Per Med 2017 11 21;14(6):503-514. Epub 2017 Nov 21.

Department of Communication, Texas A&M University, College Station, TX, USA.

Aim: Describe modifications to technical genomic terminology made by interpreters during disclosure of whole exome sequencing (WES) results.

Patients & Methods: Using discourse analysis, we identified and categorized interpretations of genomic terminology in 42 disclosure sessions where Spanish-speaking parents received their child's WES results either from a clinician using a medical interpreter, or directly from a bilingual physician.

Results: Overall, 76% of genomic terms were interpreted accordantly, 11% were misinterpreted and 13% were omitted. Misinterpretations made by interpreters and bilingual physicians included using literal and nonmedical terminology to interpret genomic concepts.

Conclusion: Modifications to genomic terminology made during interpretation highlight the need to standardize bilingual genomic lexicons. We recommend Spanish terms that can be used to refer to genomic concepts.
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http://dx.doi.org/10.2217/pme-2017-0040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6393936PMC
November 2017

The ecology of patient and caregiver participation in consultations involving advanced cancer.

Psychooncology 2018 06 16;27(6):1642-1649. Epub 2018 Apr 16.

University of Rochester, Rochester, NY, USA.

Objective: To identify predictors of participation of patients with advanced cancer in clinical encounters with oncologists and to assess the impact of patient and caregiver participation on perceptions of physician support.

Methods: This is a secondary data analysis from the Values and Options in Cancer Care study, a cluster randomized clinical trial of a patient-centered communication intervention. Patients and caregivers completed pre-visit and post-visit health and communication measures. Audio recorded patient-caregiver (when present)-physician encounters were coded for active patient/caregiver participation behaviors (eg, question asking, expressing concern) and for physicians' facilitative communication (eg, partnership-building, support). Mixed linear regression models were used to identify patient, physician, and situational factors predicting patient and patient plus caregiver communication behaviors and post-visit outcomes.

Results: Physician partnership building predicted greater expressions of concern and more assertive responses from patients and patient-caregiver pairs. Patients' perceptions of greater connectedness with their physician predicted fewer patient expressions of concern. Patient perceptions of physician respect for their autonomy were lower among patients accompanied by caregivers. Caregiver perceptions of physician respect for patient autonomy decreased with increasing patient age and varied by site.

Conclusions: In advanced cancer care, patient and caregiver communication is affected by ecological factors within their consultations. Physicians can support greater patient participation in clinical encounters through facilitative communication such as partnership-building and supportive talk. The presence of a caregiver complicates this environment, but partnership building techniques may help promote patient and caregiver participation during these visits.
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http://dx.doi.org/10.1002/pon.4710DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6103535PMC
June 2018

The effects of patient-centered communication, social capital, and internet use on patient empowerment: a cross-sectional study in China.

Glob Health Promot 2019 12 9;26(4):33-43. Epub 2018 Mar 9.

Department of Communication, Texas A&M University, College Station, TX, USA.

Patient empowerment is a relatively new concept in the context of the Chinese health care system. Based on Street's ecological framework of communication in healthcare settings, this study examined the social, clinical and media factors that could empower patients. Results from a survey of 401 Chinese adults (response rate, 34%) showed that respondents felt more empowered as health care consumers when they reported having more social capital bonding and bridging, and used the Internet for health purposes more often. Importantly, having had more positive patient-centered communicative experiences with health care providers not only predicted patient empowerment, it also moderated the effects of bridging social capital and Internet use on empowerment. Specifically, the more positive the experience of interacting with health care providers, the weaker the effects of bridging social capital and Internet use on patient empowerment. The findings have important implications for patient empowerment in health care, particularly within the context of China.
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http://dx.doi.org/10.1177/1757975917749197DOI Listing
December 2019

Whether Patients Want It or Not, Physician Recommendations Will Convince Them to Accept HIV Testing.

J Int Assoc Provid AIDS Care 2018 Jan-Dec;17:2325957417752258

2 Department of Medicine, Baylor College of Medicine, Houston, TX, USA.

Physicians are not routinely offering patients HIV testing, partly due to perceived patient discomfort with discussing HIV. This study assessed patients' comfort level and whether physician recommendations can overcome any discomfort that does exist. In a publicly funded primary care clinic, we administered a survey exploring patient facilitators to HIV testing, with 266 patients answering the 2 main survey questions of interest. Most participants wanted their physician to offer HIV testing (n = 175; 65.8%). Even among participants who did not want their physician to offer HIV testing (n = 91), over half (n = 54; 59.3%) reported they would "likely" or "very likely" accept HIV testing if their physician recommended it. Based on our findings, not only are negative attitudes about HIV testing among patients uncommon but physician recommendations may be able to convince patients to receive HIV testing in spite of patients stating they do not want the test.
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http://dx.doi.org/10.1177/2325957417752258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748523PMC
September 2019
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