BACKGROUND/RATIONALE:
Chronic heart failure (CHF) is a major chronic condition in the United States and within Veterans Affairs hospitals (VA). The burden of CHF is estimated to increase over several decades as the population ages. In the VA, CHF patients had frequent utilization of medical care with 1-2 hospitalizations, 6-7 visits with a primary care physician, and 1-2 urgent care visits over a 12 month period in 1996. CHF disproportionately affects black compared with white Americans. Black patients with CHF have higher rates of hospitalization and faster rates of functional decline than white patients with CHF. Reasons for the racial disparities have not been explained by several traditional measures. There is evidence in several other conditions that physician-patient communication varies by race. There is also evidence that better physician and patient communication skills lead to improved clinical outcomes. These communication skills include several patient-centered communication skills used by the physician and the patient. The project will assess the relationship of the content of physician-patient communication with outcomes in patients with CHF while controlling for potential confounders including patient (e.g., demographics, comorbidity, and severity of illness) and physician (e.g., demographics) characteristics. The long term goal of the proposed research is to improve the care of patients with CHF.
OBJECTIVE(S):
The specific aim is to assess the relationship of communication to outcomes in patients with chronic heart failure (CHF) We hypothesize that interactions characterized by more effective communication are associated with (a) better CHF outcomes (e.g., higher functional status, and lower emergency room and hospital utilization) than interactions with less effective communication; and with (b) improved patient perceptions (e.g., increased trust, satisfaction, communication) and improved behaviors (e.g., adherence). We also hypothesize that (for a number of reasons) black patients have more difficulty communicating with physicians than white patients.
METHODS:
This is a 5 year, two-site, prospective, observational study examining physician-patient interactions using a multi-method technique to examine the association of communicative behaviors with intermediate and clinical outcomes. Patients are identified at hospitalization for CHF and up to two outpatient visits (during the 6 months following discharge) are audio recorded for consenting patients and physicians. Variable and co-variates include patients' functional status, self-efficacy, perceptions of communication, pre and post visit trust, satisfaction, adherence, and self management behaviors, clinical severity, comorbidity and physician perceptions of the visit. Outcomes include functional status, urgent care and emergency room visits, and hospital admissions.
FINDINGS/RESULTS:
Recruitment, enrollment, and data collection are progressing. We have a certificate of confidentiality from NIH to help protect our sensitive study data (audio recordings) from forced disclosure. Recruitment is up and running at both sites. We have screened over 1000 patients for eligibility and have identified over 600 potentially eligible patients with 233 patients enrolled in the study and over 70 primary care providers.
IMPACT:
The proposed project will identify whether doctor-patient communication behaviors are associated with specific CHF outcomes. Depending on the findings, future work would pursue additional funding to design and test communication interventions to improve CHF outcomes.
PUBLICATIONS:
Journal Articles
- Street RL. Aiding medical decision making: a communication perspective. Medical Decision Making. 2007; 27(5): 550-3.
- Deswal A. Outcomes in Women vs. Men with Heart Failure and Preserved Ejection Fraction. Cardiology in Review. 2007; 24: 24-27.
- Street RL, Gordon HS, Ward MM, Krupat E, Kravitz RL. Patient participation in medical consultations: why some patients are more involved than others. Medical Care. 2005; 43(10): 960-9.
- Sharf BF, Stelljes LA, Gordon HS. 'A little bitty spot and I'm a big man': patients' perspectives on refusing diagnosis or treatment for lung cancer. Psycho-Oncology. 2005; 14(8): 636-46.
- Gordon HS, Johnson ML, Wray NP, Petersen NJ, Henderson WG, Khuri SF, Geraci JM. Mortality after noncardiac surgery: prediction from administrative versus clinical data. Medical Care. 2005; 43(2): 159-67.
