HEALTH-CARE ENCOUNTERS BETWEEN ELDERLY PATIENTS, PHYSICIANS, AND OTHER CARE
PROVIDERS

Release Date: April 28, 1998 

PA NUMBER:  PA-98-059

P.T.

National Institute on Aging
National Institute of Nursing Research

PURPOSE

The National Institute on Aging (NIA) and the National Institute of Nursing
Research (NINR) invite qualified researchers to submit applications to
investigate issues relevant to the interaction and/or relationship between health
providers and older patients.  This program announcement solicits research grant
applications to investigate how multiple factors influence the content, process,
and outcomes of these health-care or medical encounters.  Goals of this program
announcement are to:  (1) identify the demographic, psychosocial, cognitive, and
contextual factors associated with effective interactions between health-care
providers and older individuals; (2) assess the nature and quality of the
interaction that influences health-care communication; (3) determine the role of
caregivers and companions in facilitating or impeding effective provider-patient
relationships; (4) further the development of methodologies to link these factors
to medical or psychosocial outcomes; and (5) investigate interventions to improve
effective interaction styles.  This Program Announcement focuses primarily on
physician-elder patient interactions, but includes attention to the full range
of health care providers in recognition of changing patterns in the delivery of
health care.

HEALTHY PEOPLE 2000

The Public Health Service (PHS) is committed to achieving the health promotion
and disease prevention objectives of "Healthy People 2000," a PHS-led national
activity for setting priority areas.  This program announcement, Health-Care
Encounters Between Elderly Patients, Physicians, and Other Care Providers, is
related to the priority area of chronic disabling conditions.  Potential
applicants may obtain a copy of "Healthy People 2000" (Full Report:  Stock No.
017-001-00474-0 or Summary Report:  Stock No. 017-001-00473-1) through the
Superintendent of Documents, Government Printing Office, Washington, DC
20402-9325 (telephone 202-512-1800).  The report may also be found via the world
wide web at URL:http://www.crisny.org/health/us/health7.html.

ELIGIBILITY REQUIREMENTS

Applications may be submitted by domestic and foreign for-profit and non-profit
organizations, public and private, such as universities, colleges, hospitals,
laboratories, units of State and local governments, and eligible agencies of the
Federal government.  Applications may be submitted by single institutions or by
a consortium of institutions.  Women and minority investigators are encouraged
to apply.

MECHANISM OF SUPPORT

This program announcement will use the NIH investigator-initiated research
project grant (R01).  NIA is also soliciting applications on this topic that have
the potential for commercial application (see SBIR and STTR solicitations, which
are available on the World Wide Web at:
http://www.nih.gov/grants/funding/sbir.htm).  Responsibility for the planning,
direction, and execution of the proposal will be solely that of the applicant.

RESEARCH OBJECTIVES

Research has repeatedly shown that encouragement by physicians is one of the
single most important factors influencing preventive health behaviors and healthy
lifestyle changes among patients.  There is also some suggestion that malpractice
suits can be attributed, in part, to poor doctor-patient communication.  Thus,
efforts to improve the nature and quality of the health-care encounter can have
positive effects for both patients and the providers who treat them.  Less is
known, however, about the antecedents and consequences of interaction with older
patients.  The aging of the U.S. population, coupled with the disproportionately
large number of health care visits made by older person, makes it important to
examine provider-elderly patient encounters, their process and outcomes.

With an increased movement toward managed care, it is important that we
investigate the effect of managed care practices on provider-older patient
interactions in terms of interaction length and content, patient satisfaction,
patient recall and adherence, patient costs, and health outcomes.  A better
understanding is needed of the complex factors affecting older patients'
preferences for different styles of interaction and strategies for fostering
mutually satisfying interaction and clinical decision-making over the course of
multiple encounters in varied settings (e.g., office visits; hospitalizations;
telephone calls).  Little attention has been paid to intervention strategies
directed toward either older patients or their providers.

In today's health care delivery system, older people are now more likely than in
the past to be treated by an expanded network of providers (e.g., the nurse,
physician assistant, or social worker).  Older patient-doctor research must
expand beyond the limited dyadic relationship to include the role of multiple
providers as well as the influence of companions who often accompany the older
person on medical visits and can be instrumental in helping the patient
understand and adhere to suggested medical regimens. Of particular interest is
how cross cutting sociodemographic factors such as age, race/ethnicity and
gender, as well as cross-national factors (e.g., the effects of different health
care structures and patient/provider norms) influence provider-patient
communication.

Furthermore, studies to date have been limited by conceptual and methodological
problems, including lack of theoretical framework and inadequate tools to assess
the nature and quality of older patient þ physician encounters.  Establishing
standardized methodologies and assessment instruments will improve research as
well as clinical practice, and will advance knowledge on appropriate
interventions to improve health care.  Methodological research may be
incorporated into substantive research proposals.

Through an invitational conference titled Research Issues Related to Physician-
Elderly Patient Interactions (April, 1995; sponsored by NIA and AHCPR), the
following broad topical areas have been identified as needing further study:
patient and provider characteristics, contextual features, the process and
content of the interaction, and the outcomes of the encounter.  Papers based on
this report can be found in Research on Aging, 18(1), March 1996.

The following are offered as illustrations of appropriate topics for research. 
Applications need not, however, be limited to these specific issues.

Patient/Provider Characteristics.  Patient and provider characteristics influence
the process and content of health-care encounters.  These factors, including age,
gender, training/education, and ethnicity, affect outcomes of the medical
encounter.  Other characteristics, including belief systems, personality, and
interaction style need to be linked to health outcomes.  Research suggestions
include:

o How different ethnic, cultural, and social backgrounds affect elderly patients'
expectations for interacting with physicians and other providers.

o How providers' personal backgrounds, empathetic styles, views about provider-
patient relationships, and expectations about aging affect their interaction
patterns with elderly patients.

o How the congruence or incongruence between patient/provider characteristics
influences interactions and associated outcomes.

Context of Care: Contextual Factors Relating to Process/Content and Health Status
Outcomes.  The role context plays in the provider-patient interaction,
particularly the effectiveness of the communication process, needs further
examination.  Contextual factors include the physical location of the encounter,
the social context, the patient's physical and cognitive status, time-of-day, and
the influence of organizational and financial variables.  Examples of research
areas are:

o How family members or other caregivers (social context) assist elderly patients
to make health-care or medical decisions, including decisions about when to visit
a physician or other provider, or how to follow a treatment regimen.

o How location of encounters (home visit, nursing home, inpatient setting,
hospice, emergency room) may influence the provider-patient interaction.

o The role of emerging technologies, such as telemedicine, on provider-elderly
patient interactions.

o The influence of different medical care arrangements on provider-patient
interactions and related outcomes.

Process and Content of the Health-Care Encounter: Factors relating to the
Effectiveness of Communication.  Communication is a broad term that encompasses
a range of social, psychological, and cognitive processes occurring in the
relationship or encounter between a provider and an elderly patient or their
caregiver.  This area includes the content of medical and health-care information
and how the provider conveys it, which influences outcomes such as comprehension
and recall, and compliance. Areas of needed research include:

o How duration of visit and other restrictions placed on the encounter affect the
amount and type of information exchanged and the interaction style of
participants.

o How physical and psychosocial status (e.g., hearing loss, cognitive impairment,
depression, chronic ill health) are interpreted by providers and caregivers,
influence the interaction, and affect outcome.

o How the provider-patient relationship evolves over time and multiple visits. 
How the recurrent interaction is different from the initial visit between
provider and elderly patient.

o Receptiveness of elderly patients to content of communication.  How patients
perceive and respond to preventive health recommendations or to complicated
verbal instructions.

Outcomes and Intervention Research.  Multiple outcomes should be assessed to
determine short- and long-term effects of medical encounters on the health status
of elderly patients.  Outcomes include patient and provider satisfaction,
comprehension and recall of medical and health-care information, compliance with
treatment regimen, functional and health status outcomes, as well as cost
effectiveness.  Intervention studies can be targeted to improving health status
outcomes.  Areas needing further study include:

o Development of new tools or refining of existing tools for examining the nature
and quality of interactions between physicians or other providers and older
patients.

o Social and health impact of various provider-patient interaction styles.

o Intervention research on theory-based strategies for improving the quality of
health-care encounters.  Research directed at patients, family members, or
providers (or any combination of the above), is encouraged.

INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN SUBJECTS

It is the policy of the NIH that women and members of minority groups and their
sub-populations must be included in all NIH supported biomedical and behavioral
research projects involving human subjects, unless a clear and compelling
rationale and justification is provided that inclusion is inappropriate with
respect to the health of the subjects or the purpose of the research.  This
policy results from the NIH Revitalization Act of 1993 (Section 492B of Public
Law 103-43).

All investigators proposing research involving human subjects should read the
"NIH Guidelines for Inclusion of Women and Minorities as Subjects in Clinical
Research," which have been published in the Federal Register of March 28, 1994
(FR 59 14508-14512), and in the NIH Guide for Grants and Contracts, Volume 23,
Number 11, March 18, 1994.

APPLICATION PROCEDURES

Applications are to be submitted on the grant application form PHS 398 (rev.
5/95) and will be accepted at the standard application deadlines as indicated in
the application kit.  Applications kits are available at most institutional
offices of sponsored research and may be obtained from the Division of Extramural
Outreach and Information Resources, National Institutes of Health, 6701 Rockledge
Drive, MSC 7910, Bethesda, MD 20892-7910, telephone 301/435-0714, email:
ASKNIH@od.nih.gov.

The number and title of this program announcement must be typed in Section 2 on
the face page of the application.

The complete original and five permanent, legible copies must be sent or
delivered to:

CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE, ROOM 1040-MSC 7710
BETHESDA, MD 20892-7710
BETHESDA, MD 20817-7710 (for express/courier service)

REVIEW CONSIDERATIONS

Applications will be assigned on the basis of established PHS referral
guidelines.  Applications that are complete will be evaluated for scientific and
technical merit by an appropriate peer review group convened in accordance with
the standard NIH peer review procedures.  As part of the initial merit review,
all applications will receive a written critique and undergo a process in which
only those applications deemed to have the highest scientific merit, generally
the top half of applications under review, will be discussed, assigned a priority
score, and receive a second level review by the appropriate national advisory
council or board, when applicable.

Review Criteria

The goals of NIH-supported research are to advance our understanding of
biological systems, improve the control of disease, and enhance health.  In the
written review, comments on the following aspects of the application will be made
in order to judge the likelihood that the proposed research will have a
substantial impact on the pursuit of these goals. Each of these criteria will be
addressed and considered in the assignment of the overall score.

(1) Significance.  Does this study address an important problem?  If the aims of
the application are achieved, how will scientific knowledge be advanced? What
will be the effect of these studies on the concepts or methods that drive this
field?

(2) Approach.  Are the conceptual framework, design, methods, and analyses
adequately developed, well-integrated, and appropriate to the aims of the
project?  Does the applicant acknowledge potential problem areas and consider
alternative tactics?

(3) Innovation.  Does the project employ novel concepts, approaches or methods? 
Are the aims original and innovative?  Does the project challenge existing
paradigms or develop new methodologies or technologies?

(4) Investigator.  Is the investigator appropriately trained and well suited to
carry out this work?  Is the work proposed appropriate to the experience level
of the principal investigator and other researchers (if any)?

(5) Environment.  Does the scientific environment in which the work will be done
contribute to the probability of success?  Do the proposed experiments take
advantage of unique features of the scientific environment or employ useful
collaborative arrangements?  Is there evidence of institutional support?

In addition, the adequacy of plans to include both genders and minorities and
their subgroups as appropriate for the scientific goals of the research will be
reviewed.  Plans for the recruitment and retention of subjects will also be
evaluated.

The initial review group will also examine the provisions for the protection of
human and animal subjects, the safety of the research environment, and
conformance with the NIH Guidelines for the Inclusion of Women and Minorities as
Subjects in Clinical Research.

AWARD CRITERIA

Applications will compete for funding with all other approved applications.  The
following will be considered in making funding decisions:  quality of the
proposed project as determined by peer review, availability of funds, and program
priority.

INQUIRIES

Inquiries are encouraged.  The opportunity to clarify any issues or questions
from potential applicants is welcome.

Direct inquiries regarding programmatic issues to:

Marcia G. Ory, Ph.D., M.P.H.
Behavioral and Social Research Program
National Institute on Aging
7201 Wisconsin Avenue, Room 533, MSC 9025
Bethesda, MD  20892-9205
Telephone:  (301) 402-4156
FAX:  (301) 402-0051
Email:  Marcia_Ory@NIH.GOV

Further information about NIA priorities and procedures can be found on the NIA
Home Page at:  http://www.nih.gov/nia.  For information on NIA's broader
initiative on organizational issues in health care, contact Sidney Stahl, Ph.D
at Sidney_Stahl@NIH.GOV.

Carole I. Hudgings, Ph.D., R.N.
Division of Extramural Activities
National Institute of Nursing Research
45 Center Drive, Room 3AN-12, MSC 6300
Bethesda, MD  20892-6300
Telephone:  (301) 594-5976
FAX:  (301) 480-8260
Email:  Carole_Hudgings@nih.gov

Direct inquiries regarding fiscal matters to:

Mr. David Reiter
Grants Management Office
National Institute on Aging
Gateway Building, Room 2N212
Bethesda, MD  20892
Telephone:  (301) 496-1472
FAX:  (301) 402-3672
Email:  David_Reiter@NIH.GOV

Mr. Jeff Carow
Grants Management Office
National Institute of Nursing Research
45 Center Drive, Room 3AN-12, MSC 6301
Bethesda, MD  20892-6301
Telephone:  (301) 594-6869
FAX:  (301) 480-8260
Email:  Jeff_Carow@nih.gov

The National Institute of Mental Health (NIMH) has an interest in encounters
involving mental disorders and treatments for mental disorders.  For information
contact:

Dr. Kathryn Magruder
Division of Services and Intervention Research
National Institute of Mental Health
5600 Fishers Lane, Room 10C-06
Rockville, MD  20857
Telephone:  (301) 443-3364
FAX:  (301) 443-4045
Email:  km87e@nih.gov

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic Assistance No.
93.866 and No. 93.361, Nursing Research.  Awards are made under authorization of
the Public Health Service Act, Title IV, Part A (Public Law 78-410, as amended
by Public Law 99-158, 42 USC 241 and 285) and administered under PHS grants
policies and Federal Regulations 42 CFR 52 and 45 CFR Part 74.  This program is
not subject to the intergovernmental review requirements of Executive Order 12372
or Health Systems Agency review.

The PHS strongly encourages all grant and contract recipients to provide a
smoke-free workplace and promote the non-use of all tobacco products.  In
addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in
certain facilities (or in some cases, any portion of a facility) in which regular
or routine education, library, day care, health care or early childhood
development services are provided to children.  This is consistent with the PHS
mission to protect and advance the physical and mental health of the American
people.

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