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Financial barriers can substantially delay medical care seeking. Using patient narratives provided by 252 colorectal cancer patients, we explored the experience of financial barriers to care seeking. Of the 252 patients interviewed, 84 identified financial barriers as a significant hurdle to obtaining health care for their colorectal cancer symptoms. Using verbatim transcripts of the narratives collected from patients between 2008 and 2010, three themes were identified: insurance status as a barrier (discussed by n = 84; 100% of subsample), finding medical care (discussed by n = 30; 36% of subsample) and, insurance companies as barriers (discussed by n = 7; 8% of subsample). Our analysis revealed that insurance status is more nuanced than the categories insured/uninsured and differentially affects how patients attempt to secure health care. While barriers to medical care for the uninsured have been well documented, the experiences of those who are underinsured are less well understood. To improve outcomes in these patients it is critical to understand how financial barriers to medical care are manifested. Even with anticipated changes of the Affordable Care Act, it remains important to understand how perceived financial barriers may be influencing patient behaviors, particularly those who have limited health care options due to insufficient health insurance coverage.

Background: Patient gender and race, and physician–patient communication are associated with clinical outcomes. Aim: To understand the role of these factors in the diagnosis of colorectal cancer (CRC) during primary care visits as measured by appropriate outcome. Materials and Methods: Caucasian and African American unannounced standardized patients (USPs) of both genders presented to 207 primary care physicians (PCPs) from community and academic practices in Ohio and Virginia as new patients with CRC symptoms. PCPs were blinded to the diagnosis. Physician subjects consented to audiotaping the encounter. Medical records were obtained. Communication elements were coded by trained observers and appropriate visit outcomes were coded from the medical record and audiofiles, defined as (1) recommendation for colonoscopy/sigmoidoscopy/fecal occult blood test (FOBT) or (2) referral to gastroenterologist. Results: A total of 141 of 367 USP visits (38%) resulted in appropriate clinical outcomes. Patient race was not associated with outcome, but being a male USP was (χ2 = 4.12, p = 0.04). Relational communication was represented as a latent variable with seven indicators (alpha = 0.84) and was independently associated with outcome (beta = 0.15; p = 0.025). After controlling for clustered sampling, relational communication, and race, structural equational modeling indicated that female USPs were less likely to have an appropriate clinical visit outcome (beta = −0.13; p = 0.033). Conclusions: Using a novel and innovative methodology capturing PCP behaviors during real-time clinician–patient interaction, appropriate clinical outcome was independently associated with being male and PCP relational communication factors such as encouraging patient communication, being engaged and expressive in the physician–patient conversation, and appearing friendly and sincere. There are persistent biases in the delivery of health care to female patients and further research into targeted communication skills programs may be warranted. [ABSTRACT FROM AUTHOR]

Context--Families' refusal to consent to solid organ donation is a major contributor to the organ deficit in the United States. Previous research has identified organ procurement coordinators as best able to obtain consent from families; however, few studies have examined the effects of coordinator training programs on consent rates. Objective--To test the effects of the Communicating Effectively About Donation intervention on the rate of family consent to solid organ donation. Design--A nonrandomized repeated measures design. Setting and Participants--Participants included 17 hospitals, 502 donor-eligible patients and their families, and 22 coordinators from an organ procurement organization in Ohio. Intervention--Coordinators were given in-service training on the use of effective relational and affective communication techniques through a day-long interactive workshop and simulated donation scenarios. Main Outcome Measures--Families' final donation decision and coordinators' donation-related behaviors. Results--Training of coordinators was associated with increases in coordinators' comfort speaking with patients' families about donation and answering donation-related questions, in the amount of time coordinators spent discussing donation with family members, and in the number of donation-related topics discussed with families. Consent rates increased from 46.3% to 55.5% after the intervention. Conclusions--The results suggest that improving coordinators' communication skills may be a fruitful avenue for increasing the rate of family consent to donation; however, a more definitive test of the training is needed to confirm the intervention's effectiveness. [ABSTRACT FROM AUTHOR]

Background. Disease-specific beliefs may impact patients' perceptions of the efficacy of various treatment options, thus, it is important to understand these beliefs. We examined the relationship between patients' demographic characteristics and arthritis-specific beliefs related to aging. Methods. We performed a cross-sectional survey of 591 elderly primary care patients, who had symptomatic osteoarthritis (OA) of the knee and/or hip, at the Louis Stokes VA Medical Center in Cleveland, Ohio. Data were collected on age, race, educational level, income, and whether patients agreed or disagreed with four statements regarding aging and arthritis. We also assessed OA symptom severity using the Western Ontario McMaster Universities Index (WOMAC) and depressive symptoms using the Geriatric Depression Scale. We used logistic regression analyses to examine relationships between patients' age, race, and educational level and arthritis-specific health beliefs, while adjusting for OA symptom severity, radiographic confirmation of OA, OA joint burden, depressive symptoms, and income. Results. Patients 70 years old or older, as compared to patients 50-59 years old, were more likely to believe that: arthritis is a natural part of growing old; people should expect that when they get older, they won't be able to walk as well, and people should expect to live with pain as they grow older. Conclusion. Among older, male veterans, health beliefs regarding the relationship between aging and arthritis vary by age. Clinicians should consider these differences when discussing treatment strategies with their patients with knee and/or hip OA. [ABSTRACT FROM AUTHOR]

Objectives: To identify reasons for lower organ donation rates by African Americans, we examined knowledge and attitudes about brain death, donation, and transplantation and trust in the health care system.Methods: Data were collected from 1,283 subjects in Ohio using a random digit dial telephone survey. Items were developed based on focus group results. Willingness-to-donate indicators included a signed donor card and willingness to donate one's own and a loved one's organs.Results: Compared with whites, African-Americans had lower rates of signing a donor card (39.1% vs 64.9%, P < .001), and willingness to donate their own organs (72.6% vs 88.3%, P < .001) or a loved one's organs (53.0% vs 66.2%, P < .001). African Americans had lower scores on the Trust in the Health Care System scale (mean scores +/- SD, 9.43 +/- 3.05 vs 9.93 +/- 2.88, P < .01) and were more likely to agree that "if doctors know I am an organ donor, they won't try to save my life" (38.6% vs 25.9%, P < .001), the rich or famous are more likely to get a transplant (81.9% vs 75.7%, P < .05), and less likely to agree that doctors can be trusted to pronounce death (68.2% vs 82.9, P < .001). African Americans were also more likely to agree that families should receive money for donating organs (45.6% vs 28.0%, P < .001) and funeral expenses (63.1% vs 46.6%, P < .001).Conclusions: African Americans reported greater mistrust in the equity of the donation system and were more favorable about providing tangible benefits to donor families than white respondents. [ABSTRACT FROM AUTHOR]

Purpose/Objectives: To examine family disagreements about treatment decisions for patients with advanced lung cancer. Research Approach: Descriptive, qualitative study. Setting: A large comprehensive cancer center in Cleveland, OH. Participants: 37 patients with stage III or IV lung cancer and 40 caregivers (24 primary and 16 secondary)from 26 families were interviewed. Methodologic Approach: Open-ended audiotaped interviews were transcribed verbatim. NUD*IST (non-numerical unstructured data indexing, searching, and theorizing)computer software (QSR International, Melbourne, Australia) was used to perform content analysis. Main Research Variables: Vast differences in opinions between patients and family caregivers about treatment decisions and care. Findings: Sixty-five percent of families reported various family disagreements that mainly concerned routine treatment decisions, discontinuation of therapeutic treatment, and use of hospice care. Conclusions: Family disagreements about treatment decisions for patients with advanced lung cancer are common and include a wide range of issues. Family members play an important role in the selection of patients' doctors, hospitals, treatment options, and provisions of care. Interpretation: The findings suggest that nurses need to be aware of differences of opinion between patients with advanced cancer and their caregivers. Knowledge of family disagreements about treatment decisions can help nurses' efforts to integrate families into decision--making processes in clinical settings to facilitate family communications and improve patients' and caregivers' satisfaction with treatment decisions. [ABSTRACT FROM AUTHOR]

Objective: This study examined differences in attitudes and preferences between African American and White caregivers about cancer treatment and care., Methods: There were 173 White and 26 African American caregivers of advanced lung cancer patients who were recruited as a convenience sample. A telephone interview was conducted to collect information using a semi-structured questionnaire. Using logistic regression, we examined differences between racial groups concerning therapeutic and caregiving issues controlling for socioeconomic and demographic variables., Results: The regression analyses showed that African American caregivers had higher expectations for treatment outcomes (p ≤ 0.05) but poorer understanding of hospice and a stronger preference for hospice care outside the home (p ≤ 0.05). They were more likely to believe that the patient communicates with the family about cancer treatment to meet the family's expectations rather than seek emotional support (p ≤ 0.01). They were also more reluctant to endorse children's responsibility to make a treatment decision and are less likely to be fully satisfied with the decision-making process (p ≤ 0.05)., Conclusions: The findings suggest some differences in beliefs and cultural values between African American and White caregivers. African American caregivers appear to believe more in the possibility of curative care for advanced lung cancer and eschew hospice care. The findings inform possible challenges regarding communication about end-of-life treatment and care with African American caregivers and a need for the provision of adequate information and education., (Copyright © 2011 John Wiley & Sons, Ltd.)

Context: Deficiencies in the donation process continue to contribute to the shortage of organs available for transplant. Continuous quality improvement of hospitals' donation processes is needed to identify and correct the problems., Objective: To test the Rapid Assessment of Hospital Procurement Barriers in Donation (RAPiD), a direct observation technique with a focused ethnographic strategy, for assessing hospitals' donation processes and identifying areas in need of continuous quality improvement interventions., Design: A pre-post assessment of hospitals' barriers to patient identification and referral, and family consent to donation., Setting and Participants: Seventeen hospitals within the catchment area of a Northeastern organ procurement organization were assessed by using the RAPiD method. Hospital administrators, health care providers, and staff (N = 537) were interviewed as part of the assessments., Intervention: Interventions, including on-site training and education, and the use of in-house coordinators, were specifically tailored to each hospital's unique set of barriers to donation. The interventions were delivered to the hospitals in the form of recommendations. The participating organ procurement organization was responsible for implementation of the interventions., Results: The RAPiD hospital evaluations revealed gaps in respondents' knowledge of organ donation, brain death, and referral criteria; a reluctance to declare brain death; and a rocky relationship between the hospitals and the organ procurement organization. As a result of the interventions, 9 hospitals' environments for organ donation improved, 7 showed no change, and 1 was worse.

Objectives: To identify reasons for lower organ donation rates by African Americans, we examined knowledge and attitudes about brain death, donation, and transplantation and trust in the health care system., Methods: Data were collected from 1,283 subjects in Ohio using a random digit dial telephone survey. Items were developed based on focus group results. Willingness-to-donate indicators included a signed donor card and willingness to donate one's own and a loved one's organs., Results: Compared with whites, African-Americans had lower rates of signing a donor card (39.1% vs 64.9%, P < .001), and willingness to donate their own organs (72.6% vs 88.3%, P < .001) or a loved one's organs (53.0% vs 66.2%, P < .001). African Americans had lower scores on the Trust in the Health Care System scale (mean scores +/- SD, 9.43 +/- 3.05 vs 9.93 +/- 2.88, P < .01) and were more likely to agree that "if doctors know I am an organ donor, they won't try to save my life" (38.6% vs 25.9%, P < .001), the rich or famous are more likely to get a transplant (81.9% vs 75.7%, P < .05), and less likely to agree that doctors can be trusted to pronounce death (68.2% vs 82.9, P < .001). African Americans were also more likely to agree that families should receive money for donating organs (45.6% vs 28.0%, P < .001) and funeral expenses (63.1% vs 46.6%, P < .001)., Conclusions: African Americans reported greater mistrust in the equity of the donation system and were more favorable about providing tangible benefits to donor families than white respondents.

While brain death and the dead donor rule (patients must not be killed by organ retrieval) have been clinically and legally accepted in the US as a prerequisite to organ removal, there is little data about public attitudes and beliefs concerning these matters. To examine the public attitudes and beliefs about the determination of death and its relationship to organ transplantation, 1351 Ohio residents >or=18 years were randomly selected and surveyed using random digit dialing (RDD) sample frames. The RDD telephone survey was conducted using computer-assisted telephone interviews. The survey instrument was developed from information provided by 12 focus groups and a pilot study of the questionnaire. Three scenarios based on hypothetical patients were presented: brain dead, in a coma, or in a persistent vegetative state (PVS). Respondents' provided personal assessments of whether the patient in each scenario was dead and their willingness to donate that patient's organs in these circumstances. Over 98% of respondents had heard of the term brain death, but only one-third (33.7%) believed that someone who was brain dead was legally dead. The majority of respondents (86.2%) identified the brain dead patient in the first scenario as dead, 57.2% identified the patient in a coma as dead (Scenario 2), and 34.1% identified the patient in a PVS as dead (Scenario 3). Nearly, a third (33.5%) were willing to donate the organs of patients they classified as alive for at least one scenario, in seeming violation of the dead donor rule. Most respondents were not willing to violate the dead donor rule, although a substantial minority was. However, the majority of respondents were unaware, misinformed or held beliefs that were not congruent with current definitions of brain death. This study highlights the need for more public dialogue and education about brain death and organ donation.

Context: Families' understanding of brain death may be a factor that contributes to decisions regarding organ donation., Objective: To examine factors related to families' understanding of brain death and how those factors affect families' decisions about organ donation., Design: Chart reviews were conducted on all deceased patients at 9 trauma hospitals. Interviews were then conducted with healthcare providers who spoke with families about organ donation and family decision makers., Setting: Southwest Pennsylvania and Northeast Ohio., Participants: The sample consisted of 403 families of organ donor-eligible patients who reported that someone at the hospital told them the patient was brain dead., Main Outcome Measures: Families' awareness of brain-death testing procedures, understanding of brain death, and donation decision., Results: Most families (96%) were told their family member was brain dead, but only 28.3% were able to provide a completely correct definition of brain death. No association between the definition of brain death and willingness to donate was found. Those who donated were less likely to agree with the statement that someone is dead only when the heart stops than those who did not donate. Respondents who accepted that their loved one was dead when informed the patient was brain dead were more likely to donate than those who did not consider the patient dead until mechanical support was turned off and the heart stopped.

Background: The increasing morbidity attributable to asthma among school-aged children suggests the potential utility of school-based asthma screening programs., Objective: We report our efforts to develop and validate culturally sensitive and clinically useful screening questionnaires (parent and child versions) for asthma and allergies among urban US school children., Methods: Instrument development was accomplished through literature review, expert medical and child developmental input, focus group feedback, and a rigorous trial of the instruments in a public school setting. Questionnaires were distributed to 2,800 children and their families in an urban public school system (grades kindergarten through 6). Validity was evaluated by blinded comparison of results against a standardized clinical evaluation in 107 children, with final designations determined by an expert panel., Results: Questionnaires pertaining to 2,083 children were returned (participation rate of 74%). A moderate level of agreement was observed between parent and student questionnaire responses (r values = 0.36 to 0.50; P values < 0.001). The highest frequency of asthma-like symptoms was reported for African-American boys and the lowest for Caucasian girls. The items from the parent questionnaire that best predicted asthma were "breathing problems" (occurring rarely or more; odds ratio 12.8; 95% confidence interval, 4.5 to 36.1) and "problems coughing" (sometimes or more; odds ratio 9.7; 95% confidence interval, 3.6 to 26.5). Considering the presence of cough (sometimes or more) and/or breathing problem (rarely or more) yielded a sensitivity of 80%; a specificity of 75%, a positive predictive value of 50%, and a negative predictive value of 92%. Similar levels of prediction were observed for the items "trouble breathing" and "noisy breathing" as directly reported by the students. Allergic rhinitis was best predicted by report of a runny/stuffy no se (sometimes or more; sensitivity of 83%, specificity of 61%). Allergic conjunctivitis was best predicted by "itchy eyes.", Conclusions: Administration of a school-based questionnaire is feasible, with a high response rate and excellent internal consistency. A high sensitivity and acceptable specificity was achieved by using one to two questions for asthma, allergic rhinitis, and allergic conjunctivitis. Among the children in grades 2 or above, comparable levels of prediction could be achieved with the student or parent version.

Context: Black families donate at a lower rate than white families. To help develop effective interventions, we compared black and white families' experiences., Objective: To compare the organ donation request experiences of black and white patients' families with the hope of identifying factors to better inform consent-rate interventions among blacks., Design: Chart reviews were conducted on files of all deceased patients. Audiotaped in-person interviews were conducted with family members, and telephone interviews were conducted with involved healthcare providers and organ procurement organization staff., Setting: Nine trauma hospitals located in southwest Pennsylvania and northeast Ohio., Participants: A sample of 415 families of organ donor-eligible patients (61 black, 354 white)., Measures: Measures of families' attitudes about and experiences with donation and transplantation., Results: White families were more likely to be correctly perceived as receptive to donation. Black families viewed as receptive were less likely to be engaged in discussing as many donation-related issues as white families (p <.01). They were also less likely to have spoken to an organ procurement organization representative (p =.024) and were given fewer opportunities to consider the decision with healthcare provider or organ procurement organization staff. Black families had less knowledge about their family member's wishes, expressed less-favorable attitudes toward organ donation and the health care system, and, finally, were less likely than white families to donate organs (p =.001). A minority of black families (32.8%) knew about the need for more black donors., Conclusions: Interventions to increase consent among blacks need to encourage openness about organ donation within the black community and change healthcare provider and organ procurement organization attitudes and practices toward black families as potential donor families.

Background: There is a marked difference between black patients and white patients in the utilization of joint replacement therapy. The reasons behind this disparity remain unknown., Objectives: To examine how black and white potential candidates for joint replacement compare with respect to their overall familiarity with joint replacement as an option, as well as their perceptions of the risks/benefits of this procedure., Methods: Cross-sectional survey of 596 elderly patients with symptomatic osteoarthritis of the knee or hip or both attending primary care clinics at Cleveland VAMC., Results: Black (44%) and white (56%) patients in this cohort were comparable with respect to age and clinical factors. However, black patients were less likely to be employed (8% vs. 15%, P = 0.017) or to be married (39% vs. 56%, P = 0.000), but more likely to report an annual household income of less than $10,000 (41% vs. 20%, P = 0.000) and less than high school education (43% vs. 29%, P = 0.001). Black patients were less likely than white patients to have had family or friends who had had joint replacement (OR, 0.39 [0.26-0.61]), or to report a good understanding of joint replacement as a form of treatment (OR, 0.62 [0.42-0.92]). They were more likely than white patients to expect longer hospital course (OR, 4.09 [2.57-6.54]), moderate to extreme pain (OR, 2.61 [1.74-3.89]), and moderate to extreme difficulty walking after replacement surgery (OR, 2.76 [1.83-4.16])., Conclusion: Black patients were less likely than white patients to be familiar with joint replacement surgery and more likely to express concerns about postsurgical pain and difficulty walking.