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Women are often the victims of intimate partner violence (IPV). Though China has established its first statute against domestic violence, there were limited studies related to IPV and only few focused on women’s perspectives of IPV. This study aimed to explore how women recognize and cope with IPV. This study completed the Short Explanatory Model Interview (SEMI) among a subset sample from a large epidemiology study in rural Sichuan China. After open coding, axial coding, and selective coding, we applied brief content analysis method to analyze qualitative interviews. Among 339 participants, the average age was 46.01 ± 12.42 years old and there were 49.26% of them had experienced violence from their partners in the last year. There were only 18 participants could recognize IPV; and there were 160 participants denied the violent relationship while blaming the victim for mental problems, serving a terrible role of wife, and less educated. One hundred and fifty-seven participants suggested solving IPV by oneself including fixing the relationship, empowering herself, enduring, doing housework, and even committing suicide; and 92 participants suggested seeking help from others including government agencies, her parents, friends, doctors, and legal aids. The results indicated that when women attributed the blame for IPV to the victim which may limit their coping strategies for self-help, and should they find themselves victimized. We believe future interventions should consider culture barriers and help vulnerable women define and perceive IPV in their lives, build broader social networks, and help victims dispel self-blame.

Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients' outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization.

Little is known about the characteristics of patients, physicians, and organizations that influence treatment decisions in older patients with AML. We conducted qualitative interviews with community oncologists and older patients with AML to elicit factors that influence their treatment decision-making. Recruitment was done via purposive sampling and continued until theoretical saturation was reached, resulting in the inclusion of 15 patients and 15 oncologists. Participants’ responses were analyzed using directed content analysis. Oncologists and patients considered comorbidities, functional status, emotional health, cognition, and social factors when deciding treatment; most oncologists evaluated these using clinical gestalt. Sixty-seven percent of patients perceived that treatment was their only option and that they had not been offered a choice. In conclusion, treatment decision-making is complex and influenced by patient-related factors. These factors can be assessed as part of a geriatric assessment which can help oncologists better determine fitness and guide treatment decision-making.

Patients with severe mental illnesses and related conditions, such as substance misuse and suicide attempts, are among the highest utilizers of acute inpatient medical services. The objective of this study was to assess the impact of a specialized medical unit that uses a comprehensive biopsychosocial model to care for patients with severe mental illnesses.The study used administrative data to compare patients with severe mental illnesses admitted to a specialized unit with patients admitted to medically similar acute (non-intensive care) medical units in a tertiary academic medical center. With controls for sociodemographic variables, illness severity, and medical complexity, multivariate regression analyses compared utilization outcomes for patients from the specialized unit with outcomes from comparison units.Patients on the specialized unit (N=2,077) were younger, had more mental disorder diagnoses, and were more likely to have less severe general medical illness and less medical complexity than patients from comparison units (N=12,824). Analyses of a subsample of patients with complex behavioral health diagnoses indicated that those on the specialized unit had a shorter average stay, higher odds of discharge to home, and lower odds of 30-day readmission, compared with those on comparison units.Specialized units targeted to the needs of patients with serious mental illnesses can provide a moment of engagement when vulnerable patients are likely to benefit from more coordinated care. Findings suggest that a specialized unit that capitalizes on this moment of engagement and uses a biopsychosocial model of care can improve utilization outcomes.

Background: Despite recent widespread acceptance that unmet social needs are critically relevant to health, limited guidance exists about how best to address them in the context of women's health care delivery. We aimed to evaluate two interventions: enhanced screening and referral (ESR), a screening intervention with facilitated referral and follow-up calls, and personalized support for progress (PSP), a community health worker intervention tailored to women's priorities. Materials and Methods: Women >18 years were screened for presence of elevated depressive symptoms in three women's health clinics serving primarily Medicaid-eligible patients. If eligible and interested, we enrolled and randomized women to ESR or PSP. Pre- and postintervention assessments were conducted. Primary outcomes were satisfaction, depression, and quality of life (QOL). Planned analyses of subgroup differences were also explored. Results: A total of 235 participants were randomized; 54% identified as African American, 19% as White, and 15% as Latina. Participant mean age was 30 years; 77% reported annual incomes below US $20,000/year; and 30% were pregnant at enrollment. Participants in both arms found the interventions satisfactory and improved for depression (p

Suicide prevention in clinical settings requires coordination among multiple clinicians with expertise in different disciplines. We aimed to understand the benefits and challenges of a team approach to suicide prevention in primary care, with a particular focus on Veterans. The Veterans Health Administration has both a vested interest in preventing suicide and it has rapidly and systematically adopted team-based approaches for primary care interventions, including suicide prevention. We conducted eight focus groups and eight in-depth interviews with primary care providers (PCPs), behavioral health providers and nurses located in six regions within one Veterans Administration Catchment Area in the northeast of the US. Transcripts were analyzed using simultaneous deductive and inductive content analysis. Findings revealed that different clinicians were thought to have particular expertise and roles. Nurses were recognized as being well positioned to identify subtle changes in patient behavior that could put patients at risk for suicide; behavioral health providers were recognized for their skill in suicide risk assessment; and PCPs were felt to be an integral conduit between needed services and treatment. Our findings suggest that clinician role-differentiation may be an important by-product of team-based suicide prevention efforts in VHA settings. We contextualize our findings within both a processual and relational interprofessional framework and discuss implications for the implementation of team-based suicide prevention.

PURPOSE To study the effectiveness of the Patient Preferences for Prostate Cancer Care (PreProCare) intervention in improving the primary outcome of satisfaction with care and secondary outcomes of satisfaction with decision, decision regret, and treatment choice among patients with localized prostate cancer. METHODS In this multicenter randomized controlled study, we randomly assigned patients with localized prostate cancer to the PreProCare intervention or usual care. Outcomes were satisfaction with care, satisfaction with decision, decision regret, and treatment choice. Assessments were performed at baseline and at 3, 6, 12, and 24 months, and were analyzed using repeated measures. We compared treatment choice across intervention groups by prostate cancer risk categories. RESULTS Between January 2014 and March 2015, 743 patients with localized prostate cancer were recruited and randomly assigned to receive PreProCare (n = 372) or usual care (n = 371). For the general satisfaction subscale, improvement at 24 months from baseline was significantly different between groups ( P < .001). For the intervention group, mean scores at 24 months improved by 0.44 (SE, 0.06; P < .001) from baseline. This improvement was 0.5 standard deviation, which was clinically significant. The proportion reporting satisfaction with decision and no regret increased over time and was higher for the intervention group, compared with the usual care group at 24 months ( P < .05). Among low-risk patients, a higher proportion of the intervention group was receiving active surveillance, compared with the usual care group ( P < .001). CONCLUSION Our patient-centered PreProCare intervention improved satisfaction with care, satisfaction with decision, reduced regrets, and aligned treatment choice with risk category. The majority of our participants had a high income, with implications for generalizability. Additional studies can evaluate the effectiveness of PreProCare as a mechanism for improving clinical and patient-reported outcomes in different settings.

Socioeconomic disadvantage is extremely common among women with depressive symptoms presenting for women's health care. While social stressors related to socioeconomic disadvantage can contribute to depression, health care tends to focus on patients' symptoms in isolation of context. Health care providers may be more effective by addressing issues related to socioeconomic disadvantage. It is imperative to identify common challenges related to socioeconomic disadvantage, as well as sources of resilience. In this qualitative study, we interviewed 20 women's health patients experiencing depressive symptoms and socioeconomic disadvantage about their views of their mental health, the impact of social stressors, and their resources and skills. A Consensual Qualitative Research approach was used to identify domains consisting of challenges and resiliencies. We applied the socioecological model when coding the data and identified cross-cutting themes of chaos and distress, as well as resilience. These findings suggest the importance of incorporating context in the health care of women with depression and socioeconomic disadvantage.

BACKGROUND Older patients with advanced cancer who are 100% certain they will be cured pose unique challenges for clinical decision making, but to the authors' knowledge, the prevalence and correlates of absolute certainty about curability (ACC) are unknown. METHODS Cross-sectional data were collected in a geriatric assessment trial. ACC was assessed by asking patients, "What do you believe are the chances that your cancer will go away and never come back with treatment?" Response options were 100% (coded as ACC), >50%, 50/50

Integrated medical and psychiatric hospital units hold great promise for improving the value and quality of care for patients with severe mental illness and concomitant acute medical needs. It is important to explore the utility of providing a range of multidisciplinary inpatient services to meet patients' complex needs. Within this context, services typically provided by psychologists have received little research attention. To address this gap in the literature, this study assessed inpatient clinicians' perceptions of the need for specific behavioural services on a medical psychiatric unit, exploring their overlap with established psychological services. Results indicate the potential utility of specific psychological services, including psychological assessments, direct psychosocial interventions, and psychoeducational training. While reimbursement and billing barriers still exist for psychologists to be routinely incorporated into hospital settings, the movement towards value-based care could provide the opportunity to think about the value added. Embedding evidence-based psychological services has the potential to promote high quality, well-rounded care that aligns with the established mission of multidisciplinary teamwork on integrated medical and psychiatric inpatient units.

To evaluate the impact of a community health worker intervention (CHW) (referred to as Personalized Support for Progress (PSP)) on all-cause health care utilization and cost of care compared with Enhanced Screening and Referral (ESR) among women with depression. A total of 223 patients (111 in PSP and 112 in ESR randomly assigned) from three women’s health clinics with elevated depressive symptoms were enrolled in the study. Their electronic health records were queried to extract all-cause health care encounters along with the corresponding billing information 12 months before and after the intervention, as well as during the first 4-month intervention period. The health care encounters were then grouped into three mutually exclusive categories: high-cost (> US$1000 per encounter), medium-cost (US$201–$999), and low-cost (≤ US$200). A difference-in-difference analysis of mean total charge per patient between PSP and ESR was used to assess cost differences between treatment groups. The results suggest the PSP group was associated with a higher total cost of care at the baseline; taking this baseline difference into account, the PSP group was associated with lower mean total charge amounts (p = 0.008) as well as a reduction in the frequency of high-cost encounters (p

PURPOSE: The purpose of this study was to describe family caregivers’ perspectives of the final month of life of patients with advanced cancer, particularly whether and how chemotherapy was discontinued and the effect of clinical decision-making on family caregivers’ perceptions of the patient’s experience of care at the end of life (EOL). METHODS: Qualitative descriptive design using semi-structured interviews collected from 92 family caregivers of patients with end stage cancer enrolled in a randomized clinical trial. We used a phased approach to data analysis including open coding, focused coding, and within and across analyses. RESULTS: We identified three patterns of transitions characterizing the shift away from active cancer treatment: 1) “We Pretty Much Knew,” characterized by explicit discussions about EOL care, seemingly shared understanding about prognosis and seamless transitions from disease-oriented treatment to comfort-oriented care, 2) “Beating the Odds,” characterized by explicit discussions about disease-directed treatment and EOL care options, but no shared understanding about prognosis and often chaotic transitions to EOL care, and 3) “Left to Die,” characterized by no recall of EOL discussions with transitions to EOL occurring in crisis. CONCLUSIONS: As communication and palliative care interventions continue to develop to improve care for patients with advanced cancer, it is imperative that we take into account the different patterns of transition and their unique patient and caregiver needs near the end of life. Our findings reveal considerable, and potentially unwarranted, variation in transitions from active treatment to death.

Objectives Older self-perceived age is associated with poor health and higher healthcare utilization in the geriatric population. We evaluated the associations of self-perceived age with geriatric assessment (GA) domain impairments in older adults with cancer. Methods This was a secondary analysis of baseline data from a GA cluster-randomized trial (URCC 13070; PI: Mohile). We included patients aged ≥70 with incurable stage III/IV solid tumor or lymphoma considering or receiving treatment and had ≥1 GA domain impairment other than polypharmacy. Multivariate analyses were used to evaluate the associations of age difference between chronological and self-perceived age (categorized into “feeling younger than chronological age” vs. “feeling the same or older than their chronological age”) with GA domain impairments. Results We included 533 patients; mean age was 76.6 (SD 5.2). On multivariate analyses, compared to those who felt younger than their chronological age, those who felt the same or older were more likely to have impairments in physical performance [Adjusted Odds Ratio (AOR) 5.42, 95% Confidence Interval (CI) 1.69–17.40)], functional status (AOR 2.31, 95% CI 1.73–3.07), comorbidity (AOR 1.62, 95% CI 1.20–2.19), psychological health (AOR 2.62, 95% CI 1.85–3.73), and nutrition (AOR 1.65, 95% CI 1.20–2.28). They were also more likely to screen positively for polypharmacy (AOR 1.86, 95% CI 1.30–2.65). Conclusions Older adults with cancer who felt the same or older than their chronological age were more likely to have GA domain impairments. Further studies are needed to better understand the relationships between self-perceived age, aging-related conditions, and outcomes in this population.

Objective Patients with multiple chronic conditions face many stressors (e.g. financial, safety, transportation stressors) that are rarely prioritized for discussion with the primary care provider (PCP). In this pilot randomized controlled trial we examined the effects of a novel technology-based intervention called Customized Care on stressor disclosure. Methods The main outcomes were stressor disclosure, patient confidence and activation, as assessed by self-report and observational methods (transcribed and coded audio-recordings of the office visit). Results Sixty patients were enrolled. Compared with care as usual, intervention patients were 6 times more likely to disclose stressors to the PCP (OR = 6.16, 95% CI [1.53, 24.81], p = 0.011) and reported greater stressor disclosure confidence (exp[B] = 1.06, 95% CI [1.01, 1.12], p = 0.028). No differences were found in patient activation or the length of the office visit. Conclusion Customized Care improved the likelihood of stressor disclosure without affecting the length of the PCP visit. Practice implications Brief technology-based interventions, like Customized Care could be made available through patient portals, or on smart phones, to prime patient-PCP discussion about difficult subjects, thereby improving the patient experience and efficiency of the visit.

Background As part of a larger epidemiological study of depression among rural Chinese women, we sought to understand their explanatory models of depression. We explored how participants describe depression, to what cause they attribute depression, and what sources of treatment they would recommend. Methods Participants first were assessed with the Center for Epidemiological-Depression scale (CES-D), with a cut-point of 16 or greater indicative of depression. The Short Explanatory Model Interview (SEMI), a semi-structured questionnaire, was our primary tool for exploring participants’ explanatory models relating to a vignette describing a rural Chinese woman with depression. Results Among the 416 women who consented and completed the SEMI, 277(66.6%) reported that the woman in the vignette had something wrong with her health. Among these, only 8(2.9%) women provided a specific psychiatric name for the condition, while 150(54.2%) provided non-specific psychiatric disease names or affective symptoms, and 78(28.2%)of the sample provided physical disease names. Participants attributed causes largely to internal factors (41.5%) or external factors (36.8%). In terms of help-seeking, 101(36.4%) said the woman in the vignette should see a doctor, 70(25.3%) indicated that she should solve the problem herself, and 42(15.2%) recommended seeking support from family members and friends. We did not find any differences in recognition, causal attribution, and help-seeking suggestions between women with a CES-D ≥ 16 and those with CES-D Limitations The use of a vignette to prompt discussion was not the same as talking about real-life personal situations. Conclusion Our results point to potential challenges and opportunities that lay ahead as China develops mental health services in its vast rural areas among women who may be at risk for developing depression. We found that our participants often attributed their symptoms to internal or external social causes, and preferred not speaking with family members and friends. Our findings suggest that rural Chinese women may be reticent to recognize or describe categorical concepts such as “depression” as a health problem, and they invite further consideration about how best to develop new health services in China's rural regions.

Most of current scales for assessing intimate partner violence (IPV) were developed for Western populations. The Chinese Risk Assessment Tool for Victims (CRAT-V) was a new scale evaluating the risk of IPV, which was developed based on Chinese populations in the context of Chinese culture. To determine whether the CRAT-V could add further value to research involving IPV and violence against women in rural China, we sought to implement the CRAT-V and to explore its factor structure among a rural population in the mainland of China. This study included women from rural Sichuan Province of China, who aged 16 years and older, had been living locally for at least 2 years, and reported that they were married or in a relationship in the preceding year. A total of 670 participants completed the CRAT-V during the field survey. We utilized exploratory factor analysis to validate the fact structure of CRAT-V. The Cronbach’s alpha of the CRAT-V was 0.90, indicating good reliability. The CRAT-V reported that 45.07% (302/670) of participants were in risk of IPV, and the risk was higher in women who were 16 to 29 years old, having 7 years and higher education, and living in stem families. The CRAT-V fit a 5-factor model including healthy relationship, jealous feeling, jealous reaction, stressful living condition, and sexual abuse. Our findings provided support for using the CRAT-V as a culturally sensitive measure to predict the risk of experiencing IPV in China, and lend insights into factors that may contribute to timely IPV prevention and intervention.

Demand for training in mixed methods is high, with little research on faculty development or assessment in mixed methods. We describe the development of a self-rated mixed methods skills assessment and provide validity evidence. The instrument taps six research domains: "Research question," "Design/approach," "Sampling," "Data collection," "Analysis," and "Dissemination." Respondents are asked to rate their ability to define or explain concepts of mixed methods under each domain, their ability to apply the concepts to problems, and the extent to which they need to improve.We administered the questionnaire to 145 faculty and students using an internet survey. We analyzed descriptive statistics and performance characteristics of the questionnaire using the Cronbach alpha to assess reliability and an analysis of variance that compared a mixed methods experience index with assessment scores to assess criterion relatedness.Internal consistency reliability was high for the total set of items (0.95) and adequate (≥0.71) for all but one subscale. Consistent with establishing criterion validity, respondents who had more professional experiences with mixed methods (eg, published a mixed methods article) rated themselves as more skilled, which was statistically significant across the research domains.This self-rated mixed methods assessment instrument may be a useful tool to assess skills in mixed methods for training programs. It can be applied widely at the graduate and faculty level. For the learner, assessment may lead to enhanced motivation to learn and training focused on self-identified needs. For faculty, the assessment may improve curriculum and course content planning.

Introduction Many primary care patients with multimorbidity (two or more chronic conditions) and depression or anxiety have day-to-day challenges that affect health outcomes, such as having financial or housing concerns, or dealing with social or emotional stressors. Yet, primary care providers (PCPs) are often unaware of patients' daily challenges coping with chronic disease. We developed Customized Care, an intervention, to address the barriers to effective communication about patient's day-to-day challenges. Methods In this report we describe the rationale and design of a randomized clinical pilot study to examine the effect of Customized Care on patient-PCP communication and patient health outcomes, including depression, anxiety and functional outcomes. Customized Care comprises two components: (1) a computer-based discussion prioritization tool (DPT) designed to empower patients to communicate their health related priorities; and (2) a customized question prompt list (QPL) tailored to these priorities. Primary care clinic patients and PCPs participated in the study, which consisted of in-person patient assessments, audio recording and transcription of the patient-PCP office visit, and follow-up patient assessments by phone. Results We describe study participant demographics and development of a coding manual to assess communication within the office visit. Participants were recruited from an urban primary care clinic. Sixty patients and 12 PCPs were enrolled over six months. Conclusions With better communication about everyday challenges, patients and PCPs can have more informed discussions about health care options that positively influence patient outcomes. We expect that Customized Care will improve patient-PCP communication about day-to-day challenges, which can lead to better health outcomes.

Background: Care teams are increasingly expected to attend to the needs of patient's personal caregivers (e.g., family members). Improving communication among oncologists, patients with advanced cancer, and their personal caregivers might enhance caregivers' experiences of end-of-life (EoL) cancer care and bereavement outcomes. Objective: To explore the effects of the Values and Options in Cancer Care intervention on caregivers' experiences of EoL care and bereavement outcomes. Design: We developed a brief behavioral intervention to improve communication among oncologists, patients with advanced cancer, and their personal caregivers. The intervention was designed to help patients/caregivers ask questions, express concerns, and help oncologists respond effectively. We randomly assigned oncologists (and their patients/caregivers) to the intervention or usual care. Setting/Subjects: Medical oncologists in NY and CA; patients/personal caregivers with advanced cancer. Measurements: Two months after the patient's death, caregivers completed three instruments assessing their experiences of EoL care. Seven months after the patient's death, caregivers completed the Prolonged Grief Disorder-13 (PG-13; primary prespecified outcome), the Purpose-in-Life scale, and scales assessing mental health function, depression, and anxiety. Results: The intervention did not significantly improve caregivers' scores on the PG-13 (p = 0.21), mental health function, depression, or anxiety, but it did improve purpose-in-life scores (p = 0.018). Cohen's d (95% confidence interval) for all three experiences of EoL care outcomes were promising, ranging from 0.22 (−0.19 to 0.63) to 0.39 (−0.07 to 0.86) although none was statistically significant. Conclusion: Preliminary findings show promise that scalable interventions in cancer care settings may improve caregiver experiences with cancer care and some bereavement outcomes.

BACKGROUND. Ensuring older patients with advanced cancer and their oncologists have similar beliefs about curability is important. We investigated discordance in beliefs about curability in patient‐oncologist and caregiver‐oncologist dyads. MATERIALS AND METHODS. We used baseline data from a cluster randomized trial assessing whether geriatric assessment improves communication and quality of life in older patients with advanced cancer and their caregivers. Patients were aged ≥70 years with incurable cancer from community oncology practices. Patients, caregivers, and oncologists were asked: “What do you believe are the chances the cancer will go away and never come back with treatment?” Options were 100%, >50%, 50/50

Objective To explore family caregivers’ emotional experiences while caring for patients with advanced cancer and navigating distressing information, awareness of dying, and difficult decisions. Methods Qualitative descriptive study of semi-structured interviews with 92 bereaved caregivers of patients with advanced cancer. Interviews explored caregivers’ experiences as patients transitioned out of active cancer treatment and neared the end of life. Results Included in caregivers’ characterization of this transition time were three particularly emotionally charged experiences. The first occurred when caregivers felt jolted into awareness that patients were dying.They were startled to realize that patients would die sooner than expected; some expressed frustration that they had not been adequately warned. In the second, caregivers felt conflicted when involved in decisions that pitted patients’ preferences against what caregivers felt patients needed, resulting in ambivalence, guilt, and grief. Thirdly, caregivers who felt they did their best for patients expressed fulfillment and gratitude. Conclusion Caregivers of patients with advanced cancer face unique, emotionally charged experiences that can lead to distress and affect care at the end of life. Practice implications Awareness of these situations may help oncology teams to provide sufficient guidance and support, partner with caregivers to clarify patients’ needs, and deliver higher quality care.

Direct and indirect communication through the electronic medical record play a vital role in helping medical home primary care teams implement suicide prevention efforts. The purpose of this study is to examine how communication related to suicide prevention occurs among primary care team members working within a group of clinics in the Veterans Health Administration that has embedded integrated behavioral health providers (BHPs) and uses a shared electronic medical record. Using sequential exploratory mixed methods design, eight focus groups and 11 in-depth interviews with primary care providers (PCPs), nurses, and BHPs comprised the qualitative portion of the study, which was used to help develop an online questionnaire distributed to all primary care teams. Participants (n = 86) of the online survey included 15 BHPs, 32 PCPs, and 39 registered nurses. Qualitative data included asking a series of questions concerning how suicide prevention is accomplished in primary care. Themes concerning how providers communicate both directly and indirectly arose from the data and were used to develop questions for the survey to help further understand the data. Overall, the data suggested good team communication was occurring. However, there were opportunities to enhance communication through the use of huddles and enhancing communication from PCPs to other team members when the patient's medical status changed. Direct communication was preferred, and finding ways to increase communication may be important to help decrease potential errors that may occur via diffusion of responsibility. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Information seeking is essential for effective patient-centered decision-making. However, prostate cancer patients report a gap between information needed and information received. The importance of different information sources for treatment decision remains unclear. Thus, using the Comprehensive Model of Health Information (CMIS) framework, we assessed the antecedent factors, information carrier factors, and information-seeking activities in localized prostate cancer patients. Data were collected via semistructured one-on-one, interviews and structured survey. Men with localized prostate cancer were recruited from two urban health-care centers. Following the interview, participants completed a survey about sources that were helpful in learning about prostate cancer treatment and decision-making. The interviews were audio-recorded, transcribed, and subjected to a thematic analysis using NVivo 10. Fifty localized prostate cancer survivors completed the interviews and surveys. Important antecedent factors that were observed were age, marital status, uncertainty, anxiety, caregiver burden, and out-of-pocket expenses. We identified complexity, magnitude, and reliability as information carrier characteristics. Preferred sources for information were health providers, medical websites, and pamphlets from the doctor’s office. These sources were also perceived as most helpful for decision-making. Urologists, urological oncologists, and radiation/radiation oncologists were important sources of information and helpful in decision-making. Prostate cancer patients obtained information from multiple sources. Most prostate cancer patients make patient-centered choices by incorporating personal factors and medical information. By considering factors that influence patients’ treatment decisions, health-care providers can enhance the patient-centeredness of care. Multiple strategies and interventions are necessary for disseminating valid, reliable, and unbiased information to prostate cancer patients to facilitate informed decisions.

OBJECTIVES To evaluate relationships between frailty and cognition longitudinally in adults 50 years and older with breast cancer receiving chemotherapy. DESIGN Secondary analysis of a prospective longitudinal observational study. SETTING University of Rochester NCI Community Oncology Research Program community oncology clinics. PARTICIPANTS Patients with breast cancer age 50 and older receiving adjuvant/neoadjuvant chemotherapy (n = 376) and age-matched controls without cancer (n = 234). MEASUREMENTS Frailty was assessed using a modified frailty score from self-reported assessments (weakness, exhaustion, physical activity, and gait speed). Cognition was assessed by patient report (Functional Assessment of Cancer Therapy-Cognition [FACT-Cog]) and objective measures. Frailty and cognition were measured at three time points (prechemotherapy [A1], postchemotherapy [A2], and 6 months postchemotherapy [A3]; similar time interval for controls). Linear regression models evaluated associations between frailty and cognition adjusting for covariates. RESULTS The average age was 59 years (standard deviation = 6.4 y). At baseline, patients with cancer had a higher mean frailty score (1.21 vs .73; P

Objective To elicit patient stakeholders’ experience and perspectives about patient-centred care. Design Qualitative. Setting A large urban healthcare system. Participants Four patient stakeholders who are prostate cancer survivors. Main outcome measures Experience and perspectives of patient stakeholders regarding patient-centred care and treatment decisions. Results Our patient stakeholders represented a diverse socio-demographic group. The patient stakeholders identified engagement and dialogue with physicians as crucial elements of patient-centred care model. The degree of patient-centred care was observed to be dependent on the situations. High severity conditions warranted a higher level of patient involvement, compared to mild conditions. They agreed that patient-centred care should not mean that patients can demand inappropriate treatments. Conclusions An important attribute of patient-centred outcomes research model is the involvement of stakeholders. However, we have limited knowledge about the experience of patient stakeholders in patient-centred outcomes research. Our study indicates that patient stakeholders offer a unique perspective as researchers and policy-makers aim to precisely define patient-centred research and care.

Background: This study's objectives were to describe community oncologists' beliefs about and confidence with geriatric care and to determine whether geriatric-relevant information influences cancer treatment decisions. Methods: Community oncologists were recruited to participate in 2 multisite geriatric oncology trials. Participants shared their beliefs about and confidence in caring for older adults. They were also asked to make a first-line chemotherapy recommendation (combination vs single-agent vs no chemotherapy) for a hypothetical vignette of an older patient with advanced pancreatic cancer. Each oncologist received one randomly chosen vignette that varied on 3 variables: age (72/84 years), impaired function (yes/no), and cognitive impairment (yes/no). Other patient characteristics were held constant. Logistic regression models were used to identify associations between oncologist/vignette-patient characteristics and treatment decisions. Results: Oncologist response rate was 61% (n=305/498). Most oncologists agreed that "the care of older adults with cancer needs to be improved" (89%) and that "geriatrics training is essential" (72%). However

Supplemental Digital Content is available in the text, Background: In the context of prostate cancer (PCa) characterized by the multiple alternative treatment strategies, comparative effectiveness analysis is essential for informed decision-making. We analyzed the comparative effectiveness of PCa treatments through systematic review and meta-analysis with a focus on outcomes that matter most to newly diagnosed localized PCa patients. Methods: We performed a systematic review of literature published in English from 1995 to October 2016. A search strategy was employed using terms “prostate cancer,” “localized,” “outcomes,” “mortality,” “health related quality of life,” and “complications” to identify relevant randomized controlled trials (RCTs), prospective, and retrospective studies. For observational studies, only those adjusting for selection bias using propensity-score or instrumental-variables approaches were included. Multivariable adjusted hazard ratio was used to assess all-cause and disease-specific mortality. Funnel plots were used to assess the level of bias. Results: Our search strategy yielded 58 articles, of which 29 were RCTs, 6 were prospective studies, and 23 were retrospective studies. The studies provided moderate data for the patient-centered outcome of mortality. Radical prostatectomy demonstrated mortality benefit compared to watchful waiting (all-cause HR = 0.63 CI = 0.45, 0.87; disease-specific HR = 0.48 CI = 0.40, 0.58), and radiation therapy (all-cause HR = 0.65 CI = 0.57, 0.74; disease-specific HR = 0.51 CI = 0.40, 0.65). However, we had minimal comparative information about tradeoffs between and within treatment for other patient-centered outcomes in the short and long-term. Conclusion: Lack of patient-centered outcomes in comparative effectiveness research in localized PCa is a major hurdle to informed and shared decision-making. More rigorous studies that can integrate patient-centered and intermediate outcomes in addition to mortality are needed.

What you need to know A middle aged woman, divorced many years, presents to her general practitioner for a routine follow-up visit with arthritis, weight gain, and intermittent migraines. She appears stressed and tired. Upon questioning, she reports strain, fatigue, poor sleep, and worry. She is caring for her mother, who lives with her and has Alzheimer’s disease, and she is adjusting to having her daughter’s family (husband and three young children) move in with her due to unemployment. Many patients present to primary care in emotional distress, simply referred to as “distress” hereafter. Brief behavioural interventions offered in primary care can reduce distress in the moment and may confer longer term benefits as well, potentially helping patients achieve personally meaningful goals, reduce distress, and improve physical outcomes. In doing so, providers also may experience benefits in their relationships with patients and job satisfaction.1 In this Practice Pointer, we present an approach for non-specialists to use in their consultation with patients in distress. Figure 1 presents an overview. These behavioural strategies can be used with distressed patients whether or not they are taking psychiatric medications.23 Most …

Objectives. To describe the development of our Patient Preferences for Prostate Cancer Care (PreProCare) tool to aid patient-centered treatment decision among localized prostate cancer patients. Methods. We incorporated patient and provider experiences to develop a patient preference elicitation tool using adaptive conjoint analysis. Our patient-centered approach used systematic literature review, semistructured patient interviews, and provider focus groups to determine the treatment attributes most important for decision making. The resulting computer-based PreProCare tool was pilot tested in a clinical setting. Results. A systematic review of 56 articles published between 1995 and 2015 yielded survival, cancer recurrence, side effects, and complications as attributes of treatment options. We conducted one-on-one interviews with 50 prostate cancer survivors and 5 focus groups of providers. Patients reported anxiety, depression, treatment specifics, and caregiver burden as important for decision making. Providers identified clinical characteristics as important attribute. Input from stakeholders’ advisory group, physicians, and researchers helped finalize 15 attributes for our PreProCare preference assessment tool. Conclusion. The PreProCare tool was developed using a patient-centered approach and may be a feasible and acceptable preference clarification intervention for localized prostate cancer patients. The PreProCare tool may translate into higher participant engagement and self-efficacy, consistent with patients’ personal values.

OBJECTIVES: The objective was to identify adolescent preferences for emergency department (ED)-based education about emergency contraception. METHODS: This was a cross-sectional computerized survey using adaptive conjoint analysis (ACA). Patients were eligible if they were females ages 14 through 19 years old and were seeking care in one of two urban EDs. Patients were excluded if they were too ill to participate in the survey or if they were non-English speaking. Participants completed a computerized survey that used ACA a technique that can be used to assess patients relative preferences for services. ACA uses the individuals answers to update and refine questions through trade-off comparisons so that each respondent answers a customized set of questions. The survey assessed preferences for the following attributes of emergency contraception education: who should deliver the education if anyone (e.g. nurse doctor); how the education should be delivered (e.g. by a person or via video); how often the education should be offered if patients were to frequent the ED (e.g. every time or only when asking for it); length (e.g. 5 minutes 10 minutes); and chief complaint that would trigger the education (e.g. headache or stomach pain). RESULTS: A total of 223 patients were enrolled (37.2% at Hospital 1 and 62.8% at Hospital 2). The mean (+/-SD) age of the participants was 16.1 (+/-1.3) years. Just over half (55%) reported a history of sexual activity; 8% reported a history of pregnancy. Overall the participants preferred education that was delivered by a person specifically a doctor or nurse. They preferred a slightly longer education session and preferred education directed at patients seeking care in the ED for complaints potentially related to sexual activity. CONCLUSIONS: Adolescents have specific preferences for how education about emergency contraception would best serve their needs. This information can inform clinicians as they work to improve adolescents knowledge about pregnancy prevention and emergency contraception in particular. (c) 2013 by the Society for Academic Emergency Medicine.

Introduction: Despite data supporting the safety and efficacy of treatment for many older adults with AML, Methods: We conducted semi-structured interviews with 13 community oncologists (9 states) and 9 patients aged ≥60 with AML at any stage of treatment to elicit potential factors that influence treatment decisions. Patients were recruited from the outpatient clinics in a single institution and oncologists were recruited via email using purposive samples (patients: based on treatment received and stage of treatment; oncologists: based on practice location). Interviews were audio-recorded and transcribed. We utilized directed content analysis and adapted the decision-making model introduced by Zafar et al. to serve as a framework for categorizing the factors at various levels. A codebook was provisionally developed. Using Atlas.ti, two investigators independently coded the initial transcripts and resolved any discrepancies through an iterative process. The coding scheme was subsequently applied to the rest of the transcripts by one coder. Results: Median age of the oncologists was 37 years (range 34-64); 62% were females, 92% were white, 38% had practiced more than 15 years, and 92% reported seeing Conclusions: Treatment decision-making for older patients with AML is complex and influenced by many factors at the patient, disease/treatment, physician, and organizational levels. Despite studies supporting the utility of objective fitness assessments, these were not commonly performed in the community due to several barriers. Our framework will be useful to guide a larger study to assess real-life treatment decision-making in the community settings. We also identified several barriers raised by community oncologists that could be targeted to allow incorporation of objective fitness assessments. Figure 1. Figure 1. Disclosures Liesveld: Onconova: Other: DSMB; Abbvie: Honoraria. Stock:Jazz Pharmaceuticals: Consultancy. Majhail:Anthem, Inc.: Consultancy; Atara: Honoraria; Incyte: Honoraria. Wildes:Janssen: Research Funding. Klepin:Genentech Inc: Consultancy.

While 'personalized medicine' commonly refers to genetic markers or profiles associated with pharmacological treatment response, tailoring treatments to patient preferences and values is equally important.To describe and demonstrate a method to develop 'values markers,' or profiles based on the relative importance of attributes of depression treatment.Discrete choice analysis was used to assess individuals' relative preferences for features of depression treatment. Preference profiles were developed using latent profile analysis.Eighty-six adults participating in an internet-based discrete choice questionnaire.Participants were presented with two depression scenarios representing mild and severe depression. For each scenario, they were asked to compare 18 choice sets based on the type of medication side effect (nausea, dizziness, and sexual dysfunction) and severity (mild, moderate, and severe); and for counseling frequency (once per week or every other week) and provider setting (the office of a mental health professional, primary care doctor, or spiritual counselor).Three profiles were identified: profile 1 was associated with a preference for counseling and an avoidance of medication side effects; profile 2 with an avoidance of strong medication side effects and for receiving counseling in medical settings; and profile 3 with a preference for medication over counseling. When presented with a severe depression scenario, there was a higher prevalence for profile 1 and patients were more likely to prefer mental health over primary care and spiritual settings.Values markers may provide a foundation for personalized medicine, and reflect current initiatives emphasizing patient-centered care. Next steps should assess whether values markers are predictive of treatment initiation and adherence.

Objective To determine the minimal important difference (MID) in generic and prostate-specific health-related quality of life (HRQoL) using distribution- and anchor-based methods. Study Design and Setting Prospective cohort study of 602 newly diagnosed prostate cancer patients recruited from an urban academic hospital and a Veterans Administration hospital. Participants completed generic (SF-36) and prostate-specific HRQoL surveys at baseline and at 3, 6, 12, and 24 months posttreatment. Anchor-based and distribution-based methods were used to develop MID estimates. We compared the proportion of participants returning to baseline based on MID estimates from the two methods. Results MID estimates derived from combining distribution- and anchor-based methods for the SF-36 subscales are physical function = 7, role physical = 14, role emotional = 12, vitality = 9, mental health = 6, social function = 9, bodily pain = 9, and general health = 8; and for the prostate-specific scales are urinary function = 8, bowel function = 7, sexual function = 8, urinary bother = 9, bowel bother = 8, and sexual bother = 11. Proportions of participants returning to baseline values corresponding to MID estimates from the two methods were comparable. Conclusions This is the first study to assess the MID for generic and prostate-specific HRQoL using anchor-based and distribution-based methods. Although variation exists in the MID estimates derived from these two methods, the recovery patterns corresponding to these estimates were comparable.

Background: Although antidepressants and counseling have been shown to be effective in treating patients with depression, non-treatment or under-treatment for depression is common, especially among the elderly and minorities. Previous work on patient preferences has focused on medication versus counseling, but less is known about the value that patients place on attributes of medication and counseling. Objective: To examine, using conjoint analysis, the relative importance of various attributes of depression treatment at the group level as well as to determine the range of individual-level relative preference weights for specific depression treatment attributes. In addition, to predict what modifications in treatment characteristics are associated with a change in the stated preferred alternative. Methods: A total of 86 adults who participated in an internet-based panel responded to an online discrete-choice task about depression treatment. Participants chose between medication and counseling based on choice sets presented first for a 'mild depression' scenario and then for a 'severe depression' scenario. Participants were given 18 choice sets that varied for medication based on type of side effect (nausea, dizziness, and sexual dysfunction) and severity of side effect (mild, moderate, and severe); and for counseling based on frequency of counseling sessions (once per week or every other week) and location of the sessions (mental health professional's office, primary-care doctor's office, or office of a spiritual counselor). Results: Treatment type (counseling vs medication) appeared to be more important in driving treatment choice than any specific attribute that was studied; specifically, counseling was preferred by most of the respondents. After treatment type, location and frequency of treatment were important considerations. Preferred attributes were similar in both the mild and severe depression scenarios. Side effect severity appeared to be most important in driving treatment choice compared with the other attributes studied. Individual-level relative preferences for treatment type revealed a distribution that was roughly bimodal; 27 participants had a strong preference for counseling and 14 had a strong preference for medication. Conclusions: Estimating individual-level preferences for treatment type allowed us to see the variability in preferences and determine which participants had a strong affinity for medication or counseling. We found that participants preferred counseling over medication, avoided options with severe side effects, and wanted to be seen in the primary-care doctor's office as opposed to other venues.

10048Background: The prevalence of CI and the utility of CI screening for community oncology practices are not well established. We used two tools to screen for CI in older patients (pts) enrolled ...

ObjectivesTo estimate the prevalence of intimate partner violence (IPV) among a sample of rural Chinese women and to explore associated factors.DesignCross-sectional study.SettingRural areas of Guangyuan City, Sichuan, China.ParticipantsWe recruited 1501 women, aged 16 years and older, who had been living locally for at least 2 years and reported being married or in a relationship during the past 12 months. They were among a sample of 1898 potential participants from our larger parent study on the prevalence of depressive-distress symptoms.MethodsParticipants completed demographic and social economic measures, the Short Form of the Revised Conflict Tactics Scale and the Duke Social Support Index. We applied χ2test, analysis of variance and confirmatory factor analysis for analysis.ResultsThe overall prevalence of IPV in the past 12 months was 29.05%; the prevalence of physical, psychological and sexual violence was 7.66%, 26.58% and 3.20%, respectively. The overall prevalence was highest among women aged 16–29 years, and was more common among those without a high school diploma and who saw their family’s financial status as very poor or stagnant. Women who were not victims of IPV had higher levels of social support. Confirmatory factor analysis showed that the total effects of social support on physical, psychological and sexual violence were −0.12, –0.35 and −0.12, respectively. The indirect effects of objective economic status on physical, psychological and sexual violence were −0.047, –0.014 and −0.047, respectively, but the total effect was not significant. The indirect effect of education on psychological violence was −0.056.ConclusionIPV is common in rural Guangyuan. Our data are comparable with the findings from north-west of China. Social support is an important protective factor. Future work is needed to develop, test and later disseminate potential IPV interventions, with a focus on building actual and perceived supportive social networks.

Background: Recommendation of mammography may be particularly important for older women; nevertheless, physicians are less likely to recommend mammography to older women. Our objective was to examine the characteristics of older patients for whom primary care physicians recommend mammography. Methods: Two hundred sixteen women aged 65 to 80 years were screened for depressive symptoms in primary care offices and invited to participate. They then completed a baseline in-home assessment between 2001 and 2003. At the time of the baseline in-home assessment, mammogram use and psychological status were assessed with commonly used and validated standard questionnaires. At the time of the index visit, physicians were asked to provide assessments of the patients. Results: Patient-reported physician recommendation of mammography was more likely among patients the physicians rated as anxious than among patients the physicians rated as not being anxious (unadjusted odds ratio, 2.08; 95% confidence interval, 1.10‐3.94). In multivariate models that controlled for physician ratings of knowledge of the patient, the association between physician rating of anxiety with patient-reported physician recommendation of mammography remained significant. Patient-reported physician recommendation of mammography was not significantly more likely among patients the physicians rated as depressed than among patients the physicians rated as not being depressed (unadjusted odds ratio, 1.57; 95% confidence interval, 0.86‐2.85). Conclusions: Identification of anxiety may influence the recommendation of mammography among primary care physicians. An understanding of factors that influence the recommendation of mammography by primary care physicians may have important implications for interventions to improve rates of mammography use among older women. (J Am Board Fam Med 2008;21:17‐23.)

Prostate cancer is a slow progressing cancer that affects millions of men in the US. Due to uncertainties in outcomes and treatment complications, it is important that patients engage in informed decision making to choose the "optimal treatment". Patient centered care that encompasses informed decision-making can improve treatment choice and quality of care. Thus, assessing patient treatment preferences is critical for developing an effective decision support system. The objective of this patient-centered randomized clinical trial was to study the comparative effectiveness of a conjoint analysis intervention compared to usual care in improving subjective and objective outcomes in prostate cancer patients. We identified preferred attributes of alternative prostate cancer treatments that will aid in evaluating attributes of treatment options. In this two-phase study, in Phase 1 we used mixed methods to develop an adaptive conjoint task instrument. The conjoint task required the patients to trade-off attributes associated with treatments by assessing their relative importance. Phase 2 consisted of a randomized controlled trial of men with localized prostate cancer. We analyzed the effect of conjoint task intervention on the association between preferences, treatment and objective and subjective outcomes. Our conjoint task instrument can lead to a values-based patient-centered decision aid tool and help tailor treatment decision making to the values of prostate cancer patients. This will ultimately improve clinical decision making, clinical policy process, enhance patient centered care and improve prostate cancer outcomes.

Background Few studies have focused on depression and social support in Eastern populations, especially women in rural China. Our research investigated depression among women in rural China, and studied the relationships between social support and depression. Methods We recruited women ages 16 years and older from north Sichuan. Participants completed socio-demographic measures, the Center for Epidemiologic Studies Depression Scale, and the Duke Social Support Index. The analysis method included descriptive statistics and logistic regression. Results The final sample included 1,898 participants with a mean age of 48.6 years, and the prevalence of significant depressive symptoms was 12.4%. Results suggest being unemployed, having poorer perceived health/economic status, and lower social support were positively associated with depression. Younger age and greater social support were negatively associated with depression. Conclusions This study provides insights on the psychological health of women in rural China and potential directions for future research. These issues are especially pertinent during this time of rapid economic transformation and outmigration in rural China.

Introduction Significant health disparities exist among socioeconomically disadvantaged women, who experience elevated rates of depression and increased risk for poor depression treatment engagement and outcomes. We aimed to use stakeholder input to develop innovative methods for a comparative effectiveness trial to address the needs of socioeconomically disadvantaged women with depression in women's health practices. Methods Using a community advisory board, focus groups, and individual patient input, we determined the feasibility and acceptability of an electronic psychosocial screening and referral tool; developed and finalized a prioritization tool for women with depression; and piloted the prioritization tool. Two intervention approaches, enhanced screening and referral using an electronic psychosocial screening, and mentoring using the prioritization tool, were developed as intervention options for socioeconomically disadvantaged women attending women's health practices. We describe the developmental steps and the final design for the comparative effectiveness trial evaluating both intervention approaches. Conclusions Stakeholder input allowed us to develop an acceptable clinical trial of two patient-centered interventions with patient-driven outcomes.

Suicide prevention efforts have largely been informed by a biomedical paradigm. Yet the more we learn about suicide, the more it seems that reliance on that paradigm is unwise if not harmful. A person-centered approach is needed but it has not gained traction. In the first section of this chapter, “Biomedicalism Misdirected,” we argue that unfettered biomedicalism generates opportunity costs and forces clinicians to rely on cognitive heuristics, essentialism and focalism, that can unintentionally harm patients. In “Biomedicalism Retained,” we draw on self-determination theory and terror management theory to explain why person-centeredness has not gained traction in medicine and why the clinician’s cognitive activity is characterized by focalism and essentialism even when contraindicated. In “Humanism Reimagined,” we describe how advances in information technology could mitigate clinician reliance on unhelpful cognitive heuristics and thereby help clinicians relieve patient suffering and decrease suicide risk.