Search

Nasir Umar1, Ina Schöllgen1, Darcey D Terris1,21Mannheim Institute of Public Health, Social and Preventive Medicine, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; 2Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USABackground: Patient-centered care has been proposed as a strategy for improving treatment outcomes in the management of psoriasis and other chronic diseases. A more detailed understanding of patients’ utilities and disutilities associated with treatment features may facilitate shared decision-making in the clinical encounter. The purpose of this study was to examine the features of psoriasis treatment that are most and least preferred by patients and to identify correlates of these preferences.Methods: A cross-sectional survey of 163 patients with moderate-to-severe psoriasis was conducted in a German academic medical center. We assessed patients’ characteristics, elicited their preferences for a range of potential treatment features, and quantified preference scores (utilities) associated with each treatment feature using hierarchical Bayes estimation. After identifying the most and least preferred treatment features, we explored correlates of these preferences using multivariate regression models.Results: Mean preference scores (MPS) for the least preferred treatment features were consistently greater than those for the most preferred treatment features. Patients generally expressed strong preferences against prolonged treatments in the inpatient setting (MPS = –13.48) and those with a lower probability of benefit (MPS = –12.28), while treatments with a high probability of benefit (MPS = 10.51) were generally preferred. Younger patients and women were more concerned with treatment benefit as compared with older patients and men.Conclusion: Both negative and positive preferences appear important for shared decision-making. Recognition of characteristics associated with strong negative preferences may be particularly useful in promoting patient-centered environments.Keywords: conjoint analysis, patient preferences, treatment preferences, psoriasis

Informed by ecological and family system frameworks, our study investigated the relationship between family- and community-level factors, and their cross-level interactions, with evidence-based home visiting program participation in a sample of 2409 mothers (mean age: 24.15 years). Using 2-level hierarchical linear modeling, we observed that mothers living in disadvantaged communities demonstrated less active engagement in evidence-based home visiting. Cross-level interaction effects revealed that mothers' unstable living conditions and psychiatric problems amplified the negative influence of disadvantaged communities on program engagement. Conversely, mothers who were first-time parents showed higher levels of participation in family support programs when they resided in disadvantaged communities.

Background: Eldercare and care of people with functional impairments is organized by the municipalities in Sweden. Improving care in these areas is complex, with multiple stakeholders and organizations. Appropriate strategies to develop capability for continuing organizational improvement and learning (COIL) are needed. The purpose of our study was to develop and pilot-test a flexible, multilevel approach for COIL capability building and to identify what it takes to achieve changes in key actors' approaches to COIL. The approach, named "Sustainable Improvement and Development through Strategic and Systematic Approaches" (SIDSSA), was applied through an action-research and action-learning intervention., Methods: The SIDSSA approach was tested in a regional research and development (R&D) unit, and in two municipalities handling care of the elderly and people with functional impairments. Our approach included a multilevel strategy, development loops of five flexible phases, and an action-learning loop. The approach was designed to support systems understanding, strategic focus, methodological practices, and change process knowledge - all of which required double-loop learning. Multiple qualitative methods, i.e., repeated interviews, process diaries, and documents, provided data for conventional content analyses., Results: The new approach was successfully tested on all cases and adopted and sustained by the R&D unit. Participants reported new insights and skills. The development loop facilitated a sense of coherence and control during uncertainty, improved planning and problem analysis, enhanced mapping of context and conditions, and supported problem-solving at both the individual and unit levels. The systems-level view and structured approach helped participants to explain, motivate, and implement change initiatives, especially after working more systematically with mapping, analyses, and goal setting., Conclusions: An easily understood and generalizable model internalized by key organizational actors is an important step before more complex development models can be implemented. SIDSSA facilitated individual and group learning through action-learning and supported systems-level views and structured approaches across multiple organizational levels. Active involvement of diverse organizational functions and levels in the learning process was facilitated. However, the time frame was too short to fully test all aspects of the approach, specifically in reaching beyond the involved managers to front-line staff and patients.

Background: Discussing randomized clinical trials (RCTs) with cancer patients is one of the most challenging communication tasks a physician faces. Only two prior Communication Skills Trainings (CSTs) focused on RCTs in oncology have been reported. Their results demonstrated the need for further improvement. We developed and evaluated an enhanced, individually-tailored CST focused on improving physicians' communication during discussions of RCTs., Methods: The CST focused on personal learning goals derived from video pre-assessment that were addressed in a 1.5-day group workshop and one-on-one coaching sessions. Forty physicians were recruited and randomly assigned to intervention and control groups. Video-recorded standardized consultations with actor-patients were utilized. As a primary outcome (1), training success was evaluated by blinded raters using a previously developed checklist. Change in checklist items was evaluated between pre- and post-training assessment and compared against control group results. As a secondary outcome (2), the physicians' feeling of confidence was assessed by a questionnaire., Results: (1) Significant improvements in the intervention group were observed for the score on all items (p = 0.03), for the subgroup of content-specific items (p = 0.02), and for the global rating of communication competence (p = 0.04). The improvement observed for the subgroup of general communication skill items did not achieve significance (p = 0.20). (2) The feeling of confidence improved in nine out of ten domains., Conclusion: While the individually-tailored CST program significantly improved the physicians' discussions of RCTs, specifically related to discussion content, what remains unknown is the influence of such programs in practice on participant recruitment rates. The study was registered retrospectively in 2010/07/22 under DRKS-ID: DRKS00000492 .

Background: Dissatisfaction with treatment is common among those with psoriasis. While incorporating patients' preferences into the process of treatment decision-making may improve satisfaction, this relationship has not been clearly established., Objective: To assess the extent to which matching physicians' treatment recommendations to patients' treatment preferences is associated with improvement in treatment satisfaction in patients with moderate-to-severe psoriasis., Methods: This prospective cohort study design examined change from baseline to 3-month follow-up in four subscales of an established measure of treatment satisfaction. Separate multivariate regression models investigated the association of change in these subscale scores with an index measuring the match between physicians' treatment recommendations and patients' treatment preferences at the initial study visit., Results: A closer match between physicians' recommendations and patients' preferences was associated with greater improvement in treatment satisfaction over time in each of the four subscales: effectiveness (β = 0.53, P < 0.001), side-effects (β = 0.25, P = 0.009), convenience (β = 0.78, P < 0.001) and global satisfaction (β = 0.49, P < 0.001). Adjusted models explained as much as 76% of the variation in change in treatment satisfaction subscales over 3 months., Conclusions: Further efforts to incorporate patients' preferences in treatment decision-making appear justified given the strength of independent associations between preference matching and improved treatment satisfaction and the extent to which our models explained variation in this relationship. An approach based on preference matching shows promise for increasing satisfaction in the management of other chronic diseases., (© 2012 The Authors. Journal of the European Academy of Dermatology and Venereology © 2012 European Academy of Dermatology and Venereology.)

Background: Patient preferences for psoriasis treatments can impact treatment satisfaction and adherence and may therefore influence clinical outcome., Objective: To assess the impact of treatment experience (satisfaction with current treatment, number of prior visits, disease duration, number of preceding therapies and currently prescribed treatment modalities) on treatment preferences., Methods: A computer-based conjoint analysis experiment was conducted to analyse preferences of patients with moderate or severe psoriasis (n = 163) treated at a German University Medical Center for outcome (probability, magnitude and duration of benefit; probability, severity and reversibility of side effects) and process attributes (location, frequency, duration, delivery method, individual cost) of psoriasis treatments. Relative importance scores (RIS) were calculated for each attribute and compared using anova, post hoc test and multivariate regression analysis., Results: Participants with longer disease duration attached significantly greater importance to duration of benefit (β = 0.206, P = 0.018), whereas participants on oral therapy were more concerned about magnitude of benefit by trend (β = 0.218, P = 0.058). Participants receiving injectables not only set higher value to probability of benefit (RIS = 32.80 vs. 21.89, P = 0.025) but also to treatment location (RIS = 44.74 vs. 23.03, P = 0.011), delivery method (RIS = 43.75 vs. 19.29, P = 0.019), treatment frequency (RIS = 31.24 vs. 16.89, P = 0.005) and duration (RIS = 32.54 vs. 16.57, P = 0.003) when compared with others. Treatment satisfaction was significantly higher in participants on infusions or injections compared with those on phototherapy and mere topical therapy., Conclusions: Treatment preferences may change over time course and with treatment experience. Participants on injectables attach great importance to efficiency and convenience of therapies, and are highly satisfied with their treatment., (© 2012 The Authors. Journal of the European Academy of Dermatology and Venereology © 2012 European Academy of Dermatology and Venereology.)

Our objective was to test whether the Structured Problem and Success Inventory (SPI) instrument could capture mental representations of organizational and work-related problems as described by individuals working in health care organizations and to test whether these representations varied according to organizational position. A convenience sample (n = 56) of middle managers (n = 20), lower-level managers (n = 20), and staff (n = 16) from health care organizations in Stockholm (Sweden) attending organizational development courses during 2003-2004 was recruited. Participants used the SPI to describe the 3 most pressing organizational and work-related problems. Data were systematically reviewed to identify problem categories and themes. One hundred sixty-four problems were described, clustered into 13 problem categories. Generally, middle managers focused on organizational factors and managerial responsibilities, whereas lower-level managers and staff focused on operational issues and what others did or ought to do. Furthermore, we observed similarities and variation in perceptions and their association with respondents' position within an organization. Our results support the need for further evaluation of the SPI as a promising tool for health care organizations. Collecting structured inventories of organizational and work-related problems from multiple perspectives may assist in the development of shared understandings of organizational challenges and lead to more effective and efficient processes of solution planning and implementation.

Quality Problem or Issue: Long access times for magnetic resonance imaging (MRI) can negatively impact the quality of care provided to patients. We investigated improving access by reducing MRI processing time., Initial Assessment: Data were collected for scans (n= 360) performed over 3 weeks (April-May 2008) at the University Hospital of Mannheim, Germany. Average access time, excluding emergencies, was 44 (±44) days for outpatients and 3 (±5) days for inpatients. Factors influencing total MRI processing time were identified using multivariate linear regression. In addition to region scanned, the total MRI processing time was significantly related to performing multiple scans (β = 33.57, P< 0.01), using oral contrast media (β = 13.58, P< 0.01), placing an intravenous (IV) catheter (β = 5.00, P= 0.04) and scanning patients ≤8 years old (β = 0.41, P= 0.03). Contrary to prior perceptions, emergency cases (5.6%) and late arrivals (12.8% >5 min late) were less than expected., Choice of Solution: Increasing scheduling flexibility to address non-modifiable process variation and completing preparatory activities outside the scanner room were identified as process improvement targets., Implementation: Scheduling was adapted to utilize three expected total MRI processing times and IV placement was moved outside the scanner room., Evaluation: Planned hardware and software upgrades were completed concurrent to the process improvements. As a result, it was not possible to accurately measure the effect of implementing the scheduling and preparatory activity changes., Lessons Learned: Clinical study team members' prior perceptions of workflow obstacles did not match the study findings. Utilizing insiders and outsiders during process analysis may limit bias in identification of process improvement opportunities.

Background: Patients often express strong preferences for the forms of treatment available for their disease. Incorporating these preferences into the process of treatment decision-making might improve patients' adherence to treatment, contributing to better outcomes. We describe the methodology used in a study aiming to assess treatment outcomes when patients' preferences for treatment are closely matched to recommended treatments., Method: Participants included patients with moderate and severe psoriasis attending outpatient dermatology clinics at the University Medical Centre Mannheim, University of Heidelberg, Germany. A self-administered online survey used conjoint analysis to measure participants' preferences for psoriasis treatment options at the initial study visit. Physicians' treatment recommendations were abstracted from each participant's medical records. The Preference Matching Index (PMI), a measure of concordance between the participant's preferences for treatment and the physician's recommended treatment, was determined for each participant at t(1) (initial study visit). A clinical outcome measure, the Psoriasis Area and Severity Index, and two participant-derived outcomes assessing treatment satisfaction and health related quality of life were employed at t(1), t(2) (twelve weeks post-t(1)) and t(3) (twelve weeks post-t(2)). Change in outcomes was assessed using repeated measures analysis of variance. The association between participants' PMI scores at t(1) and outcomes at t(2) and t(3) was evaluated using multivariate regressions analysis., Discussion: We describe methods for capturing concordance between patients' treatment preferences and recommended treatment and for assessing its association with specific treatment outcomes. The methods are intended to promote the incorporation of patients' preferences in treatment decision-making, enhance treatment satisfaction, and improve treatment effectiveness through greater adherence.

Patients with psoriasis have a higher risk of cardiovascular and metabolic comorbidities, attributable to lifestyle factors, but also to shared inflammatory pathways and genetic factors. To investigate the association between moderate and severe psoriasis and metabolic and cardiovascular comorbidities, 100 patients hospitalized at University Medical Centre Mannheim, Germany, for psoriasis treatment were compared to two age- and sex-matched control groups, the first comprising other hospitalized patients (HCG) and the second comprising healthy individuals from an industrial cohort study (ICG). Multivariate logistic regression analysis with stepwise inclusion of cardiovascular risk factors was performed. Patients with psoriasis had significantly increased prevalences of smoking, obesity, diabetes, insulin resistance, pro-atherogenic cholesterol profiles and myocardial infarction and significantly decreased cardioprotective adiponectin. Unexpectedly, regression models controlling for confounding factors predicted significantly decreased OR for elevated total cholesterol in psoriasis cases (vs HCG: OR=0.50, p=0.045; vs ICG: OR=0.26, p=0.006). In contrast, OR for pro-atherogenic cholesterol profiles with LDL/HDL >3 was markedly increased (OR=2.45, p=0.012 or OR=3.02, p=0.020). Moreover, participants with psoriasis had significantly increased OR for elevated CRP as compared to the ICG (5.25, p=0.001). Our findings underscore the importance of cardiovascular and metabolic risk screening for all patients with moderate and severe psoriasis, including young patients.

Digital photographs are often used in treatment monitoring for home care of less advanced pressure ulcers. We investigated assessment agreement when stage III and IV pressure ulcers in individuals with spinal cord injury were evaluated in person and with the use of digital photographs. Two wound-care nurses assessed 31 wounds among 15 participants. One nurse assessed all wounds in person, while the other used digital photographs. Twenty-four wound description categories were applied in the nurses' assessments. Kappa statistics were calculated to investigate agreement beyond chance (p < or = 0.05). For 10 randomly selected "double-rated wounds," both nurses applied both assessment methods. Fewer categories were evaluated for the double-rated wounds, because some categories were chosen infrequently and agreement could not be measured. Interrater agreement with the two methods was observed for 12 of the 24 categories (50.0%). However, of the 12 categories with agreement beyond chance, agreement was only "slight" (kappa = 0-0.20) or "fair" (kappa = 0.21-0.40) for 6 categories. The highest agreement was found for the presence of undermining (kappa = 0.853, p < 0.001). Interrater agreement was similar to intramethod agreement (41.2% of the categories demonstrated agreement beyond chance) for the nurses' in-person assessment of the double-rated wounds. The moderate agreement observed may be attributed to variation in subjective perception of qualitative wound characteristics.

Purpose: To investigate cross-sectional associations between main, interactive and gender-dependent effects of the demand-control-support (DCS) model and subjective health in managers., Methods: Data of 424 German, Austrian and Swiss managers were collected at leadership seminars and through presentation of the study at meetings of staff managers and senior executives. Hierarchical regression models controlling for age, hierarchy and non-linear relationships were computed to assess associations between main, interactive and gender-dependent effects of the DCS dimensions (measures of job demands, job control, social support) and subjective health (measures of self rated health and psychosomatic complaints)., Results: Social support was associated with both indicators of subjective health. Inconsistent results were obtained for the main effects of job demands and job control. Concerning the interaction effects of the model, a significant three-way interaction was observed: high job control and high social support seem to buffer the adverse health effects of high job demands. This interaction was moderated by gender. Female managers experience more psychosomatic complaints working in high demand, low control, low support settings than their male colleagues. While women seem to experience a higher buffering effect from social support than from job control, male managers may benefit equally from social support and job control., Conclusions: In managers, gender moderates the health-related effects of the psychosocial work environment. The gender-dependent effects of the DCS model may play a crucial role in the understanding of female managers' adverse health perceptions. Increasing social support for female managers may help to overcome gender inequalities in management positions.

Objectives: Reactive hyperemia index (RHI) measurement through digital peripheral arterial tonometry (PAT) is proposed for cardiovascular disease (CVD) risk screening. We evaluated the concurrent validity of RHI, measured in a high-throughput ambulatory setting, with known CVD risk factors and biomarkers., Methods: PAT was included in the 2007 EADS/Augsburg (Germany) cohort follow-up. CVD risk factors (age, sex, hypertension, hyperlipidemia, diabetes, smoking, physical activity, prevalent coronary heart disease, family history, cholesterol, triglycerides, blood pressure (BP), waist-to-hip ratio (WHR)) and biomarkers (d-dimers, fibrinogen, log(c-reactive protein)) were assessed. The relationship between RHI and CVD risk factors and biomarkers was evaluated using multivariate linear regression, controlling for potential confounders (time of day, time since subject's last meal, baseline heart rate, examiner)., Results: Of 926 subjects approached, 710 underwent PAT and 603 (mean age 44.9+/-10 years, 88.7% men) with complete data were included for analysis. RHI was significantly related to being female (beta=0.128, p=0.02), low-density lipoprotein cholesterol (beta=-0.001, p=0.02), systolic BP (beta=0.007, p<0.001), WHR (beta=-1.04, p<0.01), time of day (beta=-0.011, p=0.04) and time since last meal (beta=0.013, p<0.01)., Conclusions: Concurrent validity was partially demonstrated, while the need to control for potential confounding was reinforced. Participation was high and may be higher in less time-constrained settings.

Earlier studies have demonstrated that music interventions can lessen symptoms of depression. Depression and burnout are closely related. We hypothesized that specially designed receptive music therapy programs and protocols might reduce the symptoms of burnout. In a four-arm randomized, placebo- and waiting-list-controlled double-blind study, including 150 participants, two specific music programs significantly reduced burnout symptoms after 5 weeks. The effects were maintained over a long time period. This newly developed method of receptive music therapy was also evaluated for the treatment of depression and dysthymia, with significant outcomes.

Health promotion activities to improve employee health to reduce health care costs and increase productivity are of particular importance for organizations and society. The evaluation of employee health and health promotion programs has typically focused on absenteeism, disability and increasingly, "presenteeism", which refers to an employee's presence at work with reduced performance due to illness. Existing psychometric measures of presenteeism may be subject to the effects of recall bias as they typically rely on questionnaires. Biomarkers such as heart rate variability and salivary cortisol can provide additional objective measures of illness and stress. Combining such physiologic measures of stress with assessments of presenteeism may offer a more comprehensive way to assess workplace productivity when developing health promotion programs.

Background: Stress-related diseases are increasing in prevalence, with workplace interventions targeting stress receiving greater attention. Cortisol levels, a marker of physiological stress reaction, can be used to evaluate intervention effects, but measurement can be challenging to implement. Objective workload and subjective stress measures are alternatives previously related to cortisol secretion. We evaluated the validity of a one-item subjective stress measure based on its association with cortisol levels., Methods: Eighty-two pediatric critical care nurses participated in a prospective cohort study in Switzerland between September 2004 and March 2005. Salivary cortisol samples were collected during three, nine-day periods. Sampling occurred at shift start, repeating every two hours. Subjective stress was recorded with each sample and at shift end. Objective workload for each shift and nursing unit was derived from the hospital's LEP Nursing Workload Management System. Multilevel regression models were employed in the analysis., Results: Subjective stress, measured contemporaneously (beta=0.098, p=0.044), but not retrospectively (beta=0.012, p=0.556), was significantly related to increased cortisol secretion. Objective workload was not significantly associated with cortisol levels., Conclusions: The one-item summary measure of subjective work stress, administered contemporaneously,may be a valid tool for evaluation of workplace interventions. Future study is needed to establish reliability and generalizability

Objective: Productivity losses are associated with both employees' sleep and weight problems. Addressing these issues independently may be complicated by a potential link between sleep duration and weight. The mixed results of prior studies, both supporting and refuting an association between sleep duration and weight, may have been subject to missing variable bias. To clarify future strategies for workplace health promotion, possible confounders to the sleep duration/weight relationship were investigated., Method: Multivariate models were used to explore the relationship between self-reported average sleep duration and body mass index (BMI) by sequentially adding blocks of demographic, health behavior, work status, physical health, and emotional status variables. Cross-sectional data from the 2007 EADS/Augsburg (Germany) cohort follow-up study (n=1163) were used in the analysis., Results: The relationship between average sleep duration and BMI was significant (beta(St)=-0.06, p=0.04) when demographic, health behavior, and work status variables were included. When physical health and emotional status variables were added, the relationship between sleep duration and BMI did not persist., Conclusion: The relationship between employees' sleep duration and weight, if present, involves several pathways and potential confounders that should be taken into account when designing workplace health promotion programs.

Pay-for-performance (P4P) initiatives, in which provider reimbursement is linked to quality assessment, are receiving increasing attention as a possible approach to encouraging and accelerating quality improvement in America's health care systems. The potential of P4P programs, however, is constrained by the quality of data and information resources available for performance reporting. Accurate and reliable appraisal of health care quality is a challenging issue, as achieving recommended processes of care and desired health outcomes is influenced by a diverse range of interrelated factors occurring at multiple levels and arising from multiple sources within the patient encounter, health care system, and larger environment. The challenge of quality assessment is further complicated by the variable quality of data available for reporting by each provider. When data quality varies systematically among providers, a significant risk of inequity in assessment, and therefore reimbursement under P4P programs, may occur. The issue of data quality should be investigated and addressed before widespread implementation of P4P programs is pursued. Significant investment in data collection and reporting mechanisms may be required, especially in resource-limited settings, to achieve the intended effects and avoid increasing disparities in health care quality.

Objective: Secondary databases are used in descriptive studies of patient subgroups; evaluation of associations between individual characteristics and diagnosis, prognosis, and/or service utilization rates; and studies of the quality of health care delivered. This article identifies sources of bias for health state characteristics stored in secondary databases that arise from patients' encounters with health systems, highlighting sources of bias that arise from organizational and environmental factors., Study Design and Setting: Potential sources of bias, from patient access of services and diagnosis, through encoding and filing of patient information in secondary databases, are discussed. A patient presenting with acute myocardial infarction is used as an illustrative example., Results: The accuracy of health state characteristics derived from secondary databases is a function of both the quality and quantity of information collected before data entry and is dependent on complex interactions between patients, clinicians, and the structures and systems surrounding them., Conclusion: The use of health state information included in secondary databases requires that estimates of potential bias from all sources be included in the analysis and presentation of results. By making this common practice in the field, greater value can be achieved from secondary database analyses.

Sendi et al. (Soc. Sci. Med. 57 (2003) 2207) extend previous research on cost-effectiveness analysis to the evaluation of a portfolio of interventions with risky outcomes using a "second best" approach that can identify improvements in efficiency in the allocation of resources. This method, however, cannot be used to directly identify the optimal solution to the resource allocation problem. Theoretically, a stricter adherence to the foundations of portfolio theory would permit direct optimization in portfolio selection, however, when we include uncertainty in our analysis in addition to the traditional concept of risk (which is often mislabelled uncertainty) complexities are introduced that create significant hurdles in the development of practical applications of portfolio theory for health care policy decision making.