Health disparities by race in the United States have been persistent over decades and one possible reason for that could be that physicians are communicating differently with different races. The purpose of this study was to systematically review literature regarding the relationship of patient race/ethnicity with physician-patient communication. The overall project of which this is a part is a mixed methods review, but my part of the study involved only studies using observational data such as audio and video recordings of physician-patient encounters. This study investigated research that compares physician communication with patients across a wide range of ethnic groups, including multiple communication behaviors. Eighteen different content analysis-based studies were identified and analyzed. Most of the studies drew a comparison between White patients and Black patients. Physicians were more likely to use more positive affective behavior with White patients than Black patients. All of the other analyses did not show a difference by race. Overall, few studies showed whether any racial differences affect health outcomes of patients.

This thesis is a qualitative study exploring the role of case managers in the evolving Australian case management models. It represents the perspectives of front-line case managers based on their first-hand knowledge of the models’ effect on their own role as well as the perceived effects on the clients. (For complete abstract open document)

Thesis (Ph. D.)--Northeastern University, 2008. / Title from title page (viewed Feb. 27, 2009). Graduate School of Arts and Sciences, Dept. of Political Science. Includes bibliographical references (p. 302-324).

Healthcare associated infections (HAI) continue to be a significant patient safety problem. Researchers have found that nurses; perception of organizational climate is associated with patient outcomes. However, given the increased prevalence of HAI, an examination of multiple organizational factors within the healthcare organization particularly amongst infection prevention and control staff is warranted. The purpose of this study was to gain a knowledge base on the issue of HAI in acute care hospitals and the role organizational climate plays in improving clinician;s performance and ultimately decreasing HAI rates. Guided by the integrative model of organizational climate and safety conceptual framework the specific aims were to: 1) systematically review published evidence examining relationships between organizational climate, adherence to infection prevention and control processes and HAI rates in hospital settings; 2) assess the psychometric properties of an organizational climate measure, the Leading a Culture of Quality (LCQ) scale, in a national sample of Infection Preventionists (IPs); and 3) identify setting characteristics that predict a more positive perception of organizational climate by the IP and measured by the LCQ revised, using a national sample. Ten studies, mostly cross sectional design, were included in the systematic review. There was evidence that positive perceptions of organizational climate as perceived by nurses and/or an intervention aimed at improving organizational climate are associated with decreased HAI rates and adherence to evidence based guidelines. The exploratory factor analysis on the LCQ identified a four factor solution explaining 59.65% of the total variance. The Cronbach's alpha of the new subscales ranged from .74 to .90 and .93 for the final composite LCQ, the LCQ revised. The subscales are: Psychological Safety, Organizational Leadership and Work Environment, HAI Prevention/Communication and Vision/Perspective of Organization. In a sample of 1,013 IPs, relationships were found between the structural characteristics examined and organizational climate. IPs who worked in hospitals that share or pool infection prevention resources with a larger facility perceived the climate more positively among 2 subscales (Psychological Safety β = 0.113, p-value = 0.006; HAI Prevention/Communication β = 0.129, p-value = 0.005) and the overall climate (β = 0.085, p-value = 0.027). IPs in hospitals with an Infection Control Director position in the Infection Control department perceived the organizational climate more positively among 3 subscales (Psychological Safety β = 0.120, p-value = 0.005; Organizational Leadership β = 0.198, p-value = 0.000; HAI Prevention/Communication β = 0.159 , p-value = 0.001) and the overall climate (β = 0.152, p-value = 0.000). IPs working in hospitals located in a rural area as compared to urban perceived organizational climate more negatively on all 4 subscales (Psychological Safety β = -0.123, p-value = 0.001; Organizational Leadership and Work Environment β = -0.099, p-value = 0.029; HAI Prevention/Communication β = -0.168, p-value = 0.002; Vision/Perspective of Organization β = -0.179, p-value = 0.000) and the overall climate (β = -0.124, p-value = 0.001). Also, IPs working in hospitals located in a suburban area as compared to urban perceived organizational climate more negatively among HAI Prevention/Communication (β = -0.111, p-value = 0.039). These findings suggest the need for additional support and organizational resources for the infection prevention and control department. As the issue of patient safety continues to progress, particularly around HAI, concerns of how to improve organizational systems to enable implementation and adherence to safety processes should be a priority on the research agenda. This is the first study to evaluate associations between structural characteristics of the hospital setting and organizational climate via the IP perspective using a large national sample. Future research should focus on other structural variables such as IP staffing. Also, further analyses on organizational climate and outcomes such as clinician adherence to evidence based practices and HAI rates should be conducted.

The recent trend toward patients participating in their own healthcare has opened up numerous opportunities for computing research. This dissertation focuses on how technology can foster this participation, through user interfaces to effectively communicate personal health status and care progress to hospital patients. I first characterize the design space for electronic information communication to patients through field studies conducted in multiple hospital settings. These studies utilize a combination of survey instruments, and low- and high-fidelity prototypes, including a document-editing prototype through which users can view and manage clinical data to automatically associate it with progress notes. The prototype, activeNotes, includes the first known techniques supporting clinical information requests directly within a document editor. A usage study with ICU physicians at New York-Presbyterian Hospital (NYP) substantiated our design and revealed how electronic information related to patient status and care progress is derived from a typical Electronic Health Record system. Insights gained from this study informed following studies to understand how to design abstracted, plain-language views suitable for patients. We gauged both patient and physician responses to information display prototypes deployed in patient rooms for a formative study exploring their design. Following my reports on this study, I discuss the design, development and pilot evaluations of a prototype Personal Health Record application providing live, abstracted clinical information for patients at NYP. The portal, evaluated by cardiothoracic surgery patients, is the first of its kind to allow patients to capture and monitor live data related to their care. Patient use of the portal influenced the subsequent design of tools to support users in making sense of online medication information. These tools, designed with nurses and pharmacists and evaluated by cardiothoracic surgery patients at NYP, were developed using topic modeling approaches and text analysis techniques. Embodied in a prototype called Remedy, they enable rapid filtering and comparison of medication-related search results, based on a number of website features and content topics. I conclude by discussing how findings from this series of studies can help shape the ongoing design and development of patient-centered technology.

The major objective of this research was to investigate factors involved in discharge planning for terminal patients and their families where alternatives exist--home vs. institution. This was an exploratory-descriptive survey, utilizing questionnaires and telephone interviews. The respondents were 86 trained social workers from acute care hospitals and hospice units within hospitals. Data collected were analyzed quantitatively and qualitatively. The social workers who responded came from hospitals within one state, and from hospices across the country. Sampling was a two-stage process, with hospitals and hospices selected in the first stage, and social workers in the second. The major research aims were: (1) Identify the parameters of discharge plans for terminal patients, including those factors already suggested in the literature as being involved in discharge planning. (2) Specify the relative importance among factors that social workers consider in their formulation of discharge plans for terminal patients. (3) Compare differences in worker reactions to discharge planning as between the hospital and hospice settings. Most social workers felt terminal patients needed nursing services upon discharge, and doctors and nurses were important team members in discharge planning. Hospice workers were more likely than hospital workers to take patients' needs and home conditions into account. Hospice workers recognized patients' spiritual needs and considered religious personnel to be significant team members. Hospital workers saw their patients as more helpful, while hospice workers perceived their patients to be more accepting of prognosis. Although most social workers felt patients and families needed counseling around death and dying, hospice workers especially noted the need for bereavement counseling. They were more likely than hospital workers to consider the family attitude of leaving the decision of disposition to the patient. All hospice workers and many hospital workers had personal experience with family and terminal illness. Most workers preferred sending patients home to die, rather than to an institution. Plans to send patients home generated workers' feelings of competence and empathy toward their work, while plans to send patients to institutions provoked feelings of sadness, guilt, and frustration. Generally, workers believed patients were aware of their prognosis, despite their feelings that the patients were not formally told by their physicians. Principal factors influencing discharge planning were found to be the family's desire to have the patient home, financial conditions, and the patient's desire to go home.

Sometimes experts need to provide potentially upsetting advice. For example, physicians may recommend hospice for a terminally ill patient because it best meets their needs, but the patient and their family dislike this advised option. The present research examines whether regulatory non-fit could be used to improve these types of situations. The findings from eight studies in which participants imagined receiving upsetting advice from a physician demonstrate that regulatory non-fit between the form of the physician’s advice (emphasizing gains vs. avoiding losses) and the participants’ motivational orientation (promotion vs. prevention) improves participants’ evaluation of an initially disliked option. Regulatory non-fit de-intensifies participants’ initial attitudes by making them less confident in their initial judgments and motivating them to think more thoroughly about the arguments presented. Furthermore, consistent with previous research on regulatory fit, the studies show that the mechanism of regulatory non-fit differs as a function of participants’ involvement in the evaluation of the option.

Organizational change is undeniably difficult, and change efforts often fail to overcome the status quo processes and routines. By threatening these structures, change becomes an existential danger to organizations, who often respond with significant resistance. Organizations will look to their experiences with past change efforts to inform future changes, limiting the ability of change actors who seek to implement change beyond this narrow scope. The “Heart Failure Lite” model was a change effort that exceeded the scope of previous changes at an organization with deeply embedded routines and processes. This model threatened the traditional revenue streams that had benefited the organization for years. The resistance exhibited by the organization when presented with the change was consistent with the underlying theory. Although change failure is common, proactive efforts on the part of change actors can help break down the organizational barriers. Conceptual models like PARiHS can be utilized to identify the evidence supporting the change, the contextual environment in which the change will be introduced, and the facilitation efforts needed to guide the project to a successful conclusion. The “Heart Failure Lite” team failed to survey the organizational landscape and tailor the project accordingly. Therefore, the change effort failed. Shifting clinical practices toward a population health model presents a unique opportunity for healthcare organizations. A concerted effort from all stakeholders to find common ground will allow change agents to overcome the traditional barriers, and will help organizations to truly transform the delivery of healthcare services.

Compared to wealthy individuals, individuals with low socioeconomic status (SES) often receive health services of lower intensity or quality and have difficulty accessing care. This is particularly true in the area of inpatient surgery. Individuals with low socioeconomic status are often less likely than individuals associated with high socioeconomic status to receive timely surgical care, and less likely than high SES to receive evidence-based treatments for surgical care. Despite these large gaps, there is a lack of consensus whether disparities in surgical outcomes are primarily due to differences in patient characteristics such as acuity or whether they are attributable to disparities in the quality of surgical care among those with access. The overall goal of this dissertation is to illuminate the relationship between socioeconomic status and surgical outcomes. The project aims are: 1) classify trends in post-surgical quality and analyze data on the relationship between socioeconomic status and surgical outcomes; 2) to evaluate whether changes in access to care can eliminate disparities in outcomes by analyzing the impact of the Massachusetts health reform on socioeconomic disparities in inpatient surgery; and 3) to show the potential effects of SES on surgical outcomes by using the Theory of Fundamental Causes. To meet the study objectives, this study proposes to use data from the Nationwide Inpatient Sample (NIS) and the State Inpatient Database (SID). This approach uses socioeconomic information in the NIS and SID that is a quartile classification of the estimated median household income of residents in the patient’s ZIP Code. The outcomes of interest are widely used quality measures: post-surgery mortality and complications at the national level, post-surgical mortality in Massachusetts for select inpatient surgeries, and difference-in-difference estimates. The approach used to identify trends in post-surgical quality uses two analytical software products to analyze the NIS using a regression-based approach. Study findings will identify progress and gaps in the quality of inpatient surgical care over recent years and further determine whether improving access to care through policy design can eliminate or reduce disparities in surgical care outcomes. In the face of health reform, this research will offer important insight into the study of surgical disparities and potential impact following health policy changes such as the expansion of Medicaid, implementation of health insurance exchanges, and the individual mandate requiring individuals to obtain health coverage.

Thesis (Ph. D.)--Open University. BLDSC no. DX242927.