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Background Recruitment and retention are two significant barriers in research, particularly for historically underrepresented groups, including racial and ethnic minorities, patients who are low-income, or people with substance use or mental health issues. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and disproportionately affects many underrepresented groups. The lack of representation of these groups in research limits the generalizability and applicability of clinical research and results. In this paper we describe our experience and rates of recruitment and retention of underrepresented groups for the Aides in Respiration (AIR) COPD Health Coaching Study. Methods A priori design strategies included minimizing exclusion criteria, including patients in the study process, establishing partnerships with the community clinics, and ensuring that the health coaching intervention was flexible enough to accommodate patient needs. Results Challenges to recruitment included lack of spirometric data in patient records, space constraints at the clinic sites, barriers to patient access to clinic sites, lack of current patient contact information and poor patient health. Of 282 patients identified as eligible, 192 (68%) were enrolled in the study and 158 (82%) completed the study. Race, gender, educational attainment, severity of disease, health literacy, and clinic site were not associated with recruitment or retention. However, older patients were less likely to enroll in the study and patients who used home oxygen or had more than one hospitalization during the study period were less likely to complete the study. Three key strategies to maximize recruitment and retention were identified during the study: incorporating the patient perspective, partnering with the community clinics, and building patient rapport. Conclusions While the AIR study included design features to maximize the recruitment and retention of patients from underrepresented groups, additional challenges were encountered and responded to during the study. We also identified three key strategies recommended for future studies of COPD and similar conditions. Incorporating the approaches described into future studies may increase participation rates from underrepresented groups, providing results that can be more accurately applied to patients who carry a disparate burden of disease. Trial registration This trial was registered at ClinicalTrial.gov at identifier NCT02234284 on August 12, 2014. Descriptor number: 2.9 Racial, ethnic, or social disparities in lung disease and treatment.

Background Patient trust plays a central role in the patient-physician relationship. This study aimed to determine whether the number of outpatient visits with a covering rheumatologist is associated with patient trust in their usual rheumatologist. Methods Japanese adults with systemic lupus erythematosus (SLE) who met the 1997 revised classification criteria of the American College of Rheumatology and had outpatient visits with a covering rheumatologist in the past year were included. We used the 11-item Japanese version of the modified Trust in Physician Scale (range 0–100) to assess patient trust. A general linear model with cluster-robust variance estimation was used to evaluate the association between the number of outpatient visits with covering rheumatologists and the patient’s trust in their usual rheumatologist. Results Of the 515 enrolled participants, 421 patients with SLE were included in our analyses. Patients were divided into groups according to the number of outpatient visits with a covering rheumatologist in the past year as follows: no visits (59.9%; reference group), one to three visits (24.2%; low-frequency group), and four or more visits (15.9%; high-frequency group). The median Trust in Physician Scale score was 81.8 (interquartile range: 72.7–93.2). Both the low-frequency group (mean difference: -3.03; 95% confidence interval [CI] -5.93 to -0.80) and high-frequency group (mean difference: -4.17; 95% CI -7.77 to -0.58) exhibited lower trust in their usual rheumatologist. Conclusion This study revealed that the number of outpatient visits with a covering rheumatologist was associated with lower trust in a patient’s usual rheumatologist.

Trust is a fundamentally important aspect of medical treatment relationships. Studies have established that patient trust predicts instrumental variables such as use of preventive services, adherence, and continued enrollment at least as well as satisfaction does, and is more salient for measuring the quality of ongoing relationships. Measuring trust would help to inform public policy deliberations and balance market forces that threaten the doctor-patient relationship. Several validated measures could be easily included in surveys. While further studies to evaluate the cost-effectiveness of measuring trust and test interventions to improve trust are desirable, the action merits serious consideration. [PUBLICATION ABSTRACT]

In this issue of JGIM, Scuffham et al. report the results of atrial of population-based health coaching to improve disease management.1 To better understand these results, it is useful to consider the recent evolution and expansion of the role of health coaching in health care. Health coaching has been defined as a patient-centered process in which a trained coach works with a patient to identify health-related goals, providing education and working with the patient to create action plans to achieve these goals while self-monitoring behaviors to increase accountability.2

BackgroundPrevious qualitative research has described that previous misdiagnoses may reduce patient and their families’ trust in healthcare.ObjectiveTo quantify the associations between patients or family members’ misdiagnosis experiences and trust in their physician.DesignCross-sectional study.ParticipantsAdult Japanese people with non-communicable diseases (cancer, diabetes, depression, heart disease, and connective tissue disease), recruited using a web-based panel survey.Main MeasuresSurveys assessed the patient and the patient’s family’s experience with misdiagnosis. Trust in the respondent’s current physician was measured using the Japanese version of the 11-item Trust in Physician Scale.Key ResultsAmong 661 patients (response rate 30.1%), 23.2% had a personal history of misdiagnosis and 20.4% had a family history of misdiagnosis. In a multivariable-adjusted general linear model, patients or a family members’ misdiagnosis experiences were associated with lower confidence in their current physician (mean difference −4.3, 95%CI −8.1 to −0.49 and −3.2, 95%CI −6.3 to −0.05, respectively). The impact of having a personal and a family member’s experience of misdiagnosis on trust was additive, with no evidence of interaction (P for interaction = 0.494).ConclusionsThe patient’s or family members’ misdiagnosis experiences reduced trust in the patient’s current physicians. Interventions specifically targeting misdiagnosed patients are needed to restore trust.

Background Chronic obstructive pulmonary disease (COPD) severely hinders quality of life for those affected and is costly to the health care system. Care gaps in areas such as pharmacotherapy, inhaler technique, and knowledge of disease are prevalent, particularly for vulnerable populations served by community clinics. Non-professionally licensed health coaches have been shown to be an effective and cost-efficient solution in bridging care gaps and facilitating self-management for patients with other chronic diseases, but no research to date has explored their efficacy in improving care for people living with COPD. Method This is multi-site, single blinded, randomized controlled trial evaluates the efficacy of health coaches to facilitate patient self-management of disease and improve quality of life for patients with moderate to severe COPD. Spirometry, survey, and an exercise capacity test are conducted at baseline and at 9 months. A short survey is administered by phone at 3 and 6 months post-enrollment. The nine month health coaching intervention focuses on enhancing disease understanding and symptom awareness, improving use of inhalers; making personalized plans to increase physical activity, smoking cessation, or otherwise improve disease management; and facilitating care coordination. Discussion The results of this study will provide evidence regarding the efficacy and feasibility of health coaching to improve self-management and quality of life for urban underserved patients with moderate to severe COPD. Trial registration ClinicalTrials.gov identifier NCT02234284 . Registered 12 August 2014.

In the original article [1], the authors reference their intention to use the 'Morisky Medication Adherence Scale'.In the original article [1], the authors reference their intention to use the 'Morisky Medication Adherence Scale'.

Background Although self-management support improves diabetes outcomes, it is not consistently provided in health care settings strained for time and resources. One proposed solution to personnel and funding shortages is to utilize peer coaches, patients trained to provide diabetes education and support to other patients. Coaches share similar experiences about living with diabetes and are able to reach patients within and beyond the health care setting. Given the limited body of evidence that demonstrates peer coaching significantly improves chronic disease care, this present study examines the impact of peer coaching delivered in a primary care setting on diabetes outcomes. Methods/Design The aim of this multicenter, randomized control trial is to evaluate the effectiveness of utilizing peer coaches to improve clinical outcomes and self-management skills in low-income patients with poorly controlled diabetes. A total of 400 patients from six primary health centers based in San Francisco that serve primarily low-income populations will be randomized to receive peer coaching (n = 200) or usual care (n = 200) over 6 months. Patients in the peer coach group receive coaching from patients with diabetes who are trained and mentored as peer coaches. The primary outcome is change in HbA1c. Secondary outcomes include change in: systolic blood pressure, body mass index (BMI), LDL cholesterol, diabetes self-care activities, medication adherence, diabetes-related quality of life, diabetes self-efficacy, and depression. Clinical values (HbA1c, LDL cholesterol and blood pressure) and self-reported diabetes self-efficacy and self-care activities are measured at baseline and after 6 months for patients and coaches. Peer coaches are also assessed at 12 months. Discussion Patients with diabetes, who are trained as peer health coaches, are uniquely poised to provide diabetes self management support and education to patients. This study is designed to investigate the impact of peer health coaching in patients with poorly controlled diabetes. Additionally, we will assess disease outcomes in patients with well controlled diabetes who are trained and work as peer health coaches. Trial Registration ClinicalTrials.gov identifier: NCT01040806

Personal health records (PHR) may improve patients' health by providing access to and context for health information. Among patients receiving care at a safety-net HIV/AIDS clinic, we examined the hypothesis that a mental health (MH) or substance use (SU) condition represents a barrier to engagement with web-based health information, as measured by consent to participate in a trial that provided access to personal (PHR) or general (non-PHR) health information portals and by completion of baseline study surveys posted there. Participants were individually trained to access and navigate individualized online accounts and to complete study surveys. In response to need, during accrual months 4 to 12 we enhanced participant training to encourage survey completion with the help of staff. Using logistic regression models, we estimated odds ratios for study participation and for survey completion by combined MH/SU status, adjusted for levels of computer competency, on-study training, and demographics. Among 2,871 clinic patients, 70% had MH/SU conditions, with depression (38%) and methamphetamine use (17%) most commonly documented. Middle-aged patients and those with a MH/SU condition were over-represented among study participants (N = 338). Survey completion was statistically independent of MH/SU status (OR, 1.85 [95% CI, 0.93-3.66]) but tended to be higher among those with MH/SU conditions. Completion rates were low among beginner computer users, regardless of training level (<50%), but adequate among advanced users (>70%). Among patients attending a safety-net clinic, MH/SU conditions were not barriers to engagement with web-based health information. Instead, level of computer competency was useful for identifying individuals requiring substantial computer training in order to fully participate in the study. Intensive on-study training was insufficient to enable beginner computer users to complete study surveys.

ABSTRACT BACKGROUND Peer health coaching is an effective method of enhancing self-management support in patients with diabetes. It is unclear whether peer health coaching is equally beneficial to all patients with poor glycemic control, or is most effective for subgroups of patients. OBJECTIVE To examine whether the effect of peer health coaching on hemoglobin A1c (A1c) is modified by characteristics that are known to be associated with diabetes control. DESIGN Sub-group analyses of randomized control trial. PARTICIPANTS Two hundred and ninety nine patients with diabetes receiving care in public health clinics who participated in a randomized controlled trial of peer health coaches. MAIN MEASURES We examined whether the association between study group and change in A1c was modified by differences in patients’ demographic, behavioral or psychosocial characteristics. Analyses were adjusted for co-variables associated with change in A1c. KEY RESULTS The effect of coaching on patient A1c was modified by patients’ level of self-management and degree of medication adherence as baseline ( p  = .02, and p  = .03 respectively in adjusted models). For participants with “low” self-management (one standard deviation below the mean score), the usual care group experienced a slight increase in A1c (0.3 %), while the health coaching group experienced a decrease (−0.9 %). For participants with “high” self-management (one standard deviation above the mean score), both groups experienced a similar decrease in A1c (usual care group: -1.0 %; health coaching group: −1.1 %). Participants with “low” medication adherence in the usual care group experienced an increase in A1c (0.5 %), while the health coaching group experienced a decrease (−0.8 %). Participants with “high” medication adherence experienced similar decreases (usual care group: −1.1 %; health coaching group: −1.3 %). CONCLUSION Peer health coaching had a larger effect on lowering A1c in patients with low levels of medication adherence and self-management support than in patients with higher levels. Peer health coaching interventions may be most effective if targeted to high-risk patients with diabetes with poor glycemic control and with poor self-management and medication adherence.