No abstract

Background: Chronic pain poses numerous challenges for patients and providers, particularly when opioid treatment is discussed. Despite accounts of antagonistic patient-provider communication, little is known about how communication about opioids unfolds during clinic visits and, importantly, how the relationship history of a patient and physician shapes this communication. This study's objective was to advance understanding of communication about opioid treatment by recording primary care clinic visits and conducting in-depth interviews with patients to gain insight into the patient-provider relationship and its influence on clinical communication. Methods: Forty patients with chronic pain were audio recorded during their primary care clinic appointments and then interviewed about their pain care and relationships with their providers. Ten patients were excluded from analysis because pain was not discussed during the clinic visit. Results: Qualitative analysis revealed that patients responded in markedly different ways to similar physician treatment decisions about opioids. Some patients attributed limiting or denying opioids to physicians' distrust or lack of caring. Others attributed these limitations to acting out of genuine concern for patients' health. These attributions appeared to be shaped by features of the patient-physician relationship as described by patients. Results are discussed within the framework of attribution theory. Conclusions: Understanding how patients and providers discuss opioid treatment is critical for optimal pain treatment. Physicians might be able to improve communication by re-framing treatment discussions about opioids around external factors, such as benefits and harms, and engaging in communication that fosters a strong therapeutic alliance and emphasizes concern for the patient.

Competing demands of primary care practice, differing beliefs about pain, and uncertainties about the appropriate place of opioid therapy in chronic pain management likely contributed to the identified tensions. Several clinical communication strategies to help PCPs mitigate and manage pain-related tensions are discussed.

No abstract

Since 2008, the American College of Sports Medicine (ACSM) American Fitness Index program has provided data, materials, resources, and connections to help city officials, public health professionals, and community-based organizations assess the fitness of their residents, identify opportunities to improve health outcomes, and enable physically active lifestyles. The purpose of this article was to describe the development and methods used to create the annual scores and rankings for the Fitness Index. Fitness Index indicators were originally selected by ACSM content experts and other nationally recognized fitness experts who understood the importance of community assets to improve health behaviors and outcomes. Indicator values for the 100 largest US cities were gathered from reputable, regularly updated, publicly available data sources. Indicator values for the cities were ranked, weighted, and combined into a personal health subscore, a community/environment subscore, and a total score that were then ranked from the most fit (rank 1) to least fit (rank 100) cities. Fitness Index indicators are reviewed by ACSM content experts and updated annually to ensure the Fitness Index stays true to its goal. Strengths of the Fitness Index include the use of multiple indicators related to the health and behaviors of residents as well as community assets and policies. Some data limitations for the Fitness Index include sample variability from year to year, use of self-reported survey data with well-known biases and variability, and lack of availability of important data indicators. The annual summary report suggests how these rankings and data can be translated into action within cities. Additional resources for the American Fitness Index, including an interactive tool that allows comparison of indicator values among cities, are available online.

This study explored the relationship between race and two key aspects of patient engagementpatient activation and working alliance -among a sample of African-American and White veterans (N=152) seeking medication management for mental health conditions. After adjusting for demographics, race was significantly associated with patient activation, working alliance, and medication adherence scores. Patient activation was also associated with working alliance. These results provide support for the consideration of race and ethnicity in facilitating patient engagement and patient activation in mental healthcare. Minority patients may benefit from targeted efforts to improve their active engagement in mental healthcare.

We assessed guideline adherence in incident NDBE in a VA-based study.

IMPORTANCE The recommendations about antithrombotic medication use after bioprosthetic aortic valve replacement (bAVR) vary. OBJECTIVES To describe the post-bAVR antithrombotic medication practice across the Veterans Health Administration (VHA) and to assess the association between antithrombotic strategies and post-bAVR outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study. Multivariable modeling with propensity scores was conducted to adjust for differences in patient characteristics across the 3 most common antithrombotic medication strategies (aspirin plus warfarin sodium, aspirin only, and dual antiplatelets). Text mining of notes was used to identify the patients with bAVR (fiscal years 2005-2015). MAIN OUTCOMES AND MEASURES This study used VHA and non-VHA outpatient pharmacy data and text notes to classify the following antithrombotic medications prescribed within 1 week after discharge from the bAVR hospitalization: aspirin plus warfarin, aspirin only, dual antiplatelets, no antithrombotics, other only, and warfarin only. The 90-day outcomes included all-cause mortality, thromboembolism risk, and bleeding events. Outcomes were identified using primary diagnosis codes from emergency department visits or hospital admissions. RESULTS The cohort included 9060 veterans with bAVR at 47 facilities (mean [SD] age, 69.3 [8.8] years; 98.6% male). The number of bAVR procedures per year increased from 610 in fiscal year 2005 to 1072 in fiscal year 2015. The most commonly prescribed antithrombotic strategy was aspirin only (4240 [46.8%]), followed by aspirin plus warfarin (1638 [18.1%]), no antithrombotics (1451 [16.0%]), dual antiplatelets (1010 [11.1%]), warfarin only (439 [4.8%]), and other only (282 [3.1%]). Facility variation in antithrombotic prescription patterns was observed. During the 90-day post-bAVR period, adverse events were uncommon, including all-cause mortality in 127 (1.4%), thromboembolism risk in 142 (1.6%), and bleeding events in 149 (1.6%). No differences in 90-day mortality or thromboembolism were identified across the 3 antithrombotic medication groups in either the unadjusted or adjusted models. Patients receiving the combination of aspirin plus warfarin had higher odds of bleeding than patients receiving aspirin only in the unadjusted analysis (odds ratio, 2.58; 95% CI, 1.71-3.89) and after full risk adjustment (adjusted odds ratio, 1.92; 95% CI, 1.17-3.14). CONCLUSIONS AND RELEVANCE These data demonstrate that bAVR procedures are increasingly being performed in VHA facilities and that aspirin only was the most commonly used antithrombotic medication strategy after bAVR. The risk-adjusted results suggest that the combination of aspirin plus warfarin does not improve either all-cause mortality or thromboembolism risk but increases the risk of bleeding events compared with aspirin only.