Pre-visit Assessment of Patient
Agendas & Their Discussion in a
Clinic Visit: An RCT
Academy of Health - 2009
Betty Chewning PhD1, Betsy Sleath PhD2, Carolyn Bell MD,
Kevin McKown MD, Morris Weinberger PhD, Brenda and
Bob Devellis PhD, Dave Kreling PhD, Rich Van Koningsveld
MS, Dale Wilson, MA
Funded by National Institute of Aging, NIH AG-18362
1University
of Wisconsin School of Pharmacy & Sonderegger Research Center
2University of North Carolina, School of Pharmacy & Sheps Center
Significance

Unvoiced patient (Pt) agendas & incomplete
attention to agendas has been documented widely
Particularly for psychosocial issues (Greene et al, 1989)
 Older adults may be less active (Kaplan et al, 1995).


Goal: To increase MD attention to Pt health
priorities in way that cues Pt & MD to discuss in
midst of increasing time pressures
Goals Today:


Present results of a computer assisted
intervention (CAI) to increase discussion of Pt
priorities in rheumatology clinic visits
Discuss implications for future research and
health care organizations
Study Design

Longitudinal, RCT (baseline, 6-mo, 12-mo)


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After baseline Pts randomized Within MD for
computer assessment at 6-mo & 12-mo visits
(C) Control group had CAI lifestyle assessment
(E) Experimental group had CAI priority assessment
of top 3 health priorities to improve 30 days
Pts and MD’s received summary printouts for both
Study Design

(C) Printout listed lifestyle status with respect to:

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Veggies, fruit, seatbelt, tobacco, alcohol use.
(E) Printout listed top 3 priorities for improvement
(E) Pt Agendas – AIMS2

(Meenan et al, 1990)
Computer asked: In the next month what 3 areas of your
health would you most like to improve? (subscales within
AIMS2)
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




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Mobility
Hand finger function
Arm function
Walking/bending
Pain
Family support
Social Activity
Mood
Tension
Self Care
Work
Household tasks
Fatigue * - Added as non-AIMS2
Sample

6 rheumatology clinics in Wisconsin & North
Carolina

18 rheumatologists

440 patients >44 years of age, RA diagnosis
91 % approached agreed to participate
 73 % retained one year for observations

Data Collection
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Baseline, 6-mo, 12-mo data collected
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Audiotaped & coded all encounters
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Topics discussed at visit
Pts surveyed post-visit at clinic visits
Recalled pre-visit health priorities
 AIMS 2 health status for each domain
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Collected Pt computer assessments
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Pre-visit health priorities
Inter-Rater Reliability of Discussion Events
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7+ coders in two locations; bi-weekly calls
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Inter-Rater Reliability of Tape Coding High (Kappa)

.76-.95 Were the patient’s top priorities for improvement
(AIMS2 items) discussed in the visit?
Sample Demographics

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Women:
76%
White:
87%
Mean Age:
62
Education:
42% H S or less
Mean Income: <$40,000.
Health Concerns Discussed Baseline
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Pain discussed often (98% visits)
Walk/ bend (50%); Hand/finger function (21%); Work
(21%); Household tasks (20%); Fatigue (20%)
Mobility (7.1%); Arm (6%); Mood (4.5%) Social
activities (3%); Tension (2.1%)
Self Care & Support discussed rarely (< 1% visits)
Compared 3 Printout Groups For
Each AIMS2 Priority Area
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Group 1: (E1) Printout says Pt wants to improve X
target priority domain in next 30 days.
Group 2: (E2) Printout says Pt wants to improve other
health domains, but NOT the X target priority domain.
Group 3: (Control) Printout summarizes lifestyle issues,
NOT health domain priorities Pt wants to improve
% Taped Visits Discussed Mood
Example:
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(E) Baseline (226):
No cue = 5.8% visits
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(C) Baseline (214)
No cue = 3.3% visits
(E) 12-Mo (155)=19%
 (C) 12-Mo (166)=3%
Cued Priority = 56% visits
No cue = 3% visits:
(9/16 visits)
(5/166 visits)
Not Cued P = 13% visits:
(21/134 visits)
Analyzed Probability That Topic
Discussed For 3 Groups

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Predicted probability separately that each of AIMS
topics was discussed separately at visit (Logistic Regression)
Tracked experimental & control groups

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Divided experimental groups by whether topic was cued as a
pre-visit priority or not at the 6-mo (T1) or 12-mo (T2) visit
Model probabilities adjusted for clinic differences & Pt
AIMS dimension score at time of visit; baseline score
referent
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Cases insufficient to model 3 psycho-social domains
discussed rarely and also pain discussed almost all the time
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Graph Key:
+ <.10;
*< .05;
** <.01
Probability Mood Discussed by 3
Groups at Baseline, 6-mo, 12-mo
30
Percent
Probability Mood Discussed
40
22.9
19.6
20
EXP Mood Priority
EXP Mood Not Priority
Control Not Cued
8.8
10
0
4.5
1.6
3.3
T0
T6
10.5
4
T12
Hand-Finger
Arm Function
60
60
40
35.4 *
30
23
21.9
21
15.5
10
Percent
Percent
44.5 **
40
20
51.8 **
50
50
33 **
30
21.9
20
17.6
10
6.8
6
0
0
TO
T1
TO
T2
80
30
5
13.1
12.7
12.7
50
Percent
Percent
19.3+
T2
40
50.1
46.4
43.1
47.9
46.9
40.8
38.4
30
20
6.7
6.2
7.1
T1
60
22.4 **
10
2.7
73.1 **
70
20
15
8
Walk Bend
Mobility
25
6.2
5.7
10
0
0
TO
T1
T2
EXP not Priority
EXP Priority
Control Not Cued
TO
T1
T2
Household Tasks
Fatigue
40
37.2 **
50
41.8 +
30
20
20.2
17.8
15.9
15.8
10
20.1
12.1
17.9
20.6
14.1
0
T1
T2
TO
T1
T2
Work
Social
80
30
72.9 *
70
25
17.3 *
15
10
5.6
3
2.8
TO
EXP not Priority
7.2
5.2
3.4
T1
EXP Priority
Percent
60
21.7 +
20
Percent
21.3
19.7
8.2
TO
0
21.7
20
10
0
5
33.4 **
30
Percent
Percent
40
50
40
30
20
27.8
20.6
21.5
19.8
19.2
10
18.9
17
0
T2
Control Not Cued
TO
T1
T2
Found Overall Trend
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Probability to discuss most AIMS domains
higher at 6-mo or 12-mo if printout listed
domain as Pt priority
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For 6 of 9 domains it was true for both 6-mo and
12-mo visit
In general Experimental group Pts without
priority listed on their printout trended toward
similar probabilities as the control group
Limitations

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Study conducted with RA Pts only
Study conducted with specialists; need primary care
provider study
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Two states
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Small sample Pts:
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Dividing E groups limited sample for infrequent priorities
In Summary
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Some Pt health topics discussed frequently; some
discussed rarely regardless of whether a Pt priority
Insufficient to depend on CAI cue alone to raise
topics
CAI assessment & printout increased probability
discussing Pt’s health priorities esp Mood (Note:
tobacco also)
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Easily transferrable and inexpensive
Feasible to implement prior to visit
Accepted and found useful by patients and physicians
Next Research/ Analysis

Analyzing intervention & discussion of
priorities in relation to:
Outcomes (pain, HQOL, mood, self efficacy,
helplessness)
 Pt characteristics
 Encounter characteristics

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RCT - larger Pt sample with mood issues

Plan to use a depression screener for eligibility
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THANK YOU to all of our patients, physicians
and colleagues who collaborated on this project.
Questions/ Suggestions!
Other Domains Besides Mood
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If Pt reported domain was priority, probability it would be
discussed was significantly higher (predicted by regression with covariates clinic,
AIMs-2 scale score same time, baseline discussion score is referent)
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Arm/Shoulder
(6 mo P<.001; 12 mo P< .002)
Fatigue (no AIMS) (6 mo P<.014; 12 mo P< .006)
Hand/Finger
(6 mo P<.002; 12 mo P< .04)
Social Activities
(6 mo P<.032; 12 mo P< .03)
Mobility
(6 mo P<.01; 12 mo P< .11)
Walk/Bend
(6 mo P<.007)
Household
(12 mo P< .063)
Work
(12 mo P<.045)
Pain
(discussed usually)
Self care, support, tension (very rare priority/discussion)