Analyzing Patient-Provider Communication to Understand Disparities in HIV Care

这项研究的长期目标是了解患者与提供者之间的沟通差异 影响艾滋病毒携带者接受护理方面的差距。这一知识将有助于发展 以证据为基础的干预措施，包括患者和提供者，以消除这些差异。 白人和非白人之间在艾滋病毒护理方面存在着各种类型的差异， 包括对患者可能最重要的是什么，启动和坚持 艾滋病毒抗逆转录病毒药物(ARV)。这些差距有许多根本原因，包括护理制度 获得机会、对治疗价值的偏好或信念的差异以及对污名化的偏见 注射吸毒者等群体。 这些差异的一个重要来源可能是患者-提供者的性质和质量的差异 沟通，这是一个很少受到艾滋病毒研究人员关注的话题。为了填补这一空白，我们开发了 并验证了一种新的方法来编码和分析艾滋病毒护理中患者与提供者互动的录音带， 通用医学相互作用分析系统(GMIAS)。这种编码系统的一个独特特征是它可以 描述患者-提供者对话中与抗逆转录病毒药物依从性特别相关的话语。 我们建议使用GMIAS来分析收集到的435例HIV感染者的患者-提供者访问的记录 来自巴尔的摩、纽约、底特律和波特兰4个不同护理地点的45名医生，作为 一项现有的研究。从参与的医生诊所中抽取的患者中，大约有一半 其中一半是白人，一半是非白人，这便于医生内部对种族差异的比较。 利用GMIAS编码系统，我们提出了以下具体目标：1)比较通用模式 白人和非白人患者之间的患者-提供者沟通，2)比较抗逆转录病毒相关的依从性 白人和非白人患者之间的对话，3)使用方差分量分析，确定如何进行方差 以患者为中心在患者和提供者之间进行划分，以及4)决定一年内是否感染艾滋病毒 结果(病毒载量和CD4计数的变化)在黑人和白人之间不同，以及在多大程度上 总体上和依从性特定对话质量的差异解释了艾滋病毒结果的差异。 这项研究与公共卫生的相关性在于，消除与以下方面相关的护理差异的努力 种族/族裔将需要关于这些差异的来源的更好的数据。这项研究的结果将有助于 我们更好地了解患者-提供者对话如何有助于艾滋病毒护理中的这些差异，并提供 消除这些差距的努力亟需证据基础。项目叙事 虽然感染艾滋病毒的白人和非白人之间的护理存在重大差异，但 有记录，包括抗逆转录病毒治疗接受率的差异，这些差异的来源是 人们对此知之甚少。该项目将使用一种新的方法来编码和分析供应商的录音带 沟通以了解患者与提供者的对话如何因种族和民族而不同。的一个独特功能 这种新的编码方法允许对抗逆转录病毒药物依从性进行详细评估。

The long-term objective of this research is to understand how differences in patient-provider communication affect disparities in the care received by persons with HIV. This knowledge will facilitate the development of evidence based interventions, with both patient and providers, to eliminate these disparities. A variety of types of disparities in HIV care between whites and non-whites have been demonstrated, including what may be the most consequential for patients, disparities in rates of initiation of and adhering to HIV antiretroviral medications (ARVs). These disparities have many root causes, including care system access, differences in preferences or beliefs about the value of treatments, and bias against stigmatized groups such as injection drug users. An important source of these disparities may be differences in the nature and quality of patient-provider communication, a topic which has received little attention from HIV researchers. To fill this gap, we developed and validated a new method to code and analysis audiotapes of patient-provider interactions in HIV care, the General Medical Interaction Analysis System (GMIAS). A unique feature of this coding system is that it can characterize utterances in patient-provider dialog that are specifically related to ARV medication adherence. We propose to use GMIAS to analyze transcripts of 435 patient-provider visits for persons with HIV collected from 45 physicians practicing at 4 different care sites in Baltimore, New York, Detroit, and Portland as part of an existing study. Patients were sampled from participating physicians' practice such that approximately half were white and half were non-white, which facilitates within-physician comparisons of racial differences. Using the GMIAS coding system, we propose the following specific aims: 1) Compare general patterns of patient-provider communication between white and non-white patients, 2) Compare ARV related adherence dialog between white and non-white patients, 3) Determine, using variance components analysis, how variance in patient-centeredness is partitioned between patients and providers, and 4) Determine whether 1-year HIV outcomes (changes in viral loads and CD4 counts) differ between blacks and whites, and the extent to which differences in overall and adherence specific dialog quality explain differences in HIV outcomes. The relevance of this research to public health is that efforts to eliminate disparities in care related to race/ethnicity will require better data about the sources of those disparities. The results of this study will help us better understand how patient-provider dialog contributes to these disparities in HIV care, and provide a much needed evidence base for efforts to eliminate these disparities. Project Narrative While important disparities between the care received by whites and non-whites with HIV infection have been documented, including differences in rates of receipt of antiretroviral therapy, the source of these disparities is poorly understood. This project will use a new method to code and analyze audiotapes of provider communication to understand how patient-provider dialogue differs by race and ethnicity. A unique feature of this new coding method is that it permits detailed assessment of antiretroviral medication adherence.