Analyzing Patient-Provider Communication to Understand Disparities in HIV Care

描述（由申请人提供）：本研究的长期目标是了解患者-提供者沟通的差异如何影响艾滋病毒感染者接受护理的差异。这些知识将促进基于证据的干预措施的发展，与患者和提供者一起，减少或消除这些差异。白人和非白人之间在艾滋病毒护理方面存在各种类型的差异，包括可能对患者最重要的因素，即开始和坚持艾滋病毒抗逆转录病毒治疗（ART）的比例差异。这些差异有许多根本原因，包括保健系统的可及性、对治疗价值的偏好或信念的差异，以及对注射吸毒者等被污名化群体的偏见。这些差异的一个重要来源可能是患者-提供者沟通的性质和质量的差异，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，我们开发并验证了一种新的方法来编码和分析艾滋病护理中患者与提供者互动的录音带，即通用医疗互动分析系统（GMIAS）。该编码系统的一个独特之处在于，它可以表征患者-提供者对话中与抗逆转录病毒治疗依从性具体相关的话语。我们建议使用GMIAS来分析437名HIV感染者的患者-提供者访问记录，这些记录是现有研究的一部分，来自巴尔的摩、纽约、底特律和波特兰4个不同护理点的45名医生。患者从参与医生的实践中抽样，大约一半是白人，一半是非白人，这有助于在医生内部比较种族/民族差异。使用GMIAS编码系统，我们提出以下具体目标：1)比较白人，黑人和西班牙裔患者之间患者-提供者沟通的一般模式；2)比较白人，黑人和西班牙裔患者之间与ARV相关的依从性对话；3)使用方差成分分析确定患者和提供者之间以患者为中心的差异是如何划分的。此外，我们将进行探索性分析，以确定1年的临床结果（血清HIV病毒RNA和CD4计数的变化）在黑人、西班牙裔和白人之间是否存在差异，以及总体和依从性特定对话质量的差异在多大程度上解释了这些结果的差异。这项研究与公共卫生的相关性在于，消除与种族/族裔有关的护理差异的努力将需要有关这些差异来源的更好数据。本研究的结果将帮助我们更好地了解患者-提供者对话如何导致艾滋病毒护理中的这些差异，并为医学生、研究生实习生、执业医生、其他卫生专业人员和患者的干预措施提供急需的证据基础，以消除这些差异。

DESCRIPTION (provided by applicant): 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 reduce or 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 therapy (ART). 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 ART adherence. We propose to use GMIAS to analyze transcripts of 437 patient-provider visits for persons with HIV collected as part of an existing study from 45 physicians practicing at 4 different care sites in Baltimore, New York, Detroit, and Portland. 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/ethnic differences. Using the GMIAS coding system, we propose the following specific aims: 1) Compare general patterns of patient-provider communication between white, black, and Hispanic patients, 2) Compare ARV related adherence dialog between white, black, and Hispanic patients, and 3) Determine, using variance components analysis, how variance in patient-centeredness is partitioned between patients and providers. In addition, we will conduct exploratory analyses to determine whether 1-year clinical outcomes (changes in serum HIV viral RNA and CD4 counts) differ between blacks, Hispanics, and whites, and the extent to which differences in overall and adherence specific dialog quality explain differences in these 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 interventions with medical students, post-graduate trainees, practicing physicians, other health professionals, and patients to eliminate these disparities. PUBLIC HEALTH RELEVANCE 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 analyze audiotapes of routine office visits to understand how patient-provider dialogue differs by race and ethnicity. Findings from this work will guide the development of interventions to reduce disparities in HIV care.