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Health Services Research & Development

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2012 HSR&D/QUERI National Conference Abstract

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2012 National Meeting

3074 — Dropped Cues and Missed Referrals: Talk of Primary Care Providers and Veterans with Poorly Controlled Diabetes

Pope CA, and North-Lee B, Ralph H. Johnson VA Medical Center; Davis BH, University of North Carolina at Charlotte;

Though studies show patient-provider communication (PPC) to be associated with diabetes outcomes, the specific communication practices that characterize interactions with persons who have poorly controlled diabetes have not been specifically identified for intervention. Since poor communication in diabetes encounters has been associated with a 19% higher rate of non-adherence, ways of speaking when providers in Primary Care speak with Veterans require closer examination. This mixed methods research study will: 1) examine racial disparities in Veterans with poorly controlled diabetes; and 2) apply linguistic qualitative methodology to demonstrate particular communication practices associated with PPC for a specific cohort of Veterans from a larger VA study with high A1cs >9.

From a larger study of 100 Black and 100 White Veterans with Type 2 diabetes, typical primary care patient-provider visits were recorded and transcribed for analysis. For intervention development, 32 Veterans with the highest A1cs (greater than 9) were selected from the sample and examined for racial differences, type and frequency of referrals, and scored for shared decision-making. Using discourse analysis, 3 coders classified communication practices associated with engagement, types of questions, provider identification, and response to Veterans’ cues, Veteran participation, topic maintenance and management, positioning, and agency. Particular patterns were identified and confirmed.

Though a small sample in which 69% of patients were Black and 31% were White, suggestive trends marked the referrals that Black and White Veterans received. The predominant pattern of questions relied on yes-no and close-ended types that restricted the topics and how they were managed. Providers relied on particular monologues cataloged as types of scripts (example: medication dosage listing, food lectures), often with little Veteran participation. Veterans who offered questions or concerns often had cues bypassed. Examples from interactions will show how providers displaced Veteran agency and how often Veterans accepted diminished personal agency or buffered its loss with humor.

Results offer the basis for future intervention to improve PPC in discussions of diabetes self-management.

Expanding the work of Street and colleagues (2007), findings point to the identification of specific communication practices that, if changed, would promote more patient-centered care and shared decision-making.

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