UNDERSTANDING TEAM-BASED QUALITY IMPROVEMENT FOR DEPRESSION IN PRIMARY CARE. L.V. Rubenstein 1 , L.E. Parker 2 , L.S. Meredith 2 , N.P. Gordon 3 ; 1 VA Greater Los Angeles, RAND and UCLA, Sepulveda, CA; 2 RAND, Santa Monica, CA; 3 Kaiser Permanente Division of Research, Oakland, CA PURPOSE: Team-based quality improvement (QI) methods are an attractive option for designing and implementing improvements in depression care in primary care (PC) practices. QI methods experts disagree, however, about whether teams should be centralized (the CT approach), or local (the LT approach). In CTs a few key experts, with input from local clinicians based in the target practice sites, are responsible for developing the QI intervention design. In LTs the local clinicians develop the QI design through on-site interdisciplinary team meetings. The qualitative analyses presented here compare the success of the two approaches and evaluate the characteristics of teams and organizational environments that affect success. METHODS: We partnered with two non-profit staff model managed care organizations ± VA Greater Los Angeles and Kaiser Permanente of Northern California ± to initiate and evaluate five QI teams tasked with improving care for depression. Teams were structured as either CTs or LTs. The three LTs involved three PC practices and the two CTs involved three PC practices. Trained observers transcribed process notes during all team meetings, and carried out structured interviews with team and clinical practice leaders and members at one and two years. Three social scientists with qualitative expertise independently reviewed all study data and rated teams. Six national depression experts independently rated team QI designs (plans). Analysis of team success used qualitative predictor-outcome matrices. RESULTS: The two CTs ranked higher for depression program planning than two of the three LTs, but one LT received equivalently high ratings. Across all teams, team leadership and primary care and mental health top management support for depression QI had the most effect on plan quality and implementation. CTs, however, had better success than LTs in less supportive environments. For example, PC top management for one of the two PC practices linked to one CT was relatively unsupportive, as was mental health top management for the practice linked to the other CT; the two CTs did better than the two LTs that were based in similarly low support organizational environments. The one LT with favorable team leadership and organizational environment did as well as the best performing CT. CONCLUSION: CT and LT approaches have equivalent success when team leadership and organizational support are strong, while CTs have better success than LTs in less supportive environments. Our results suggest that depression QI approaches that depend on local interdisciplinary team design and implementation should be reserved for favorable organizational environments. Less favorable environments are likely to be better served by a more centralized, expert directed QI approach. PURPOSE: Patients fail to recall and comprehend as many as half of the critical pieces of information conveyed during a clinical encounter. To maximize patients' recall, understanding, and ultimately their treatment adherence, it is recommended that clinicians limit the number of new concepts they present and always elicit patients' comprehension of these points. This educational technique may be particularly important for patients with low functional health literacy (FHL) and chronic conditions such as type 2 diabetes (DM2), since these patients grapple with complex clinical management regimens and often have difficulties processing oral communication. In this study, we measured the extent to which primary care physicians (PCPs) assess these patients' recall and comprehension of their advice. METHODS: The study was conducted in primary care centers at a public hospital. Outpatient encounters between 30 English-speaking, DM2 patients with low FHL (score < 23 on shortform Test of Functional Health Literacy) and 22 PCPs were audiotaped. 2 trained coders measured the duration of each encounter, and identified the following communication events: (1) new concepts raised by physicians (such as an explanation of how blood pressure affects the kidneys, or a change in medication regimen); and (2) whether each new concept was followed up by the physician with an attempt to ensure that patients comprehended the key points, e.g. by a request for patient restatements, or eliciting patient perceptions. The percentage of new concepts for which follow-up assessments occurred was then calculated. RESULTS: The mean number of new concepts conveyed by PCPs was 2.0 (range 0 ± 5). The mean number of follow-up assessments was 0.27 (range 0 ± 2) or 13%; in over half of these assessments the patient did not recall or comprehend the new concept, allowing the PCP to tailor subsequent information. Visits including one or more follow-up assessments did not differ in duration when compared to visits that lacked such follow-up (18 vs. 21 min, p=0.2). CONCLUSION: The vast majority of PCPs caring for DM2 patients with low FHL do not assess patient recall or comprehension of new concepts conveyed during the clinical encounter. Overlooking this critical step in the communication process reflects a missed opportunity to enhance patient care. Future studies should evaluate whether more consistent application of this communication technique improves patient recall, adherence, and health outcomes. PURPOSE: Breakdown can be described as a disruption in smooth unreflective practice that forces an individual to adopt a more explicit, deliberate and abstract perspective. This study examined a series of breakdowns in an ambulatory medical clinic. It examined the response of residents to these breakdowns and its effect on patient care and learning. METHODS: Trained observers collected ethnographic data from waiting areas, workstations and exam rooms. Real-time field notes from sixty-eight separate observations (total 130 hours) were immediately transcribed into the data set, 2919 paragraphs of text. Two analysts coded text units at the paragraph level into recurrent themes using template analysis. Breakdown emerged as the major theme, and was fine coded at the phrase level to create a taxonomy. Using this taxonomy, 156 vignettes were selected to represent the full spectrum of breakdown. Recursive analysis of the vignettes was used to create a structural model of breakdown and learning. Triangulation and member checking were used to validate the model. RESULTS: Breakdown occurred in 1255 (43%) of the text units, and was clearly important for learning. Breakdowns occurred both from individual actions and from clinic structure and process. Preliminary results indicate that the computer-based patient record is an important source of breakdown; it interferes with communication and structures the interview, more so for residents than for faculty. The structural model of breakdown has three levels: psychomotor, conceptual and cultural. Breakdown begins at the psychomotor level of automatic behaviors (e.g., withdrawal in response to patient anger). If the breakdown persists, it moves to the conceptual level, where models are shared to determine correct action. At conceptual level, breakdowns often involve heuristic biases (e.g., favor curable diagnoses over chronic ones). Unresolved breakdowns become obtrusive and progress to the cultural level, where the entire process of norms, concepts, actions and consequences are reflected upon. At the cultural level, breakdowns reflect failure to engage with cultural norms. CONCLUSION: Our observations reinforce previous research that indicates a need to provide time and training for communication, cognitive and reflective skills. In addition, new heuristic biases are described, and problems arising from physician interface with computer-based patient records may have implications for clinic structure, process and training needs. Finally, the data suggest a need to align norms, expectations and resources. PURPOSE: Surrogates are often entrusted to make decisions regarding cardiopulmonary resuscitation (CPR) for patients who lack decision making capacity. Not infrequently, surrogates refuse to authorize Do-Not-Resuscitate (DNR) orders, even when clinicians deem CPR futile in a strict biomedical sense. Few states besides NY have legislation to address these cases. In NY, patients or surrogates must generally sign complex DNR consent forms. However, by statute, NY physicians also have the authority to write DNR orders over the objections of surrogates. Before writing such an order, a physician must conduct a``dispute mediation'' meeting with the patient's surrogates. The purpose of this paper is to provide a description and moral analysis of a series of such cases. METHODS: We present a case series of 6 dispute mediation meetings in which surrogates refused to sign for DNR orders when clinicians thought CPR was futile, convened and moderated by the ethics consult service of a single academic medical center. We use casuistic moral analysis to compare what occurred in these cases with the paradigmatic practice of requiring surrogates to provide substituted judgments and to give formal consent for DNR orders. RESULTS: The average patient age in our series was 60. Two of these patients were from nonwhite minority groups, 1 from a recent white immigrant group, 2 had malignancies, 2 had HIV, and 2 had cardiovascular disease. In all 6 cases, surrogates expressed their refusals to sign DNR orders in similar terms. Some voiced religious concerns; others``could not give up hope.'' In 5/6 cases the surrogates refused to sign the DNR order form even after the dispute mediation meeting. Nonetheless, DNR orders were written in all 6 cases with the implicit assent of the surrogates even in the absence of formal consent. After being told that DNR orders would be written even over their objections, surrogates' comments included:``Well, you gotta do what you gotta do.''``I no make decision. Doctor decision.''``I know he is dying. Just don't make me sign. I feel like I'm signing a death warrant.'' A psychiatrist involved in 3 of these cases noted denial, anxiety, pathological ambivalence, and guilt in the surrogates. No attempts were made by surrogates to transfer the patients to other physicians or facilities. All of the patients expired within one week. To date, no lawsuits have occurred. CONCLUSION: These cases suggest that what appear to be``futility'' disputes may in fact represent the complex emotional states that surrogates experience when they believe that they are responsible for making these decisions. All of the surrogates seemed relieved when they were told that a DNR order would be written regardless of whether they had chosen to`sign' the formal document. These cases raise questions for policy and clinical ethics about the extent to which asking surrogates to consent to DNR when CPR is futile imposes unnecessary burdens and no benefits for either patients or their surrogates. PURPOSE: A variety of factors influence clinical ethical decision-making by physicians. The process by which physicians weigh these many factors against one another in order to make a treatment decision is poorly understood and documented. This study examines the influential factors involved in clinical ethical decision-making by using Q Sort by-person factor analysis. METHODS: A convenience sample of internal medicine attending physicians and housestaff (n = 35) at a university affiliated medical center were presented with a series of four hypothetical case vignettes and asked to select a specific treatment action for each case. Case vignettes involved clinical decision-making near the end-of-life. Based on the selected treatment action, participants arranged twenty-five self-referenced opinion items into a unique quasi-normal factor array according to a continuum of preferences from most to least salient. Q sort factor analysis was performed by means of standard factor extraction whereby individuals with correlated Q sorts are clustered into homogenous attitude groups. A second order factor analysis was used to cluster factors to reveal their underlying commonalities. Subjective interpretation of the salient factors in relation to the specific clinical case scenario was performed in order to explain the different ethical perspectives utilized in clinical ethical decision-making. RESULTS: Data analysis revealed four non-correlated salient factors which guided ethical decision making in the four hypothetical cases. The primary salient factors were defined by the perspectives of: 1) beneficence, 2) patient guided decision-making, 3) patient and family focused decision-making, and 4) legally guided decision-making. Normalized factor scores for statements included in each viewpoint had a Z score > 1.00. Non-influential statements noted across all four cases were the economic impact on the physician, expediency in resolving the situation, and the expense of medical treatment (Z < À1.00). CONCLUSION: Q sort factor analysis is a useful tool with which to study clinical ethical decision-making because it provides an analytical method for discerning salient factors selfidentified by physicians in making ethically-challenging treatment decisions. The four factors identified are grounded in current bioethical values. METHODS: A convenience sample of internal medicine attending physicians and housestaff (n = 35) at a university affiliated medical center were presented a series of four hypothetical case vignettes involving clinical decision making near the end of life, and were asked to choose between aggressive, conservative, and consultative courses of action. An aggressive course of action was one in which medical and/or surgical treatment was pursued in spite of poor prognostic outcome. A conservative course of action was a treatment decision that withdrew medical therapy and instituted palliative treatment. A consultative course of action was defined by a request for information and guidance from an ethics committee or family members. RESULTS: Twenty percent (7/35) of respondents demonstrated a consistent pattern of clinical course of action by choosing either an aggressive, conservative, or consultation course of action three or more times. 8.6% (3/35) of respondents chose an aggressive course of action three or more times, whereas 2.9% (1/35) of respondents chose a conservative course of action three or more times. Three respondents (8.6%) chose a consultative course of action three times or more. A majority (80%, 28/35) of respondents did not demonstrate an identifiable pattern of clinical ethical decision-making by choosing an aggressive, conservative, or consultative course of action for more than two out of the four cases presented. CONCLUSION: When confronted with an ethically challenging clinical case, most physicians adapted their responses to the particulars of the case presented by demonstrating variability in their treatment approaches. Only a minority of physicians demonstrated a consistent pattern of behavior by selecting either an aggressive, conservative, or consultative treatment option. Physician interpretation of the specific ethical situation of each case guides their clinical ethical decision-making.`T HEY TREATED ME LIKE A LEPER'' Ð STIGMATIZATION AND THE EMOTIONAL BURDEN OF HEPATITIS. C S. Zickmund 1 ; University of Iowa, Iowa City, IA PURPOSE: Hepatitis C is a chronic progressive disease that is typically acquired through contaminated blood products or needle sharing. While the widely known association between this illness and intravenous drug use may lead to stigmatization, no study has explored the consequences of such stereotyping. The goal of this investigation was to identify the prevalence and impact of stigmatization on patients with chronic hepatitic C virus (HCV) infection. METHODS: Patients with HCV infection attending the University of Iowa Health Care liver clinic were randomly chosen to participate. All patients completed a semi-structured interview and the Sickness Impact Profile (SIP). Two blinded coders analyzed the interviews, identifying the frequency of stigmatization, characteristics of relationships with friends, family and colleagues in the work environment, anxiety, depression, and helplessness. RESULTS: A total of 193 patients (44.80.7 years; 33% women) with HCV infection were enrolled. The analysis of qualitative data demonstrated an excellent intercoder reliability (kappa=0.86). Eighty-five patients (44%) experienced stigmatization which they attributed to the disease. Gender, education, professional status and mode of HCV infection did not influence the likelihood of stigmatization. Negative stereotyping was associated with a higher score of the psychological SIP subscore (11.11.5 vs. 15.61.9; p =0.05). The responses demonstrated that stigmatization affected all facets of social interactions from family life to the work environment, causing a significant emotional burden for the patients. Stereotyping was associated with increased expressions of depression and anxiety (depression: 58% vs. 37%; p < 0.01; anxiety: 72% vs. 47%; p < 0.01), problems with family (38% vs. 15%; p < 0.01), friends (35% vs. 9%; p < 0.01) or coworkers (34% vs. 7%, p < 0.001). These experiences led to a sense of loss of control (38% vs. 19%; p < 0.01) and problems coping with the disease (38% vs. 19%; p < 0.01). CONCLUSION: Stigmatization is a very common experience of patients with HCV infection and erodes important support structures. The resulting distance from family, friends and colleagues increases feelings of anxiety and depression, common emotional disturbances in this group of patients. These data support the need for broad-based educational efforts to reach patients as well as their relatives and friends. Lowering the emotional impact of negative stereotyping may enhance both the quality of life of patients as well as their compliance with the medical therapy and required life style changes. Differentially profiling the low-expression transcriptomes of human hepatoma using a novel SSH/microarray approach BACKGROUND: The main limitation in performing genome-wide gene-expression profiling is the assay of low-expression genes. Approaches with high throughput and high sensitivity for assaying low-expression transcripts are urgently needed for functional genomic studies. Combination of the suppressive subtractive hybridization (SSH) and cDNA microarray techniques using the subtracted cDNA clones as probes printed on chips has greatly improved the efficiency for fishing out the differentially expressed clones and has been used before. However, it remains tedious and inefficient sequencing works for identifying genes including the great number of redundancy in the subtracted amplicons, and sacrifices the original advantages of high sensitivity of SSH in profiling low-expression transcriptomes. RESULTS: We modified the previous combination of SSH and microarray methods by directly using the subtracted amplicons as targets to hybridize the pre-made cDNA microarrays (named as "SSH/microarray"). mRNA prepared from three pairs of hepatoma and non-hepatoma liver tissues was subjected to the SSH/microarray assays, as well as directly to regular cDNA microarray assays for comparison. As compared to the original SSH and microarray combination assays, the modified SSH/microarray assays allowed for much easier inspection of the subtraction efficiency and identification of genes in the subtracted amplicons without tedious and inefficient sequencing work. On the other hand, 5015 of the 9376 genes originally filtered out by the regular cDNA microarray assays because of low expression became analyzable by the SSH/microarray assays. Moreover, the SSH/microarray assays detected about ten times more (701 vs. 69) HCC differentially expressed genes (at least a two-fold difference and P < 0.01), particularly for those with rare transcripts, than did the regular cDNA microarray assays. The differential expression was validated in 9 randomly selected genes in 18 pairs of hepatoma/non-hepatoma liver tissues using quantitative RT-PCR. The SSH/microarray approaches resulted in identifying many differentially expressed genes implicated in the regulation of cell cycle, cell death, signal transduction and cell morphogenesis, suggesting the involvement of multi-biological processes in hepato-carcinogenesis. CONCLUSION: The modified SSH/microarray approach is a simple but high-sensitive and high-efficient tool for differentially profiling the low-expression transcriptomes. It is most adequate for applying to functional genomic studies. Microarray is a powerful technique for simultaneously determining the expression of thousands of genes [1] [2] [3] . Such studies can quickly yield a genome-wide description of mRNA expression, called transcriptomes, in a given cell or tissue at a given physiologic or pathologic condition [4] . Even though, one of the main challenges in such genome-wide gene-expression profiling is the difficult inspection of genes with rare transcripts.