PA-98-059: HEALTH-CARE ENCOUNTERS BETWEEN ELDERLY PATIENTS, PHYSICIANS, AND OTHER CARE PROVIDERS

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HEALTH-CARE ENCOUNTERS BETWEEN ELDERLY PATIENTS, PHYSICIANS, AND OTHER CARE PROVIDERS Release Date: April 28, 1998 PA NUMBER: PA-98-059 P.T. National Institute on Aging National Institute of Nursing Research PURPOSE The National Institute on Aging (NIA) and the National Institute of Nursing Research (NINR) invite qualified researchers to submit applications to investigate issues relevant to the interaction and/or relationship between health providers and older patients. This program announcement solicits research grant applications to investigate how multiple factors influence the content, process, and outcomes of these health-care or medical encounters. Goals of this program announcement are to: (1) identify the demographic, psychosocial, cognitive, and contextual factors associated with effective interactions between health-care providers and older individuals, (2) assess the nature and quality of the interaction that influences health-care communication, (3) determine the role of caregivers and companions in facilitating or impeding effective provider-patient relationships, (4) further the development of methodologies to link these factors to medical or psychosocial outcomes, and (5) investigate interventions to improve effective interaction styles. This Program Announcement focuses primarily on physician-elder patient interactions, but includes attention to the full range of health care providers in recognition of changing patterns in the delivery of health care. HEALTHY PEOPLE 2000 The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of "Healthy People 2000," a PHS-led national activity for setting priority areas. This program announcement, Health-Care Encounters Between Elderly Patients, Physicians, and Other Care Providers, is related to the priority area of chronic disabling conditions. Potential applicants may obtain a copy of "Healthy People 2000" (Full Report: Stock No. 017-001-00474-0 or Summary Report: Stock No. 017-001-00473-1) through the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325 (telephone 202-512-1800). The report may also be found via the world wide web at URL:http://www.crisny.org/health/us/health7.html. ELIGIBILITY REQUIREMENTS Applications may be submitted by domestic and foreign for-profit and non-profit organizations, public and private, such as universities, colleges, hospitals, laboratories, units of State and local governments, and eligible agencies of the Federal government. Applications may be submitted by single institutions or by a consortium of institutions. Women and minority investigators are encouraged to apply. MECHANISM OF SUPPORT This program announcement will use the NIH investigator-initiated research project grant (R01). NIA is also soliciting applications on this topic that have the potential for commercial application (see SBIR and STTR solicitations, which are available on the World Wide Web at: http://www.nih.gov/grants/funding/sbir.htm). Responsibility for the planning, direction, and execution of the proposal will be solely that of the applicant. RESEARCH OBJECTIVES Research has repeatedly shown that encouragement by physicians is one of the single most important factors influencing preventive health behaviors and healthy lifestyle changes among patients. There is also some suggestion that malpractice suits can be attributed, in part, to poor doctor-patient communication. Thus, efforts to improve the nature and quality of the health-care encounter can have positive effects for both patients and the providers who treat them. Less is known, however, about the antecedents and consequences of interaction with older patients. The aging of the U.S. population, coupled with the disproportionately large number of health care visits made by older person, makes it important to examine provider-elderly patient encounters, their process and outcomes. With an increased movement toward managed care, it is important that we investigate the effect of managed care practices on provider-older patient interactions in terms of interaction length and content, patient satisfaction, patient recall and adherence, patient costs, and health outcomes. A better understanding is needed of the complex factors affecting older patients" preferences for different styles of interaction and strategies for fostering mutually satisfying interaction and clinical decision-making over the course of multiple encounters in varied settings (e.g., office visits, hospitalizations, telephone calls). Little attention has been paid to intervention strategies directed toward either older patients or their providers. In today"s health care delivery system, older people are now more likely than in the past to be treated by an expanded network of providers (e.g., the nurse, physician assistant, or social worker). Older patient-doctor research must expand beyond the limited dyadic relationship to include the role of multiple providers as well as the influence of companions who often accompany the older person on medical visits and can be instrumental in helping the patient understand and adhere to suggested medical regimens. Of particular interest is how cross cutting sociodemographic factors such as age, race/ethnicity and gender, as well as cross-national factors (e.g., the effects of different health care structures and patient/provider norms) influence provider-patient communication. Furthermore, studies to date have been limited by conceptual and methodological problems, including lack of theoretical framework and inadequate tools to assess the nature and quality of older patient physician encounters. Establishing standardized methodologies and assessment instruments will improve research as well as clinical practice, and will advance knowledge on appropriate interventions to improve health care. Methodological research may be incorporated into substantive research proposals. Through an invitational conference titled Research Issues Related to Physician- Elderly Patient Interactions (April, 1995, sponsored by NIA and AHCPR), the following broad topical areas have been identified as needing further study: patient and provider characteristics, contextual features, the process and content of the interaction, and the outcomes of the encounter. Papers based on this report can be found in Research on Aging, 18(1), March 1996. The following are offered as illustrations of appropriate topics for research. Applications need not, however, be limited to these specific issues. Patient/Provider Characteristics. Patient and provider characteristics influence the process and content of health-care encounters. These factors, including age, gender, training/education, and ethnicity, affect outcomes of the medical encounter. Other characteristics, including belief systems, personality, and interaction style need to be linked to health outcomes. Research suggestions include: o How different ethnic, cultural, and social backgrounds affect elderly patients" expectations for interacting with physicians and other providers. o How providers" personal backgrounds, empathetic styles, views about provider- patient relationships, and expectations about aging affect their interaction patterns with elderly patients. o How the congruence or incongruence between patient/provider characteristics influences interactions and associated outcomes. Context of Care: Contextual Factors Relating to Process/Content and Health Status Outcomes. The role context plays in the provider-patient interaction, particularly the effectiveness of the communication process, needs further examination. Contextual factors include the physical location of the encounter, the social context, the patient"s physical and cognitive status, time-of-day, and the influence of organizational and financial variables. Examples of research areas are: o How family members or other caregivers (social context) assist elderly patients to make health-care or medical decisions, including decisions about when to visit a physician or other provider, or how to follow a treatment regimen. o How location of encounters (home visit, nursing home, inpatient setting, hospice, emergency room) may influence the provider-patient interaction. o The role of emerging technologies, such as telemedicine, on provider-elderly patient interactions. o The influence of different medical care arrangements on provider-patient interactions and related outcomes. Process and Content of the Health-Care Encounter: Factors relating to the Effectiveness of Communication. Communication is a broad term that encompasses a range of social, psychological, and cognitive processes occurring in the relationship or encounter between a provider and an elderly patient or their caregiver. This area includes the content of medical and health-care information and how the provider conveys it, which influences outcomes such as comprehension and recall, and compliance. Areas of needed research include: o How duration of visit and other restrictions placed on the encounter affect the amount and type of information exchanged and the interaction style of participants. o How physical and psychosocial status (e.g., hearing loss, cognitive impairment, depression, chronic ill health) are interpreted by providers and caregivers, influence the interaction, and affect outcome. o How the provider-patient relationship evolves over time and multiple visits. How the recurrent interaction is different from the initial visit between provider and elderly patient. o Receptiveness of elderly patients to content of communication. How patients perceive and respond to preventive health recommendations or to complicated verbal instructions. Outcomes and Intervention Research. Multiple outcomes should be assessed to determine short- and long-term effects of medical encounters on the health status of elderly patients. Outcomes include patient and provider satisfaction, comprehension and recall of medical and health-care information, compliance with treatment regimen, functional and health status outcomes, as well as cost effectiveness. Intervention studies can be targeted to improving health status outcomes. Areas needing further study include: o Development of new tools or refining of existing tools for examining the nature and quality of interactions between physicians or other providers and older patients. o Social and health impact of various provider-patient interaction styles. o Intervention research on theory-based strategies for improving the quality of health-care encounters. Research directed at patients, family members, or providers (or any combination of the above), is encouraged. INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN SUBJECTS It is the policy of the NIH that women and members of minority groups and their sub-populations must be included in all NIH supported biomedical and behavioral research projects involving human subjects, unless a clear and compelling rationale and justification is provided that inclusion is inappropriate with respect to the health of the subjects or the purpose of the research. This policy results from the NIH Revitalization Act of 1993 (Section 492B of Public Law 103-43). All investigators proposing research involving human subjects should read the "NIH Guidelines for Inclusion of Women and Minorities as Subjects in Clinical Research," which have been published in the Federal Register of March 28, 1994 (FR 59 14508-14512), and in the NIH Guide for Grants and Contracts, Volume 23, Number 11, March 18, 1994. APPLICATION PROCEDURES Applications are to be submitted on the grant application form PHS 398 (rev. 5/95) and will be accepted at the standard application deadlines as indicated in the application kit. Applications kits are available at most institutional offices of sponsored research and may be obtained from the Division of Extramural Outreach and Information Resources, National Institutes of Health, 6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone 301/710-0267, email: ASKNIH@od.nih.gov. The number and title of this program announcement must be typed in Section 2 on the face page of the application. The complete original and five permanent, legible copies must be sent or delivered to: CENTER FOR SCIENTIFIC REVIEW NATIONAL INSTITUTES OF HEALTH 6701 ROCKLEDGE DRIVE, ROOM 1040-MSC 7710 BETHESDA, MD 20892-7710 BETHESDA, MD 20817-7710 (for express/courier service) REVIEW CONSIDERATIONS Applications will be assigned on the basis of established PHS referral guidelines. Applications that are complete will be evaluated for scientific and technical merit by an appropriate peer review group convened in accordance with the standard NIH peer review procedures. As part of the initial merit review, all applications will receive a written critique and undergo a process in which only those applications deemed to have the highest scientific merit, generally the top half of applications under review, will be discussed, assigned a priority score, and receive a second level review by the appropriate national advisory council or board, when applicable. Review Criteria The goals of NIH-supported research are to advance our understanding of biological systems, improve the control of disease, and enhance health. In the written review, comments on the following aspects of the application will be made in order to judge the likelihood that the proposed research will have a substantial impact on the pursuit of these goals. Each of these criteria will be addressed and considered in the assignment of the overall score. (1) Significance. Does this study address an important problem? If the aims of the application are achieved, how will scientific knowledge be advanced? What will be the effect of these studies on the concepts or methods that drive this field? (2) Approach. Are the conceptual framework, design, methods, and analyses adequately developed, well-integrated, and appropriate to the aims of the project? Does the applicant acknowledge potential problem areas and consider alternative tactics? (3) Innovation. Does the project employ novel concepts, approaches or methods? Are the aims original and innovative? Does the project challenge existing paradigms or develop new methodologies or technologies? (4) Investigator. Is the investigator appropriately trained and well suited to carry out this work? Is the work proposed appropriate to the experience level of the principal investigator and other researchers (if any)? (5) Environment. Does the scientific environment in which the work will be done contribute to the probability of success? Do the proposed experiments take advantage of unique features of the scientific environment or employ useful collaborative arrangements? Is there evidence of institutional support? In addition, the adequacy of plans to include both genders and minorities and their subgroups as appropriate for the scientific goals of the research will be reviewed. Plans for the recruitment and retention of subjects will also be evaluated. The initial review group will also examine the provisions for the protection of human and animal subjects, the safety of the research environment, and conformance with the NIH Guidelines for the Inclusion of Women and Minorities as Subjects in Clinical Research. AWARD CRITERIA Applications will compete for funding with all other approved applications. The following will be considered in making funding decisions: quality of the proposed project as determined by peer review, availability of funds, and program priority. INQUIRIES Inquiries are encouraged. The opportunity to clarify any issues or questions from potential applicants is welcome. Direct inquiries regarding programmatic issues to: Marcia G. Ory, Ph.D., M.P.H. Behavioral and Social Research Program National Institute on Aging 7201 Wisconsin Avenue, Room 533, MSC 9025 Bethesda, MD 20892-9205 Telephone: (301) 402-4156 FAX: (301) 402-0051 Email: Marcia_Ory@NIH.GOV Further information about NIA priorities and procedures can be found on the NIA Home Page at: http://www.nih.gov/nia. For information on NIA"s broader initiative on organizational issues in health care, contact Sidney Stahl, Ph.D at Sidney_Stahl@NIH.GOV. Carole I. Hudgings, Ph.D., R.N. Division of Extramural Activities National Institute of Nursing Research 45 Center Drive, Room 3AN-12, MSC 6300 Bethesda, MD 20892-6300 Telephone: (301) 594-5976 FAX: (301) 480-8260 Email: Carole_Hudgings@nih.gov Direct inquiries regarding fiscal matters to: Mr. David Reiter Grants Management Office National Institute on Aging Gateway Building, Room 2N212 Bethesda, MD 20892 Telephone: (301) 496-1472 FAX: (301) 402-3672 Email: David_Reiter@NIH.GOV Mr. Jeff Carow Grants Management Office National Institute of Nursing Research 45 Center Drive, Room 3AN-12, MSC 6301 Bethesda, MD 20892-6301 Telephone: (301) 594-6869 FAX: (301) 480-8260 Email: Jeff_Carow@nih.gov The National Institute of Mental Health (NIMH) has an interest in encounters involving mental disorders and treatments for mental disorders. For information contact: Dr. Kathryn Magruder Division of Services and Intervention Research National Institute of Mental Health 5600 Fishers Lane, Room 10C-06 Rockville, MD 20857 Telephone: (301) 443-3364 FAX: (301) 443-4045 Email: km87e@nih.gov AUTHORITY AND REGULATIONS This program is described in the Catalog of Federal Domestic Assistance No. 93.866 and No. 93.361, Nursing Research. Awards are made under authorization of the Public Health Service Act, Title IV, Part A (Public Law 78-410, as amended by Public Law 99-158, 42 USC 241 and 285) and administered under PHS grants policies and Federal Regulations 42 CFR 52 and 45 CFR Part 74. This program is not subject to the intergovernmental review requirements of Executive Order 12372 or Health Systems Agency review. The PHS strongly encourages all grant and contract recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of a facility) in which regular or routine education, library, day care, health care or early childhood development services are provided to children. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people.

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