Browsing by Author "Alexander, Stewart C."

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    “I’m Not Gonna Pull the Rug out from under You”: Patient-Provider Communication about Opioid Tapering
    (Elsevier, 2017) Matthias, Marianne S.; Johnson, Nicole L.; Shields, Cleveland G.; Bair, Matthew J.; MacKie, Palmer; Huffman, Monica; Alexander, Stewart C.; Department of Medicine, School of Medicine
    In response to increases in harms associated with prescription opioids, opioid prescribing has come under greater scrutiny, leading many healthcare organizations and providers to consider or mandate opioid dose reductions (tapering) for patients with chronic pain. Communicating about tapering can be difficult, particularly for patients on long-term opioids who perceive benefits and are using their medications as prescribed. Given the importance of effective patient-provider communication for pain management and recent health system-level initiatives and provider practices to taper opioids, this study used qualitative methods to understand communication processes related to opioid tapering, to identify best practices and opportunities for improvement. Up to 3 clinic visits per patient were audio-recorded, and individual interviews were conducted with patients and their providers. Four major themes emerged: 1) Explaining—Patients needed to understand individualized reasons for tapering, beyond general, population-level concerns such as addiction potential; 2) Negotiating—Patients needed to have input, even if it was simply the rate of tapering; 3) Managing difficult conversations—When patients and providers did not reach a shared understanding, difficulties and misunderstandings arose; 4) Non-abandonment—Patients needed to know that their providers would not abandon them throughout the tapering process.
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    Sexuality talk during adolescent health maintenance visits
    (AMA, 2014-02) Alexander, Stewart C.; Fortenberry, J. Dennis; Pollak, Kathryn I.; Bravender, Terrill; Davis, J. Kelly; Østbye, Truls; Tulsky, James A.; Dolor, Rowena J.; Shields, Cleveland G.; Department of Pediatrics, Indiana University School of Medicine
    IMPORTANCE: Physicians may be important sources of sexuality information and preventive services, and one-on-one confidential time during health maintenance visits is recommended to allow discussions of sexual development, behavior, and risk reduction. However, little is known about the occurrence and characteristics of physician-adolescent discussions about sexuality. OBJECTIVE: To examine predictors of time spent discussing sexuality, level of adolescent participation, and physician and patient characteristics associated with sexuality discussions during health maintenance visits by early and middle adolescents. DESIGN, SETTING, AND PARTICIPANTS: Observational study of audio-recorded conversations between 253 adolescents (mean age, 14.3 years; 53% female; 40% white; 47% African American) and 49 physicians (82% pediatricians; 84% white; 65% female; mean age, 40.9 years; mean [SD] duration in practice, 11.8 [8.7] years) coded for sexuality content at 11 clinics (3 academic and 8 community-based practices) located throughout the Raleigh/Durham, North Carolina, area. MAIN OUTCOMES AND MEASURES: Total time per visit during which sexuality issues were discussed. RESULTS One hundred sixty-five (65%) of all visits had some sexual content within it. The average time of sexuality talk was 36 seconds (35% 0 seconds; 30% 1-35 seconds; and 35% ≥ 36 seconds). Ordinal logistic regression (outcome of duration: 0, 1-35, or ≥ 36 seconds), adjusted for clustering of patients within physicians, found that female patients (odds ratio [OR] = 2.58; 95% CI, 1.53-4.36), older patients (OR = 1.37; 95% CI, 1.13-1.65), conversations with explicit confidentiality discussions (OR = 4.33; 95% CI, 2.58-7.28), African American adolescents (OR = 1.58; 95% CI, 1.01-2.48), and longer overall visit (OR = 1.07; 95% CI, 1.03-1.11) were associated with more sexuality talk, and Asian physicians were associated with less sexuality talk (OR = 0.13; 95% CI, 0.08-0.20). In addition, the same significant associations between adolescent, physician, and visit characteristics were significantly associated with greater adolescent participation. CONCLUSIONS AND RELEVANCE: Our study may be the first to directly observe sexuality talk between physicians and adolescents. We found that one-third of all adolescents had annual visits without any mention of sexuality issues; when sexuality talk occurred, it was brief. Research is needed to identify successful strategies physicians can use to engage adolescents in discussions about sexuality to help promote healthy sexual development and decision making. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01040975.