David A Fleming

University of Missouri, Columbia, Missouri, United States

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Publications (28)137.41 Total impact

  • Robert M Centor · David A Fleming · Darilyn V Moyer ·

    Annals of internal medicine 01/2015; 162(1):80. DOI:10.7326/L15-5040-7 · 17.81 Impact Factor
  • Blake C Corcoran · Lea Brandt · David A Fleming · Chris N Gu ·
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    ABSTRACT: As a medical student, I observed that different physicians had strikingly different attitudes and approaches when caring for patients. The care of one patient in particular continues to challenge my understanding of illness and moral responsibility in the practice of medicine. In this paper, I illustrate the care of this patient in order to evaluate the dominant ethics I was taught in medical school, in theory and in practice, and argue neither principlism nor the ethics of care fully captures the moral responsibility of physicians. Emphasising fidelity to the healing relationship, a core principle derived from Pellegrino's virtue theory, I conclude that this approach to clinical ethics fully explains physician responsibility. Pellegrino deconstructs the practice of medicine to clarify the moral event within the clinical encounter and offers a sufficiently useful and justified approach to patient care.
    Journal of Medical Ethics 07/2014; DOI:10.1136/medethics-2013-101718 · 1.51 Impact Factor

  • Journal of palliative medicine 05/2014; 17(6). DOI:10.1089/jpm.2013.0353 · 1.91 Impact Factor
  • Robert M Centor · David A Fleming · Darilyn V Moyer ·

    Annals of internal medicine 05/2014; 161(3). DOI:10.7326/M14-1014 · 17.81 Impact Factor
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    ABSTRACT: The purpose of this study is to determine the prevalence of diabetes distress and its relationship with health behaviours and clinical outcomes in low-income patients. Secondary analyses were conducted using baseline data from a clinical trial evaluating a diabetes self-management intervention. Interviews were conducted with 666 participants receiving care at nine safety net clinics in Missouri. Distress was measured using the Diabetes Distress Scale, and outcomes included medication adherence, physical activity, nutrition and clinical biomarkers (haemoglobin A1C (HbA1C), blood pressure, low-density lipoprotein (LDL) cholesterol). In a sample of 666 participants, 14.1% and 27.3% of patients were identified as highly and moderately distressed, respectively, with higher rates among younger, female and lower income patients. When compared with moderately and no distress groups, highly distressed patients were less adherent to medications (20.7% vs 29.9% vs 39.4%, p<0.001) and had higher HbA1C values (9.3% (SD=2.0) vs 8.2% (SD=1.8) vs 7.8% (SD=1.7), p<0.001), diastolic blood pressure (81.8 (SD=9.4) vs 80.2 (9.7) vs 78.9 (SD=8.8), p=0.02) and LDL cholesterol (104.6 (SD=42.4) vs 97.2 (34.3) vs 95.5 (37.9)) In multivariable analyses, high and moderate distress were associated with lower medication adherence (OR=0.44; 0.27 to 0.23, p=0.001) and (OR=0.58; 0.42 to 0.79; p=0.001), respectively, and higher HbA1C in only the highly distressed group (B=1.3; 0.81 to 1.85; p<0.001) compared with the no distress group. Diabetes distress is prevalent and linked to poorer adherence to health behaviours and glycemic control in a sample of patients receiving care from low-income clinics.
    Journal of epidemiology and community health 01/2014; 68(6). DOI:10.1136/jech-2013-203063 · 3.50 Impact Factor
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    ABSTRACT: We compared two implementation approaches for a health literacy diabetes intervention designed for community health centers. A quasi-experimental, clinic-randomized evaluation was conducted at six community health centers from rural, suburban, and urban locations in Missouri between August 2008 and January 2010. In all, 486 adult patients with type 2 diabetes mellitus participated. Clinics were set up to implement either: 1) a clinic-based approach that involved practice re-design to routinely provide brief diabetes education and counseling services, set action-plans, and perform follow-up without additional financial resources [CARVE-IN]; or 2) an outsourced approach where clinics referred patients to a telephone-based diabetes educator for the same services [CARVE-OUT]. The fidelity of each intervention was determined by the number of contacts with patients, self-report of services received, and patient satisfaction. Intervention effectiveness was investigated by assessing patient knowledge, self-efficacy, health behaviors, and clinical outcomes. Carve-out patients received on average 4.3 contacts (SD = 2.2) from the telephone-based diabetes educator versus 1.7 contacts (SD = 2.0) from the clinic nurse in the carve-in arm (p < 0.001). They were also more likely to recall setting action plans and rated the process more positively than carve-in patients (p < 0.001). Few differences in diabetes knowledge, self-efficacy, or health behaviors were found between the two approaches. However, clinical outcomes did vary in multivariable analyses; carve-out patients had a lower HbA1c (β = -0.31, 95 % CI -0.56 to -0.06, p = 0.02), systolic blood pressure (β = -3.65, 95 % CI -6.39 to -0.90, p = 0.01), and low-density lipoprotein (LDL) cholesterol (β = -7.96, 95 % CI -10.08 to -5.83, p < 0.001) at 6 months. An outsourced diabetes education and counseling approach for community health centers appears more feasible than clinic-based models. Patients receiving the carve-out strategy also demonstrated better clinical outcomes compared to those receiving the carve-in approach. Study limitations and unclear causal mechanisms explaining change in patient behavior suggest that further research is needed.
    Journal of General Internal Medicine 09/2013; 29(1). DOI:10.1007/s11606-013-2582-2 · 3.42 Impact Factor
  • David A Fleming · Lois Snyder Sulmasy ·

    JAMA The Journal of the American Medical Association 06/2013; 309(21):2209-10. DOI:10.1001/jama.2013.5570 · 35.29 Impact Factor
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    ABSTRACT: Background: The body of research is rapidly growing regarding the use of telemedicine in patient care, including cost-effectiveness, patient access, patient outcomes, etc. Less has been done describing physician communication during different aspects of the clinical visit (i.e., education, assessment, treatment, etc.) during actual versus virtual patient visits. The purpose of this study was to evaluate dermatology healthcare providers' communication via both modalities with regard to content and style. Subjects and methods: In-person and teledermatology patient visits were observed, audio-recorded, and transcribed over an 8-month period. A content analysis was performed. Results: The Wilcoxon rank sum test was used to compare the content differences between visit modalities for each category. A p value of 0.05 was considered as significant for all tests. There were no statistically significant differences between modalities in the average number of physician words in seven of eight communication categories: small talk, clinical assessment, psychosocial issues, patient education, patient compliance, patient treatment, and administrative issues (p value range, 0.16-0.91). As well, the same communication themes occurred in each modality to essentially the same degree. For instance, assessment and discussion of treatment occurred in 100% of in-person and teledermatology visits, as did small talk. Conclusions: This research indicates that physician providers communicate with similar style and content whether using teledermatology or in-person.
    Telemedicine and e-Health 05/2013; 19(7). DOI:10.1089/tmj.2012.0227 · 1.67 Impact Factor
  • Dominic E Sanford · David A Fleming ·
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    ABSTRACT: This essay explores the unique perspective of medical students regarding the ethical challenges of providing full disclosure to patients and their families when medical mistakes are made, especially when such mistakes lead to tragic outcomes. This narrative underscores core precepts of the healing profession, challenging the health care team to be open and truthful, even when doing so is uncomfortable. This account also reminds us that nonabandonment is an obligation that assumes accountability for one's actions in the healing relationship and that apologizing for mistakes can serve to heal. It argues that even medical students have an obligation to speak up when actions violate their moral beliefs, even if this means confronting a superior. Ethical principles cannot be abandoned in fear of adverse evaluation or failure to conform. Healthcare workers have an obligation to address mistakes made around the time of a patient's death with the patient's family. This responsibility trumps any selfish desire to avoid unpleasant feelings of guilt or regret. Such events often bring closure to already anguished relatives and spouses, and may help to facilitate the grieving process. This includes pressing forward the need to apologize to patients and/or their families when mistakes are made and when decisions are made that lead to poor outcomes for the patient, even when benevolently intended.
    HEC Forum 06/2010; 22(2):159-69. DOI:10.1007/s10730-010-9131-8
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    Lanis L Hicks · David A Fleming · Adam Desaulnier ·
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    ABSTRACT: The objective of this study was to evaluate the impact of remote monitoring home telehealth on client and provider satisfaction, clinical outcomes, and cost. The project design was a pragmatic evaluation of the technology in a real-world setting at an operational scale rather than a controlled clinical trial. Patients receiving monitoring were selected by the home health agency, and a random sample of other agency clients was selected for comparative purposes. Data were collected on additional costs and benefits associated with home telehealth monitoring. Quantitative and qualitative data suggest that when remote monitoring telehealth technology was utilized in the home-care setting, both clients and providers were very satisfied with services; they felt it was easy to communicate, and that the technology was convenient and user friendly. Clients also felt that home telehealth technology had a very positive impact on the provider-client relationship and improved care. The study also suggests that home care monitoring reduces hospitalizations and decreases personnel expenses. This preliminary study provides evidence as to the value of remote monitoring home telehealth in the delivery of services to home care populations. It also provides evidence as to the positive impact that this form of technology may have on healthcare systems, provider and client satisfaction, and on the relationships that form between providers and clients.
    Telemedicine and e-Health 09/2009; 15(7):664-71. DOI:10.1089/tmj.2009.0009 · 1.67 Impact Factor
  • Win Phillips · David Fleming ·
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    ABSTRACT: The use of electronic medical record systems raises important ethical concerns about patient privacy and confidentiality, medical errors, expectations of structured data entry by clinicians, documentation integrity, and provider-patient interaction. Clinicians and health care organizations need to define best practices and policies in the use of EMR systems to improve quality and maintain clinician efficiency without compromising patient welfare and safety.
    Missouri medicine 09/2009; 106(5):328-33.
  • David A Fleming · Karen E Edison · Hon Pak ·
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    ABSTRACT: The ethical implications of telehealth go well beyond providers' obligations to ensure privacy and confidentiality. The ethical conundrum of telehealth realizes the uniquely positive impact that telehealth can have on patients, providers, and clinical outcomes, as well as the potential for harm and abuse that may ensue. This article explores telehealth as one of many evolving information technologies that have ethical questions extending well beyond the confines of privacy and confidentiality. Providers and systems who utilize telehealth should also consider how it influences relationships with patients, access to healthcare, capacity for equitable treatment, cost, and quality of life. The ability to respond to these concerns will be important to the future development and deployment of this important technology as one means by which to improve access and quality of healthcare for all members of our society.
    Telemedicine and e-Health 09/2009; 15(8):797-803. DOI:10.1089/tmj.2009.0035 · 1.67 Impact Factor
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    Clinical Infectious Diseases 06/2009; 48(10):1335-44. DOI:10.1086/598169 · 8.89 Impact Factor
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    ABSTRACT: Research is yet to fully examine the utility and effectiveness of telehealth in primary care resident ambulatory training. This study examined the attitudes of preceptors, residents, and nurses on (1) the impact of telehealth on healthcare; (2) the impact of telehealth on the work activity of resident clinics; (3) the impact of telehealth on resident training in the outpatient setting; and (4) the impact of telehealth on relationships. There were three focus groups, one each of preceptors (N = 5), residents (N = 10), nurses (N = 7). Eight focus group themes evolved regarding the use of telehealth in the resident clinic: (1) impact on patient/provider relationships; (2) consistent with the values of those using telehealth; (3) logistics; (4) reduces patient transfers; (5) appropriate level of care; (6) reimbursement concerns; (7) psychological risk; and (8) impact on resident/attending relationships. Though as yet not generalizable, results of this pilot study suggest that there is general acceptability of telehealth in ambulatory resident training settings, but there is concern about the impact that telehealth may have on relationships, logistics, finances, and the need to see patients face-to-face when there is greater complexity.
    Telemedicine and e-Health 05/2009; 15(3):277-82. DOI:10.1089/tmj.2008.0113 · 1.67 Impact Factor
  • Don Reynolds · David A Fleming ·

    The American Journal of Bioethics 03/2009; 9(2):16-7. DOI:10.1080/15265160802666297 · 5.29 Impact Factor
  • David A Fleming · Don Reynolds ·

    The American Journal of Bioethics 12/2008; 8(11):21-2. DOI:10.1080/15265160802516864 · 5.29 Impact Factor
  • Cheryl Rathert · David A Fleming ·
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    ABSTRACT: Health care delivery teams have received much attention in recent years from researchers and practitioners. Recent empirical research has demonstrated that objective and subjective outcomes tend to be improved when care teams function smoothly and efficiently. However, little is known about how the work environment, or care context, influences team processes that lead to better outcomes. The purposes of this study were to explore acute care staff's perceptions of how two components of the work environment, the ethical climate and continuous quality improvement leadership, influence teamwork and to begin to identify actionable approaches for improving teamwork. Although ethical climate influences have been studied in several sectors, research is lacking in health care. A cross-sectional field study explored how the ethical climate impacted teamwork in an acute care setting and how continuous quality improvement leadership behaviors moderated the relationship between the ethical climate and teamwork. Results indicated that clinicians who perceived the ethical climate to be benevolent were significantly more likely to say that teamwork was better. Furthermore, we found that continuous quality improvement leadership styles moderated the relationship between the ethical climate and teamwork. Although a benevolent ethical climate appears to be associated with effective teamwork, it appears that the proximate continuous quality improvement behaviors exhibited by leaders have a significant impact as well, above and beyond the climate. Implications for research and practice are discussed.
    Health care management review 10/2008; 33(4):323-31. DOI:10.1097/01.HCM.0000318769.75018.8d · 1.30 Impact Factor
  • David A Fleming · Don Reynolds ·

    The American Journal of Bioethics 04/2008; 8(3):24-5; discussion W4-6. DOI:10.1080/15265160802109447 · 5.29 Impact Factor
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    ABSTRACT: This position paper concerns improving health care in the United States. Unlike previous highly focused policy papers by the American College of Physicians, this article takes a comprehensive approach to improving access, quality, and efficiency of care. The first part describes health care in the United States. The second compares it with health care in other countries. The concluding section proposes lessons that the United States can learn from these countries and recommendations for achieving a high-performance health care system in the United States. The articles are based on a position paper developed by the American College of Physicians' Health and Public Policy Committee. This policy paper (not included in this article) also provides a detailed analysis of health care systems in 12 other industrialized countries. Although we can learn much from other health systems, the College recognizes that our political and social culture, demographics, and form of government will shape any solution for the United States. This caution notwithstanding, we have identified several approaches that have worked well for countries like ours and could probably be adapted to the unique circumstances in the United States.
    Annals of internal medicine 02/2008; 148(1):55-75. DOI:10.7326/0003-4819-148-1-200801010-00196 · 17.81 Impact Factor
  • David A Fleming ·
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    ABSTRACT: Late one night you are called to the room of an elderly nursing home patient who has been febrile for three days and is now short of breath, coughing, and tachycardic. She has already received three days of oral antibiotics. The patient was treated for pneumonia a year ago in the nursing home and has a history of hypertension and early dementia but has otherwise been healthy. Though mildly confused at times, presently she is alert and oriented and appears to understand her circumstances. Her respiratory status is quickly deteriorating, however. You and the other nursing staff are concerned about impending respiratory failure. There is no Do-Not-Resuscitate order in the chart. You feel hospitalization may improve her chances for survival and that short-term intubation with ventilator support may even be indicated in order to stabilize her medical condition. She has a living will indicating “no life support if terminal conditions” and the patient has recently refused hospitalization, yet her family is telling you that “she really doesn’t mean it” under these circumstances because she is sick and confused and has agreed to being hospitalized before. It’s time to act—what to do? Making decisions within the complexities of modern health care is not easy. This is especially true in long term care situations where the preferences of often chronically debilitated patients may not be known and for whom hospitalization or other intervention may increase their risk of death, suffering, and further impairment. Ethical dilemmas often present themselves in this context, and having a mechanism available to effectively address complex ethical issues in a timely fashion is critical to the quality and safety of patient care. One of the most common ethical challenges occurs when the patient has questionable capacity to make decisions and it is unclear as to what they would want us to do, and whether the burden of treatment is worth the expected benefit and expense. Not uncommonly in
    HEC Forum 10/2007; 19(3):245-59. DOI:10.1007/s10730-007-9043-4