Long-term lifestyle intervention lowers the incidence of stroke in Japanese patients with type 2 diabetes: a nationwide multicentre randomised controlled trial (the Japan Diabetes Complications Study)

AIMS/HYPOTHESIS

The aim of the study was to clarify whether a therapeutic intervention focused on lifestyle modification affected the incidence of vascular complications in patients with established diabetes.

METHODS

A total of 2,033 eligible Japanese men and women aged 40-70 years with type 2 diabetes from 59 institutes were randomised to a conventional treatment group (CON), which continued to receive the usual care, and a lifestyle intervention group (INT), which received education on lifestyle modification regarding dietary habits, physical activities and adherence to treatment by telephone counselling and at each outpatient clinic visit, in addition to the usual care. Randomisation and open-label allocation were done by a central computer system. Primary analysis regarding measurements of control status and occurrence of macro- and microvascular complications was based on 1,304 participants followed for an 8 year period.

RESULTS

Although status of control of most classic cardiovascular risk factors, including body weight, glycaemia, serum lipids and BP, did not differ between groups during the study period, the incidence of stroke in the INT group (5.48/1,000 patient-years) was significantly lower than in the CON group (9.52/1,000 patient-years) by Kaplan- Meier analysis (p=0.02 by logrank test) and by multivariate Cox analysis (HR 0.62, 95% CI 0.39-0.98, p=0.04). The incidence of CHD, retinopathy and nephropathy did not differ significantly between groups. Lipoprotein(a) was another significant independent risk factor for stroke.

CONCLUSIONS/INTERPRETATION

These findings suggest that lifestyle modification had limited effects on most typical control variables, but did have a significant effect on stroke incidence in patients with established type 2 diabetes.

CLINICAL TRIAL REGISTRATION

UMIN-CTR C000000222

FUNDING

The Ministry of Health, Labour and Welfare, Japan

Patients' perspectives on the role of prepared childbirth education in decision making regarding elective labor induction

The purpose of our study was to explore reasons why nulliparous women chose to have an elective labor induction and to identify the influence of prepared childbirth classes on their decision. The study included 1,349 nulliparous women at term who participated in a survey regarding their choices for childbirth, their attendance at prepared childbirth classes, and their experience with labor and birth. Sixty-three percent of women who attended childbirth classes and did not have elective induction reported that classes provided helpful information to assist in their decision-making process. Study results suggest attendance at prepared childbirth classes can be an effective source of information regarding elective labor induction and influential in women's decisions regarding whether or not to have elective labor induction. Women perceive prepared childbirth classes positively and find the information provided valuable.

Promoting smoking cessation in pregnancy with Video Doctor plus provider cueing: a randomized trial

OBJECTIVE

This study examined the use of a Video Doctor plus provider cueing to promote provider advice and smoking cessation outcomes in pregnancy.

DESIGN

A randomized clinical trial was conducted from 2006 to 2008.

SETTING

Five community prenatal clinics in the San Francisco Bay Area of the United States.

PARTICIPANTS

A total of 410 pregnant patients completed screening for behavioral risks including tobacco use in the past 30 days. Pregnant smokers (n = 42) were randomized regardless of their intention to quit smoking.

METHODS

Participants were assigned to either usual care or intervention. Intervention participants received 15-minute Video Doctor sessions plus provider cueing, at baseline and one month, prior to their routine prenatal visit. The Video Doctor delivered interactive tailored messages, an educational worksheet for participants, and a cueing sheet for providers.

MAIN OUTCOME MEASURES

Receipt of advice from the provider and 30-day smoking abstinence, both by self-report.

RESULTS

Intervention participants were more likely to receive provider advice on tobacco use at both prenatal visits during the intervention period (60.9 vs. 15.8%, p = 0.003). The intervention yielded a significantly greater decrease in the number of days smoked and in cigarettes smoked per day. The 30-day abstinence rate at two months post baseline was 2.5 times greater in the intervention group; the difference was not significant (26.1 vs. 10.5%, p = 0.12).

CONCLUSIONS

The Video Doctor plus provider cueing is an efficacious adjunct to routine prenatal care by promoting provider advice and smoking reduction among pregnant smokers.

Goal setting in diabetes self-management: taking the baby steps to success

OBJECTIVE

To evaluate the usefulness of a diabetes self-management guide and a brief counseling intervention in helping patients set and achieve their behavioral goals.

METHODS

We conducted a quasi-experimental study using a one group pretest posttest design to assess the effectiveness of a goal setting intervention along with a self-management guide. English- and Spanish-speaking patients with diabetes had one in-person session and two telephone follow-up calls with a non-clinical provider over a 12-16-week period. At each call and at the end of the study, we assessed success in achieving behavioral goals and problem solving toward those goals. Satisfaction with the self-management guide was assessed at the end of the study.

RESULTS

We enrolled 250 patients across three sites and 229 patients completed the study. Most patients chose to set goals in diet and exercise domains. 93% of patients achieved at least one behavioral goal during the study and 73% achieved at least two behavioral goals. Many patients exhibited problem solving behavior to achieve their goals. We found no significant differences in reported achievement of behavior goals by literacy or language. Patients were very satisfied with the guide.

CONCLUSIONS

A brief goal setting intervention along with a diabetes self-management guide helped patients set and achieve healthy behavioral goals.

PRACTICE IMPLICATIONS

Non-clinical providers can successfully help a diverse range of patients with diabetes set and achieve behavioral goals.

Testing the effects of educational strategies on comprehension of a genomic concept using virtual reality technology

OBJECTIVE

Applying genetic susceptibility information to improve health will likely require educating patients about abstract concepts, for which there is little existing research. This experimental study examined the effect of learning mode on comprehension of a genomic concept.

METHODS

156 individuals aged 18-40 without specialized knowledge were randomly assigned to either a virtual reality active learning or didactic learning condition. The outcome was comprehension (recall, transfer, mental models).

RESULTS

Change in recall was greater for didactic learning than for active learning (p<0.001). Mean transfer and change in mental models were also higher for didactic learning (p<0.0001 and p<0.05, respectively). Believability was higher for didactic learning (p<0.05), while ratings for motivation (p<0.05), interest (p<0.0001), and enjoyment (p<0.0001) were higher for active learning, but these variables did not mediate the association between learning mode and comprehension.

CONCLUSION

These results show that learning mode affects comprehension, but additional research is needed regarding how and in what contexts different approaches are best for educating patients about abstract concepts.

PRACTICE IMPLICATIONS

Didactic, interpersonal health education approaches may be more effective than interactive games in educating patients about abstract, unfamiliar concepts. These findings indicate the importance of traditional health education approaches in emerging areas like genomics.

Focus groups inform a web-based program to increase fruit and vegetable intake

OBJECTIVE

To use focus groups to inform a web-based educational intervention for increased fruit and vegetable (FV) consumption.

METHODS

Twelve groups (participants=137, aged 21-65) were recruited from four geographically diverse health systems. Four groups were stratified by gender and eight by race (white and African American) and gender. Questions included perceptions of healthy eating, factors that encourage or serve as barriers to FV consumption and features preferred for a web-based educational intervention.

RESULTS

Though knowledgeable about healthy eating, participants did not know how to achieve or always care about healthy nutritional choices. Motivators for FV consumption included being role models and health concerns. Barriers included: lack of time, expense and FV availability. Website preferences included: visuals, links, tailored materials, menu suggestions, goal setting assistance, printable summaries and built in motivation. The developers incorporated nearly all suggestions.

CONCLUSION

Focus groups provided needs-based tactical strategies for an online, education intervention targeting factors to improve FV consumption.

PRACTICE IMPLICATIONS

Focus groups can provide valuable input to inform interventions. Further, web-based programs' abilities to offer information without time or geographic constraints, with capacity for tailoring and tracking progress makes them a valuable addition in the arsenal of efforts to promote healthy behaviors.

Development of a patient decision aid for prevention of myocardial infarction in type 2 diabetes - rationale, design and pilot testing

AIMS

Development and testing of a decision aid about prevention of myocardial infarction for persons with type 2 diabetes.

METHODS

Development and testing were guided by the UK Medical Research Council's guidance for the development and evaluation of complex interventions. This comprised a systematic literature review, a focus group of 9 potential providers, modelling a prototype, interviews to qualitatively explore understanding and additional information needs, and revision of the decision aid.

RESULTS

The decision aid includes evidence-based information, a tool for individual risk-assessment, worksheets, and an action plan. Five diabetes educators and 15 patients underwent two 60-minutes face-to-face interviews, firstly browsing the decision aid for the first time and then after using it. Both groups differed in their ratings. Overall, the decision aid was rated to present essential information in a complex but understandable and unbiased manner. Difficulties involved understanding of terminology and risk interpretation. "Social status as a risk factor" was the most challenged content by educators but considered as highly important by patients. The risk assessment tool was used inadequately. 5 patients allocated themselves into false risk categories. After revision of the tool, all 12 patients who were recruited for reassessment used the tool correctly.

CONCLUSION

The decision aid was evaluated with diabetes educators and patients. Qualitative data analysis revealed aspects for revision. The decision aid is planned to be part of a shared decision making programme, comprising a strategy for patient counselling and educational modules addressed to providers. Quantitative evaluation is required to assess its effectiveness.

Applying qualitative methods in developing a culturally tailored workbook for black patients with hypertension

OBJECTIVE

To apply qualitative research methods in developing a culturally tailored, educational workbook for hypertensive black patients.

METHODS

The workbook was developed using formative qualitative data from 60 black primary care patients with hypertension. Participants were interviewed using qualitative methods and data were analyzed through sequential steps of open coding, axial coding, and selective coding. From these analyses, themes describing patients' cultural beliefs about hypertension were derived and used to develop the workbook.

RESULTS

The workbook, "Living With Hypertension: Taking Control" is a 37-page illustrated workbook with 11 chapters based on patients' perceptions of hypertension. These chapters focus on strengthening participants' ability to take control and manage hypertension and on providing knowledge and health behavior techniques.

CONCLUSION

Qualitative research methods were used to inform the development of a culturally tailored educational workbook.

PRACTICE IMPLICATIONS

The workbook developed in this study may offer a practical and effective means of educating patients about blood pressure control in primary care settings.

Information needs of people with spinal cord injuries

BACKGROUND/OBJECTIVE

To determine the information needs, level of Internet access, and current and preferred formats and sources of information of adults with spinal cord injuries (SCIs). Individuals with SCIs have a high lifetime risk for medical complications and other health conditions secondary to their injury. Many secondary conditions can be prevented or mitigated through appropriate self-care and/or self-management. People with SCIs need timely, high-quality information about health and medical issues after discharge and throughout their lifetime to improve self-care and maximize quality of life.

METHODS

A survey was administered as part of the third time point of a longitudinal research study on individuals with SCI.

RESULTS

A total of 80.2% of the 277 respondents reported having Internet access. The most frequently selected format used currently and preferred by respondents for receiving SCI information was "Web pages/Internet". The top-ranked current and preferred source of SCI information was from a "Physician: SCI Expert/Rehabilitation Specialist". Respondents reported needing information on medical issues the most. Significantly higher percentages of individuals identified as "white" and with higher education levels had access to the Internet and ranked the selection of Web pages/Internet as their top choice.

CONCLUSIONS

Results confirm that, although people with SCI prefer to receive SCI information from SCI experts, the Internet is a more accessible and more currently used source. Educational level and race predicted current and preferred use of the Internet for obtaining SCI information, suggesting that Internet distribution of SCI information will exclude subgroups.

Ethnic and gender differences in patient education about heart disease risk and prevention

OBJECTIVE

To investigate whether there are gender and ethnic disparities in the patient education provided by primary healthcare providers about heart disease (HD) risk and prevention.

METHODS

A telephone survey, conducted in four languages, was completed by 976 people, 40+ years of age, in Metro Vancouver, Canada. Questions assessing communication with healthcare providers' provision of HD risk and management education were the focus.

RESULTS

Statistically significant gender and ethnic differences were found. Women were less likely to report discussing HD risk and management with their healthcare providers. Chinese-Canadian participants had less likelihood of receiving HD education compared with participants of other ethnic origins. These differences persisted after multivariate adjustment with income, highest level of education attained, age, and other factors.

CONCLUSION

Primary healthcare providers should make improved efforts towards education about HD and its risk factors for women in general, and for postmenopausal women especially.

PRACTICE IMPLICATIONS

Healthcare providers should be aware that some ethnic populations may not be receiving patient education similar to that received by people of other communities, as found for Chinese-Canadian members of this study community. Further understanding of the barriers faced by ethnic groups must be gained to develop solutions.

Impact of a public sensitization campaign on migraine management in France

Migraine is a common and frequently disabling condition. Nevertheless, many migraine sufferers do not consult for migraine, are not medically followed up and self-treat the attacks. "Tour de France of migraine" consisted of free-access conferences held in six large towns in France following a wide public information campaign. This sensitization campaign aimed at providing participants with educational information on migraine disease and on current therapies. Headache sufferers were then invited to respond to two consecutive questionnaires delivered at the end of the conferences and 3 months later to assess the influence of the information delivered on their migraine management. Tour de France of migraine recruited mainly severe migraine sufferers, most of whom had already consulted and were medically followed up. However, migraine management was often suboptimal in these subjects since most of them found their acute treatment of attacks ineffective and only few of them received a prophylactic treatment. Three months after the conferences, more than half of respondents had consulted for headaches. There was a significant improvement in migraine-related disability, as reflected by a significant decrease in mean Headache Impact Test 6-item score, which might have been related to the higher proportion of subjects receiving a prophylactic treatment of migraine. The Tour de France of migraine campaign revealed the difficulty in sensitizing migraine sufferers towards the necessity of being medically followed up. Mainly patients with severe migraine attended the conferences and derived clinical benefit from the educational program. Other strategies should be developed to reach a wider population of migraine sufferers.

Do school-based asthma education programs improve self-management and health outcomes?

CONTEXT

Asthma self-management education is critical for high-quality asthma care for children. A number of studies have assessed the effectiveness of providing asthma education in schools to augment education provided by primary care providers.

OBJECTIVE

To conduct a systematic review of the literature on school-based asthma education programs.

METHODS

As our data sources, we used 3 databases that index peer-reviewed literature: MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature. Inclusion criteria included publication in English and enrollment of children aged 4 to 17 years with a clinical diagnosis of asthma or symptoms consistent with asthma.

RESULTS

Twenty-five articles met the inclusion criteria. Synthesizing findings across studies was difficult because the characteristics of interventions and target populations varied widely, as did the outcomes assessed. In addition, some studies had major methodologic weaknesses. Most studies that compared asthma education to usual care found that school-based asthma education improved knowledge of asthma (7 of 10 studies), self-efficacy (6 of 8 studies), and self-management behaviors (7 of 8 studies). Fewer studies reported favorable effects on quality of life (4 of 8 studies), days of symptoms (5 of 11 studies), nights with symptoms (2 of 4 studies), and school absences (5 of 17 studies).

CONCLUSIONS

Although findings regarding effects of school-based asthma education programs on quality of life, school absences, and days and nights with symptoms were not consistent, our analyses suggest that school-based asthma education improves knowledge of asthma, self-efficacy, and self-management behaviors.

SGS: a structured treatment and teaching programme for older patients with diabetes mellitus--a prospective randomised controlled multi-centre trial

OBJECTIVES

evaluation of the effectiveness of a new structured diabetes teaching and treatment programme (DTTP) with specific didactical approaches and topics for geriatric patients with diabetes mellitus.

DESIGN

a prospective randomised controlled multi-centre trial.

SETTING AND PARTICIPANTS

a total of 155 geriatric patients were randomly admitted to either the new DTTP SGS (n = 83) or the standard DTTP (n = 72) for insulin-treated patients with type 2 diabetes mellitus (HbA1c 8.0 +/- 1.4%, age 76.2 +/- 6.3 years).

MEASUREMENTS

biometrical data, metabolic control, acute complications, diabetes knowledge, self-management.

RESULTS

SGS participants showed improved levels of HbA1c 6 months after the DTTP, and less acute complications than the standard group (P<0.009). Both groups demonstrated a good capacity for diabetes self-management and improvement in diabetes knowledge after the DTTP (P<0.01).

CONCLUSION

the new SGS diabetes education programme, focusing on the learning capabilities and the particular needs of older persons, is effective in improving metabolic control and in maintaining auto-sufficiency in geriatric patients with diabetes mellitus.

Assessing risk communication in breast cancer: are continuous measures of patient knowledge better than categorical?

OBJECTIVE

To compare the performance of categorical and continuous measures of patient knowledge in the context of risk communication about breast cancer, in terms of statistical and clinical significance as well as efficiency.

METHODS

Twenty breast cancer patients provided estimates of 10-year mortality risk before and after their oncology visit. The oncologist reviewed risk estimates from Adjuvant!, a well-validated and commonly used prognostic model. Using the Adjuvant! estimates as a gold standard, we calculated how accurate the patient estimates were before and after the visit. We used three novel continuous measures of patient accuracy, the absolute bias, Brier, and Kullback-Leibler scores, and compared them to a categorical measure in terms of sensitivity to intervention effects. We also calculated the sample size required to replicate the primary study using the categorical and continuous measures, as a means of comparing efficiency.

RESULTS

In this sample, the Kullback-Leibler measure was most sensitive to the intervention effects (p=0.004), followed by Brier and absolute bias (both p=0.011), and finally the categorical measure (0.125). The sample size required to replicate the primary study was 18 for the Kullback-Leibler measure, 23 for absolute bias and Brier, and 37 for the categorical measure.

CONCLUSIONS

The continuous measures led to more efficient sample sizes and to rejection of the null hypothesis of no intervention effect. However, the difference in sensitivity of the continuous measures was not statistically significant, and the performance of the categorical measure depends on the researcher's categorical cutoff for accuracy. Continuous measures of patient accuracy may be more sensitive and efficient, while categorical measures may be more clinically relevant.

PRACTICE IMPLICATIONS

Researchers and others interested in assessing the accuracy of patient knowledge should weigh the trade-offs between clinical relevance and statistical significance while designing or evaluating risk communication studies.

Content and frequency of writing on diabetes bulletin boards: does race make a difference?

BACKGROUND

Diabetes-related disparities are well documented among racial minority groups in the United States. Online programs hold great potential for reducing these disparities. However, little is known about how people of different races utilize and communicate in such groups. This type of research is necessary to ensure that online programs respond to the needs of diverse populations.

OBJECTIVE

This exploratory study investigated message frequency and content on bulletin boards by race in the Internet Diabetes Self-Management Program (IDSMP). Two questions were asked: (1) Do participants of different races utilize bulletin boards with different frequency? (2) Do message, content, and communication style differ by race? If so, how?

METHODS

Subjects were drawn by purposeful sampling from participants in an ongoing study of the effectiveness of the IDSMP. All subjects had completed a 6-week intervention that included the opportunity to use four diabetes-specific bulletin boards. The sample (N = 45) consisted of three groups of 15 participants, each who self-identified as American Indian or Alaskan Native (AI/AN), African American (AA), or Caucasian, and was stratified by gender, age, and education. Utilization was assessed by counting the number of messages per participant and the range of days of participation. Messages were coded blindly for message type, content, and communication style. Data were analyzed using descriptive and nonparametric statistics.

RESULTS

In assessing board utilization, AAs wrote fewer overall messages (P = .02) and AIs/ANs wrote fewer action planning posts (P = .05) compared with Caucasians. AIs/ANs logged in to the program for a shorter time period than Caucasians (P = .04). For message content, there were no statistical (P <or= .05) differences among groups in message type. No differences were found in message content between AAs and Caucasians, but AIs/ANs differed in content from both other groups. Caucasians wrote more on food behaviors than AIs/ANs (P = .01), and AIs/ANs wrote more about physical activity than Caucasians (P = .05) and about walking than the other two groups (P = .01). There were no differences in communication style.

CONCLUSIONS

Although Caucasians utilized the boards more than the other two groups, there were few differences in message type, content, or style. Since participation in bulletin boards is largely blind to race, age, gender, and other characteristics, it is not clear if finding few differences was due to this optional anonymity or because non-Caucasian participants assumed that they were communicating with Caucasians. If the low variability between racial groups indicates that the IDSMP is flexible enough to meet the needs of multiple racial groups, then online programs may be an accessible and effective tool to reduce health disparities. These questions need to be investigated in future studies.

Literacy-appropriate educational materials and brief counseling improve diabetes self-management

OBJECTIVE

In this pilot study, we evaluated the impact of providing patients with a literacy-appropriate diabetes education guide accompanied by brief counseling designed for use in primary care.

METHODS

We provided the Living with Diabetes guide and brief behavior change counseling to 250 English and Spanish speaking patients with type 2 diabetes. Counseling sessions using collaborative goal setting occurred at baseline and by telephone at 2 and 4 weeks. We measured patients' activation, self-efficacy, diabetes distress, knowledge, and self-care at baseline and 3-month follow-up.

RESULTS

Statistically significant (p<or=0.001) and clinically important (effect sizes=0.29-0.42) improvements were observed in participants' activation, self-efficacy, diabetes-related distress, self-reported behaviors, and knowledge. Improvements were similar across literacy levels. Spanish speakers experienced both greater improvement in diabetes-related distress and less improvement in self-efficacy levels than English speakers.

CONCLUSION

A diabetes self-management support package combining literacy-appropriate patient education materials with brief counseling suitable for use in primary care resulted in important short-term health-related psychological and behavioral changes across literacy levels.

PRACTICE IMPLICATIONS

Coupling literacy-appropriate education materials with brief counseling in primary care settings may be an effective and efficient strategy for imparting skills necessary for diabetes self-management.

A randomized controlled trial of an intervention to reduce low literacy barriers in inflammatory arthritis management

OBJECTIVE

Test the efficacy of educational interventions to reduce literacy barriers and enhance health outcomes among patients with inflammatory arthritis.

METHODS

The intervention consisted of plain language information materials and/or two individualized sessions with an arthritis educator. Randomization was stratified by education level. Principal outcomes included adherence to treatments, self-efficacy, satisfaction with care, and appointment keeping. Secondary outcomes included health status and mental health. Data were collected at baseline, six, and twelve months post.

RESULTS

Of the 127 patients, half had education beyond high school and three quarters had disease duration greater than five years. There were no differences in the primary outcome measures between the groups. In mixed models controlling for baseline score and demographic factors, the intervention group showed improvement in mental health score at six and twelve months (3.0 and 3.7 points, respectively), while the control group showed diminished scores (-4.5 and -2.6 points, respectively) (p=0.03 and 0.01).

CONCLUSION

While the intervention appears to have had no effect on primary outcomes, further studies with continued attention to literacy are warranted. Study site and disease duration must be considered as participants in this study had higher than average health literacy and had established diagnoses for years prior to this study.

PRACTICE IMPLICATIONS

The study offers insight into an application of many of the protocols currently recommended to ameliorate effects of limited literacy.

SCIRehab Project series: the supplemental nursing taxonomy

CONTEXT

Spinal cord injury (SCI) rehabilitation nurses document the occurrence of educational and care management efforts in traditional nursing documentation methods but not the intensity (or dose) of such interactions. This article describes a process to capture these nursing interventions.

METHODS

Nurses at 6 US inpatient SCI centers used 2 in-person meetings and weekly telephone calls over 9 months to develop a taxonomy of nursing patient education efforts and care management.

RESULTS

This was subsequently incorporated into a point-of-care documentation system and used to capture details of nursing care for 1,500 SCI rehabilitation patients enrolled in the SCIRehab study. The taxonomy consists of 10 education and 3 care management categories. The point-of-care system includes time spent on each category along with an indication of whether the patient and/or family received the education/care management. In addition, a subjective measure of patient participation in nursing activities is included.

CONCLUSIONS

Creation of a SCI rehabilitation nursing taxonomy is feasible, and its use has had an impact on nursing practice. It also has implications for future clinical documentation, because greater accuracy and details of patient education and care management will be a permanent practice in the participating systems at the conclusion of the study.

Pilot survey of oncologists regarding treatment-related infertility and fertility preservation in female cancer patients

OBJECTIVE

To conduct a quantitative survey that focuses on oncologists' practice patterns and attitudes surrounding treatment-related infertility and fertility preservation, specifically among women of reproductive age.

STUDY DESIGN

A 19-item survey was emailed to medical, pediatric, radiation and surgical oncologists at Duke University. Descriptive statistics were used.

RESULTS

Most oncologists (61%) who responded always or usually discuss the impact treatment will have on fertility. Nearly half (45%) never refer women to reproductive specialists. Respondents who attended an educational session on fertility preservation were more likely to consider a patient's desire for fertility when planning her treatment than those who did not attend (45% vs. 33%). More than half (55%) of attendees were willing to consider a less aggressive regimen to preserve fertility, compared with 29% of those who did not attend.

CONCLUSION

While most oncologists recognize the importance of discussing infertility risks, many do not discuss fertility preservation routinely. Reasons for this discrepancy included poor prognosis and emergent need to start therapy. Increasing awareness through educational events may influence current practice patterns and increase collaboration between reproductive endocrinologists and oncologists.

An advanced pharmacy practice experience in inpatient medication education

OBJECTIVE

To describe a unique advanced pharmacy practice experience (APPE) in which pharmacy students provided medication education to hospitalized patients.

DESIGN

Students were trained to independently assess patients' needs for education and identify drug-related problems. Students then provided medication education and performed medication therapy management under the supervision of clinical staff pharmacists. To assess the impact of the APPE, the number of hospitalized patients assessed and educated during the 3-month time period prior to student involvement was compared to the first 3 months of the APPE.

ASSESSMENT

Student participation increased the number of patients receiving medication education and medication therapy management from the hospital pharmacy. At the end of the APPE, students reported that the experience positively affected their ability to impact patients' care and to critique their own learning and skills.

CONCLUSION

The inpatient medication education APPE provided students the opportunity to be responsible and accountable for the provision of direct patient care. In addition, the APPE benefitted the hospital, the school of pharmacy, and, most importantly, the patients.

Psychological distress across the course of care: a case study from implantable cardioverter defibrillator to cardiac transplantation evaluation

The psychological distress of cardiac patients can complicate treatment or the recovery process. This case study presents a 47-year-old male recipient of an implantable cardioverter defibrillator who experienced multiple, consecutive shocks and subsequently developed anxiety and depressive difficulties. Psychological treatment to diminish these symptoms was employed. Despite declining cardiac function, the patient made significant progress in managing this negative affect. Subsequently, he was evaluated for cardiac transplant, and this treatment progress became critical evidence of his psychosocial suitability for transplant.

Dietary Approaches to Stop Hypertension (DASH) in clinical practice: a primary care experience

BACKGROUND

The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure placed increased emphasis on lifestyle modification for the prevention and management of hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet, rich in fruits, vegetables, nuts, and low-fat dairy foods, with reduced saturated and total fats, was found in clinical trials to lower blood pressure substantially and significantly. The DASH diet appears appropriate for use in the primary care setting, although it is unknown whether results will mirror those found in clinical trial.

METHODS

A review of the literature of successful physician-based dietary interventions and of the Stages of Change model as it applies to dietary behavior was completed. Some changes needed to adapt the DASH diet to the outpatient family practice setting were identified and implemented among a predominantly non-Caucasian (56%), female (61%) population. The most common concerns and diagnoses among this population are essential hypertension, diabetes, and general medical examination.

RESULTS

Under study conditions, DASH reported that patients experienced an average reduction of 6 mmHg systolic and 3 mmHg diastolic blood pressure. Results were better in those with high blood pressure--systolic dropped by 11 mmHg and diastolic dropped by 6 mmHg. This reduction occurred within 2 weeks of starting the plan. Our clinical experience matches these published results.

Evaluating knowledge of autonomic dysreflexia among individuals with spinal cord injury and their families

BACKGROUND/OBJECTIVE

Autonomic dysreflexia (AD) is a potentially life-threatening complication of spinal cord injury (SCI) characterized by episodic paroxysmal hypertension and bradycardia in response to a noxious stimulus below the level of injury. Recognition of AD is crucial for individuals with SCI and their family members to facilitate timely and appropriate management. The objectives of this study were to (a) evaluate knowledge of AD among SCI consumers and their family members and (b) identify the preferred format and timing of education regarding AD recognition and management for these stakeholders.

METHODS

Cross-sectional descriptive study on a cohort of community-dwelling individuals with chronic SCI (N = 100) and their family members (N = 16) by self-report mail survey. Frequency distributions were used to tabulate survey responses on AD knowledge level and to characterize learning preferences and 2 x 2 chi2 analyses were conducted to determine whether there were factors (ie, impairment) associated with AD knowledge (ie, how to treat AD).

RESULTS

Individuals with SCI and their family members have gaps in their knowledge of AD. Traumatic SCI etiology (vs nontrauma) was associated with greater knowledge about treating AD. Although the SCI sample was a high-risk group, 41% had not heard of AD. More concerning was that 22% of individuals with SCI reported symptoms consistent with unrecognized AD. Respondents indicated that AD education would be best delivered during rehabilitation by a healthcare professional.

CONCLUSIONS

Further work is needed to promote knowledge about recognizing and managing AD. This may help reduce risk of cardiac and cerebrovascular disease in the SCI population.

Discussing coronary risk with patients to improve blood pressure treatment: secondary results from the CHECK-UP study

OBJECTIVES

Hypertension is common among patients with dyslipidemia but is often poorly treated. The objective of this analysis was to evaluate how a decision aid, used by primary care physicians to improve lipid therapy, impacted on the treatment of hypertension.

STUDY DESIGN

Data were analyzed from patients enrolled in a randomized trial focusing primarily on the treatment of dyslipidemia. Patients received usual care or a coronary risk profile every three months to monitor the risk reduction following lifestyle changes and/or pharmacotherapy to treat dyslipidemia. Hypertension management was assessed based on a post hoc analysis of individuals whose blood pressure exceeded current national hypertension guidelines.

RESULTS

There were 2,631 subjects who completed the study. Among 1,352 patients without diagnosed hypertension, 30% were above target on at least three consecutive visits. Among 1,279 individuals with known hypertension, 69% were above target on at least two consecutive visits. Overall, patients receiving risk profiles were more likely to receive appropriate antihypertensive therapy (OR = 1.40, 95% CI 1.11-1.78) compared to those receiving usual care. After adjustment for inter-physician variability and potential confounders, the use of the risk profile was associated with an increased likelihood of starting therapy (OR = 1.78, 95% CI 1.06-3.00) or modifying therapy (OR = 1.40, 95% CI 1.03-1.91).

CONCLUSIONS

In this clinical trial of dyslipidemia management, inadequately controlled hypertension was common, occurring in nearly 50% of individuals. Ongoing coronary risk assessment was associated with more appropriate blood pressure management. Cardiovascular risk assessment decision aids should be further evaluated in a randomized trial of hypertension therapy.

Validation of the Brazilian-Portuguese version of the Gesture Behavior Test for patients with non-specific chronic low back pain

OBJECTIVE

To develop a Brazilian version of the gesture behavior test (GBT) for patients with chronic low back pain.

METHODS

Translation of GBT into Portuguese was performed by a rheumatologist fluent in the language of origin (French) and skilled in the validation of questionnaires. This translated version was back-translated into French by a native-speaking teacher of the language. The two translators then created a final consensual version in Portuguese. Cultural adaptation was carried out by two rheumatologists, one educated patient and the native-speaking French teacher. Thirty patients with chronic low back pain and fifteen healthcare professionals involved in the education of patients with low back pain through back schools (gold-standard) were evaluated. Reproducibility was initially tested by two observers (inter-observer); the procedures were also videotaped for later evaluation by one of the observers (intra-observer). For construct validation, we compared patients' scores against the scores of the healthcare professionals.

RESULTS

Modifications were made to the GBT for cultural reasons. The Spearman's correlation coefficient and the intra-class coefficient, which was employed to measure reproducibility, ranged between 0.87 and 0.99 and 0.94 to 0.99, respectively (p < 0.01). With regard to validation, the Mann-Whitney test revealed a significant difference (p < 0.01) between the averages for healthcare professionals (26.60; SD 2.79) and patients (16.30; SD 6.39). There was a positive correlation between the GBT score and the score on the Roland Morris Disability Questionnaire (r= 0.47).

CONCLUSIONS

The Brazilian version of the GBT proved to be a reproducible and valid instrument. In addition, according to the questionnaire results, more disabled patients exhibited more protective gesture behavior related to low-back.

The construct of breast cancer risk perception: need for a better risk communication?

Breast cancer risk assessment and communication are much neglected aspects of women's health care. Breast cancer is the most prevalent cancer-related disease that touches the deepest of a women's feelings and the subject thus attracts much of the attention of the media. Disease prevalence and media coverage are the roots of inappropriate breast cancer risk perception. Many women overestimate their personal breast cancer risk. Inappropriate risk perception precedes inappropriate health behaviour and it is pivotal to understand the underlying mechanisms in order to plan intervention. Whether interventions such as patient education through counselling and objective risk assessment are effective in restoring inappropriate breast cancer risk perception remains a question unanswered, but the tools to measure breast cancer risk are available and were validated.

Does patient education facilitate diabetic patients' possibilities to reach national treatment targets? A national survey in Swedish primary healthcare

OBJECTIVE

To describe how patient education is arranged in Swedish primary healthcare (PHC) and to assess whether the type of patient education and individual goal setting have an impact on diabetic patients' possibilities of reaching national treatment targets.

DESIGN

A Swedish national survey.

SETTING

Swedish PHC.

SUBJECTS

Data from 485 primary healthcare centres (PHCCs) and 91,637 diabetic patients reported by the PHCCs to the National Diabetes Register in 2006.

MAIN OUTCOME MEASURES

Description of how patient education is arranged, HbA(1c), body mass index, cholesterol, blood pressure, and physical activity.

RESULTS

Of the PHCCs that reported how they performed the individual counselling, 50% reported checklist-driven counselling and 8% individualized counselling based on patients' needs. A total of 105 PHCCs reported that they arranged group education. Of these, 67% used pre-planned programmes and 9% individualized the programme to the patients' needs. The majority of PHCCs (96%) reported that they set individual goals (HbA(1c), blood pressure, lipids, and lifestyle). A minority of the PHCCs (27%) reported that the patients were involved in the final decision concerning their goals. Individual goal-setting facilitated patients' possibilities of reaching treatment targets. Goal-setting, list size of PHCCs, and personnel resources explained a variance of 2.1-5.7%. Neither individual counselling (checklist-driven or individualized to patients' needs) nor group education had an impact on patients' possibilities of reaching the targets.

CONCLUSION

The current study indicates that improvement is needed in patient education in PHC to facilitate diabetic patients' possibilities of reaching national treatment targets.

National prevalence of lifestyle counseling or referral among African-Americans and whites with diabetes

BACKGROUND

Modifiable risk factors such as diet and physical activity contribute to racial disparities among patients with diabetes. Despite this, little is known about how frequently physicians provide counseling or referral to address these risk factors, or whether such rates differ by patient race.

METHODS

We analyzed cross-sectional data from the 2002-2004 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. We used logistic regression to investigate the relationship between counseling/referral for nutrition or exercise and patient factors, provider factors, and geographic location, with a focus on whether counseling rates were independently associated with patient race.

RESULTS

Overall, counseling/referral for nutrition occurred in 36% of patient visits and counseling/referral for exercise occurred in 18% of patient visits. After adjusting for patient, physician, and practice characteristics, there was no statistically significant association between race and counseling/referral for nutrition (odds ratio for African-Americans compared to whites [OR] 1.00, 95% confidence intervals [CI] 0.71-1.41) or for exercise (OR 0.74, CI 0.49-1.11). Significant predictors of counseling/referral for both lifestyle interventions included younger patient age, private insurance, and treatment by a primary care provider.

CONCLUSIONS

Rates of lifestyle modification counseling/referral were similarly low among African-Americans and whites in this national study. Our results highlight a need for interventions to enhance physician counseling for patients with diabetes, particularly those at high-risk for diabetes-associated morbidity and mortality, such as racial/ethnic minorities.

Communicating side effect risks in a tamoxifen prophylaxis decision aid: the debiasing influence of pictographs

OBJECTIVE

To experimentally test whether using pictographs (image matrices), incremental risk formats, and varied risk denominators would influence perceptions and comprehension of side effect risks in an online decision aid about prophylactic use of tamoxifen to prevent primary breast cancers.

METHODS

We recruited 631 women with elevated breast cancer risk from two healthcare organizations. Participants saw tailored estimates of the risks of 5 side effects: endometrial cancer, blood clotting, cataracts, hormonal symptoms, and sexual problems. Presentation format was randomly varied in a three factor design: (A) risk information was displayed either in pictographs or numeric text; (B) presentations either reported total risks with and without tamoxifen or highlighted the incremental risk most relevant for decision making; and (C) risk estimates used 100 or 1000 person denominators. Primary outcome measures included risk perceptions and gist knowledge.

RESULTS

Incremental risk formats consistently lowered perceived risk of side effects but resulted in low knowledge when displayed by numeric text only. Adding pictographs, however, produced significantly higher comprehension levels.

CONCLUSIONS

Pictographs make risk statistics easier to interpret, reducing biases associated with incremental risk presentations.

PRACTICE IMPLICATIONS

Including graphs in risk communications is essential to support an informed treatment decision-making process.

Predictors of refusal during a multi-step recruitment process for a randomized controlled trial of arthritis education

OBJECTIVE

Randomized controlled trials in patient education often have difficulty enrolling vulnerable populations-specifically, older, poorer, and less educated individuals. We undertook a randomized controlled trial (RCT) of an educational intervention for arthritis management, which included strategies to remove literacy-related barriers to participation. This paper reports on the multi-stage recruitment process and assesses whether refusal to participate was related to education, age, gender, working status, or insurance status.

METHODS

The recruitment protocol was designed to eliminate literacy-related barriers to participation. Patients were never asked to read or fill out forms. Interactions were oral, using everyday terms and short, clear sentences. Patients who declined during a screening call were considered Stage 1 Refusers. Patients who initially expressed interest but neither completed a baseline questionnaire nor provided consent were considered Stage 2 Refusers. Patients who consented were considered Enrollees. Age, gender, and insurance status were compared between Stage 1 Refusers and Enrollees. A second analysis compared these variables, plus educational attainment and working status, between Stage 2 Refusers, and Enrollees.

RESULTS

Of 408 eligible patients, there were 193 (47.3%) Stage 1 Refusers, 81 (19.9%) Stage 2 Refusers and 134 (32.8%) Enrollees. A higher proportion of Stage 1 Refusers than Enrollees were > or = 65 years old (58% vs. 37%, p = .0003). Multivariate analysis, adjusting for gender and insurance status, confirmed the effect of older age on refusal (OR = 2.3 (1.4, 3.6)). There were no significant differences between Stage 2 Refusers and Enrollees.

CONCLUSION

We found no evidence of refusal to participate due to educational attainment, working status, insurance status, or gender. Older patients were more likely to refuse participation at the first stage of recruitment.

PRACTICE IMPLICATIONS

Researchers should continue efforts to increase participation among older patients, particularly when studies are designed to be generalized to an elderly population as is the case with arthritis research. Strategies used in this recruitment protocol designed to remove literacy-related barriers to recruitment may be responsible for the observation that subjects with lower education did not have a higher rate of refusal. Such strategies deserve further study.

The impact of an educational pamphlet on knowledge and anxiety in women with preeclampsia

OBJECTIVE

This study was undertaken to evaluate whether or not an educational pamphlet could improve knowledge without increasing anxiety in women with preeclampsia.

METHODS

One hundred women recruited from an inpatient setting with suspected or proven preeclampsia were asked to answer a questionnaire assessing demographics, knowledge (primary outcome), anxiety and satisfaction (secondary outcomes) after being randomized to an intervention group (who received a pamphlet) or a control group (who did not received a pamphlet). The pamphlet and questionnaire, both designed by a multidisciplinary team, were read and answered at the same time.

RESULTS

Baseline and demographic characteristics were similar between the two groups. Knowledge about the symptoms of pre-eclampsia was excellent in both groups (61% to 100% correct answers). Women in both groups were well aware that preeclampsia in the past (P = 0.22) and a family history of preeclampsia (P = 0.57) were risk factors. There was a significant difference in knowledge about the risk of some fetal complications, including death (90% versus 39%, P < 0.01) and all maternal complications (P < 0.05) favouring the intervention group. Despite increased knowledge about preeclampsia and its risks, anxiety was not greater in the intervention group. Overall, there was a trend towards less knowledge in vulnerable subgroups (non-white, low income and schooling levels), but the improvement of knowledge with the pamphlet was equivalent. Baseline anxiety was higher in the vulnerable groups, but was generally not increased by the pamphlet.

CONCLUSION

An educational pamphlet for women with suspected preeclampsia was able to increase knowledge without increasing anxiety.

EDUC'AVK: reduction of oral anticoagulant-related adverse events after patient education: a prospective multicenter open randomized study

BACKGROUND

Long-term oral anticoagulation treatment is associated with potential morbidity. Insufficient patient education is linked to poorly controlled anticoagulation. However the impact of a specific educational program on anticoagulation related morbidity remains unknown.

OBJECTIVE

To evaluate the effect of an oral anticoagulation patient education program in reducing both hemorrhagic and recurrent thrombotic complications.

DESIGN/PARTICIPANTS

We conducted a prospective, multicenter open randomized study, comparing an interventional group who received a specific oral anticoagulation treatment educational program with a control group. Eligible patients were older than 18 and diagnosed as having deep vein thrombosis or pulmonary embolism requiring therapy with a vitamin K antagonist for 3 months or more. Our primary outcome was the occurrence of hemorrhagic or thromboembolic events.

RESULTS

During the 3-month follow-up the main outcome criteria were observed 20 times (6.6% of patients), 5 (3.1%) in the experimental and 15 (10.6%) in the control group. Consequently, in multivariate analysis, the cumulative risk reduction in the experimental group was statistically significant (OR 0.25, 95% CI 0.1-0.7, p < 0.01).

CONCLUSIONS

Patient education using an educational program reduced VKA-related adverse event rates.

Recall-promoting physician behaviors in primary care

BACKGROUND

Effective treatments can be rendered useless by poor patient recall of treatment instructions. Studies suggest that patients forget a great deal of important information and that recall can be increased through recall-promoting behaviors (RPBs) like repetition or summarization.

OBJECTIVE

To assess how frequently RPBs are used in primary care, and to reveal how they might be applied more effectively.

DESIGN

Recordings of 49 unannounced standardized patient (SP) visits were obtained using hidden audiorecorders. All SPs presented with typical gastroesophageal reflux disease symptoms. Transcripts were coded for treatment recommendations and RPBs.

PARTICIPANTS

Forty-nine primary care physicians.

RESULTS

Of 1,140 RPBs, 53.7% were repetitions, 28.2% were communication of the rationale for a treatment, 11.7% were categorizations of treatments (i.e., stating that a treatment could be placed into a treatment category, such as medication-related or lifestyle-related categories), and 3.8% were emphasis of a recommendation's importance. Physicians varied substantially in their use of most RPBs, although no physicians summarized or asked patients to restate recommendations. The number of RPBs was positively correlated with visit length.

CONCLUSIONS

Primary care physicians apply most RPBs inconsistently, do not utilize several RPBs that are particularly helpful, and may use RPBs inefficiently. Simple principles guiding RPB use may help physicians apply these communication tools more effectively.

Do clinical rehabilitation education programs really improve stroke-related knowledge?

OBJECTIVE

We evaluated the effectiveness of a clinical stroke education program for improving stroke-related health knowledge after inpatient rehabilitation in a "real world" setting.

DESIGN

Thirty-four patients participated in an inpatient rehabilitation clinical stroke education program. Their stroke-related health knowledge in three key domains-risk factors, warning signs, and appropriate actions to take if a stroke is suspected-was evaluated at admission and 12 wks later using a single-group, pretest-posttest design. Pretest and posttest comparisons were conducted using the Marginal Homogeneity test and the McNemar test.

RESULTS

Small, nonsignificant improvements in stroke-related health knowledge were detected at posttest. Twelve weeks after the education program, 29% of participants were unable to name a single risk factor, 32% were unable to name a single warning sign, and 29% were unable to name appropriate emergency action in the event they suspected a stroke.

CONCLUSIONS

A substantial proportion of patients who completed our clinical stroke education program continued to have poor stroke-related health knowledge. We noted several limitations in our program that may have contributed to this outcome. Changes may be useful for improving the success of clinical stroke education programs, thereby reducing knowledge deficits.

Miscoding and other user errors: importance of ongoing education for proper blood glucose monitoring procedures

BACKGROUND

This article reviews the literature to date and reports on a new study that documented the frequency of manual code-requiring blood glucose (BG) meters that were miscoded at the time of the patient's initial appointment in a hospital-based outpatient diabetes education program.

METHOD

Between January 1 and May 31, 2007, the type of BG meter and the accuracy of the patient's meter code (if required) and procedure for checking BG were checked during the initial appointment with the outpatient diabetes educator. If indicated, reeducation regarding the procedure for the BG meter code entry and/or BG test was provided.

RESULTS

Of the 65 patients who brought their meter requiring manual entry of a code number or code chip to the initial appointment, 16 (25%) were miscoded at the time of the appointment. Two additional problems, one of dead batteries and one of improperly stored test strips, were identified and corrected at the first appointment.

CONCLUSIONS

These findings underscore the importance of checking the patient's BG meter code (if required) and procedure for testing BG at each encounter with a health care professional or providing the patient with a meter that does not require manual entry of a code number or chip to match the container of test strips (i.e., an autocode meter).

Patients prefer pictures to numbers to express cardiovascular benefit from treatment

PURPOSE

This study aimed to determine which methods of expressing a preventive medication's benefit encourage patients with known cardiovascular disease to decide to take the medication and which methods patients prefer.

METHODS

We identified patients in Auckland, New Zealand, family practices located in areas of differing socioeconomic status who had preexisting heart disease (myocardial infarction, angina, or both) and were taking statins. The patients were interviewed about their preference for methods of expressing the benefit of a hypothetical medication. Benefits were expressed numerically (relative risk, absolute risk, number needed to treat, odds ratio, natural frequency) and graphically. Statistical testing was adjusted for practice.

RESULTS

We interviewed 100 eligible patients, representing a 53% response rate. No matter how the risk was expressed, the majority of patients indicated they would be encouraged to take the medication. Two-thirds (68) of the patients preferred 1 method of expressing benefit over others. Of this group, 57% preferred the information presented graphically. This value was significantly greater (P <.001) than the 19% who chose the next most preferred option, relative risk. Few patients preferred absolute risk (13%) or natural frequencies (9%). Only a single patient (1%) preferred the odds ratio. None preferred number needed to treat. Ninety percent of patients responding to a question about framing preferred positive framing (description of the benefit of treatment) over negative framing (description of the harm of not being treated).

CONCLUSIONS

Although number needed to treat is a useful tool for communicating risk and benefit to clinicians, this format was the least likely to encourage patients to take medication. As graphical representation of benefit was the method patients preferred most, consideration should be given to developing visual aids to support shared clinical decision making.

Informing men about prostate cancer screening: a randomized controlled trial of patient education materials

BACKGROUND

Patient education materials can assist patient decision making on prostate cancer screening.

OBJECTIVE

To explore the effectiveness of presenting health information on prostate cancer screening using video, internet, and written interventions on patient decision making, attitudes, knowledge, and screening interest.

DESIGN

Randomized controlled trial.

PARTICIPANTS

A total of 161 men aged over 45, who had never been screened for prostate cancer, were randomized to receive information on prostate cancer screening.

MEASUREMENTS

Participants were assessed at baseline and 1-week postintervention for decisional conflict, screening interest, knowledge, anxiety, and decision-making preference.

RESULTS

A total of 156 men were followed-up at 1-week postintervention. There was no statistical, or clinical, difference in mean change in decisional conflict scores between the 3 intervention groups (video vs internet -0.06 [95% CI -0.24 to 0.12]; video vs pamphlet 0.04 [95%CI -0.15 to 0.22]; internet vs pamphlet 0.10 [95%CI -0.09 to 0.28]). There was also no statistically significant difference in mean knowledge, anxiety, decision-making preference, and screening interest between the 3 intervention groups.

CONCLUSION

Results from this study indicate that there are no clinically significant differences in decisional conflict when men are presented health information on prostate cancer screening via video, written materials, or the internet. Given the equivalence of the 3 methods, other factors need to be considered in deciding which method to use. Health professionals should provide patient health education materials via a method that is most convenient to the patient and their preferred learning style.

Effects of asthma education on children's use of acute care services: a meta-analysis

OBJECTIVE

National Heart, Lung, and Blood Institute clinical practice guidelines strongly recommend that health professionals educate children with asthma and their caregivers about self-management. We conducted a meta-analysis to estimate the effects of pediatric asthma education on hospitalizations, emergency department visits, and urgent physician visits for asthma.

PATIENTS AND METHODS

Inclusion criteria included enrollment of children aged 2 to 17 years with a clinical diagnosis of asthma who resided in the United States. Pooled standardized mean differences and pooled odds ratios were calculated. Random-effects models were estimated for all outcomes assessed.

RESULTS

Of the 208 studies identified and screened, 37 met the inclusion criteria. Twenty-seven compared educational interventions to usual care, and 10 compared different interventions. Among studies that compared asthma education to usual care, education was associated with statistically significant decreases in mean hospitalizations and mean emergency department visits and a trend toward lower odds of an emergency department visit. Education did not affect the odds of hospitalization or the mean number of urgent physician visits. Findings from studies that compared different types of asthma education interventions suggest that providing more sessions and more opportunities for interactive learning may produce better outcomes.

CONCLUSIONS

Providing pediatric asthma education reduces mean number of hospitalizations and emergency department visits and the odds of an emergency department visit for asthma, but not the odds of hospitalization or mean number of urgent physician visits. Health plans should invest in pediatric asthma education or provide health professionals with incentives to furnish such education. Additional research is needed to determine the most important components of interventions and compare the cost-effectiveness of different interventions.

The study circle as a tool in multiple sclerosis patient education in Sweden

OBJECTIVE

Patient education plays an important role in the management of chronic diseases that can cause disability and predictable psychosocial problems. Quality of life assessment in multiple sclerosis (MS) has confirmed that psychosocial complications related to working life, marriage/partnership, and the family often occur. Furthermore, symptoms such as fatigue, pain, and sexual dysfunction have a great impact. We wanted to develop and implement study circles to promote the patients' abilities to meet such common problems and to provide a network where they can be autonomous and develop appropriate strategies in self-care and existential problems.

METHODS

Together with the MS patient organization and a study association, we have arranged study circles for patients with MS, thus providing structured information according to a pedagogic model. The patients are encouraged to work together in groups to learn about the disease and its key symptoms, to develop strategies to master these symptoms in everyday life, and to make necessary changes, ie, self-care management. The programme also contains handicap policies.

RESULTS

Fifteen study circles with a total of 105 patients started during the first year. Fifteen circle leaders were approved. A focus interview showed that the patients are highly satisfied but also revealed some problems in interactions with health care professionals. The study circles were included in a wider project from a newly started multidisciplinary centre for health education for a variety of chronic diseases causing disability, which aims at becoming a regional interface between the health care system, patient organizations, and educational services.

CONCLUSION

The study circles have an important role to play in the management of MS. Good organization is required to make such a project work since health care services do not normally work so closely with patient organizations and educational services.

PRACTICE IMPLICATIONS

Study circles that are permanently established and function well are of great help for the patients and the work at the MS clinic is substantially facilitated. Health care professionals also gain from the arrangement by learning more about the self-perceived impact of the disease.

Patient knowledge and perception of upper respiratory infections, antibiotic indications and resistance

BACKGROUND AND OBJECTIVE

The misuse of antibiotics is not a harmless practice; rather, it can render future antibiotic treatments ineffective. This study looked to determine patient knowledge and perception of upper respiratory infections and indicated treatment.

METHODS

The authors developed and administered a questionnaire to 98 patients visiting affiliated family medicine clinical sites. Participants were selected randomly, either while sitting in the waiting room, or after being seen by the clinician.

RESULTS

While more than half the respondents recognized that treatment for colds did not require antibiotics, 70% erroneously indicated that viruses require antibiotic treatment. Additionally, almost 90% of respondents thought that yellow nasal discharge or coughing up yellow mucous requires antibiotic treatment. It was interesting to note that 95% of patients reported satisfaction when advised by their physician that antibiotic treatment wasn't necessary, even if they initially thought they needed antibiotics.

CONCLUSIONS

Primary care providers have the greatest opportunity to curb inappropriate antibiotic use by both prescribing appropriately and educating their patients about proper antibiotic use when indicated.

Pacific Islanders' perspectives on heart failure management

OBJECTIVE

To identify the health beliefs, attitudes, practices, and social and family relations important in heart failure treatment among Pacific Islanders.

METHODS

Four focus groups were convened with 36 Native Hawaiians and Samoans with heart failure and their family caregivers. Thematic data analysis was used to categorize data into four domains: health beliefs and attitudes, preferred health practices, social support systems, and barriers to heart failure care.

RESULTS

Common coping styles and emotional experiences of heart failure in this population included avoidance or denial of illness, hopelessness and despair, and reliance on spiritual/religious beliefs as a means of support. Among study participants, more Samoans preferred to be treated by physicians whereas more Native Hawaiians preferred traditional Hawaiian methods of healing. Two types of social support (informational and tangible-instrumental) were identified as important in heart failure care. Barriers to heart failure care included poor knowledge of heart failure, lack of trust in physicians' care, poor physician-patient relations, finances, dietary changes, and competing demands on time.

CONCLUSION

The recruitment, retention, and adherence of Pacific Islanders to heart failure interventions is affected by an array of psychosocial and socio-cultural factors.

PRACTICE IMPLICATIONS

Interventions might be improved by offering participants accurate and detailed information about heart failure and its treatment, engaging the extended family in providing necessary supports, and providing tools to facilitate physician-patient relationships, among others, within the context of a larger socio-cultural system.

Medication use in the transition from hospital to home

After hospital discharge, correct understanding and use of medications are key components of patient safety. The current discharge process does not provide adequate fail-safes to ensure quality post-discharge care. This often leads to preventable medication errors as well as nonadherence. Several barriers to successful discharge counselling, including use of medical jargon, lack of educational and administrative resources, time constraints, and low health literacy, contribute to ineffective communication between hospital physicians and patients. Other obstacles include inaccurate or incomplete documentation of the medication history, lack of social support, financial constraints, and poor transfer of information to outpatient physicians. Solutions to improve medication use in the transition period after hospital discharge require effective communication with patients through the use of easily understood language, highlighting key information, and ensuring patient comprehension through the "teach back" technique. More timely communication with outpatient physicians in addition to a more comprehensive transfer of information further facilitates the transition home. Finally, a systematic process of medication reconciliation also aids in decreasing the incidence of medication errors. Hospital-based physicians who attend to key details in the process of discharging patients can have a profound impact on improving medication adherence, avoiding medication errors, and decreasing adverse outcomes in the post-discharge period.

Meta-analysis of patient education interventions to increase physical activity among chronically ill adults

OBJECTIVE

This meta-analysis integrates primary research testing the effect of patient education to increase physical activity (PA) on behavior outcomes among adults with diverse chronic illnesses.

METHODS

Extensive literature searching strategies located published and unpublished intervention studies that measured PA behavior outcomes. Primary study results were coded. Fixed- and random-effects meta-analytic procedures included moderator analyses.

RESULTS

Data were synthesized across 22,527 subjects from 213 samples in 163 reports. The overall mean weighted effect size for two-group comparisons was 0.45 (higher mean for treatment than control). This effect size is consistent with a difference of 48 min of PA per week or 945 steps per day. Preliminary moderator analyses suggest interventions were most effective when they targeted only PA behavior, used behavioral strategies (versus cognitive strategies), and encouraged PA self-monitoring. Differences among chronic illnesses were documented. Individual strategies unrelated to PA outcomes included supervised exercise sessions, exercise prescription, fitness testing, goal setting, contracting, problem solving, barriers management, and stimulus/cues. PA outcomes were unrelated to gender, age, ethnicity, or socioeconomic distribution among samples.

CONCLUSION

These findings suggest that some patient education interventions to increase PA are effective, despite considerable heterogeneity in the magnitude of intervention effect.

PRACTICE IMPLICATIONS

Moderator analyses are preliminary and provide suggestive evidence for further testing of interventions to inform practice.

Computerized learning technologies for diabetes: a systematic review

BACKGROUND

The objective of this study was to evaluate computerized learning technology interventions that can empower patients in the self-management of diabetes and support diabetes education over a distance.

METHODS

We searched Medline (1966-2006), CINAHL (1982-2006), and the Cochrane Central Register of Controlled Trials (first quarter 2007) databases. We also reviewed reference lists from included studies to identify additional studies. We included 25 articles representing 21 randomized controlled trials that evaluated a computerized learning technology and measured the outcome of patient care. We extracted patient sample, intervention, educational content topics, outcome measures, and statistical significance.

RESULTS

Of 21 eligible trials, 18 trials (85.7%) reported significant positive outcomes. Almost 44% (43.8%) of the outcomes demonstrated significant improvements (49 of 112 outcomes).

CONCLUSIONS

Patient self-management behaviors are important in chronic disease management, and initial evidence suggests that computerized learning technology interventions can play a significant role in the future.

Attitudes and beliefs about emergency contraception among patients at academic family medicine clinics

PURPOSE

The possible mechanisms of action of emergency contraception (EC) include preventing ovulation, fertilization, or implantation of an embryo. Differences in the use of terminology between medical personnel and the general public could be misleading to patients who would use EC. This cross-sectional survey evaluated women's beliefs regarding pregnancy and EC's possible mechanisms of actions.

METHODS

An anonymous questionnaire was developed and pilot tested for an appropriate reading level and ease of analysis. It collected information on demographics and beliefs about pregnancy and EC. During an 8-week period, the questionnaire was given to a convenience sample of female patients aged 18 to 50 years visiting 2 academic family medicine clinics in the southeastern United States. Descriptive statistics and logistic regression models were used for analysis.

RESULTS

A total of 178 women completed questionnaires. Nearly one-half (47%) of respondents believed that pregnancy begins with fertilization; however, less than one-third (30%) believed that life begins with fertilization. Thirty-eight percent of respondents stated that they would use EC only if they believed it worked before fertilization or implantation. Generally similar proportions thought that EC works before fertilization (24%) and before implantation (36%), or were unsure about when it works (34%). Younger age was associated with higher odds of believing that EC works before fertilization; none of the other demographic factors studied conferred either higher or lower odds.

CONCLUSIONS

Many women are uninformed about the possible mechanisms of action of EC, and we found no reliable predictors for those who were better informed. This study raises questions regarding women's understanding of EC and demonstrates the need to better educate them about its possible mechanisms of action.

Observational studies of a one year self-management program and a two year pulmonary rehabilitation program in patients with COPD

OBJECTIVE

To describe the outcome of a one year self-management program (SMG) and a two year pulmonary rehabilitation program (PRG).

METHODS

Two open prospective observational studies with 30 patients in each study. SMG had 46 hours over 12 months. PRG had in addition three weekly exercise sessions parallel which lasted an additional year.

RESULTS

In SMG, health-related quality of life (HRQoL, measured by St. George's Respiratory Questionnaire) had an improvement of-3.6 points (95% CI -6.7 to -0.5) one year after the end of the intervention, but there was no change in the six minutes walking test (6MWT). The PRG had an improvement in HRQoL at the end of the intervention of -11.2 points (95% CI -13.9 to -8.4) and the 6MWT was clinically significant improved with 86 metres (95% CI 63 to 109). None of the groups showed any clinical relevant change in lung function.

CONCLUSION

Participants in the SMG had had an improvement in quality of life and no deterioration in exercise tolerance one year after the end of the program compared to the start. Participants in the PRG significantly improved their quality of life and exercise tolerance the first year, but had no further clinical relevant improvement the second year.

Parental food allergy information needs: a qualitative study

OBJECTIVE

To examine information needs and preferences of parents regarding food allergy.

DESIGN

Qualitative study including in-depth semi-structured interviews and focus group discussions. Data were audio-recorded, transcribed verbatim and analysed using the constant comparative method, aided by participant checking of interview summaries, independent reviewers and qualitative analysis software.

PARTICIPANTS

84 parents of children with food allergy.

SETTING

Three paediatric allergy clinics and a national consumer organisation.

RESULTS

Most parent participants had received third level education (72%) and 39% had occupational backgrounds in health and education. Parents experienced different phases in their need for information: at diagnosis when there is an intense desire for information, at follow-up when there is continuing uncertainty about allergy severity and appropriate management, and at new events and milestones. They preferred information to be provided in a variety of formats, with access to reliable individualised advice between clinic appointments, within the context of an ongoing relationship with a health professional. Parents wished to know the reasoning behind doctor's opinions and identified areas of core information content, including unaddressed topics such as what to feed their child rather than what to avoid. Suboptimal information provision was cited by parents as a key reason for seeking second opinions.

CONCLUSION

Parents with children with food allergies have unmet information needs. Study findings may assist in the design and implementation of targeted educational strategies which better meet parental needs and preferences.

Views of Ontarians about health professionals' smoking cessation advice

BACKGROUND

Health professionals have important roles in helping smokers quit. However, it is not known how the public, especially smokers, view smoking cessation advice from different health professionals.

METHODS

We added questions regarding opinions and experiences with health professionals' smoking cessation advice to the 2002 CAMH Monitor, an annual random-digit-dialled survey of adult Ontarians. We report on how good a source of advice physicians, pharmacists, and dentists are perceived to be, how likely smokers are to consult each of these professionals, who smokers would ask for advice on the use of NRT, and advice received by smokers in the past year.

RESULTS

About two thirds of respondents viewed physicians as a very good source of advice on quitting, compared to just over one third and about one quarter who thought this of pharmacists and dentists, respectively. Over half of current smokers would be very likely to ask a physician for quit advice, compared to about 20% and only 3% for a pharmacist or a dentist, respectively. Among smokers, over 40% would first ask a physician for advice on NRT; about 20% would first ask a pharmacist. About 42% and 8% of current smokers reported that they received advice in the past year from a physician and pharmacist, respectively.

INTERPRETATION

Smokers are receptive to quit advice from physicians, but less likely to ask other health professionals. Few smokers received advice from pharmacists and dentists. Increasing the reach of quit advice requires both increased professional intervention and education of the public.

Social marketing meets health literacy: Innovative improvement of health care providers' comfort with patient interaction

OBJECTIVE

It is essential to train health care providers to deliver care sensitive to the needs of diverse individuals with varying degrees of health literacy. We aimed to evaluate an innovative, theory-based, educational intervention involving social marketing and health literacy.

METHODS

In 2006 at a large medical school, all first-year students were exposed to the intervention. They completed pre- and post-test anonymous surveys including demographic data, covariates, and key outcome variables. Paired t-tests and multiple linear regression were used to evaluate the intervention and to determine independent associations among the key outcome variables.

RESULTS

Post-intervention scores were significantly higher than pre-intervention scores for social marketing (3.31 versus 1.90, p<0.001), health literacy (3.41 versus 2.98, p<0.001), and comfort in brochure development (3.11 versus 2.52, p<0.001) (N=83). After controlling for demographic and covariate data, health literacy and comfort in brochure development were independent predictors of comfort interacting with diverse populations.

CONCLUSION

A brief intervention involving social marketing and health literacy can improve skills that improve medical students' comfort with patients of diverse backgrounds.

PRACTICE IMPLICATIONS

Health care providers can be taught educational principles and skills involved in developing effective patient education materials. These skills may improve providers' comfort with direct patient interaction.

The development of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression

Post-operative management after lumbar surgery is inconsistent leading to uncertainty amongst surgeons and patients about post-operative restrictions, reactivation, and return to work. This study aimed to review the evidence on post-operative management, with a view to developing evidence-based messages for a patient booklet on post-operative management after lumbar discectomy or un-instrumented decompression. A systematic literature search produced a best-evidence synthesis of information and advice on post-operative restrictions, activation, rehabilitation, and expectations about outcomes. Evidence statements were extracted and developed into patient-centred messages for an educational booklet. The draft text was evaluated by peer and patient review. The literature review found little evidence for post-operative activity restrictions, and a strong case for an early active approach to post-operative management. The booklet was built around key messages derived from the literature review and aimed to reduce uncertainty, promote positive beliefs, encourage early reactivation, and provide practical advice on self-management. Feedback from the evaluations were favourable from both review groups, suggesting that this evidence-based approach to management is acceptable and it has clinical potential.