Parent-Child Vaccination Concordance and Its Relationship to Child Age, Parent Age and Education, and Perceived Social Norms

Researchers established that parental vaccination status often predicts that of their children, but a limited number of studies have examined factors influencing dyadic concordance or discordance (i.e., same or different vaccination status or intent for both members). We investigated how child versus parent age as well as parents' perceptions of their respective friends' immunization behavior impacted un/vaccinated parents' decisions regarding vaccinating their child. An online survey obtained the COVID-19 vaccination status and views of 762 parents of 5-17-year-old children. More than three-quarters of all dyads were concordant; 24.1% of vaccinated parents would not vaccinate their child, with greater hesitancy for younger children and among younger or less educated parents. Children of vaccinated parents and of parents who thought most of their child's friends were vaccinated were 4.7 and 1.9 times, respectively, more likely to be vaccinated; unvaccinated parents were 3.2 times more likely to accept the vaccine for their child if they believed most of their friends would vaccinate their children. Further, parents who reported that most of their friends were vaccinated were 1.9 times more likely to have obtained the vaccine themselves, illustrating the influence of social norms. Regardless of their own vaccination status, parents of unvaccinated children were more likely to be politically conservative. If communities or circles of friends could achieve or convey a vaccinated norm, this might persuade undecided or reluctant parents to vaccinate their children. Future research should examine the effects of community behavior and messages highlighting social norms on pediatric vaccine uptake.

Attitudes towards diversity, equity, and inclusion across the CTSA Programs: Strong but not uniform support and commitment

Background

This study describes attitudes towards diversity, equity, and inclusion (DEI) among members of the Clinical and Translational Science Awards (CTSA) Program. It also explores associations between program members' roles and their perceived importance of and commitment to improving DEI and assesses the link between perceived importance of and commitment to improving DEI. Lastly, it ascertains barriers and priorities concerning health equity research, workforce development, CTSA consortium leadership, and clinical trials participation among respondents.

Methods

A survey was administered to registrants of the virtual CTSA Program 2020 Fall Meeting. Respondents reported their roles, perceived importance of and commitment to improving DEI. Bivariate cross-tabulations and structural equation modeling examined associations between respondents' roles, perceived importance of DEI, and commitment to improving DEI. Grounded theory was used to code and analyze open-ended questions.

Results

Among 796 registrants, 231 individuals completed the survey. DEI was "extremely important" among 72.7 percent of respondents and lowest among UL1 PIs (66.7%). Being "extremely committed" to improving DEI was reported by 56.3 percent of respondents and lowest among "other staff" (49.6%). Perceived importance of DEI was positively associated with commitment to improve DEI. Institutional and CTSA Commitment, Support, and Prioritization of DEI represented a key theme for improving DEI among respondents.

Conclusion

Clinical and translational science organizations must take bold steps to transform individual perceptions of DEI into commitment and commitment into action. Institutions must set visionary objectives spanning leadership, training, research, and clinical trials research to meet the promise and benefits of a diverse NIH-supported workforce.

Academic Medicine's Fourth Mission: Building on Community-Oriented Primary Care to Achieve Community-Engaged Health Care

A 2021 article, "Now is our time to act: Why academic medicine must embrace community collaboration as its fourth mission," by Association of American Medical Colleges (AAMC) authors, including AAMC president and CEO Dr. David J. Skorton, offers 2 aims that are highly related: community collaboration and health equity. The AAMC's call to prioritize community collaboration and health equity as pillars of the academic medicine mission echo earlier work on community-oriented primary care (COPC) and an even more robust model that builds on COPC, community-engaged health care (CEHC). COPC is a tested, systematic approach to health care by which a health clinic or system collaborates with a community to reshape priorities and services based on assessed health needs and determinants of health. COPC affirms health inequities' socioeconomic and political roots, emphasizing health care as a relationship, not a transaction or commodity. Communities where COPC is implemented often see reductions in health inequities, especially those related to socioeconomic, structural, and environmental factors. COPC was the foundation on which community health centers were built, and early models had demonstrable effects on community health and engagement. Several academic health centers build on COPC to achieve CEHC. In CEHC, primary care remains critical, but more of the academic health center's functions are pulled into community engagement and trust building. Thus, the AAMC has described and embraced a care and training model for which there are good, longitudinal examples among medical schools and teaching hospitals. Spreading CEHC and aligning the Community Health Needs Assessment requirements of academic health centers with the fourth mission could go a long way to improving equity, building trust, and repairing the social contract for health care.

It should not require a pandemic to make community engagement in research leadership essential, not optional

Efforts to move community engagement in research from marginalized to mainstream include the NIH requiring community engagement programs in all Clinical and Translational Science Awards (CTSAs). However, the COVID-19 pandemic has exposed how little these efforts have changed the dominant culture of clinical research. When faced with the urgent need to generate knowledge about prevention and treatment of the novel coronavirus, researchers largely neglected to involve community stakeholders early in the research process. This failure cannot be divorced from the broader context of systemic racism in the US that has contributed to Black, Indigenous, and People of Color (BIPOC) communities bearing a disproportionate toll from COVID-19, being underrepresented in COVID-19 clinical trials, and expressing greater hesitancy about COVID-19 vaccination. We call on research funders and research institutions to take decisive action to make community engagement obligatory, not optional, in all clinical and translational research and to center BIPOC communities in this process. Recommended actions include funding agencies requiring all research proposals involving human participants to include a community engagement plan, providing adequate funding to support ongoing community engagement, including community stakeholders in agency governance and proposal reviews, promoting racial and ethnic diversity in the research workforce, and making a course in community engaged research a requirement for Masters of Clinical Research curricula.

Engagement science: The core of dissemination, implementation, and translational research science

Stakeholder engagement is acknowledged as central to dissemination and implementation (D&I) of research that generates and answers new clinical and health service research questions. There is both benefit and risk in conducting stakeholder engagement. Done wrong, it can damage trust and adversely impact study results, outcomes, and reputations. Done correctly with sensitivity, inclusion, and respect, it can significantly facilitate improvements in research prioritization, communication, design, recruitment strategies, and ultimately provide results useful to improve population and individual health. There is a recognized science of stakeholder engagement, but a general lack of knowledge that matches its strategies and approaches to particular populations of interest based on history and characteristics. This article reviews stakeholder engagement, provides several examples of its application across the range of translational research, and recommends that Clinical Translational Science Awards, with their unique geographical, systems, and historical characteristics, actively participate in deepening our understanding of stakeholder engagement science and methods within implementation and dissemination research. These recommendations include (a) development of an inventory of successful stakeholder engagement strategies; (b) coordination and intentionally testing a variety of stakeholder engagement strategies; (c) tool kit development; and (d) identification of fundamental motivators and logic models for stakeholder engagement to help align stakeholders and researchers.

A Framework for Resident Participation in Population Health

Population health experiences have become more common in medical education. Yet, most resident population health experiences are in patient panel management and fail to connect with the rapidly growing movement of cross-sector, data-driven, and community-led initiatives dedicated to improving the health of populations defined by geography rather than insurer or employer. In this Perspective, the authors present a five-stage framework for residents' participation in the work of these initiatives. The five stages of this framework are (1) organize and prepare, (2) plan and prioritize, (3) implement, (4) monitor and evaluate, and (5) sustain. In applying this approach, residents stand to acquire new population health skills and augment the value and meaning of their work, while institutions stand to improve the health of the communities they serve, including the health of their own employees. However, a paucity of experienced role models and demanding residency schedules present significant challenges to residents effectively partnering with the community. Residencies and institutions will have to be flexible and committed to being a part of these cross-sector, data-driven, and community-led partnerships over the long term.

Developing physicians as catalysts for change

Failures in care coordination are a reflection of larger systemic shortcomings in communication and in physician engagement in shared team leadership. Traditional medical care and medical education neither focus on nor inspire responses to the challenges of coordinating care across episodes and sites. The authors suggest that the absence of attention to gaps in the continuum of care has led physicians to attempt to function as the glue that holds the health care system together. Further, medical students and residents have little opportunity to provide feedback on care processes and rarely receive the training and support they need to assess and suggest possible improvements.The authors argue that this absence of opportunity has driven cynicism, apathy, and burnout among physicians. They support a shift in culture and medical education such that students and residents are trained and inspired to act as catalysts who initiate and expedite positive changes. To become catalyst physicians, trainees require tools to partner with patients, staff, and faculty; training in implementing change; and the perception of this work as inherent to the role of the physician.The authors recommend that medical schools consider interprofessional training to be a necessary component of medical education and that future physicians be encouraged to grow in areas outside the "purely clinical" realm. They conclude that both physician catalysts and teamwork are essential for improving care coordination, reducing apathy and burnout, and supporting optimal patient outcomes.

Are we there yet? Seizing the moment to integrate medicine and public health

Multiple promising but unsustainable attempts have been made to maintain programs integrating primary care and public health since the middle of the last century. During the 1960s, social justice movements expanded access to primary care and began to integrate primary care with public health concepts both to meet community needs for medical care and to begin to address the social determinants of health. Two decades later, the managed care movement offered opportunities for integration of primary care and public health as many employers and government payers attempted to control health costs and bring disease prevention strategies in line with payment mechanisms. Today, we again have the opportunity to align primary care with public health to improve the community's health.

Family physicians as team leaders: "time" to share the care

A major contributor to shortfalls in delivery of recommended health care services is lack of physician time. On the basis of recommendations from national clinical care guidelines for preventive services and chronic disease management, and including the time needed for acute concerns, sufficiently addressing the needs of a standard patient panel of 2,500 would require 21.7 hours per day. The problem of insufficient time indicates that primary care requires broad, fundamental changes. The creation of primary care teams that include members such as physician assistants, nurse practitioners, dietitians, health educators, and lay coaches is important to meeting patients' primary care needs.

Estimated time spent on preventive services by primary care physicians

BACKGROUND

Delivery of preventive health services in primary care is lacking. One of the main barriers is lack of time. We estimated the amount of time primary care physicians spend on important preventive health services.

METHODS

We analyzed a large dataset of primary care (family and internal medicine) visits using the National Ambulatory Medical Care Survey (2001-4); analyses were conducted 2007-8. Multiple linear regression was used to estimate the amount of time spent delivering each preventive service, controlling for demographic covariates.

RESULTS

Preventive visits were longer than chronic care visits (M = 22.4, SD = 11.8, M = 18.9, SD = 9.2, respectively). New patients required more time from physicians. Services on which physicians spent relatively more time were prostate specific antigen (PSA), cholesterol, Papanicolaou (Pap) smear, mammography, exercise counseling, and blood pressure. Physicians spent less time than recommended on two "A" rated ("good evidence") services, tobacco cessation and Pap smear (in preventive visits), and one "B" rated ("at least fair evidence") service, nutrition counseling. Physicians spent substantial time on two services that have an "I" rating ("inconclusive evidence of effectiveness"), PSA and exercise counseling.

CONCLUSION

Even with limited time, physicians address many of the "A" rated services adequately. However, they may be spending less time than recommended for important services, especially smoking cessation, Pap smear, and nutrition counseling. Future research is needed to understand how physicians decide how to allocate their time to address preventive health.

Improving the health of the community: Duke's experience with community engagement

Evidence is accumulating that the United States is falling behind in its potential to translate biomedical advances into practical applications for the population. Societal forces, increased awareness of health disparities, and the direction of clinical and translational research are producing a compelling case for AHCs to bridge the gaps between scientific knowledge and medical advancement and between medical advancement and health. The Duke University Health System, the city and county of Durham, North Carolina, and multiple local nonprofit and civic organizations are actively engaged in addressing this need. More than a decade ago, Duke and its community partners began collaborating on projects to meet specific, locally defined community health needs. In 2005, Duke and Durham jointly developed a set of Principles of Community Engagement reflecting the key elements of the partnership and crafted an educational infrastructure to train health professionals in the principles and practice of community engagement. And, most recently, Duke has worked to establish the Duke Translational Medicine Institute, funded in part by a National Institutes of Health Clinical Translational Science Award, to improve health through innovative behavioral, social, and medical knowledge, matched with community engagement and the information sciences.

Dynamics of patient targeting for care management in Medicaid: a case study of the Durham Community Health Network

Targeting appropriate patients for care management is crucial to maximizing quality of care and cost-effectiveness in Medicaid care management programs. This study examined patient characteristics predicting selection for care management pre- and postmanagement changes at the Durham Community Health Network (DHCN), one of North Carolina's Medicaid primary care management networks. From the beginning, care managers were directed to target asthmatics, diabetics, and high-volume utilizers of health care, using an array of markers to identify patients who needed management. In 2003, the state reinforced its focus on chronic disease and high utilizers, and new management at DCHN began emphasizing the use of protocols for patient targeting. This study examined the relative effects of patient demographics, diagnoses, PCP group, and health care utilization as predictors of patient selection before and after these changes.

Just for Us: An Academic Medical Center–Community Partnership to Maintain the Health of a Frail Low-Income Senior Population

PURPOSE

To promote health and maintain independence, Just for Us provides financially sustainable, in-home, integrated care to medically fragile, low-income seniors and disabled adults living in subsidized housing.

DESIGN AND METHODS

The program provides primary care, care management, and mental health services delivered in patient's homes by a multidisciplinary, multiagency team.

RESULTS

After 2 years of operation, Just for Us is serving nearly 300 individuals in 10 buildings. The program is demonstrating improvement in individual indices of health. Medicaid expenditures for enrollees are shifting from ambulances and hospital services to pharmacy, personal care, and outpatient visits. The program is not breaking even, but it is moving toward that goal. The program's success is based on a partnership involving an academic medical center, a community health center, county social and mental health agencies, and a city housing authority to coordinate and leverage services.

IMPLICATIONS

Just for Us is becoming a financially sustainable way of creating a "system within a nonsystem" for low-income elderly persons in clustered housing.

Alternative models for academic family practices

Background

The Future of Family Medicine Report calls for a fundamental redesign of the American family physician workplace. At the same time, academic family practices are under economic pressure. Most family medicine departments do not have self-supporting practices, but seek support from specialty colleagues or hospital practice plans. Alternative models for academic family practices that are economically viable and consistent with the principles of family medicine are needed. This article presents several "experiments" to address these challenges.

Methods

The basis of comparison is a traditional academic family medicine center. Apart of the faculty practice plan, our center consistently operated at a deficit despite high productivity. A number of different practice types and alternative models of service delivery were therefore developed and tested. They ranged from a multi-specialty office arrangement, to a community clinic operated as part of a federally-qualified health center, to a team of providers based in and providing care for residents of an elderly public housing project. Financial comparisons using consistent accounting across models are provided.

Results

Academic family practices can, at least in some settings, operate without subsidy while providing continuity of care to a broad segment of the community. The prerequisites are that the clinicians must see patients efficiently, and be able to bill appropriately for their payer mix.

Conclusion

Experimenting within academic practice structure and organization is worthwhile, and can result in economically viable alternatives to traditional models.

Is there time for management of patients with chronic diseases in primary care?

PURPOSE

Despite the availability of national practice guidelines, many patients fail to receive recommended chronic disease care. Physician time constraints in primary care are likely one cause.

METHODS

We applied guideline recommendations for 10 common chronic diseases to a panel of 2,500 primary care patients with an age-sex distribution and chronic disease prevalences similar to those of the general population, and estimated the minimum physician time required to deliver high-quality care for these conditions. The result was compared with time available for patient care for the average primary care physician.

RESULTS

Eight hundred twenty-eight hours per year, or 3.5 hours a day, were required to provide care for the top 10 chronic diseases, provided the disease is stable and in good control. We recalculated this estimate based on increased time requirements for uncontrolled disease. Estimated time required increased by a factor of 3. Applying this factor to all 10 diseases, time demands increased to 2,484 hours, or 10.6 hours a day.

CONCLUSIONS

Current practice guidelines for only 10 chronic illnesses require more time than primary care physicians have available for patient care overall. Streamlined guidelines and alternative methods of service delivery are needed to meet recommended standards for quality health care.

Risk Classification of Adult Primary Care Patients by Self-Reported Quality of Life

BACKGROUND

: Although patient-reported health-related quality of life (HRQOL) is known to predict health services utilization, most risk assessment systems use provider-reported diagnoses as predictors rather than HRQOL.

OBJECTIVE

: We sought to classify adult primary care patients prospectively by utilization risk based on age, gender, and HRQOL at a single clinic visit.

RESEARCH DESIGN

: Patients completed the Duke Health Profile. Providers completed the Duke Severity of Illness Checklist. Diagnoses were grouped with the Ambulatory Care Groups system. Predictive coefficients for 1-year primary care charges calculated from the age, gender, and HRQOL of 728 reference patients were used to classify 474 test patients into 4 risk classes. Comparisons were made with models that used diagnoses or severity of illness as predictors.

RESULTS

: The positive likelihood ratio for predicting highest risk was 2.2 for the HRQOL model, compared with 1.8 for the diagnoses model, 1.6 for the severity model, and 1.5 for age and gender alone. One-year actual primary care visits and charges increased step-wise from lowest to highest risk class. Highest risk patients were older and more likely to be women, black, or Medicaid recipients. Although the highest-risk patients represented only 18.6% of the test group, they accounted for 26.7% of the primary care clinic visits, 31.6% of the clinic charges, 34.6% of the hospital days, 35.1% of hospital charges, and 30.8% of total charges at all healthcare sites.

CONCLUSION

: The HRQOL risk classification system can identify primary care patients at risk for high future health services utilization.

Making a home in the community for the academic medical center

Academic medical centers (AMCs) have traditionally provided primary care for low-income and other underserved populations. However, they have had difficulty developing lasting partnerships with other organizations serving the same populations. This article describes an exception to the rule, in which an academic division was created at Duke University Medical Center to develop effective collaborations with health care and social service providers in Durham, North Carolina, including both public agencies and private organizations. Together, the division and its partners have created and operate programs that improve health outcomes and access to care for those at risk. These programs share a number of characteristics: they are designed to meet the needs of the patient, not the provider; they are based in the community, not in the AMC; they bring services to people's homes, schools, and neighborhoods; they are multidisciplinary, combining health, social, and even mental health services; and, once established, they are revenue-generating and can be made self-supporting when grant funding ends. These programs are also innovative. They are designed to model and test new ways of organizing and delivering care. Preliminary indications suggest that they also strengthen the AMC's relationships with the surrounding community.

Primary care: is there enough time for prevention?

OBJECTIVES

We sought to determine the amount of time required for a primary care physician to provide recommended preventive services to an average patient panel.

METHODS

We used published and estimated times per service to determine the physician time required to provide all services recommended by the US Preventive Services Task Force (USPSTF), at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population.

RESULTS

To fully satisfy the USPSTF recommendations, 1773 hours of a physician's annual time, or 7.4 hours per working day, is needed for the provision of preventive services.

CONCLUSIONS

Time constraints limit the ability of physicians to comply with preventive services recommendations.

Duke Case-Mix System (DUMIX) for ambulatory health care

The Duke Case-Mix System (DUMIX), which combines age, gender, patient-reported perceived and physical health status, and provider-reported or auditor-reported severity of illness to classify patients by their risk of high future utilization, explained 17.1% of the variance in future clinic charges and 16.6% of the variance in return visits. When a random half of 413 ambulatory adults were classified into four risk classes by predictive regression coefficients from the other half, there was a stepwise increase in actual future utilization by risk class. The most accurate classification was for Class 4 (highest risk) patients, with a sensitivity of 40.8%, specificity of 82.1%, and likelihood ratio of 2.3. These 23.7% of patients accounted for 44.2% of charges for all patients. When predictive coefficients from this population were used to classify a different group of 206 ambulatory adults, past utilization also increased in stepwise order by case-mix class.

Computer-prompted diagnostic codes

BACKGROUND

The purpose of this study was to develop and evaluate a computer system that would translate patient diagnoses noted by a physician into appropriate International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes and maintain a patient-specific up-to-date problem list.

METHODS

The intervention consisted of a computerized list (dictionary) of diagnoses, including practice-specific synonyms and abbreviations, linked to their corresponding ICD-9-CM codes. To record the diagnoses for the office visit before the intervention, physicians used International Classification of Health Problems in Primary Care (ICHPPC-2) codes. After the intervention, physicians used their own words or checked previously identified diagnoses on the computer-generated problem list. The computer then identified the correct ICD-9-CM code. Accuracy of coding was compared before and after the new computerized system was implemented.

RESULTS

Visits in which all diagnoses matched increased from 58% to 76% (P < .001) with use of the computer system. Visits in which no computer diagnoses matched the chart decreased from 22% to 8% (P < .001). Errors of omission declined from 38% to 18% (P < .001). Errors of commission decreased from 19% to 11% (P = .006). Overall accuracy increased from 62% to 82% (P < .001).

CONCLUSIONS

Outpatient medical diagnosis coding can be simplified and accuracy improved by using a computerized dictionary of practice-specific diagnoses and synonyms linked to appropriate ICD-9-CM codes. Such a system provides a computer-generated problem list that accurately reflects the chart and assists with prompted coding on subsequent visits.

Tracking medical students' clinical experiences with a computerized medical records system

A fully computerized system for recording and reporting of medical students' patient contacts has been developed and successfully used in a high-volume outpatient practice. In contrast to previously described systems, the need for manual recording and/or entry of patient data has been eliminated by the use of an existing, integrated computerized medical records system. This makes possible the generation of frequent reports and timely review and adjustment of student experiences. The system has broad applicability and may also be useful for research in medical education.

The medical record: a comprehensive computer system for the family physician

BACKGROUND

Despite the early excitement regarding the possible uses of computers in medical care in the 1980s, the computer has not had much effect on routine outpatient medicine except for billing and accounting.

METHODS

An emerging comprehensive ambulatory care computer system, The Medical Record (TMR), is used extensively in a large family practice, the Duke Family Medicine Center. TMR is the central system for accounting, appointments, billing, and reporting of laboratory results, radiographic findings, and medications. TMR also records problem lists and generates prompts to the clinicians for needed health maintenance, laboratory tests, and reminder letters. The most innovative function of TMR is the computerized obstetric patient record, which can be accessed from multiple sites. Cost savings compared with a manual system were found to be in excess of $7 per patient visit or approximately $500,000 per year for the Duke Family Medicine Center.

RESULTS AND CONCLUSIONS

A comprehensive computer system in a large family practice is cost effective and facilitates better patient care through improved access to patient data.

Attitudes, experience, and influence of family medicine predoctoral education directors

BACKGROUND AND OBJECTIVES

While debate surrounds the determinants of medical students' specialty choices, the presence of favorable role models is generally agreed upon as beneficial to students' selection of a specialty. This study assessed the influence of family medicine predoctoral education directors on students' choice of family practice careers.

METHODS

A nine-question survey was mailed to 120 predoctoral directors identified by American Academy of Family Physicians' listings; 102 completed forms were returned (85% response).

RESULTS

The vast majority (97%) of directors responded that they enjoyed their role, although 14% indicated they did not want the position. Almost half (41%) reported they had extensive training in education, but almost 10% had no formal education training. Time as predoctoral director was often short, with a median of 3.5 years. When responses were linked to institutional rates of graduate entry into family practice, the only significant predictor of student entry into family practice with multivariate analysis was the number of years the predoctoral director had served in that position.

CONCLUSION

Long-term service of an interested predoctoral director may assist in successful recruitment of students to family practice.

Increasing compliance with mammography recommendations: health assessment forms

BACKGROUND

Inexpensive reminder systems are needed to ensure that primary care physicians consistently provide health maintenance services to their patients. The purpose of this study was to determine the effectiveness of a simple, inexpensive health assessment form in place of the standard chart note to increase physician compliance with mammography recommendations.

METHODS

A health assessment form with a reminder for screening mammography was implemented in a family practice in 1987 and was to be used as the official chart record for health maintenance visits. The charts of all women 50 years of age and older with two or more office visits during the years 1985 through 1988 were audited to determine how many mammograms were completed. Results were compared with mammography completion rates at a similar practice that did not use a health assessment form.

RESULTS

The study group showed a significant increase in mammography completion after implementation of the form, with compliance increasing from 7.3% to 32.0% (P < .001). The comparison group had an increase in mammogram completion from 12.0% to 17.8% (P < .001). The difference between the changes in rates of mammography in the two practices was statistically significant (P < .001). Among women in the study group who had a scheduled health maintenance visit during the study period the average rate of mammography completion increased from 21.2% to 65.2% (P < .001).

CONCLUSIONS

The addition of a health assessment form with a mammography reminder at the health maintenance visit is an effective and inexpensive method to increase compliance with mammography.

The effect of a telephone family assessment intervention on the functional health of patients with elevated family stress

A randomized trial of a telephone family assessment intervention was conducted during a 2.5 month period on 224 ambulatory primary care patients, aged 18-49 years, who were selected according to self-report of elevated family stress levels. Family physicians conducted telephone interviews to collect information from patients on their supportive and stressful family members. The working hypothesis was that this process would lead to reduction in the patient's family stress and to improvement in family support and personal health status. Patients reported that the intervention caused them to think about their family support and helped them to feel better. Comparison of family factor and functional health scores before and after intervention also indicated a limited beneficial effect, but only for a small subset of black patients. These results suggest that the telephone family assessment alone is inadequate as an intervention and should be strengthened to include professional assistance to patients for the family problems that are identified by the assessment.

Associations among family support, family stress, and personal functional health status

The self-reported family support and stress of 249 ambulatory adult patients, aged 18-49 years, were studied relative to their self-reported functional health. Support from family members was found to be related positively with emotional function. Stress from family members was associated negatively with symptom status, physical function, and emotional function. Patients' severity of illness was related negatively to their symptom status, physical function, and social function, but not to their emotional function. During the study a new self-report instrument, the Duke Social Support and Stress Scale (DUSOCS), was developed to measure family and non-family support and stress. Also, a new chart audit methodology, the Duke Severity of Illness Scale (DUSOI), was designed to assess severity in the ambulatory setting. Reliability and validity of the DUSOCS and the DUSOI were supported. The importance of the patient's perception of health and its family determinants is emphasized.