Predictors of Coordinated and Comprehensive Care Within a Medical Home for Children With Special Healthcare (CHSCN) Needs

The purpose of this study was to examine predictors of coordinated and comprehensive care within a medical home among children with special health care needs (CSHCN). The latest version of the National Survey of Children with Special Health Care Needs (NS-CSHCN) employed a national random-digit-dial sample whereby US households were screened, resulting in 40,242 eligible respondents. Logistic regression analyses were performed modeling the probability of coordinated, comprehensive care in a medical home based on shared decision-making and other factors. A total of 29,845 cases were selected for inclusion in the model. Of these, 17,390 cases (58.3%) met the criteria for coordinated, comprehensive care in a medical home. Access to a community-based service systems had the greatest positive impact on coordinated, comprehensive care in a medical home. Adequate insurance coverage and being White/Caucasian were also positively associated with the dependent variable. Shared decision-making was reported by 72% of respondents and had a negative, but relatively negligible impact on coordinated, comprehensive care in a medical home. Increasing age, non-traditional family structures, urban residence, and public insurance were more influential, and negatively impacted the dependent variable. Providers and their respective organizations should seek to expand and improve health and support services at the community level.

Assessing the transactional nature of wilderness experiences: construct validation of the wilderness-hassles appraisal scale

Concerns over the increasing popularity of wilderness recreation have resulted in attempts to determine the amount of use that different areas can tolerate without adverse affects to the resource. Early attempts to establish recreational carrying capacities focused on managers' assessments of biophysical impacts. The perceptions of wilderness visitors, however, are now considered integral to capacity decisions. This study used a stress appraisal framework to understand wilderness visitors' perceptions of on-site conditions. It was based on the premise that negative appraisals of wilderness conditions produce stress and that individual perceptions vary based on personal and situational characteristics. The purpose of the study was to assess the validity of a wilderness-hassles appraisal scale by testing hypothesized relationships between experience-use history (EUH), place attachment, and stress appraisal. Data collection occurred through a postal survey of hikers (n = 385) contacted in the High Peaks and Pemigewasset Wilderness Areas during the summer of 2004. An exploratory factor analysis indicated that stress appraisal is a multi-dimensional construct. Validity testing procedures were restricted to those dimensions that were consistent between study areas and provided partial support for the hassles scale. As hypothesized, EUH did not influence perceptions of wilderness conditions. Place attachment, on the other hand, was positively correlated with stressful appraisals of social and managerial conditions. Although Kruskall Wallis tests revealed significant differences in visitors' perceptions of managerial conditions between study sites, perceptions of social conditions did not vary significantly. Implications for management and recommendations for further refinement of the wilderness hassles construct are discussed.

Teaching dietary counseling skills to residents: patient and physician outcomes. The CADRE Study Group

Our objective was to determine whether an educational intervention and prompting intervention for physicians improved dietary counseling of patients with high blood cholesterol and resulted in beneficial changes in patients' diets and cholesterol levels. We instituted a factorial design, multicenter, randomized, placebo-controlled trial to test two interventions. We tested the trial at continuity care clinics of internal medicine residents at seven community and university medical centers in the northern and eastern United States. Our participants were 130 internal medicine residents and 254 adult outpatients with blood cholesterol levels of 240-300 mg/dL. Interventions included an educational program for resident physicians designed to improve their skills and confidence in dietary counseling (two one-hour sessions with specially prepared printed materials for use in counseling) and a prompting intervention, which was a fingerstick blood cholesterol determination prior to the patient's clinic visit. Resident physicians' knowledge, attitudes, and self-reported behaviors were assessed prior to the intervention and 10 months later using chart audits and questionnaires. Residents' behaviors were also assessed by exit interviews with patients. Patients' knowledge, attitudes, behaviors, and fingerstick blood cholesterol levels were measured at baseline and 10 months later. The educational program increased the percentage of physicians who were confident in providing effective dietary counseling (baseline of 26% to 67%-78%; P < .01). The prompting intervention approximately doubled the frequency of physician counseling (P = .0005) and increased the likelihood that patients would try to change their diets. When both interventions were combined, most outcomes were better, although not statistically significant. Cholesterol levels, however, decreased only marginally and were no different among groups at 10-month follow-up. Despite success in changing physicians' attitudes and behaviors and increasing patients' willingness to change their diets, there was no significant change in patients' cholesterol levels. Medical Subject Headings (MeSH): randomized controlled trial; cholesterol; patient education; behavior therapy; education, medical; diet.

Combination antidepressant therapy in primary care

Increasing clinical experience with the selective serotonin reuptake inhibitors and tricyclic antidepressants make combination antidepressant therapy at times a reasonable alternative to single-agent therapy in primary care patients with depression. This article describes three cases that illustrate possible rationales for combination antidepressant therapy: reduced side effects, synergistic treatment effects, reduced treatment response time, prescriber familiarity, and clinical experience. The combination of selective serotonin reuptake inhibitors and tricyclic antidepressants may be useful in treating patients who experience intolerable side effects or who are resistant to therapy with a single antidepressant. Further research should be done to define the role of combination antidepressant therapy in the treatment of primary care patients with depression.

Patient-carried card prompts vs computer-generated prompts to remind private practice physicians to perform health maintenance measures

BACKGROUND

We compared the efficacy of a computer-generated prompt sheet placed on the front of patients' charts with a patient-carried prompt card to remind physicians to perform selected health maintenance items.

METHODS

A randomized prospective single-blind study was performed in private practice offices in rural eastern North Carolina, with 28 family practitioners and nine general internists participating. Twenty-two physicians were randomized to the computer prompt group and 22 to the card prompt group. Four physicians in the computer group did not complete the study because of computer software problems, and three physicians did not complete the study because their limited staff was unable to enter patient data into the computer. Before the intervention, 20 patient charts (10 males and 10 females) from each physician were audited for the performance of influenza vaccinations, stool for occult blood, pap smears, breast examinations performed by the physicians, and mammograms. One year after the intervention was instituted, chart audits for the above five items were done again on 20 different patient charts for each physician.

RESULTS

There was a 7% increase in the performance of influenza vaccinations in the card group (17% vs 24%) compared with a 6% increase in the computer group (20% vs 26%). There was a 5% decrease in the performance of stool for occult blood in the card group (28% vs 23%) compared with a 1% increase in the computer group (30% vs 31%). There was an 11% decrease in the performance of pap smears in the card group (26% vs 15%) compared with a 3% increase in the computer group (23% vs 26%). There was a 2% decrease in the performance of breast examinations by the physician in the card group (35% vs 33%) compared with a 3% increase in the computer group (30% vs 33%). Finally, there was a 3% increase in the performance of mammograms in the card group (22% vs 25%) compared with an 11% increase in the computer group (15% vs 26%).

CONCLUSIONS

Our data show a greater increase in performance of health maintenance items in the computer-prompted group. The performance of stool for occult blood, pap smears, breast examinations performed by the physician, and mammograms were increased more in the computer-prompted group than in the card group. However, there was not a statistically significant difference after intervention for any of the audited health maintenance items for either the computer group or the card group. Overall, health maintenance measures were performed in only a minority of appropriate patients.

Dietary counseling of hypercholesterolemic patients by internal medicine residents

OBJECTIVE

To assess the knowledge, attitudes, and practices of internal medicine residents concerning dietary counseling for hypercholesterolemic patients.

DESIGN

Cross-sectional, self-administered questionnaire survey.

SETTING

Survey conducted August 1989 in seven internal medicine residency programs in four southeastern and middle Atlantic states.

PARTICIPANTS

All 130 internal medicine residents who were actively participating in outpatient continuity clinic.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Only 32% of the residents felt prepared to provide effective dietary counseling, and only 25% felt successful in helping patients change their diets. Residents had good scientific knowledge, but the degree of practical knowledge about dietary facts varied. Residents reported giving dietary counseling to 58% of their hypercholesterolemic patients and educational materials to only 35%. Residents who felt more self-confident and prepared to counsel reported more frequent use of effective behavior modification techniques in counseling. Forty-three percent of residents had received no training in dietary counseling skills during medical school or residency.

CONCLUSION

Internal medicine residents know much more about the rationale for treatment for hypercholesterolemia than about the practical aspects of dietary therapy, and they feel ineffective and ill-prepared to provide dietary counseling to patients.

Heimlich valve treatment of Pneumocystis carinii-associated pneumothorax

Two patients were treated for AIDS-associated bilateral pneumothoraces which persisted despite prolonged chest tube drainage. Heimlich flutter valves were used to facilitate the outpatient management of these patients.

Central nervous system side effects of nonsteroidal anti-inflammatory drugs. Aseptic meningitis, psychosis, and cognitive dysfunction

A review of the literature regarding central nervous system side effects of the nonsteroidal anti-inflammatory drugs (NSAIDs) revealed three general categories: aseptic meningitis, psychosis, and cognitive dysfunction. Aseptic meningitis is found most commonly in patients with lupus treated with ibuprofen, but it should be considered in any patient with meningitis if the patient has used NSAIDs. Psychosis, although infrequently reported with NSAIDs, should be suspected in an elderly patient started on a regimen of indomethacin who acutely develops disorientation, paranoia, or hallucinations. Finally, there appears to be some potential for memory dysfunction and attention deficits in elderly patients treated with NSAIDs. Until further studies are available on the incidence and severity of these cognitive changes, physicians should use low doses of NSAIDs in the elderly and remain alert to the possibility of such adverse side effects.