Are patient education materials about cancer screening more effective when co-created with patients? A qualitative interview study and randomized controlled trial

Background

Patient education materials (pems) are frequently used to help patients make cancer screening decisions. However, because pems are typically developed by experts, they might inadequately address patient barriers to screening. We co-created, with patients, a prostate cancer (pca) screening pem, and we compared how the co-created pem and a pem developed by experts affected decisional conflict and screening intention in patients.

Methods

We identified and used patient barriers to pca screening to co-create a pca screening pem with patients, clinicians, and researchers. We then conducted a parallel-group randomized controlled trial with men 40 years of age and older in Ontario to compare decisional conflict and intention about pca screening after those men had viewed the co-created pem (intervention) or an expert-created pem (control). Participants were randomized using dynamic block randomization, and the study team was blinded to the allocation.

Results

Of 287 participants randomized to exposure to the co-created pem, 230 were analyzed, and of 287 randomized to exposure to the expert-created pem, 223 were analyzed. After pem exposure, intervention and control participants did not differ significantly in Decisional Conflict Scale scores [mean difference: 0.37 ± 1.23; 95% confidence interval (ci): -2.05 to 2.79]; in sure (Sure of myself, Understand information, Risk-benefit ratio, or Encouragement) scores (odds ratio: 0.75; 95% ci: 0.52 to 1.08); or in screening intention (mean difference: 0.09 ± 0.08; 95% ci: -0.06 to 0.24]).

Conclusions

The effectiveness of the co-created pem did not differ from that of the pem developed by experts. Thus, pem developers should choose the method that best fits their goals and resources.

Oral bisphosphonates are associated with reduced mortality after hip fracture

Intravenous bisphosphonates reduce mortality following hip fracture. We determined whether new use of oral bisphosphonates was also associated with reductions in mortality in 209 hip fracture patients. Oral bisphosphonate exposure led to relative reduction of 8% per month of use (p = 0.001) or about a 60% reduction in mortality per year of use.

INTRODUCTION

Intravenous bisphosphonates reduce mortality following hip fracture. Using prospectively collected long-term data from a randomized trial of osteoporosis quality improvement for hip fracture, we determined whether new use of oral bisphosphonates was associated with reductions in mortality or the composite outcome of death or new fracture.

METHODS

Originally, 220 hip fracture patients were randomized to case manager (n = 110) or usual care followed by facilitated bone mineral density (BMD) testing (n = 110) interventions. All were eligible for bisphosphonate treatment. Post-randomization, we followed patients for 3 years and ascertained bisphosphonate treatment, medication adherence and persistence, all-cause mortality, and new clinical fractures. Proportional hazards analyses with time-varying treatment status were undertaken.

RESULTS

The final study cohort included 209 patients: 136 (65%) females, 104 (50%) older than 75 years, 90 (43%) with poor self-reported health, and 38 (18%) underweight. Of these, 76 (36%) had a previous fracture before hip fracture and 132 (81%) had low BMD. A total of 101 (46%) patients started oral bisphosphonates and 65 (64%) remained on treatment at the final evaluation. Overall, 24 (11%) patients died, 19 (9%) had new fractures, and 42 (20%) reached the composite outcome of death or fracture. Compared to no treatment, bisphosphonate exposure was independently associated with reduced mortality (17[16%] vs. 7[7%]; adjusted hazard ratio (aHR) = 0.92 per month treated; 95%CI, 0.88-0.97) and composite endpoints (28[26%] vs. 5[15%]; aHR = 0.94 per month treated; 95%CI, 0.91-0.97).

CONCLUSION

Like intravenous bisphosphonates after hip fracture, our study suggests that oral bisphosphonates may be associated with reductions in all-cause mortality.

Increased continuity of care associated with decreased hospital care and emergency department visits for patients with asthma

The objective of this study was to determine the association between continuity of care and emergency room visits/hospital care for patients with asthma. A population-based study was conducted using administrative healthcare datasets obtained from Alberta Health and Wellness, Alberta, Canada. The 4-year study period extended from April 1, 1996 to March 31, 2000, and took place at the Palliser Health Region in Alberta, Canada, which has a population of 88,000 people. A population-based sample of 2774 patients, diagnosed with asthma between ages 5 and 45 with two or more office visits for asthma and who lived in the Palliser Health Region for 2 consecutive years during the study period, was studied. The main outcome measure was the association of continuity of care with hospitalizations and emergency room visits for patients with asthma. Continuity of care was the proportion of total physician visits made to the most frequently visited physician. High continuity of care was associated with a decreased risk of an emergency visit (OR = 0.24: 95% CI 0.19-0.29), number of emergency visits (RR = 0.37; 95% CI 0.32-0.42), decreased risk of number of hospitalizations (RR = 0.69; 95% CI 0.54-0.89), and total days in hospital (average difference = 0.77; 95% CI 0.63-0.95), but not with ever hospitalized. High continuity of care was associated with a 60%-75% reduction in emergency room visits and an approximate 25% reduction in number of hospitalizations in patients with asthma. Interventions to improve continuity of care could have the potential to improve care and reduce cost.

Use of walk-in clinics by rural and urban patients

OBJECTIVE

To compare use of walk-in clinics by rural and urban family practice patients and to describe patients' perceptions of the quality of care in physicians' offices.

DESIGN

Questionnaire completed by patients in family physicians' offices.

SETTING

Nine community-based family practices located in rural and urban areas of Alberta.

PARTICIPANTS

Patients who had visited their family physicians' offices during April, May, June, or July 1997. Response rate was 89.6% (403 of 450 questionnaires were completed).

MAIN OUTCOME MEASURES

Use of walk-in clinics, patients' perceptions of the quality of care in physicians' offices.

RESULTS

Overall, 27.5% of patients (22.2% of rural, 35.5% of urban patients) attended walk-in clinics in the 6 months before visiting their family physicians' offices: 43.3% went during weekdays when their family physicians' offices were open. Significantly more rural (91.1%) than urban (60.7%) patients felt they could contact their doctors during evenings and weekends (P.004). Significantly more urban (67.2%) than rural (33.3%) patients did not call their own physicians before going to walk-in clinics (P.002). Patients who attended walk-in clinics were more likely (P.01) than patients who did not to rate their family physicians' office hours poor to good (27.9% vs 15.6%).

CONCLUSIONS

Many patients attending the offices of community-based family physicians in both urban and rural areas of Alberta also attend walk-in clinics. Family practice patients attend walk-in clinics primarily because their own physicians' offices are less convenient.

Continuity of care. Opportunity for residents to see repeat patients

OBJECTIVE

To examine the opportunity for first-year family medicine residents to experience continuity of care during family medicine block time and half-day returns.

DESIGN

Retrospective analysis of patient encounter data during the 1987-1988 and 1991-1992 academic years to determine how much contact residents had with repeat patients.

SETTING

Two family medicine teaching centres in Edmonton.

PARTICIPANTS

First-year family medicine residents: 24 residents during 1987-1988 and 24 during 1991-1992.

MAIN OUTCOME MEASURES

Number of patient-resident contacts and number of repeat contacts.

RESULTS

During the 4-month block time and half-day return, residents had repeat contact with 25.9% and 20.3% of the patients seen. These patients provided 48.3% and 37.7% of all visits at Centres A and B, respectively.

CONCLUSION

Increasing block time from 2 to 4 months resulted in only a slight increase in repeat contact with patients. Half-day returns did not appear to enhance the opportunity for continuity of care.

Enhancing research through partnerships

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Relation of family physician or specialist care to obstetric interventions and outcomes in patients at low risk: a western Canadian cohort study

To determine the relation of family physician or specialist care to intrapartum interventions and outcomes, we carried out a historical cohort study of 1456 obstetric patients at low risk admitted between Nov. 15, 1984, and Mar. 15, 1986, to a western Canadian teaching hospital. The patients were classified as being at low risk on admission by means of chart review. Family physicians and specialists were found to have similar rates for most of the interventions measured, although the interventions for which significantly different rates were found suggest a less interventionist style of intrapartum care by family physicians. There were no significant differences in maternal or neonatal outcomes except for a higher proportion of infants weighing less than 2500 g among primigravid women cared for by family physicians compared with those under the care of specialists. Self-selection of physician specialty by patients resulted in differences in the demographic characteristics of the two patient populations. The findings support the continued involvement of family physicians in the provision of obstetric care.