Asthma controller medications: what do patients want?

Our goal was to understand which features of asthma controller medications are important to patients. We used a cross-sectional survey of primary care patients (N = 394) with the diagnosis of asthma. Using conjoint or "trade-off analysis," we measured patient preferences for hypothetical asthma controller medications based upon their route and frequency of administration, and need for blood test monitoring. Patients were not willing to use medications that required blood test monitoring. Preference regarding blood test monitoring was the strongest of any medication attribute that we studied, accounting for 45% of the variation. Patients' decisions were also highly affected by the frequency of dosing (40% of the variation). Patients did not have strong preferences regarding the route of administration (15% of the variation). Understanding these patient preferences may lead to increased compliance with treatment plans and promote physician-patient partnership.

Health beliefs and compliance with inhaled corticosteroids by asthmatic patients in primary care practices.

The aim of this study was to determine factors associated with regular use of inhaled corticosteroids (ICS) by asthmatic patients in primary care practices. A cross-sectional survey was carried out over 12 family practices in the Philadelphia greater Metropolitan area. A total of 394 patients aged 18-49 years, who received medical care for asthma from their primary care physician and had been prescribed ICS between 1 January 1995 and 31 December 1996, were included. The study measured self-reported demographics, experience with asthma, use of and attitudes about ICS, and health beliefs in six domains. Only 38% of patients reported using ICS at least twice a day almost every day. The most frequently cited reasons for inconsistent or non-use of ICS were related to a belief that ICS were unnecessary during asymptomatic periods and to a general concern about side-effects. By logistic regression, factors associated with regular use of ICS were two patient health beliefs, namely the health belief of 'Active' participation in clinical decision-making with their physician (OR = 4.6, 95% CI 2.8, 7.5), and the health belief that asthma was a 'Serious' health problem (OR = 2.3, 95% CI 1.4, 3.7), and hospitalization for asthma within the previous 12 months (OR = 2.3, 95% CI 1.6, 4.6). Patients were more likely to report regular use of ICS if they saw themselves as active participants in their treatment planning and conceptualized asthma as a potentially serious illness. These results support the themes of patient education and shared decision-making between patients and physicians that are promoted by the Asthma Guïdelines from the National Heart, Lung and Blood Institute (NHLBI).

An evaluation of colchicine as an alternative to inhaled corticosteriods in moderate asthma. National Heart, Lung, and Blood Institute's Asthma Clinical Research Network.

Colchicine demonstrates an array of anti-inflammatory properties of potential relevance to asthma. However, the efficacy of colchicine as an alternative to inhaled corticosteroid therapy for asthma is unknown. Five centers participated in a controlled trial testing the hypothesis that in patients with moderate asthma needing inhaled corticosteroids for control, colchicine provides therapeutic benefit as measured by maintenance of control when inhaled steroids are discontinued. Subjects were stabilized on triamcinolane acetonide (800 microg daily) and then enrolled in a 2-wk run-in during which all subjects took both colchicine (0.6 mg/twice a day) and triamcinolone. At the end of the run-in, all subjects discontinued triamcinolone and were randomized to continued colchicine (n = 35) or placebo (n = 36) for a 6-wk double-blind treatment period. The treatment groups were similar in terms of disease severity. After corticosteroid withdrawal, 60% of colchicine-treated and 56% of placebo-treated subjects were considered treatment failures as defined by preset criteria. No significant difference in survival curves was found between treatment groups (log rank = 0.38). Other measures, including changes in FEV1, peak expiratory flow, symptoms, rescue albuterol use, and quality of life scores, also did not differ between groups. Of note, subjects failing treatment had significantly greater methacholine responsiveness at baseline than did survivors (PC20, 0.81+/-1.38 versus 2.11+/-2.74 mg/ml; p = 0.01). An analysis of treatment failures suggested that the criteria selected for failure reflected a clinically meaningful but safe level of deterioration. We conclude that colchicine is no better than placebo as an alternative to inhaled corticosteroids in patients with moderate asthma. Additionally, we conclude that the use of treatment failure as the primary outcome variable in an asthma clinical trial where treatment is withdrawn is feasible and safe under carefully monitored conditions.

The princess and the pea. An unusual complication after a laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is the preferred treatment for uncomplicated cholelithiasis. After brief perioperative surveillance and a follow-up visit, most of patients who have undergone laparoscopic cholecystectomy are discharged from further surgical care and treated by their primary care physician. This case report discusses an unusual complication in a patient who presented to her family physician 4 years after a laparoscopic cholecystectomy. The surgical literature on this complication is reviewed.

Attitudes toward sexual responsibility and parenting: an exploratory study of young urban males.

The self-reported sexual and parenting behaviors and attitudes of 42 urban males aged 16-22 who had fathered a child were compared with those of 49 demographically similar young men who were not fathers when they sought medical care at a public health center. Use of a questionnaire and structured interviews established that both groups had similar levels of self-esteem and similar ages at first intercourse. Fathers were less likely than the other respondents to feel that parenthood would interfere with their future (71% vs. 92%) or to have a concrete five-year plan (57% vs. 90%). They were more likely to believe that family (62% vs. 37%) and peers (68% vs. 40%) looked favorably upon early parenthood, to have a mother who was a teenage parent (74% vs. 47%) and to state that they lacked an adequate father figure while growing up (50% vs. 18%). Fathers also reported more frequent sexual activity and less consistent contraceptive use than did the others.

PIP: An exploratory study conducted at a health center in a low-income neighborhood in Philadelphia, Pennsylvania (US), in 1995 compared the characteristics of and attitudes toward sexual responsibility and parenting on the part of young fathers (n = 42) and their counterparts who were not fathers (n = 49). The average age of fathers at the time of their child's birth was 18.1 years. Mean age at first intercourse and mean number of current sexual partners were similar in both groups; however, fathers were less likely to have used contraception at last intercourse than non-fathers (43% vs. 70%). 64% of fathers reported they were happy when they learned their partner was pregnant, while only 36% of non-fathers anticipated such a response to this news. Fathers were more likely than non-fathers to believe that family (62% vs. 37%) and peers (68% vs. 40%) regarded early parenthood favorably. Fathers were also less likely than non-fathers to believe that fatherhood would interfere with their future (71% vs. 92%) or to have a 5-year career or educational plan (57% vs. 90%). 74% of fathers but only 47% of non-fathers were offspring of a teenage mother. Although both groups reported positive relationships with their own mothers, 50% of fathers compared with only 18% of non-fathers reported unsatisfactory relationships with their own fathers during childhood. Larger sample size and a prospective study design are required to confirm the validity of these results. Nonetheless, many of these findings provide information that can be incorporated into pregnancy prevention programs and services for teen parents.

The importance of advance directives in primary care.

The advance directive has been acknowledged widely by patients and physicians as a desirable tool to promote patient autonomy at the end of life. Rates of completion of advance directives, however, remain low among all segments of the population. Significant patient and physician barriers to completion of advance directives are considered. Legal and ethical principles of advance directives, as well as some practical means of overcoming barriers to these important discussions, are reviewed.

Conversion disorder presenting as gait disturbance in an adolescent.

Conversion disorder is a psychiatric diagnosis in which the loss of function on presentation mimics organic disease. Although rare, it is most common in adolescents and young adults. This report describes an adolescent with conversion disorder who presented with progressive bilateral lower-extremity weakness and impaired gait. As with all patients with conversion disorder, prompt diagnosis without extensive testing was essential to initiating appropriate therapy in this patient.

Relationship of advance directives to hospital charges in a Medicare population.

OBJECTIVE: There is a growing demand both for respect for patient autonomy regarding the use of sophisticated technology and for consideration of health care expenditures at the end of life. The major objective of this study was to assess the relationship between the documentation of a discussion of advance directives and hospital charges for Medicare patients during the last hospitalization of the patient's life. DESIGN: Multivariate analysis of a retrospective cohort. SETTING: Large (700+ beds), private university, tertiary care hospital. PATIENTS: All 474 patients who had Medicare listed as their primary insurer and who died in the hospital between January 1 and June 30 in 1990, 1991, or 1992. MAIN OUTCOME MEASURE: Total inpatient charges. RESULTS: The mean inpatient charge for the 342 patients without documentation of a discussion of advance directives was more than three times that of the 132 patients with such documentation ($95.305 vs $30,478). This relationship remained statistically significant after controlling for severity of disease, use of an intensive care unit, and number of procedures. Demographics, length of stay, admitting service, admitting diagnosis, and previous admission to the study hospital did not contribute to the predictive model. CONCLUSIONS: During discussions of advance directives, patients often opt to limit the extent of care they desire in certain situations. Although the most appropriate setting for developing advance directives is not clear, the results of this study imply that an enormous cost savings to society may be realized if such discussions take place, while, at the same time, autonomous patient choice will be respected.

Compliance with universal precautions in a medical practice with a high rate of HIV infection.

BACKGROUND: Universal precautions have been recommended to limit occupational exposure to the human immunodeficiency virus (HIV) and other infectious agents, but whether these recommendations have been incorporated into routine practice has not been demonstrated. METHODS: Using a one-group, before-after design, we assessed the knowledge and attitudes concerning universal precautions and the level of compliance with these recommendations. The health care professionals had various levels of training and worked in an ambulatory practice with a high rate of HIV. A total of 195 procedures involving potential exposure to various body fluids were observed. RESULTS: No improvement in compliance with recommended precautions was observed following a didactic educational program for either latex glove use (44 percent versus 49 percent, chi 2 less than 1, P greater than 0.2) or appropriate use of hand washing (34 percent versus 47 percent, chi 2 = 3.38, P = 0.07). Faculty demonstrated the lowest levels of adherence to universal precautions. While knowledge of precautions was high, staff members at all levels overestimated their own compliance with these recommendations. CONCLUSIONS: Although the number of observations limits the conclusions, the results suggest that the basic protective measures included in universal precautions are not being routinely applied in ambulatory medical practice. Furthermore, didactic educational programs might not be sufficient to improve compliance. Finally, faculty in training programs should monitor their own compliance with universal precautions because of their responsibilities as role models for physicians in training.

The effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center.

Less than 20 percent of elderly and other high-risk persons targeted for annual influenza vaccination are immunized each year. In most busy practice settings, it is difficult for primary care physicians to identify every patient in need of preventive health interventions. The purpose of this study was to assess the effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center. The practice uses an interactive encounter form system from which updated clinical information is routinely entered into a cumulative database. During a 2-month period, 686 patients were identified in the database as eligible to receive influenza vaccine according to accepted criteria. Practice physicians (n = 32) were stratified by level of training and randomized to one of three groups, thereby receiving printed reminders on the encounter forms of all, none, or half of their eligible patients. Patients of physicians who always received reminders were more likely to receive influenza vaccine during the study period than patients of the never-reminded physicians (51 percent versus 30 percent, P less than 0.001). Patients whose physicians received reminders for only half their patients had an intermediate likelihood of receiving a vaccination if a reminder was printed (38 percent) but were less likely than the patients of never-reminded physicians to receive the vaccine if no reminder was printed (20 percent, P less than 0.001). This study suggests that physicians learn to depend on reminders for preventive health activities and that reminders are most effective when they are provided at every patient encounter.

Sexually transmitted diseases.

Over the past two decades the incidence of STDs has dramatically increased in the United States. Most patients with these infections present first to primary care physicians. All physicians must be familiar with the common STD syndromes and the indications for specific diagnostic tests in order to provide a comprehensive treatment plan. Primary prevention strategies based on patient education and secondary prevention through judicious use of screening tests in appropriate settings can also limit the morbidity associated with STDs.

Microcomputer-generated reminders. Improving the compliance of primary care physicians with mammography screening guidelines.

Recent studies have documented that physician compliance with recommended periodic health screening improves with reminders to physicians. These reminders, however, are often costly to maintain and modify. This study investigates the influence of a microcomputer tickler system on the ordering of mammograms. All women (N = 1262) aged 40 years and older who made visits to an outpatient office during a 6-month period were randomly assigned to one of two groups. For the experimental group, the date of the last mammogram ordered and recorded in the clinical database was printed on the encounter form generated for each patient visit. No information regarding previous mammograms was printed for patients in the control group. Women in the experimental group were more likely to have a mammogram ordered during the study period (19% compared with 12%, P = .001) and, as a result, were more likely to be in compliance with mammography guidelines at the study's completion (27% compared with 21%, P = .011). Microcomputerized data storage and retrieval systems may help increase physicians' attention to preventive health screening recommendations.

Microflora of the urethra in adolescent boys: relationships to sexual activity and nongonococcal urethritis.

Urethral cultures were obtained from 90 adolescent youth, 16 of whom denied previous sexual activity. Among the sexually active boys was a group of 32 with clinically significant pyuria, consistent with the diagnosis of urethritis, on a first-part urinalysis (FPU) specimen. To relate differences in urethral microflora to sexual activity, 42 sexually active patients with a negative FPU were compared with the never sexually active group. The profile of anaerobic, but not aerobic, bacteria isolated from the urethra was related to the presence or absence of previous sexual activity. Mycoplasma species and Ureaplasma urealyticum were isolated from sexually active patients only, and may be markers of sexual activity in adolescent boys. Of the 32 patients with FPU evidence of urethritis, 22 (69%) had cultures positive for Chlamydia trachomatis, and an additional three (9%) had cultures positive for Neisseria gonorrhoeae. The findings in sexually active patients with a positive FPU were otherwise similar to those of sexually active patients without evidence of urethritis. C. trachomatis appears to be the most important agent of urethritis among adolescent boys with a positive FPU.

Cognitive development and adolescent contraception: integrating theory and practice.

The cognitive skills that develop during adolescence are crucial to successful contraceptive practice because most birth control methods require at least a minimal ability to plan for, acquire, and utilize them at the appropriate time. Consequently, we must understand the special developmental setting in which adolescent sexual growth and experimentation occurs in order to have an impact on their contraceptive use. To provide optimal service to adolescents, the developmental and medical aspects should be taken into account in order to determine the best choice for each patient. This article demonstrates how mental health and medical providers can work together to better serve the adolescent population.

PIP: The cognitive skills that develop during adolescence are crucial to successful contraceptive practice because most birth control methods require at least a minimal ability to plan for, acquire, and utilize them at the appropriate time. Consequently, the special developmental setting in which adolescent sexual growth and experimentation occurs must be understood in order to have an impact on their contraceptive use. To provide optimal service to adolescents, the developmental and medical aspects should be taken into account in order to determine the best choice for each patient. This article demonstrates how mental health and medical providers can work together to better serve the adolescent population. The empahsis is on elaboration of the developmental skills needed for effective adolescent contraception and the integration of those identified skills with key facets of the medical history in order to provide the most medically and developmentally appropriate care. To aid in identifying and matching appropriate developmental skills to contraceptive needs, a table of commonly used methods and their advantages and disadvantages has been constructed.

Intense jaundice in an adolescent. An unusual presentation of infectious mononucleosis.

Hemolytic anemia is an infrequent complication of infectious mononucleosis. The hemolysis may result from the temporary production of antibodies directed against one or more red-cell antigens. This report describes an adolescent female with infectious mononucleosis who presented for evaluation of jaundice. In this patient the jaundice resulted from a combination of hemolysis and mild hepatitis.