Long-term effects of asthma education for physicians on patient satisfaction and use of health services.

This randomized clinical trial evaluated the long-term impact of an interactive seminar for physicians based on principles of self-regulation on clinician behaviour, children's use of health services for asthma, and parent's views of physician performance. Seventy-four general practice paediatricians, and 637 of their asthma patients aged 1-12 yrs, were randomized to treatment or control. Children and parents were blind to physicians' participation. Data were collected at baseline and follow-up through self-administered surveys (paediatricians), telephone interviews (parents) and medical records. The seminar focused on development of communication and teaching skills and use of therapeutic medical regimens for asthma as outlined in the National Asthma Education and Prevention Program guidelines. Approximately 2 yrs postintervention, treatment group physicians were more likely than control physicians to: use protocols for delivering asthma education (odds ratio (OR) 4.9, p=0.2), write down for patients how to adjust medicines when symptoms change (OR 5.7, p=0.05), and provide more guidelines for modifying therapy (OR 3.8, p=0.06). Parents scored treatment group physicians higher than control physicians on five specific positive communication behaviours. Children seen by treatment group physicians had fewer hospitalizations (p=0.03) and those with higher levels of emergency department (ED) use at baseline had fewer subsequent ED visits (p=0.03). No differences regarding the number of office visits were noted. There were no significant differences found between treatment and control group physicians in the amount of time spent with patients during office visits (26 versus 29 min) or in the number of patients treated with anti-inflammatory medicine. It is concluded that interactive asthma seminars for paediatricians had significant long-term benefits for their asthma care.

Impact of education for physicians on patient outcomes.

OBJECTIVES: This study was conducted to assess the impact of an interactive seminar based on self-regulation theory on 1) the treatment practices and communications and education behavior of physicians, 2) the health status and medical care utilization of their pediatric patients with asthma, and 3) the satisfaction with care of the subjects' parents. METHODS: A total of 74 general practice pediatricians were assigned to either a program or a control group in a randomized controlled study. Data were collected from physicians at baseline, and 69 (93%) provided follow-up data 5 months after the program. Data were also collected from 637 of their patients at baseline, and in a 22-month window after the intervention, 472 (74%) of this number provided follow-up data. RESULTS: After the seminar, physicians in the program group were more likely than were control group physicians to address patients' fears about medicines, review written instructions, provide a sequence of educational messages, write down how to adjust the medicines at home when symptoms change, and report that they spent less time with their patients. Parents of the children treated by program physicians were significantly more likely than were control group parents to report that the physician had been reassuring, described as a goal that the child be fully active, and gave information to relieve specific worries. After a visit with the physician, these parents were also more likely to report that they knew how to make management decisions at home. After the intervention compared to controls, patients of physicians in the program group were more likely to have received a prescription for inhaled antiinflammatory medicine and to have been asked by the physician to demonstrate how to use a metered-dose inhaler. After the intervention, children seen by program physicians made significantly fewer nonemergency office visits and visits for follow-up of an episode of symptoms; however, there were no differences in emergency department visits and hospitalizations. Among children who were placed on inhaled corticosteroids during this study, however, children treated by physicians who had received education had significantly fewer symptoms and fewer follow-up office visits, nonemergency physician office visits, emergency department visits, and hospitalizations. CONCLUSIONS: The interactive seminar based on theories of self-regulation led to patient-physician encounters that were of shorter duration, had significant impact on the prescribing and communications behavior of physicians, led to more favorable patient responses to physicians' actions, and led to reductions in health care utilization.

A scale for Assessing Health Care Providers' Teaching and Communication Behavior regarding asthma.

Partnership between health care providers and patients is important for controlling illness. A limited number of studies show how to assess health professionals' communication and partnering behavior. The relationship between these aspects of professional behavior and enhanced management of disease by patients has received little empirical study. The research reported here developed a Health Care Providers' Teaching and Communication Behavior (TCB) scale for assessing the teaching and communication behavior of clinicians treating patients with asthma. Such a tool is needed for research related to provider-patient relationships and for evaluation of professionals' performance.

Public cholesterol screening in the previously diagnosed: misuse of resources or beneficial function?

The attendance of individuals with a previous diagnosis of hyperlipidemia at public cholesterol screenings is often criticized as a misuse of such programs. This study explored the post-screening actions of 811 participants in a cholesterol screening program who had previously been diagnosed with cholesterol elevations and whose blood levels at this screening required further medical referral. We also studied the responses of physicians from whom these subjects sought care. Within five months, 559 of 753 participants completing the survey (74.0%) sought medical follow-up. Physicians retested the blood cholesterol levels of 75.0% of these 559; high-risk screenees were more likely to be retested and to be informed that their levels were elevated than moderate-risk subjects (P < .0001). Physicians increased cholesterol-lowering dietary advice for high-risk subjects (P < .0001) and medication prescriptions for both risk groups (P < .0001). Participants seeking medical care after the screening program had better cholesterol-lowering dietary practices and reported increased regimen compliance (moderate-risk: P = .01; high-risk: P < .0001) than those individuals not obtaining medical follow-up. One year after screening, blood cholesterol levels were 4.5% lower (P = .001) in those complying with referral but were virtually unchanged in noncompliers. Screening program confirmation of high blood cholesterol levels combined with referral appeared to have a positive impact on previously diagnosed screenees. We conclude that there may be merit in including previously diagnosed individuals in cholesterol screening programs.

Improving referral compliance after public cholesterol screening.

BACKGROUND: Noncompliance with referral to a physician for retesting and diagnosis is a concern in public cholesterol screening. METHODS: Participants (n = 2109) were referred by a health professional or lay communicator and randomly assigned to a coupon offer, referral reminder letter, or control group. A questionnaire was completed at screening, and a telephone interview was conducted 5 months later. RESULTS: Physician visit rates showed no professional or lay differences. For "no history" subjects, the behavioral interventions were effective compared with controls (coupon = 60.7% and reminder = 57.7% vs control = 46.1%). With professional counseling, only the coupon was effective; for lay counseling, both coupon and reminder yielded higher visit rates. Adjusted for sociodemographics, heart disease risk factors, and health perceptions, the intervention effects remained (professional-coupon offer: odds ratio [OR] = 1.94, 95% confidence interval [CI] = 1.21, 3.09; professional-reminder letter: OR = 1.04, 95% CI = 0.67, 1.63; lay-coupon offer: OR = 2.52, 95% CI = 1.52, 4.18; and lay-reminder letter: OR = 3.10, 95% CI = 1.83, 5.22). CONCLUSIONS: For unaware participants, lay counselors and referral follow-up efforts tailored to specific cholesterol risk groups are indicated.

Attendance patterns and characteristics of participants in public cholesterol screening.

We conducted free, voluntary, public cholesterol screenings in supermarkets in the Rochester, New York, area during a four-month period for demonstration and research purposes. We assessed demographic characteristics and attendance patterns of the 8,583 participants. Compared with 1980 census data for the same census tracts, our participants were likelier to be white, older, female, and better educated than the general population in the area. Most screenees knew about the screenings in advance, and 79% came to the store just for screening. Weekend and weeknight screenings attracted more men and more younger people, in comparison to weekday screenings. However, referral rates based on high cholesterol (HC) test results were similar during all screening times. Overall, 22% of screenees reported a previous diagnosis of HC, but in the highest cholesterol-level group, 45% of screenees reported a history of HC. Previous awareness of HC did not vary according to screening time. These findings indicate that, like other screenings, cholesterol screenings in a public setting do not attract a representative sample of the whole population. The screenings did, however, attract a large number of high-risk individuals, many of whom had no prior awareness of HC. These results should be valuable in planning and targeting future cholesterol screenings.

Patterns of physicians' treatments for referral patients from public cholesterol screening.

Current interest in high blood cholesterol and attendance at public cholesterol screening programs has raised the issue of whether physicians are responding to referrals according to existing national assessment and treatment recommendations. This study assessed the relationship of characteristics of referrals from a series of public blood cholesterol screenings to physicians' treatment practices. For this analysis, the sample was restricted to 1,324 subjects, from the 2,109 referred, who reported seeking physician care. At five months after screening, 75% of subjects reported their physician prescribed a diet; 16% of physicians prescribed medication. Multiple logistic regression, adjusted for sociodemographic characteristics and other coronary heart disease (CHD) risk factors, indicated that screening cholesterol risk level, prior history of high blood cholesterol levels, and type of medical contact were consistently related to receipt of diet and medication treatment, but other CHD risk factors were underutilized. "Moderate" risk subjects with no history of high blood cholesterol were less likely to have received dietary advice, but a screening-risk level interaction did not occur for medication. The results imply that current treatment guidelines may not be working and suggest the need for continued physician education in the management of hypercholesterolemia.

Deuterium oxide as a tracer for measurement of compliance in pediatric clinical drug trials.

We tested the hypothesis that a deuterium oxide (D2O) tracer could discriminate among patterns of clinically significant, imperfect compliance during drug trials. A model was developed to predict deuterium concentration during multiple dose regimens. After developing a regression equation to predict one of the model parameters for children, we selected healthy children (N = 20) at random to receive one of five 10-day D2O regimens. Five urine samples were obtained from each child during 15 days and analyzed for deuterium level by mass spectrometry. Each child's height, weight, age, and the first four urinary deuterium levels were used to estimate the amount and timing of deuterium administration. These estimates were compared with the five regimens to determine the closest match between estimate and regimen. The closest matching regimen was the regimen actually administered to 19 (95%) of the 20 children. Two of these children had D2O administration estimates that could be confused with another regimen. The correlation between the model's predicted levels and the measured levels of all urine samples was 0.96. We conclude that a D2O tracer shows excellent promise as a quantitative method of assessing compliance with liquid medications under specified conditions.

Recruitment of a large community of pediatricians in a collaborative research project.

To investigate the effects of an educational program on the compliance-enhancing behavior of pediatricians and the subsequent regimen adherence of their patients, it was necessary to enlist the participation of a large number of pediatric practitioners. The physicians had to be motivated to attend two evenings of tutorial training; to enroll their patients in the project; and to complete detailed study documents. Ultimately, 90 of the 97 pediatricians practicing in the community took part. The following factors are felt to have contributed to the widespread participation of the pediatricians: 1) the subject was interesting and of relevance to clinical practice; 2) the study was designed so as not to interfere with office routine; 3) major demands were not made on the patients; 4) due consideration was given to the value of the physicians' participation; and 5) communication between the investigators and the practitioners was facilitated by a liaison pediatrician.

Improving pediatricians' compliance-enhancing practices. A randomized trial.

Previous evaluations of continuing medical education (CME) have yielded conflicting results regarding its effects on physician knowledge, performance, and subsequent patient outcomes. Poor adherence by mothers to prescribed pediatric regimens is a separate, but well-documented, problem. In the present study we assessed the ability of CME to: (1) increase the knowledge of pediatricians about compliance-enhancing strategies; (2) increase the performance of these practices by pediatricians; and (3) improve mothers' compliance with antibiotic regimens for their children's otitis media. Ninety pediatricians were randomly assigned to either a control group or one of two CME interventions: tutorial plus printed materials or mailed printed materials only. Following the interventions, data on compliance and on reported behaviors of pediatricians were gathered from a random sample of mothers (N = 771) whose children were being treated for otitis media. Findings indicated that CME increased physician knowledge and compliance-enhancing practices and resulted in improvement in mothers' adherence to therapy.

Correlates of mothers' use of medications for their children.

This study examines the extent, determinants and quality of mothers' independent use of medications for treating their children's symptoms. Data on mother-initiated medication behavior (MIMB) were obtained from a stratified systematic random sample of 500 mothers of children presenting for a well child visit at two pediatric ambulatory care sites. Six expert pediatric judges each rated every reported medication use (N = 3908) along three dimensions (usefulness, correctness and harmfulness or helpfulness) and also evaluated the overall appropriateness of each mother's MIMB. Results indicate that: (1) mothers keep available and use for children a considerable variety of different medications and medical applicances; (2) a positive linear relationship exists between mothers' socioeconomic status (SES) and degree of MIMB; (3) mothers' attitudes toward medications and toward their children's health are associated with the number of categories of medications and applicances they possess and use; (4) the combination of SES and attitudinal characteristics accounts for substantial portions of the variance in MIMB; and (5) judges' ratings show only minimal-level support of MIMB (extending to mothers in all SES groups) and are linearly related to SES (P less than 0.001). These findings emphasize the need for health care providers to review MIMB, and to provide advice concerning use and misuse of mother-initiated treatments.

How mothers treat their children's physical symptoms.

An important area of concern in community health is the widespread practice of individuals undertaking courses of treatment in the absence of medical advice or direction. This is especially a problem when it involves the administration of medicines to children. This study examines the extent, determinants, and quality of the independent use by mothers of medications for treating their children's symptoms. Data on mother-initiated medication behavior (MIMB) were obtained from a random sample of 500 mothers of children at two pediatric ambulatory care sites. Six expert pediatric judges rated every reported medication use (N = 3,908) along three dimensions (usefulness, correctness, and harmfulness/helpfulness) and also evaluated the overall appropriateness of each mother's MIMB. Results indicate that: 1) mothers keep available and use for their children a considerable number of different medications; 2) clear relationships exist between mothers' socioeconomic status and the different categories of medications they employ; 3) mothers' perceptions of their children's vulnerability to specific illnesses, and of the efficacy of over-the-counter medications for treating those illnesses, were related to the possession and use of relevant medications; and 4) judges' ratings indicated little enthusiasm for the mothers' therapeutic actions. These findings suggest the need for pediatricians to become aware of the medications their patients may be ingesting as a result of MIMB, and to educate mothers concerning use and misuse of over-the-counter (and other) treatments.

Spouse concordance of smoking patterns: the Minnesota Heart Survey.

Spouse concordance of smoking patterns and other lifestyle factors was examined in data provided by 560 married couples from the Minnesota Heart Survey. Married pair concordance was measured against a standard of concordance based on the frequencies in surrogate spouse pairs. Smoking patterns are found to be significantly concordant for married pairs. More married pairs than surrogate pairs tended to both smoke or both not smoke. Among smokers, married pairs are more similar than surrogate pairs in daily number of cigarettes smoked. Among ex-smokers, married pairs are more similar than surrogate pairs in the year they quit smoking. Younger couples with the least amount of education were most concordant and showed the greatest smoking rate. Five additional lifestyle factors showed an increased level of concordance for married over surrogate pairs. Concordance in these factors was not correlated with smoking concordance. It is suggested that married couples respond similarly to a shared environment made up of daily practices, social life, and leisure activities. Further, smoking intervention directed toward the married couple should be considered.

Effects of sociodemographic and attitudinal factors on mother-initiated medication behavior for children.

Little is known about the therapies that people initiate for their health problems, and the available research on self-medication has focused primarily on adult populations. Only a few studies have specifically addressed mothers' independent use of medications for their children, and none has described such behavior in depth (for example, relating-perceived symptoms and conditions in the child or attempting to provide an explanation for mothers' decisions in these situations). A stratified systematic random sample of 100 mothers of children between 6 months and 12 years old was obtained at each of 3 pediatric ambulatory care clinics. Mothers were interviewed about their use of medications for their children, their concerns about their children's health, and their medication-related attitudes. The study results suggest that income and education are related to the types of medication and medical appliances mothers keep to treat the various health problems of their children. Mothers' perceptions of their children's potential susceptibility to health problems are related to possession of what they believe are relevant remedies for those problems (as well as to keeping a greater variety of medications on hand). Socioeconomic status appears to be one determinant of the number of different remedies (and especially the number of different medical appliances) that are purchased. Certain attitudes held by mothers about medications also play a role in explaining how great a variety of remedies are kept available for children in the event that they become ill, and these medication-related attitudes are highly correlated with socioeconomic status.

Strategies for enhancing patient compliance.

Patient noncompliance is a substantial obstacle to the achievement of therapeutic goals. This paper reviews a number of practical interventions with demonstrated efficacy in enhancing patient adherence, including (1) improving patients' levels of information concerning the specifics of their regimens, reinforcing essential points with review, discussion, and written instruction, and emphasizing the importance of the therapeutic plan, (2) taking clinically appropriate steps to reduce the cost, complexity, duration, and amount of behavioral change required by the regimen and increasing the regimen's convenience through "tailoring" and other approaches, (3) obtaining a compliance-oriented history of the patient's prior experiences and present health beliefs and, where necessary, employing strategies to modify those perceptions likely to inhibit compliance, (4) improving levels of patient satisfaction, particularly with the provider-patient relationship, (5) arranging for the continued monitoring of the patient's subsequent compliance to treatment, (6) increasing staff awareness of the magnitude and determinants of the noncompliance phenomenon and attempting to develop an "active influence orientation" in each member of the health care team, (7) using such techniques as patient-provider contracts to involve the patient in therapeutic decisions and in the setting of treatment objectives and creating incentives (through rewards and reinforcements) for achieving these objectives, (8) arranging for as much continuity of provider (and other staff) as possible, (9) establishing methods of supervising the patient, including involvement of the patient's social support network, and (10) involving fully the assistance of all available health care providers, assigning specific roles and responsibilities for activities directed at improving adherence to treatment.

Education for self-treatment by adult asthmatics.

A prospective experimental design evaluated the ability of a series of educational and motivational interventions to enhance self-treatment by adult asthmatics and to reduce use of emergency department services for asthma attacks. After treatment for an asthma attack, subjects were randomly assigned to the following sequential interventions: (1) reinforcement by interpersonal similarity at the time of the emergency visit, (2) recepit of positive written appeals, and (3) follow-up telephone reinforcement. The asthmatic nurse educator was generally more effective in achieving short-term reduction of emergency department visits. Although the usefulness of the positive written appeal increased when employed by the asthmatic nurse, there were no substantive independent effects of the written message on emergency department use.

Attitudes toward obesity and the obese among professionals.

Negative attitudes toward obese patients by health professionals have been attributed to termination of weight reducing attempts. This study measured attitudes concerning the obese held by professional participants in a continuing education conference on causes and treatment of obesity. Substantial variation was found on items comprising obesity-related belief dimensions: (a) Disparaging image of the obese; (b) causes of obesity; and (c) ways to lose weight. Evidence is presented for the association among measures of these dimensions. While background and educational characteristics and conditions of practice were not related to such attitudes, the professional's personal experience with successful weight reduction was the best predictor of favorable attitudes.