An evidence-based review of patient-centered behavioral interventions for hypertension.

INTRODUCTION: While behavioral interventions may be viewed as important strategies to improve blood pressure (BP), an evidence-based review of studies evaluating these interventions may help to guide clinical practice. METHODS: We employed systematic review and meta-analysis of the literature (1970-1999) to assess the independent and additive effects of three behavioral interventions on BP control (counseling, self-monitoring of BP, and structured training courses). RESULTS: Of 232 articles assessing behavioral interventions, 15 (4072 subjects) evaluated the effectiveness of patient-centered counseling, patient self-monitoring of BP, and structured training courses. Pooled results revealed that counseling was favored over usual care (3.2 mmHg [95% CI, 1.2-5.3] improvement in diastolic blood pressure [DBP] and 11.1 mmHg [95% CI, 4.1-18.1] improvement in systolic blood pressure [SBP]) and training courses (10 mmHg improvement in DBP [95% CI, 4.8-15.6]). Counseling plus training was favored over counseling (4.7 mmHg improvement in SBP [95% CI, 1.2-8.2]) and afforded more subjects hypertension control (95% [95% CI, 87-99]) than those receiving counseling (51% [95% CI, 34-66]) or training alone (64% [95% CI, 48-77]). CONCLUSIONS: Evidence suggests that counseling offers BP improvement over usual care, and that adding structured training courses to counseling may further improve BP. However, there is not enough evidence to conclude whether self-monitoring of BP or training courses alone offer consistent improvement in BP over counseling or usual care. The magnitude of BP reduction offered by counseling indicates this may be an important adjunct to pharmacologic therapy.

Effectiveness of a practice-based intervention to increase vaccination rates and reduce missed opportunities.

BACKGROUND: Although provider feedback and recall/reminder systems have been shown to increase vaccination rates for children, little is known about the effectiveness of less intensive interventions. OBJECTIVE: To determine whether provider prompting at acute care visits in an urban hospital-based outpatient clinic can increase vaccination rates and decrease missed opportunities. DESIGN AND METHODS: Study participants, 3 years or younger, were identified from a managed care organization as receiving primary care at the clinic. Eligibility criteria included 1 or more visits to the clinic without regard to continuity of enrollment. Patients' vaccination records were generated at nursing triage and attached to the encounter sheet. Vaccination and visit data were abstracted from medical records, and comparisons were made between baseline (n = 521) and postintervention (n = 642) groups for up-to-date vaccination rates, missed opportunity rates, and mean numbers of visits. RESULTS: Up-to-date rates at the age of 24 months for 4 diphtheria and tetanus toxoids and pertussis, 3 polio, 1 measles-mumps-rubella, 3 hepatitis B, and 3 Haemophilus influenzae type b vaccines changed from 70% to 78% (P =.07). Up-to-date rates increased significantly to 87% among the subset of children continuously enrolled in the managed care organization and the practice (P<.01). Overall, mean numbers of visits were similar. Missed opportunity rates among children not up-to-date for 4 diphtheria and tetanus toxoids and pertussis, 3 polio, 1 measles-mumps-rubella, 3 hepatitis B, and 3 Haemophilus influenzae type b vaccines at the age of 24 months declined from 65% to 45% (P =.04). Similar trends were noted at the age of 10 months. CONCLUSIONS: In the absence of increased funding, minor changes in standard operating procedures may improve vaccination delivery. Further improvements may require efforts to ensure continuity of provider and plan assignment.

A computerized tool for evaluating the effectiveness of preventive interventions.

In identifying appropriate strategies for effective use of preventive services for particular settings or populations, public health practitioners employ a systematic approach to evaluating the literature. Behavioral intervention studies that focus on prevention, however, pose special challenges for these traditional methods. Tools for synthesizing evidence on preventive interventions can improve public health practice. The authors developed a literature abstraction tool and a classification for preventive interventions. They incorporated the tool into a PC-based relational database and user-friendly evidence reporting system, then tested the system by reviewing behavioral interventions for hypertension management. They performed a structured literature search and reviewed 100 studies on behavioral interventions for hypertension management. They abstracted information using the abstraction tool and classified important elements of interventions for comparison across studies. The authors found that many studies in their pilot project did not report sufficient information to allow for complete evaluation, comparison across studies, or replication of the intervention. They propose that studies reporting on preventive interventions should (a) categorize interventions into discrete components; (b) report sufficient participant information; and (c) report characteristics such as intervention leaders, timing, and setting so that public health professionals can compare and select the most appropriate interventions.

Rehospitalization of children with asthma.

BACKGROUND: Although some children with asthma experience multiple admissions, asthma is considered a preventable cause of hospitalization. OBJECTIVE: To assess whether components of medical histories, ambulatory care prior to hospitalization, or ambulatory care after discharge are associated with repeated hospitalizations for children admitted with asthma. DESIGN: Nested case-control study of a cohort of children hospitalized for asthma, comparing those who were rehospitalized within 1 year with those not rehospitalized. SETTING: Urban pediatric primary care clinic. PARTICIPANTS AND METHODS: Subjects were 119 children, aged 0 to 14 years, who had an inpatient admission with a diagnosis of asthma between July 1, 1993, and June 30, 1995 (index hospitalization). Data sources included medical charts, computerized patient records, and administrative data. Use of health care services was compared among children who were rehospitalized within 1 year of the index admission and those who were not. MAIN OUTCOME MEASURE: Repeated hospitalizations. RESULTS: The proportions of children who received general pediatric, allergy, or pulmonary care in the year prior to the index hospitalization were 86%, 7%, and 8%, respectively. By report, half of all children did not receive prescribed therapies, more than half were exposed to cigarette smoke at home, and one fourth were not up-to-date with immunizations at the time of admission. Thirty-five of the 119 children hospitalized with asthma were subsequently readmitted with asthma within 1 year of the index hospitalization. Children readmitted did not differ from those with a single admission in terms of the above characteristics. However, significantly more children subsequently readmitted had a pulmonary consultation during the index admission (23% vs 4%; P = .001) or in the year following discharge (37% vs 12%; P = .002). In addition, children readmitted were more likely to have other chronic conditions (69% vs 49%; P= .048). CONCLUSION: Among low-income urban children, readmission for asthma is not associated with receipt of prescribed therapies or pediatric care.

Use of social services by pregnant Medicaid eligible women in Baltimore.

OBJECTIVES: To use linked health and social service databases to determine differences in the use of social services by pregnant women in different managed care systems. METHODS: Comparison of service use by women enrolled in a fee-for-service primary care case management program (Maryland Access to Care or MAC), in a capitated health maintenance organization (HMO), or not assigned to managed care using six state databases. Participants included 5181 women receiving Medical Assistance (MA) and delivering in Baltimore City in 1993. Outcome measures were receipt of WIC, AFDC, and Food Stamps. RESULTS: The overall proportions of women receiving WIC, AFDC, and Food Stamps at delivery were 52.7%, 89.2%, and 62.7%, respectively. Women enrolled in an HMO at delivery were less likely to be receiving WIC (adjusted odds ratios, 0.8, 95% CI, 0.69 to 0.93), AFDC (OR, 0.20; CI, 0.03 to 0.43 for women with prior children and OR 0.13; CI, 0.09 to 0.20 for women without prior children), and Food Stamps (OR 0.77; CI, 0.59 to 0.95 for women with prior children and OR, 0.49; CI, 0.35 to 0.67 for women without prior children) than their MAC counterparts. Women not assigned to managed care also generally were less likely than their MAC counterparts to receive WIC (OR 0.55; CI, 0.46, 0.66), AFDC (OR 1.07; CI 0.83, 1.30 for women with prior children and OR 0.24; CI 0.18, 0.34 for women without prior children), and Food Stamps (OR 0.31; CI 0.08, 0.55 for women with prior children and OR 0.31; CI 0.23, 0.41 for women without prior children). CONCLUSIONS: Although many low-income pregnant women qualify for select social services, receipt of WIC and Food Stamps was low. Increasing efforts are needed by managed care systems and public health agencies to ensure delivery of appropriate services for women.

Oncologists vary in their willingness to undertake anti-cancer therapies.

Previous studies have shown that groups of cancer sub-specialists differ in their stated willingness to undergo treatment for diseases lying within their area of expertise. In order to learn whether oncologists feel similarly about other forms of cancer, medical, radiation, and surgical oncologists were asked to fill out a questionnaire indicating whether they would be willing to undergo either chemotherapy or radiation therapy for a variety of common malignancies, or recommend them to a spouse or sibling. Subjects were also asked whether they would undertake an experimental therapy (interleukin-2) for any of three malignancies, or recommend such treatment to a spouse or relative. Fifty-one oncologists (14 radiation oncologists, 14 surgical oncologists, and 23 medical oncologists) were recruited from the staff of four university teaching hospitals. Although they agreed about accepting or declining therapy for some examples, there was considerable heterogeneity in their responses. In only 37% of the 30 cases involving standard therapies did greater than or equal to 85% of the oncologists agree that they would accept or refuse therapy. Only some of the variation of the responses could be attributed to the sub-specialty orientation of the oncologists. Physicians were as willing to recommend standard therapies for themselves as a spouse or sibling. Physicians were also divided in their opinion about whether they would accept a particular experimental therapy if diagnosed with one of three neoplasms. They were significantly more likely, however, to recommend it for a spouse or sibling than to accept it for themselves. Variation in the proportion of patients who receive anti-cancer therapies may relate, in part, to differences in opinion concerning the worth of such therapies among oncologists or primary physicians. This study shows that oncologists are quite heterogeneous with regard to their personal preferences for anti-cancer treatments for a variety of malignancies. Further studies are required to learn if such attitudes (among oncologists or primary physicians) directly affect the administration of such therapies.