A self-report instrument measuring readiness to change disordered eating behaviors: the Eating Disorders Stage of Change.

OBJECTIVE: To evaluate the utility of the Eating Disorders Stage of Change (EDSOC), a behavior-specific readiness questionnaire. METHOD: Patients (N=145) at a multidisciplinary eating disorder treatment facility in the United States completed the EDSOC and other questionnaires. RESULTS: One-week test-retest reliability was strong across eating disorder diagnoses and age groups. Convergent validity was strongest when the behavior in question was congruent with the diagnosis (e.g., purging behaviors for bulimia nervosa diagnosis) and compared to the patient's own intention to complete treatment. Divergent validity was demonstrated against body mass index values and age. However, the EDSOC and Body Shape Questionnaire were inversely correlated, suggesting that increased body shape concerns are associated with decreased intention to change a behavior. CONCLUSION: This preliminary cost-effective, behavior-specific measure demonstrates good psychometric properties and is appropriate for use with children and adults. Across diagnosis, the instrument should be used by looking at each single item instead of summing a total score across disparate eating disorder behaviors.

The influence of co-morbid IBS and psychological distress on outcomes and quality of life following PPI therapy in patients with gastro-oesophageal reflux disease.

BACKGROUND: A subset of patients with gastro-oesophageal reflux disease (GERD) does not achieve complete symptom resolution with proton pump inhibitor (PPI) therapy. The factors which affect response to PPI therapy in GERD patients remain unclear. AIMS: To determine the prevalence and impact of irritable bowel syndrome (IBS) and psychological distress (PD) on GERD symptoms and disease-specific quality of life (QoL) before and after PPI therapy and to assess the same outcomes before and after PPI therapy in non-erosive reflux disease (NERD) and erosive oesophagitis (EO) GERD patients. METHODS: Patients undergoing oesophago-gastroduodenoscopy (OGD) for heartburn were recruited. Participants completed validated surveys: Digestive Health Symptom Index, Reflux Disease Questionnaire, Quality of Life in Reflux and Dyspepsia and Brief Symptom Inventory (BSI). IBS was defined as >3 Manning criteria and PD as BSI score >63. At OGD, patients were classified as NERD or EO. Patients were treated with rabeprazole 20 mg/day for 8 weeks before completing follow-up surveys. RESULTS: Of 132 GERD patients enrolled, 101 completed the study. The prevalence rates of IBS and PD were 36% and 41%, respectively. IBS independently predicted worse QoL before and after PPI therapy. PD independently predicted worse GERD symptoms and QoL before and after PPI therapy. There were no differences in symptoms or QoL between NERD and EO patients before or after PPI therapy. CONCLUSIONS: IBS and PD impacted GERD symptoms and QoL before and after PPI therapy. Symptoms and QoL before and after PPI therapy were similar in NERD and EO patients.

Oesophageal hypersensitivity is associated with features of psychiatric disorders and the irritable bowel syndrome.

BACKGROUND: Twenty per cent of patients with heartburn do not respond to proton pump inhibitors (PPIs). Many have normal oesophageal acid exposure. We hypothesized that such PPI non-responders have heightened oesophageal sensation, and that oesophageal hypersensitivity is associated with psychiatric features including somatization and anxiety. AIM: To compare oesophageal sensation in subjects with heartburn categorized by response to PPI, and to correlate oesophageal sensation with psychiatric features. METHODS: Twenty-one PPI responders, nine PPI non-responders and 20 healthy volunteers completed questionnaires of psychiatric disorders and gastrointestinal symptoms. Subjects underwent oesophageal sensory testing with acid perfusion and balloon distension. RESULTS: Healthy volunteers displayed higher thresholds for sensation and discomfort from balloon distension than heartburn subjects (sensation P = 0.04, discomfort P = 0.14). Psychiatric disorders were associated with increased intensity of sensation (P = 0.02) and discomfort from acid (P = 0.01). Somatization was associated with increased discomfort from balloon distension (P = 0.006). Features of irritable bowel syndrome were associated with increased sensation and discomfort. CONCLUSIONS: Heartburn subjects tend to have heightened oesophageal sensation, suggesting that oesophageal hypersensitivity may persist despite therapy with PPI. Oesophageal hypersensitivity is associated with features of psychiatric disease and with the irritable bowel syndrome, which might partly explain the aetiology of heartburn symptoms that are refractory to PPI.

Characterizing blood pressure control in individuals with Type 2 diabetes: the relationship between clinic and self-monitored blood pressure.

AIMS: To determine the relationship between blood pressure (BP) measurement in the clinic and self-monitored blood pressure (SMBP); and to evaluate the accuracy of self-reported data in patients with Type 2 diabetes treated intensively for hypertension. METHODS: Seventy subjects had baseline and 1-week follow-up clinic BP measured using an Omron 907 automated device. During a contemporaneous 14-day period these subjects measured their BP at least four times each day using an Omron IC semiautomatic portable monitor which, unknown to them, contained an onboard memory capable of storing BP with corresponding time and date. RESULTS: There was no significant difference between mean clinic and mean self-monitored BP. Correlations between clinic BP and SMBP were r=0.61 (P<0.0001) for systolic BP and r=0.69 (P<0.0001) for diastolic BP. Clinic BP classified 56 subjects as uncontrolled hypertension (BP > or = 130/80 mmHg, adjusted for diabetes) and 14 subjects as controlled hypertension. Using World Health Organization-International Society of Hypertension criteria for SMBP (> or = 125/75 mmHg), 55 cases of clinic classified uncontrolled hypertension were confirmed, resulting in 98% sensitivity. Clinic and SMBP agreed in one case of controlled hypertension, resulting in 7% specificity. For all subjects, the median percent of values exceeding SMBP criteria for controlled hypertension was systolic 92% and diastolic 70%. Self-reporting precision averaged 89+/-10% (range 45-100%); under-reporting was 25+/-16% (ranging from 0 to 56%) and over-reporting was 12+/-15% (ranging from 0 to 46%). The overall logbook mean was not significantly different from the downloaded data from the Omron IC(R) monitors. CONCLUSIONS: SMBP was able to identify 13 patients with uncontrolled hypertension who, by clinic BP measurement, had been classified as controlled.

Reliability and validity of the digestive health status instrument in samples of community, primary care, and gastroenterology patients.

AIM: We evaluated a previously reported digestive health status instrument in community, primary care, and gastroenterology practice populations. Multiple types of reliability, validity and responsiveness were assessed to determine the performance of the questionnaire. METHODS: Study populations included community, primary care and gastroenterology subjects. Psychometric analyses included internal consistency and test-retest reliability, criterion and construct validity, and responsiveness. RESULTS: Acceptable internal consistency was seen on all scales in all three populations. Test-retest reliability was excellent in a speciality population with reflux disease. Criterion validity was demonstrated by strong correlation of reflux scale scores and results on 24-h pH monitoring. Scale scores varied predictably in those receiving gastrointestinal tract imaging and according to diagnosis, indicating construct validity. The reflux scale and pain index were sensitive to change with treatment for reflux disease. Multi-trait scaling analyses from the community sample revealed a structure equivalent to that reported from a primary care sample. CONCLUSIONS: The reliability and validity of the digestive health status instrument on multiple measures in multiple settings have been demonstrated. The instrument was responsive to change with treatment for reflux disease. The demonstrated robustness attests to the suitability for future studies and clinical application.

Self-reported effectiveness and physician consultation rate in users of over-the-counter histamine-2 receptor antagonists.

OBJECTIVE: Decreased physician visits for dyspepsia were predicted with the histamine-2 receptor antagonists (H2RA) release to over-the-counter (OTC) status. The aim of this study was to examine the presentation frequency for dyspeptic complaints before and after the OTC release of the H2RA and the self-reported effectiveness of OTC H2RA. METHODS: Two cross-sectional surveys were used in a community sample. The patients comprised a random age- and sex-stratified sample of 1600 ambulatory adults in 1993 and 1800 in 1997. Self-report, valid mail surveys gathered information on healthcare seeking and gastrointestinal symptoms in 1993 and 1997 and antisecretory use in 1997. RESULTS: Presentation frequency for dyspepsia was 22% in 1993 versus 23.5% in 1997. Only 16% of chronic users of the OTC H2RA obtained complete relief of symptomatic episodes. Use of an OTC H2RA was highly associated with presentation to a physician in the past year. CONCLUSIONS: OTC H2RA infrequently provided the complete relief desired by patients. Presentation frequency to physicians for dyspeptic complaints did not change with availability of H2RA OTC.

Initial validation of a diagnostic questionnaire for gastroesophageal reflux disease.

OBJECTIVES: Brief, reliable, and valid self-administered questionnaires could facilitate the diagnosis of gastroesophageal reflux disease in primary care. We report the development and validation of such an instrument. METHODS: Content validity was informed by literature review, expert opinion, and cognitive interviewing of 50 patients resulting in a 22-item survey. For psychometric analyses, primary care patients completed the new questionnaire at enrollment and at intervals ranging from 3 days to 3 wk. Multitrait scaling, test-retest reliability, and responsiveness were assessed. Predictive validity analyses of all scales and items used specialty physician diagnosis as the "gold standard." RESULTS: Iterative factor analyses yielded three scales of four items each including heartburn, acid regurgitation, and dyspepsia. Multitrait scaling criteria including internal consistency, item interval consistency, and item discrimination were 100% satisfied. Test-retest reliability was high in those reporting stable symptoms. Scale scores significantly changed in those reporting a global change. Regressing specialty physician diagnosis on the three scales revealed significant effects for two scales (heartburn and regurgitation). Combining the two significant scales enhanced the strength of the model. Symptom response to self-directed treatment with nonprescription antisecretory medications was highly predictive of the diagnosis also, although the item demonstrated poor validity and reliability. CONCLUSIONS: A brief, simple 12-item questionnaire demonstrated validity and reliability and seemed to be responsive to change for reflux and dyspeptic symptoms.

The use of monetary incentives in a community survey: impact on response rates, data quality, and cost.

OBJECTIVES: To assess the effect of incentive size on response rates, data quality, and cost in a digestive health status mail survey of a community sample of health plan enrollees. DATA SOURCES/SETTING: The study population was selected from a database of enrollees in various health plans obligated to receive care at Park Nicollet Clinic-HealthSystem Minnesota, a large, multispecialty group in Minneapolis, Minnesota, and the nearby suburbs. STUDY DESIGN: A total of 1,800 HealthSystem Minnesota enrollees were randomly assigned to receive a survey with an incentive of $5 or $2. The response rates for each incentive level were determined. Data quality, as indicated by item nonresponse and scale scores, was measured. Total cost and cost per completed survey were calculated. PRINCIPAL FINDINGS: The response rate among enrollees receiving $5 (74.3 percent) was significantly higher than among those receiving $2 (67.4 percent); differences were more pronounced in the first wave of data collection. Data quality did not differ between the two incentive groups. The total cost per completed survey was higher in the $5 condition than in the $2 condition. CONCLUSIONS: A $5 incentive resulted in a higher response rate among a community patient sample with one mailing than did a $2 incentive. However, the response rates in the $2 condition approached the level of the $5 incentive, and costs were significantly lower when the full follow-up protocol was completed. Response rates were marginally increased by follow-up phone calls. The incentive level did not influence data quality. The results suggest if a survey budget is limited and a timeline is not critical, a $2 incentive provides an affordable means of increasing participation.

A randomized, controlled trial of interactive, multimedia software for patient colonoscopy education.

The purpose of our study was to assess the effectiveness of computer-assisted instruction (CAI) in patients having colonoscopies. We conducted a randomized, controlled trial in large, multispecialty clinic. Eighty-six patients were referred for colonoscopies. The interventions were standard education versus standard education plus CAI, and the outcome measures were anxiety, comprehension, and satisfaction. Computer-assisted instruction had no effect on patients' anxiety. The group receiving CAI demonstrated better overall comprehension (p < 0.001). However, Comprehension of certain aspects of serious complications and appropriate postsedation behavior were unaffected by educational method. Patients in the CAI group were more likely to indicate satisfaction with the amount of information provided when compared with the standard education counterparts (p = 0.001). Overall satisfaction was unaffected by educational method. Computer-assisted instruction for colonoscopy provided better comprehension and greater satisfaction with the adequacy of education than standard education. Computer-assisted instruction helps physicians meet their educational responsibilities with no decrement to the interpersonal aspects of the patient-physician relationship.

Does using a mouthwash instead of water improve the oropharyngeal removal of inhaled flovent (fluticasone propionate)?

Rinsing the mouth with water is recommended to remove inhaled corticosteroid (ICS) deposited on the oropharyngeal mucosa. Given the lipophilicity of fluticasone propionate (FP), an ethanol-based mouthwash was hypothesized to be superior to water. This study's purpose was to compare the effectiveness of water versus Listerine (Warner Lambert, Lititz, PA) in removing FP from the oropharyngeal mucosa. Asthma patients were randomly assigned water or a Listerine-rinsing vehicle. A 440-microgram dose of FP was inhaled. After the second puff, patients rinsed for 30 seconds with 20 mL of the assigned agent and then repeated the process, spitting each "wash" into the same cup. At visit 2, patients used the alternate vehicle and repeated the procedure. Samples were frozen until analyzed using liquid chromatography/mass spectrophotometry (lower limit of detection 0.067 microgram/mL). Thirty-six patients (mean age, 44 years; 66% female) participated. Mean inhaler technique score was 11.3 (scale of 1-12). Eighty-three percent used the closed-mouth technique. The mean concentration of FP removed by Listerine was not statistically different than that removed by water, 1.67 micrograms/mL (range, 0.067-4.195 micrograms/mL) and 1.42 micrograms/mL (range, 0.067-5.107 micrograms/mL), respectively, and the total milliliter returned was assumed to be 40 mL. Regression analysis using sex, age, and inhaler technique showed no statistical relationship with the amount of FP removed. Therefore, Listerine was not more effective than water in removing FP from the oropharyngeal mucosa (p = 0.53). Thus, water is an adequate rinsing vehicle for removal of ICS deposited on the oropharyngeal mucosa. Other factors besides the rinsing vehicle are strong factors in determining the amount of drug removed.

Effect of salmeterol on patients' adherence to their prescribed refills for inhaled corticosteroids.

BACKGROUND: Optimal treatment for persistent asthma requires multiple classes of medication, including antiinflammatory agents and bronchodilators. Inhaled corticosteroids are the most effective antiinflammatory agents available and are recommended by recent guidelines as first-line treatment. Salmeterol, a long-acting inhaled bronchodilator, is recommended as adjunctive therapy to inhaled corticosteroids. Non-adherence to prescribed medication is prevalent and has been implicated in asthma exacerbations. Salmeterol's benefits in terms of asthma control are readily perceived by patients whereas the benefits of inhaled corticosteroid therapy may be less apparent. OBJECTIVE: To evaluate whether the addition of salmeterol to a medication regimen affects patient adherence to prescription refills for inhaled corticosteroids. METHODS: A retrospective medical chart and pharmacy claims record review before and after the addition of salmeterol was used. Medication adherence rates were calculated for 67 patients requiring inhaled corticosteroids for at least 8 months before and after the addition of salmeterol. RESULTS: Adherence with inhaled corticosteroid therapy before (49.7% +/- 29.3%) and after (56.5% +/- 28.6%) the introduction of salmeterol was not significantly different (P = .0785, pre versus post). Adherence with salmeterol was significantly higher (58.7% +/- 28.3%) than inhaled corticosteroids at baseline (P = .0202), but not with concurrent use. Dosing frequency of inhaled corticosteroid administration was not a significant factor in adherence, but increasing age was (r = 0.41788, P = .0048). CONCLUSIONS: The addition of salmeterol does not adversely affect the adherence rates to prescription refills for prescribed inhaled corticosteroid therapy. On average, important antiinflammatory treatment should not be supplanted with salmeterol if prescribed in combination.

Development of a digestive health status instrument: tests of scaling assumptions, structure and reliability in a primary care population.

BACKGROUND: The absence of valid and reliable health status measures for functional gastrointestinal illness has limited research and patient care for this common group of disorders. A self-report survey has been developed. METHODS: Initial development focused on extensive pre-testing of patients, primary care physicians and gastroenterologists. The disease-specific portion included the Rome criteria for dyspepsia subgroups and the Manning and Rome criteria for irritable bowel syndrome. The Short Form-36 was added. Psychometric analyses included techniques of multitrait scaling, scale internal consistency and criterion validation. RESULTS: Six hundred and ninety patients presenting to their primary care physician for treatment of heartburn, abdominal pain or discomfort completed the 98 question survey. The disease-specific portion revealed five components including reflux, dysmotility, a two-domain bowel dysfunction complex, and a pain index. Internal consistency measures demonstrated good to excellent reliability. Scaling successes were observed on multitrait scaling. The disease-specific portion was reduced to 34 questions. Criterion validity was demonstrated with the correlation of the disease-specific questions to the SF-36. CONCLUSIONS: The psychometric analyses lend credence to the concept of stomach and bowel symptom subgrouping as proposed by expert consensus. The psychometric properties of the five summated disease-specific scales compare favourably with standardized health status measures.

Impact of report cards on employees: a natural experiment.

To determine the effect of survey-based, health plan report cards on employees as they selected their 1995 health plan, the authors surveyed two groups of Minnesota State employees, one of which received the report card and one that did not. Both groups were surveyed before and after their enrollment. The authors looked for report card effects on relative changes in the employees' knowledge of health plan benefits and their ratings of quality and cost attributes, as well as their plan choice, rates of switching plans, and willingness to pay higher premiums. The only report card effect found was an increase in perceived knowledge for employees with single coverage.

Employer-specific versus community-wide report cards: is there a difference?

This article describes preliminary results from a natural experiment that tested the impact of report cards on employees. As part of the 1995 enrollment process, some members of the State of Minnesota Employee Group Insurance Program received report cards on the plans offered to them, and others did not. Both groups of employees had a chance to review a second community-wide report card covering all Minnesota plans that had been distributed by an independent organization through local newspapers. Both groups were surveyed before and after they made their health plan selections. We compare the likelihood of seeing, the intensity of reading, and the perceived helpfulness of the first, employer-specific report card with the second, community-wide report card for consumers who make plan selections.

Recognition and evaluation of oncology-related symptoms in the emergency department.

STUDY OBJECTIVE: To identify the oncology patient population presenting to the emergency department and examine the causes and clinical management of oncology symptoms in the ED. DESIGN: Retrospective review of 5,640 adult patients, with the following variables identified for oncology patients presenting to the ED: age, sex, cancer type, cancer stage, previous cancer treatment, previous hospitalization, presenting symptoms, treatment provided in the ED, admission and discharge data, and day, time, and length of ED visit. SETTING: Community teaching hospital with annual ED census of 31,000. PARTICIPANTS: All adult oncology patients who presented to the ED during the study period. We identified these patients by cross-referencing ED logs and tumor registry records. RESULTS: Cancer history was identified for 284 of the 5,640 adult ED admissions (5%). Forty-three percent (n = 122) of the 284 patients with cancer history had an oncology-related ED visit. The most common symptoms of these patients were gastrointestinal (48%), pain (40%), neurologic (38%), cardiac (25%), and pulmonary (23%). Ten percent of patients with oncology-related ED visits died during the admission, and 48% died within 1 year of the ED visit. CONCLUSION: Oncology patients present to the ED with symptoms of undiagnosed malignancy, complications of cancer treatment, and acute disease-related symptoms. Knowledge of an individual's cancer history and ability to recognize oncologic symptoms are important to the management of oncology patients.

Comparison of patients' compliance with prescribed oral and inhaled asthma medications.

BACKGROUND: Noncompliance with medications is one of the most serious problems facing health care today. However, methods to measure compliance have many limitations. METHODS: To measure specific drug compliance and dosing frequency of two asthma medications, we used medical records data and pharmacy claims data from 276 patients who had concurrent prescriptions for inhaled anti-inflammatory agents and oral theophylline. Patients were randomly selected from the pharmacy claims data files of a health maintenance organization. The patients' medical records were reviewed, and records that did not contain clear documentation of the medication, dose, and dosing frequency were excluded. Data from the remaining 119 medical records were compared with data from pharmacy claims to calculate compliance rates for each medication. RESULTS: Our calculations showed that patients were significantly more compliant with prescribed theophylline medication than with two inhaled anti-inflammatory medications (P = .0001). No significant differences in compliance were found relative to prescribed dosing frequency (twice daily or less compared with three times daily or more) for either medication (P = .6517). CONCLUSIONS: Comparison of medical record data with pharmacy claims data is an effective indirect measure of patients' compliance with prescribed oral theophylline and inhaled anti-inflammatory agents. Additional interventions must be pursued for patients with asthma regarding adherence to regimens for their prescribed inhaled anti-inflammatory agents.

Prevalence of dieting among working men and women: the healthy worker project.

Examined dieting to lose weight in a population of 2,107 men and 2,540 women employed in 32 worksites in the upper Midwest. Lifetime prevalence of this behavior was estimated to be 47% in men and 75% in women, and point prevalence was reported as 13% and 25% in men and women, respectively. Lifetime prevalence of participation in organized weight-loss programs was 6% in men and 31% in women; current prevalence was 1% in men and 6% in women. The strongest correlate of dieting behavior was relative body weight. In logistic regression analyses, dieting tended to be associated positively with education and occupational status and, in men only, was more prevalent among those with a history of hypertension. Dieters reported lower food intakes than nondieters, but the two groups did not differ consistently in reported physical activity. Overall, dieting appears to be a pervasive behavioral U.S. phenomenon that may contribute in part to population differences in the prevalence of obesity.

Injury surveillance in agriculture.

Information on agricultural trauma is limited and difficult to find. Planning for effective prevention strategies and evaluation is compromised by lack of a good surveillance system. Several agencies and organizations have provided some data. Although their summation is at best an approximation of the real situation, a critical review of current data bases is presented. The literature is also reviewed attempting to characterize agricultural trauma. This characterization was classified into: 1) case descriptions, 2) reviews of general articles on the hazards of farming, and 3) descriptive surveys of agricultural injuries. A summary of the available literature still leaves a rather superficial understanding of the entire injury picture. A new approach to surveillance is necessary to overcome past deficiencies. A combined modality approach is suggested, utilizing on-site survey, mail survey, telephone interviewing, and medical record verification. Trial applications of two such systems in Minnesota are described.