Facilitating shared decision making with patients.
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Aged↗
Biomedical subjects
James W Mold
Publications and source records attributed to James W Mold.
Does secondary smoke exposure increase the incidence and/or severity of asthma in children?
Pediatric asthma is a significant health problem in the United States. Up to 26,000 new asthma cases are identified every year. Seventeen percent of all pediatric emergency department visits are attributable to asthma. There are no universally agreed upon diagnostic criteria for asthma. Because no single agent has been identified as causing asthma and because no pathologic feature is entirely unique to asthma, the disease can more easily be described than defined. Asthma is diagnosed clinically based upon recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night in the absence of other causes. Asthma is considered a chronic inflammatory disorder associated with airflow obstruction, which is often reversible either spontaneously or with treatment. This inflammation exacerbates bronchial hyper-responsiveness to a variety of environmental stimuli including allergens and irritants. Due to inconsistency of diagnostic criteria for asthma, it is easier to measure asthma severity or to study events such as hospitalizations or deaths, rather than to measure incidence. Since a randomized controlled trial of the effect of cigarette exposure on asthma would be unethical, we must rely on either randomized trials of reduction of cigarette exposure or epidemiological studies to determine associations between secondary exposure to cigarette smoke and asthma.
Adolescent↗
What is the most sensitive non-invasive test for initial diagnosis of H. pylori infection in adults?
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Adult↗
Issues and initiatives in the testing process in primary care physician offices.
BACKGROUND: Errors occur frequently in management of the testing process in primary care physicians' offices. These errors may result in significant harm to patients and lead to inefficient practice. Important issues are summarized for primary care clinicians and their offices toconsider in improving the management of the testing processes. METHODS: To identify published efforts to improve management of the testing process, a literature search was performed and the references from the identified articles were checked for additional studies. Descriptive studies, expert opinion pieces, and controlled trials were all included. Unpublished results of ongoing studies in laboratory testing errors in primary care practice are presented. RESULTS: A conceptual model of the testing process was developed, with identified general and specific errors that occur in the testing process. On the basis largely of descriptive studies, ways are described to reduce testing process errors and the harm resulting from these errors. CONCLUSIONS: Standardization of processes, computerized test tracking systems (especially those embedded in electronic medical records), and attention to human factors issues are likely to reduce errors and harm. These ideas need confirmation in well-designed randomized trials and quality improvement initiatives.
Communication↗
Practice facilitators: a review of the literature.
BACKGROUND: Practice facilitators (PFs) are health care professionals who assist primary care clinicians in research and quality improvement projects. Although they have been used in Europe and Australia for more than 20 years, the concept is relatively new in the United States. The recent evolution of primary care practice-based research networks (PBRNs) has led to greater awareness and expansion of this concept. OBJECTIVES: This study's objective was to review the literature on PFs and describe their origin, training, funding, roles, methods they use, and their impact on patient care outcomes in primary care. METHODS: We searched four electronic databases from 1966 through the present, reviewing all articles pertaining to PFs in an effort to understand the history, training, financing, roles, methods, and impact of PFs. RESULTS: Since the early 1980s, PFs have worked with individual practices on relationship building, education, and quality improvement (QI), particularly in the area of prevention. A number of publications provide information on the roles of PFs in primary care and methods they use to enhance practices. Many prospective, uncontrolled studies and a few randomized, controlled trials have documented the effectiveness of PFs but usually in combination with other interventions. A number of primary care PBRNs in the United States have begun to use PFs as a way to bridge the gap between research and practice. Limited information has been published about the training and funding of PFs. CONCLUSIONS: The PF concept seems to be a useful practice enhancement approach in primary care.
Family Practice↗
African-American caregivers' expectations of physicians: gaining insights into the key issues of caregivers' concerns.
This qualitative study was done to determine what expectations, if any, African-American caregivers' have of physicians; what were the various causes of caregivers' distress, and what were the participants' perceived level of satisfaction or lack of satisfaction with the physician-patient-caregiver relationship The participants in this current study were either providing or had provided assistance in the activities of daily living of elders diagnosed with Alzheimer's or dementia. Focus group methodology was used and participants were recruited from Oklahoma County, Oklahoma. A total of 13 participants, whose mean age was 53.8 years of age and whose education was at least that of high school graduate, participated in the study. The majority of the caregivers were children who were caring for parents. The participants were asked three basic questions relating to their experiences or frustrations and the questions were followed by a 45-minute discussion to allow for further elaboration. The Geriatric Depression Scale (GDS), and the Zarit Burden Interview, combined with a demographic information form, was used to define the characteristics of the caregivers (Sheik, et al., 1986; Zarit, Reever & Bach-Peterson, 1980; Vitaliano, Russo, Yung, Becker, & Maiuro, 1991; National Center for Cost Containment, 1993). Findings from this study suggest that of the 13 participants only 2 could be classified as depressed. However, the caregivers expected information, referral for services and assistance in recognizing disease progression. These elements were sometimes lacking as well as not always having effctive caregiver-physician interaction. Greater attention by physicians to the needs, stressors, and expectations of African-American caregivers may improve the caregiver-physician interaction and may reduce caregiver stress. Further studies in this area can add to the sparsely available information.
Adult↗
Who are the uninsured elderly in the United States?
Because of the Medicare program, a common assumption is made that virtually all older Americans have health insurance coverage. Data from the 2000 National Health Interview Survey were analyzed to estimate the number of people aged 65 and older without health insurance; their stated reasons for being uninsured; and the associations between lack of insurance and sociodemographic variables, health status, and access to and use of healthcare services. In 2000, there were approximately 350,000 older Americans with no health insurance. Those without insurance were more likely to be younger, Hispanic, nonwhite, unmarried (widowed, divorced, or never married), poor, and foreign-born. They were less likely to hold U.S. citizenship. Despite relatively high rates of chronic medical conditions, they were unlikely to receive outpatient or home healthcare services. The most common reason given for lack of insurance was its cost. This study reveals important gaps in the availability of health insurance for the elderly, gaps that are likely to affect an increasing number of older Americans in the coming decade.
Activities of Daily Living↗
General internists and family physicians: partners in geriatric medicine?
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Aged↗
Diagnosing night sweats requires clear definition.
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Circadian Rhythm↗
RBANS performance: influences of sex and education.
A sample of 278 men and 353 elderly women who resided in the community received the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) as part of a study of health in mature adult Oklahomans. Females attained significantly higher scores on the Immediate and Delayed Memory and the Language Indexes. Males performed better on the Visuospatial/Construction Index, but there was no sex difference on the Attention or Total Indexes. Differences related to sex were modest (2-6 Index points), but combined with the larger effects of education could lead to an adjustment of up to 11 Index points.
Aged↗
Diabetes Patient Tracker, a personal digital assistant-based diabetes management system for primary care practices in Oklahoma.
It has been demonstrated that electronic patient registries combined with a clinical decision support system have a significant positive impact on the documentation and delivery of services provided by health care professionals. While implementation of available commercial systems has not always been proven effective in a number of primary care practices, development and implementation of such a system in a practice-based research network might enhance successful implementation. Physicians in our practice-based research network (Oklahoma Physicians Resource/Research Network) initiated a project that aimed at designing, testing, and implementing a personal digital assistant-based diabetes management system. We utilized the "best practice" approach to determine the principles on which the application must operate. System development and beta testing were also accomplished based on the direct feedback of user clinicians. Practice Enhancement Assistants (PEAs) were available in the practices for assistance with implementation. Implementation of the Diabetes Patient Tracker (DPT) resulted in a significant improvement (p<0.05) in nine of 10 diabetic quality of care measures compared with pre-intervention levels in 20 primary care practices. Regular PEA visits similarly increased the number of foot exams and retinal exams performed in the last year (p=0.03 and 0.02, respectively). DPT is a low-cost, feasible, easily implementable, and very effective paper-less tool that significantly improves patient care and documentation in primary care practices.
Computer-Assisted Instruction↗
Best practices research.
"Best practices research," described in this paper, refers to a systematic process used to identify, describe, combine, and disseminate effective and efficient clinical and/or management strategies developed and refined by practicing clinicians. It involves five steps: development of a conceptual model or series of steps, definition of "best" based on values and standards, identification and evaluation of potentially effective methods for each component or step, combination of most-effective methods, and testing of combined methods. The chronological development of this process is described with case examples, and the methodological steps are discussed.
Benchmarking↗
Evidence-based medicine meets goal-directed health care.
Evidence-based medicine and goal-directed, patient-centered health care seem, at times, like parallel universes, though, at a conceptual level, they are perfectly compatible. Part of the problem is that many of the kinds of information required for decision making in primary care are often unavailable or difficult to find. Several case examples are used to illustrate this problem, and reasons and solutions are suggested. The goal-directed health care model could be helpful for directing the search for evidence that is relevant to the decisions that patients and their primary care physicians must make on a regular basis.
Evidence-Based Medicine↗
Age and educational influences on RBANS index scores in a nondemented geriatric sample.
Research has indicated the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Randolph, 1998) to be sensitive to the effects of brain dysfunction and capable of accurately discriminating cortical from subcortical dementias (Randolph, Tierney, Mohr, & Chase, 1998). It recently has been demonstrated, however, that certain indices of the measure are susceptible to educational influences (Lineweaver, Zone, Chelune, Hermann, & Dow, 2001). The present investigation examined the effects of age and education on the six RBANS indices in a sample of nondemented older adults. Education accounted for a statistically significant proportion of the variance across all RBANS indices for this group (range=1.9-7.6%), while age increased the variance accounted for on four of six indices (range=0.5-2.2%). Regression-based educational corrections for index scores were derived to allow for appropriate adjustment. Effects of age, although statistically significant, were too small to make clinical adjustment on three of the four index scores worthwhile. On the Delayed Memory Index, however, correction for age for persons 80 years old and higher should be considered.
Aged↗
Prevalence of night sweats in primary care patients: an OKPRN and TAFP-Net collaborative study.
OBJECTIVE: To estimate the prevalence and factors associated with night sweats among adult primary care patients. STUDY DESIGN: This was a cross-sectional study. POPULATION: Adult patients in 2 primary care practice-based research networks (PBRNs) during 1 week in the summer and 1 week in the winter in the years 2000 and 2001. OUTCOME MEASURES: We measured the prevalence of pure night sweats and night and day sweats in all patients and subgroups defined by age and sex, clinical variables associated with night sweats, and the frequency, severity, and rate of reporting. RESULTS: Of the 2267 patients who participated, 41% reported experiencing night sweats within the last month, including 23% with pure night sweats and an additional 18% with day and night sweats. The prevalence of night sweats in both men and women was highest in the group aged 41 years to 55 years. In multivariate analyses, factors associated with pure night sweats in women were hot flashes and panic attacks; in men, sleep problems. Variables associated with night and day sweats in women were increased weight, hot flashes, sleep disturbances, use of antihistamines, selective serotonin reuptake inhibitors (SSRIs), and other (non-SSRI, non-tricyclic) antidepressants; in men, increased weight, hot flashes, and greater alcohol use. A majority of patients had not reported their night sweats to their physicians, even when frequent and severe. CONCLUSIONS: Night sweats are common and under-reported. Pure night sweats and night and day sweats may have different causes. With regard to the etiologies of pure night sweats, panic attacks and sleep disorders need further investigation.
Adult↗
The place of the nasogastric tube.
Physicians frequently take care of patients in hospital and emergency room settings where they have to utilize a variety of invasive diagnostic and therapeutic procedures in patient care. It is important that we be fully aware of the potential for complications and limitations of these techniques. The use of the nasogastric tube in patient care is not without adverse effects, and recent literature has called its routine use into question for a variety of situations. This paper is an attempt to illustrate some of these concerns, and suggests that physicians exercise greater restraint and judgment when considering its use.
Clinical Competence↗
Bridging the gap between public and private healthcare: Influenza-like illness surveillance in a practice-based research network.
This article describes the development, testing, and implementation of the OKAlert-ILI System, a bidirectional, dual-use influenza-like illness surveillance and messaging system, during the influenza seasons of 2003-2004 and 2004-2005 in the Oklahoma Physicians Resource/Research Network, a primary care practice-based research network. We describe how the Oklahoma Physicians Resource/Research Network connected 30 primary care providers to the Oklahoma State Department of Health and how surveillance results were analyzed and fed back to the clinicians on a weekly basis. We demonstrate the timeliness, sensitivity, specificity, acceptability, validity, flexibility, and cost of the system. Finally, we describe upgrades and enhancements to the system based on user evaluation and feedback.
Databases, Factual↗
Primary care practice-based research networks: working at the interface between research and quality improvement.
PURPOSE: We wanted to describe the emerging role of primary care practice-based in research, quality improvement (QI), and translation of research into practice (TRIP). METHODS: We gathered information from the published literature, discussions with PBRN leaders, case examples, and our own personal experience to describe a role for PBRNs that comfortably bridges the gap between research and QI, discovery and application, academicians and practitioners--a role that may lead to the establishment of true learning communities. We provide specific recommendations for network directors, network clinicians, and other potential stakeholders. RESULTS: PBRNs function at the interface between research and QI, an interface called TRIP by some members of the research community. In doing so, PBRNs are helping to clarify the difficulty of applying study findings to everyday care as an inappropriate disconnect between discovery and implementation, research and practice. Participatory models are emerging in which stakeholders agree on their goals; apply their collective knowledge, skills, and resources to accomplish these goals; and use research and QI methods when appropriate. CONCLUSIONS: PBRNs appear to be evolving from clinical laboratories into learning communities, proving grounds for generalizable solutions to clinical problems, and engines for improvement of primary care delivery systems.
Biomedical Research↗