An educational brochure helps improve patients' understanding of residents' role and level of training.
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Adult↗
Biomedical subjects
Rajesh Balkrishnan
Publications and source records attributed to Rajesh Balkrishnan.
Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis.
BACKGROUND: Atopic dermatitis is a common problem for which topical agents are the primary treatment. When topical medications fail, further therapy may include systemic agents with the potential for greater toxicity. Adherence to topical treatment of atopic dermatitis has not been well characterized. Poor adherence to topical medication could account for failure of topical therapy. PURPOSE: To determine adherence to topical treatment in patients with atopic dermatitis. METHODS: Thirty-seven children were given 0.1% triamcinolone ointment and were counseled to use it twice daily. They were told to return in 4 weeks, at which time they were told to continue treatment for another 4 weeks. Electronic monitors were used to measure adherence over the entire 8 week study. Patients were not informed of the compliance monitoring until the end of the study. RESULTS: Twenty-six patients completed 8 weeks of treatment. Mean adherence from the baseline to the end of the study was 32%. Adherence was higher on or near office visit days and subsequently decreased rapidly. LIMITATIONS: This study was limited by the large number of subjects who failed to return for follow-up appointments or withdrew from the study. CONCLUSIONS: Adherence to topical medications is very poor in a clinic population of children with atopic dermatitis. Office visits are one means to increase adherence. If adherence to topical treatment can be improved, exposure to more costly and potentially toxic systemic agents may be avoidable.
Administration, Topical↗
Consumer satisfaction with primary care provider choice and associated trust.
BACKGROUND: Development of managed care, characterized by limited provider choice, is believed to undermine trust. Provider choice has been identified as strongly associated with physician trust. Stakeholders in a competitive healthcare market have competing agendas related to choice. The purpose of this study is to analyze variables associated with consumer's satisfaction that they have enough choice when selecting their primary care provider (PCP), and to analyze the importance of these variables on provider trust. METHODS: A 1999 randomized national cross-sectional telephone survey conducted of United States residential households, who had a telephone, had seen a medical professional at least twice in the past two years, and aged > or = 20 years was selected for secondary data analyses. Among 1,117 households interviewed, 564 were selected as the final sample. Subjects responded to a core set of questions related to provider trust, and a subset of questions related to trust in the insurer. A previously developed conceptual framework was adopted. Linear and logistic regressions were performed based on this framework. RESULTS: Results affirmed 'satisfaction with amount of PCP choice' was significantly (p < .001) associated with provider trust. 'PCP's care being extremely effective' was strongly associated with 'satisfaction with amount of PCP choice' and 'provider trust'. Having sought a second opinion(s) was associated with lower trust. 'Spoke to the PCP outside the medical office,' 'satisfaction with the insurer' and 'insurer charges less if PCP within network' were all variables associated with 'satisfaction with amount of PCP choice' (all p < .05). CONCLUSION: This study confirmed the association of 'satisfaction with amount of PCP choice' with provider trust. Results affirmed 'enough PCP choice' was a strong predictor of provider trust. 'Second opinion on PCP' may indicate distrust in the provider. Data such as 'trust in providers in general' and 'the role of provider performance information' in choice, though import in PCP choice, were not available for analysis and should be explored in future studies. Results have implications for rethinking the relationships among consumer choice, consumer behaviors in making trade-offs in PCP choice, and the role of healthcare experiences in 'satisfaction with amount of PCP choice' or 'provider trust.'
Adult↗
Physician and patient characteristics associated with outpatient breast cancer screening recommendations in the United States: analysis of the National Ambulatory Medical Care Survey Data 1996-2004.
BACKGROUND: The primary goal of breast cancer screening tests is to find cancer at an early stage before a person has any symptoms. Evidence suggests that screening examinations such as mammography and clinical breast examinations (CBE) are effective in early detection of breast cancer. Physician recommendation is an important reason many women undergo screening. This study examined the physician and patients related factors associated with physician recommendations for breast cancer screening in the United States (US) outpatient settings. METHODS: This cross-sectional study used data from the National Ambulatory Medical Care Survey (NAMCS) from 1996-2004. Women aged >or=40 years were included in the study sample. Multivariate logistic regression analyses were used to study the objectives. RESULTS: Weighted analysis indicated that physicians performed 198 million CBEs and made 110 million mammography recommendations over the study period (1996-2004). Patients' age, duration of visits, history of previous breast cancer diagnosis, and source of insurance were significant predictors of screening recommendations in this population. Obstetricians and gynecologists were more likely to perform a CBE and recommend mammography than other specialty physicians. CONCLUSIONS: These findings indicated that there were certain disparities regarding the physician recommendations of breast cancer screening for women in the US outpatient settings.
Adult↗
Adapting electronic adherence monitors to standard packages of topical medications.
Adherence to topical medications is poorly characterized. Electronic monitors can provide objective adherence data, but these monitors are not designed to work with tubes of medications. We sought to adapt standard electronic monitors to commonly used medication tubes. An adapter was created to fit over standard medication tubes. Screw threads on the adapter were designed to fit standard electronic monitors. Adapters and monitors were tested with tubes of gel, ointment, and cream over an 8-week test period during which the adapters were opened and closed twice daily. The adapters were easily mated to both plastic and aluminum topical medication tubes. The bond between the adapter and the tube was maintained throughout the study. Electronic monitors were 100% accurate at identifying medication events over the study period. We conclude that adapting existing electronic monitors to medication tubes should facilitate a much better understanding of adherence to topical treatment.
Administration, Topical↗
Survival disadvantage among Medicaid-insured breast cancer patients treated with breast conserving surgery without radiation therapy.
BACKGROUND: Clinical studies indicate that breast cancer patients treated with breast conserving surgery (BCS) without radiotherapy (RT) have a greater risk of recurrence and mortality compared to those receiving BCS plus RT. However, this relationship has been underdeveloped among low-income women in the community who may face barriers in accessing adjuvant treatment and post-treatment surveillance. It is possible that the prognostic significance of omission of RT in clinical trials underestimates the significance of risk in the community. METHODS: Using cancer registry, Medicaid claims, and the Social Security Master Death File, we evaluated receipt of RT in women with early stage breast cancer treated with BCS and mean 6-year overall and cancer-specific survival. Logistic regression was used to assess correlates of RT. The Kaplan-Meier method was used to determine survival by RT status and a multivariate Cox proportional hazards regression was used to evaluate the role of RT status on overall and cause-specific survival. RESULTS: A total of 65% of women received RT, and 82% of the sample survived the study period. Death rates of 16% and 51% were observed among those who did and did not receive RT, respectively (P < 0.001). One-third of women who died from cancer (8 of 24) received radiation. Use of RT was associated with a statistically significant decrease in all-cause (hazard ratio = 0.42, 95% CI 0.21-0.85) and cancer-specific mortality (hazard ratio = 0.22, 95% CI -0.09 to 0.57). CONCLUSIONS: Adjuvant radiation following BCS was underused in this sample of poor breast cancer patients. Lack of adjuvant RT may be a proxy for inadequate access to care and poor cancer surveillance after treatment.
Aged↗
Quality of life in patients with psoriasis.
Psoriasis is one of the prevalent skin conditions in the United States. This chronic condition has a significant negative impact on patients' quality of life. Psoriasis has been linked to the depression and suicidal tendencies in the patients. The costs associated with decrements in quality of life, lost productivity, and work absenteeism may be enormous, increasing overall costs associated with the disease management. This review attempts to outline different quality of life measures available for psoriasis and describes their use in studies examining patient reported outcomes associated with pharmacological interventions for psoriasis. Factors associated with quality of life in psoriasis patients are described. It further describes physician's role in the psoriasis management to improve patients' overall well-being.
Absenteeism↗
Melasma in Latina patients: cross-cultural adaptation and validation of a quality-of-life questionnaire in Spanish language.
BACKGROUND: Melasma has been shown to have a significant emotional and psychologic effect on affected patients. Although this pigmentary disorder is thought to be more prevalent among Latinos, the effect of melasma on quality of life (QOL) in this population is unknown. OBJECTIVES: The goals of this study were to translate and culturally adapt the previously validated Melasma QOL (MELASQOL) scale into Spanish language, to confirm the new scale's reliability and validity, and to administer the scale to characterize melasma's effect on the health-related QOL of Spanish language-speaking Latino patients. METHODS: Cross-cultural adaptation of the original questionnaire was performed using previously established guidelines. After pretesting the questionnaire in a group of 30 patients, it was tested in a group of 112 patients recruited from a community outpatient clinic. A Spanish-language health-related QOL assessment battery was also administered for validation purposes. The degree of melasma was determined on clinical examination by the investigator using the Melasma Area and Severity Index. RESULTS: Cross-cultural adaptation of the questionnaire was successful in producing a working and understandable Spanish-language version of the MELASQOL. The Spanish-language MELASQOL scale was internally reliable and demonstrated construct and content validity. The Spanish-language MELASQOL scores of patients with little to no formal education were significantly higher than those with at least a seventh-grade education. Scores were proportional to the length of time a patient had lived with melasma and were higher in patients who had previously sought treatment. Spanish-language MELASQOL score and Melasma Area and Severity Index were shown to be moderately correlated, but no differences were seen according to patient age, marital status, employment, or coexisting medical or psychiatric conditions. LIMITATIONS: Limitations are a lack of data regarding socioeconomic status and limitation to Mexican and Central American female patients. CONCLUSIONS: We have developed a semantically equivalent translation of MELASQOL in the Spanish language and have begun to characterize the effects of melasma on the QOL in a population that has not been previously studied. Further studies in larger populations of Spanish language-speaking patients from various geographic and socioeconomic groups are warranted.
Adult↗
Risk stratification of adult patients undergoing orthotopic liver transplantation for fulminant hepatic failure.
BACKGROUND: Orthotopic liver transplantation (OLT) is an effective treatment for fulminant hepatic failure (FHF), but postOLT mortality is higher for patients with FHF than for patients with other indications for OLT. In the current study, a large cohort of patients who underwent OLT for FHF was evaluated to develop and validate a system useful for estimating postOLT patient survival. METHODS: The 1,457 patients who underwent OLT for FHF in the United States between 1988 and 2003 were enrolled through the UNOS database. This group was divided into a modeling group (n=972) and a crossvalidation group (n=486). With a multivariate regression analysis, the modeling group was used to identify clinical parameters that had a significant association with postOLT survival. This regression analysis was used to create a scoring system that was subsequently assessed in the crossvalidation group. RESULTS: Four risk factors were identified with the multivariate analysis: 1) body mass index > or = 30 kg/m2; 2) serum creatinine > 2.0 mg/dL; 3) recipient age > 50 years old; and 4) history of life support. By assigning points based on the number of risk factors present, the scoring system was able to differentiate between low-risk patients (5-year survival, 81%) and high-risk patients (5-year survival, 42%). The relative risk of postOLT mortality increased by approximately 150% for each additional point. CONCLUSION: The scoring system risk-stratified the crossvalidation group and accurately predicted postOLT survival. A scoring system utilizing clinical and demographic information readily available prior to OLT may help predict the probability of survival after OLT for FHF.
Adult↗
Comparison of medication adherence and associated health care costs after introduction of pioglitazone treatment in African Americans versus all other races in patients with type 2 diabetes mellitus: a retrospective data analysis.
OBJECTIVE: The aim of this study was to compare treatment adherence and health care costs in African Americans versus all other races (All Others) in patients with type 2 diabetes mellitus starting treatment with pioglitazone. METHODS: In this retrospective cohort study, the North Carolina Medicaid database was used (query dates: July 1, 2000, to June 30, 2003). Using at least 1 code from the International Classification of Diseases, Ninth Revision, Clinical Modification for type 2 diabetes (250.xx) and 1 National Drug Code for antidiabetic medication, we identified a cohort of male and female patients aged > or =18 years with type 2 diabetes who maintained continuous Medicaid eligibility for the entire 36-month follow-up period. Race was categorized as African American and All Others (white, Asian, Native American, Pacific Islander, other) based on self-reported data collected at the time of Medicaid enrollment. Medication adherence was expressed as medication possession ratio (calculated as the number of days of antidiabetic prescription supply dispensed [eg, a 30-day supply] divided by the number of days between the first and last dispensation). Reimbursements made by Medicaid were used to calculate diabetes-related and total health care costs, which included medical and dental care, including costs for regular checkups, office visits, home health care, inpatient and outpatient care, long-term care facility care, and prescription drugs. To compare the differences in medication adherence and annual total and diabetes-related health care costs between African Americans and All Others, multivariate regression analysis was performed using only data from the year after (year 2) the year in which pioglitazone treatment was started (year 1). RESULTS: Among the 1073 patients treated with pioglitazone (26.1% men; mean [SD] age, 49.5 [10.6] years; 50.2% African American; mean [SD] total health care costs in year 1, US $7906 [$12,256]; year 2, $9546 [$14,861]), African Americans had significantly higher adherence (62%) to pioglitazone treatment compared with All Others (57%) (P < 0.05) on unadjusted analysis. However, no significant differences in rates of adherence to the medication were found between African Americans and All Others on multivariate regression analysis. African American race was not found to be an independent predictor of increased or decreased annual total health care costs in this population. Significant reductions in total health care costs (2% for every 10% increase in adherence; P < 0.001) and diabetes-related costs (4% for every 10% increase in adherence; P < 0.01) with increased adherence were found. CONCLUSIONS: On multivariate analysis, this study found no significant differences in treatment adherence between African Americans versus all other races in this population of diabetic patients enrolled in a Medicaid program (query dates: July 1, 2000, to June 30, 2003). A higher adherence rate was associated with significantly lower diabetes-related and total health care costs in this population.
Adult↗
Adherence with topical treatment is poor compared with adherence with oral agents: implications for effective clinical use of topical agents.
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Administration, Oral↗
Surveillance and assessment of occupational dermatitis using Rhode Island workers' compensation data 1998 to 2002.
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Adult↗
An evaluation of a mass media campaign to encourage parents of adolescents to talk to their children about sex.
PURPOSE: We evaluated a mass media campaign in North Carolina that used television (TV) public service announcements (PSAs), radio PSAs, and billboards to encourage parents of adolescents to talk to their children about sex. The primary message of the campaign was "Talk to your kids about sex. Everyone else is." METHODS: Thirty-two of the 100 counties in North Carolina were chosen to evaluate the mass media campaign. Paid TV PSAs were aired in 22 of these counties, radio PSAs were aired in 21 counties, and billboards were displayed in 6 counties over a period of 9 months. The counties in our sample varied from no exposure to exposure to all 3 types of media. To assess the impact of the campaign, a sample of 1,132 parents of adolescents living in the 32 counties was administered a postexposure survey via a telephone interview. Questions about exposure to the media campaign were embedded among questions concerning media exposure to other health-related messages. The parent survey assessed the frequency the parents reported exposure to each type of media message, correct knowledge of the message, and multiple item scales that assessed how often they had talked to their child about various issues related to sex during the previous 6 months, intentions to talk to their child about these issues during the next month, and attitudes about discussing sexual issues with their child. RESULTS: In bivariate analyses the levels of parental exposure to the 3 types of media messages were associated with both having talked to their children and intentions to talk to their children about sex (p < .0001). When analyzed with multiple regression, female gender, minority ethnicity, frequency of seeing a billboard on teenage pregnancy, frequency of seeing a TV PSA about sex, and frequency of hearing a radio PSA about sex and teenage pregnancy accounted for 12.8% (p < .0001) of the variance in having talked to their child about sex. Female gender, minority ethnicity, and previously talking to their child about sex accounted for 9.9% of the variation in positive communication attitudes about sex. Positive communication attitudes, female parent, minority ethnicity, frequency of seeing a billboard about sex, frequency of seeing a TV PSA about sex, and frequency of hearing radio PSAs about sex accounted for 12.3% of the variation in parental intentions to talk to their child about sex during the next month. CONCLUSIONS: Exposure to each component of this mass media campaign was associated with parents recently having talked to their adolescent children about sex and intentions to talk to their children during the next month.
Adolescent↗
Predictors of medication adherence and associated health care costs in an older population with overactive bladder syndrome: a longitudinal cohort study.
PURPOSE: We examined the relationship between self-reported health status data, subsequent antimuscarinic medication adherence and health care service use in older adults with OAB syndrome in a managed care setting. MATERIALS AND METHODS: This was a longitudinal cohort study of older adults in the southeastern United States with OAB who completed a health status assessment, used antimuscarinic medications and were enrolled in an HMO continuously for 1 to 3 years. Demographic, clinical and use related economic variables were also retrieved from the administrative claims data of patient HMOs. Prescription refill patterns were used to measure medication adherence. Associations were examined with a sequential, mixed model regression approach. RESULTS: A total of 275 patients were included. The severity of comorbidity (Charlson index), patient perception of quality of life (Short Form-12 scores) and total number of prescribed medications during the year prior to enrollment in a Medicare HMO were independently associated with decreased antimuscarinic MPRs after enrollment. After controlling for other variables increased antimuscarinic MPR remained the strongest predictor of decreased total annual health care costs (5.6% decrease in annual costs with every 10% increase in MPR, p < 0.001). CONCLUSIONS: We found strong associations between decreased antimuscarinic medication adherence and increased health care service use in older adults with OAB in a managed care setting. Health status assessments completed at enrollment had the potential to identify enrollees at higher risk for nonadherent behaviors and poor health related outcomes.
Adult↗
The negative impact of psoriasis on the workplace.
BACKGROUND: The health-related quality of life and economic impact of psoriasis has been documented. However, the negative impact of psoriasis on the workplace is poorly understood. AIM/METHODS: Through anonymous surveys from 30 subjects of each of three psoriasis severity groups we aim to quantify the workplace impact experienced by psoriasis patients and factors that may contribute to this impact. Data were collected using several previously validated measures including the Work Productivity Assessment Index (WPAI), SF-8, Hospital Anxiety and Depression (HADS) and past medical/psoriasis history. RESULTS: Psoriasis patients experienced negative impact at work as measured by the WPAI; this impact is directly associated with disease severity. The other instruments confirmed the negative impact of psoriasis though the degree of impact did not always correlate with disease severity or work impact. Owing to the relatively small numbers, the significance of these findings is not certain. CONCLUSIONS: This preliminary study finds that psoriasis is associated with a reduction in work productivity and social functioning; this may explain the relatively high cost of this disease on both a macro- and microeconomic level. As there was a lack of significant trends in this study, formal inferences are limited and further investigation is warranted.
Adult↗
The cost-effectiveness and cost of treatment failures associated with systemic psoriasis therapies.
BACKGROUND: Psoriasis is difficult at times to treat and treatment failures are not uncommon regardless of approach. With the advent of expensive biologic therapies for psoriasis there is increasing discussion on the cost efficacy of a given systemic or biologic agent. An alternative and overlooked aspect of cost efficacy is the cost that accrues from treatment failures. METHODS: We review the literature and develop a model to analyze the cost-effectiveness and the cost of treatment failures per success for various systemic psoriasis agents using a 12-week treatment period. RESULTS: For continuous-dose agents, the cost-effectiveness results are: methotrexate $623, acitretin $2729, cyclosporine $2969, nUVB $3692, PUVA $4668, etanercept $16 312, and efalizumab $17 196. The cost of expected treatment failures to achieve one success for the same agents were: methotrexate $187, cyclosporine $505, PUVA $767, nUVB $1034, acitretin $1310, etanercept $8319, and efalizumab $12 897. CONCLUSIONS: Methotrexate appears to be the most cost-effective agent for the treatment of severe psoriasis. However, greater efficacy can be achieved with cyclosporine and PUVA, albeit at a greater cost. Because of the high cost of treatment failures, access to a wide array of therapies and combination regimens should not be discouraged by physicians or insurers.
Cost-Benefit Analysis↗
New treatments for psoriasis: which biologic is best?
Psoriasis is a chronic, debilitating disease affecting not only the skin, but also having a significant impact on a patient's quality of life. The treatment of severe psoriasis is quite challenging due to the chronic, relapsing nature of the disease and the difficulties inherent in treatment planning. Though the biologics are perhaps the most promising of available psoriasis treatments, the decision to institute a given therapy may be fraught with complexity for the clinician. Patients now hear of these promising new treatments for psoriasis via print, television and radio advertising; they frequently come to their physician asking if they are eligible for any of these agents and, if so, 'which biologic is best?'. This paper attempts to determine the ideal biologic agent based upon several parameters: FDA- and EU-approved indications, therapeutic efficacy, impact on quality of life, cost-effectiveness, and safety profile. Certainly the physician is central to medical decision-making, though ultimately patient preference may play the largest role in determining the 'best' biologic agent. There is no single ideal biologic for all patients and a physician's job is to educate patients on the relative advantages and disadvantages of each agent. Through informed discussion, the clinician can help each individual patient decide which biologic agent is ideal for them.
Adalimumab↗
Adherence in dermatology: a review of the last 20 years.
BACKGROUND: Adherence has been studied in many areas of medicine; however, there are few published articles pertaining to adherence and dermatology. OBJECTIVE: The purpose of this review is to summarize the current literature on medical adherence as it specifically applies to dermatology. METHODS: We conducted a PUBMED search between the years of 1985 and 2005 using the following terms: 1-[adherence AND dermatology] and 2-[dermatology AND treatment]. The search was limited to articles in English and human subjects. RESULTS: The literature search yielded 57 articles. Seventeen of these articles met the inclusion criteria and were reviewed in order to define, measure, quantify, validate, and understand adherence in dermatology. CONCLUSIONS: Adherence to topical therapy among dermatology patients is difficult to measure reliably, hence the few articles available on this topic. A small number of studies using new electronic monitoring technology have shown that dermatology patients have low adherence rates to treatment regimens. There are socioeconomic, cognitive, and psychological factors that contribute to non-adherence among patients. Improving patient knowledge and the doctor-patient relationship are ways to improve patient adherence.
Communication↗