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PubMed2000

Preventive services in the primary care practices of the Practice Partner Research Network.

Despite the emphasis of primary care on preventive services over the past decade, and the reminder systems that are available to promote the provision of these services, many patients still do not receive needed services. This study describes the preventive services that the primary care practices of the Practice Partner Research Network (PPRNet) monitors, and documents adherence to them. Preventive services monitored in PPRNet practices and the levels of adherence to them vary by practice and service. The lower-than-desired levels of adherence offer opportunities for improvement interventions.

Data Collection↗
PubMedDate not supplied

Effectiveness of interventions to increase Papanicolaou smear use.

BACKGROUND: Many women fail to adhere to Papanicolaou smear screening guidelines. Although many interventions have been developed to increase screening, the effectiveness of different types of interventions is unclear. METHODS: We performed a systematic review of interventions to increase Papanicolaou smear use published between 1980 and April 2001 and included concurrently or randomized controlled studies with defined outcomes. Interventions were classified as targeted to patients, providers, patients and providers, or health care systems and as behavioral, cognitive, sociologic, or a combination based on the expected action of the intervention. Effect sizes and 95% confidence intervals were calculated for each intervention. RESULTS: Forty-six studies with 63 separate interventions were included. Most interventions increased Papanicolaou smear use, although in many cases the increase was not statistically significant. Behavioral interventions targeted to patients (eg, mailed or telephone reminders) increased Papanicolaou smear use by up to 18.8%; cognitive and sociologic interventions were only marginally effective, although a single culturally specific, sociologic intervention using a lay health worker increased use by 18.0% (95% confidence interval [CI]: 7.6, 28.4). Provider-targeted interventions were heterogeneous. Interventions that targeted both patients and providers did not appear to be any more effective than interventions targeted to either patients or providers alone. One of the most effective interventions, which introduced a system change by integrating a nurse-practitioner and offered same-day screening, increased screening by 32.7% (95% CI: 20.5, 44.9). CONCLUSIONS: Overall, most interventions increased Papanicolaou smear use, although there was tremendous variability in their effectiveness. Selection of intervention strategies will depend on provider and patient population characteristics and feasibility of implementation.

Female↗
PubMed1998

Self-reported adherence, management behavior, and barriers to care after an emergency department visit by inner city children with asthma.

OBJECTIVE: The inability to adhere to a prescribed therapeutic program for the treatment of a chronic disease may be responsible in part for continued disease activity. This problem may be more of an issue in the treatment of asthma, a common, potentially lethal chronic condition in which the lack of symptoms may be interpreted as remission. Adherence was one of the key areas of interest for the National Cooperative Inner-City Asthma Study. The focus of this study was to identify those issues reported by families that could adversely affect their adherence to an asthma care program. The identification of barriers to adherence could then form the basis of a successful intervention program. This study describes barriers to adherence, asthma management behavior, and self-reported adherence. METHODS: Patients presenting during an acute attack of asthma at an emergency department (ED) were recruited for this study. The medical record of the ED encounter was abstracted and compared with information that was obtained during a baseline interview 3 to 5 weeks later. During the baseline interview, parents were asked about health care behaviors related to adherence. RESULTS: There were 344 children 4 to 9 years of age living in inner city census tracts in the study. Four areas of adherence (medicine use, appointment-keeping, emergency actions, and asthma attack prevention) were investigated. The parental report of medications prescribed at the ED and the information on the abstracted ED report agreed 94.9% of the time for the beta-agonists, 86.8% for steroids, and 69.4% for cromolyn. Among respondents, 85.4% of parents reported that they are able to follow the ED recommendations almost all of the time; side effects of medicines were a concern for 81.1% of caretakers who were adherent and for 89.5% of caretakers who were nonadherent. Doubts regarding the usefulness of medications occurred in 34.4% of those considered adherent and 54.2% who admitted nonadherence. Medications were forgotten some of the time by 45.2% of the children, and 52.8% tried to get out of taking medicine. Appointments for follow-up care were kept by 69% of those given an appointment in the ED, by an estimated 60.0% of those who were told specifically to call for an appointment, and by an estimated 25.2% of those who were neither given an appointment nor told specifically to make one. Only one third of parents report that they were able to keep the child away from known asthma triggers nearly all of the time. Approximately half avoided allergens; however, only 37.5% reported avoidance of cigarette smoke. The use of preventive medicines occurred in 23.5%. Using a medicine and taking the child to a physician were reported as the first or second action during an acute attack of asthma by 72.1% of respondents. CONCLUSIONS: Adherence to an asthma-management program involves a number of areas: medication, appointment-keeping, prevention, and applying an emergency plan of action. Barriers to adherence may exist in one or all four of these areas, leading to ineffective control of asthma. Recommendations are made for improving the patient-physician partnership to improve adherence.

Asthma↗
PubMed2003

Improving guideline adherence: a randomized trial evaluating strategies to increase beta-blocker use in heart failure.

BACKGROUND: The dissemination of clinical practice guidelines often has not been accompanied by desired improvements in guideline adherence. This study evaluated interventions for implementing a new practice guideline advocating the use of beta-blockers for heart failure patients. METHODS AND RESULTS: This was a randomized controlled trial involving heart failure patients (n=169) with an ejection fraction < or =45% and no contraindications to beta-blockers. Patients' primary providers were randomized in a stratified design to 1 of 3 interventions: (1) control: provider education; (2) provider and patient notification: computerized provider reminders and patient letters advocating beta-blockers; and (3) nurse facilitator: supervised nurse to initiate and titrate beta-blockers. The primary outcome, the proportion of patients who were initiated or uptitrated and maintained on beta-blockers, analyzed by intention to treat, was achieved in 67% (36 of 54) of patients in the nurse facilitator group compared with 16% (10 of 64) in the provider/patient notification and 27% (14 of 51) in the control groups (P<0.001 for the comparisons between the nurse facilitator group and both other groups). The proportion of patients on target beta-blocker doses at the study end (median follow-up, 12 months) was also highest in the nurse facilitator group (43%) compared with the control (10%) and provider/patient notification groups (2%) (P<0.001). There were no differences in adverse events among groups. CONCLUSIONS: The use of a nurse facilitator was a successful approach for implementing a beta-blocker guideline in heart failure patients. The use of provider education, clinical reminders, and patient education was of limited value in this setting.

Adrenergic beta-Antagonists↗
PubMed1993

Effect of nurse-client transaction on female adolescents' oral contraceptive adherence.

An experimental study was conducted to test the effect of a nurse-client transactional intervention (King, 1981) on 51 female adolescents' oral contraceptive adherence. Subjects were randomly assigned to a control or an experimental group. Both groups experienced the clinics' contraceptive teaching. Subjects in the experimental group experienced the transactional intervention. Contraceptive perceptions were measured immediately post-intervention and at the three-month follow-up. Oral contraceptive adherence was measured at the three-month follow-up. Female adolescents who experienced the transactional intervention had greater levels of oral contraceptive adherence than those who had not (F = 4.15, p < .05).

Adolescent↗
PubMed2003

Randomised controlled trial of the impact of guidelines, prioritized review criteria and feedback on implementation of recommendations for angina and asthma.

BACKGROUND: Guidelines are frequently used in an attempt to influence the performance of health professionals, and a national agency has been established in England and Wales to develop and disseminate guidelines. Professionals prefer short guidelines that highlight key recommendations, but whether such guidelines are more likely to be implemented is unknown. AIM: To determine the relative impact of the dissemination of full guidelines, reduced guidelines in the form of prioritized review criteria, and review criteria supplemented by feedback. DESIGN OF STUDY: Cluster randomised controlled trial, with an incomplete block design. SETTING: Eighty-one general practices in Leicestershire, Lincolnshire, Northamptonshire, North Derbyshire, and Nottinghamshire. METHOD: The practices received one of the study interventions, either for care of adults with asthma or for care of people with angina. Data were collected before and after the interventions, the process measures being adherence to ten recommendations about asthma and 14 about angina, and outcome measures being scores in response to an asthma symptom questionnaire or the Seattle Angina Questionnaire, and levels of patient satisfaction. RESULTS: There were no consistent differences between the interventions in stimulating improvements in performance as indicated by adherence to the recommendations for asthma or angina. Patients with angina in practices that had received criteria or criteria plus feedback reported better symptom control. CONCLUSION: The dissemination of guidelines in the format of prioritized review criteria does not increase adherence to recommendations in comparison with the traditional guideline format, and the further provision of feedback has minimal additional effect.

Aged↗
PubMed2004

Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection.

BACKGROUND: There is little evidence to support the widely accepted assertion that better physician-patient relationships result in higher rates of adherence with recommended therapies. OBJECTIVE: To determine whether and which aspects of a better physician-patient relationship are associated with higher rates of adherence with antiretroviral therapies for persons with HIV infection. DESIGN: Cross-sectional analysis. SETTING: Twenty-two outpatient HIV practices in a metropolitan area. PARTICIPANTS: Five hundred fifty-four patients with HIV infection taking antiretroviral medications. MEASUREMENTS: We measured adherence using a 4-item self-report scale (alpha= 0.75). We measured core aspects of physician-patient relationships using 6 previously tested scales (general communication, HIV-specific information, participatory decision making, overall satisfaction, willingness to recommend physician, and physician trust; alpha > 0.70 for all) and 1 new scale, adherence dialogue (alpha= 0.92). For adherence dialogue, patients rated their physician at understanding and solving problems with antiretroviral therapy regimens. RESULTS: Mean patient age was 42 years, 15% were female, 73% were white, and 57% reported gay or bisexual sexual contact as their primary HIV risk factor. In multivariable models that accounted for the clustering of patients within physicians' practices, 6 of the 7 physician-patient relationship quality variables were significantly (P < .05) associated with adherence. In all 7 models worse adherence was independently associated (P < .05) with lower age, not believing in the importance of antiretroviral therapy, and worse mental health. CONCLUSIONS: This study showed that multiple, mutable dimensions of the physician-patient relationship were associated with medication adherence in persons with HIV infection, suggesting that physician-patient relationship quality is a potentially important point of intervention to improve patients' medication adherence. In addition, our data suggest that it is critical to investigate and incorporate patients' belief systems about antiretroviral therapy into adherence discussions, and to identify and treat mental disorders.

Adult↗
PubMedDate not supplied

Initial testing of the Antiretroviral Medication Complexity Index.

This article describes the initial development and testing of the Antiretroviral Medication Complexity Index (AMCI), an instrument to measure complexity of antiretroviral medications and regimens. Data were derived from a pilot study and the main study of an intervention designed to promote adherence to antiretroviral medications. Interrater reliability coefficients ranged from .74 to 1.0 for project staff and from .33 to 1.0 for nurse clinicians. Test-retest coefficients ranged from .297 to .988 for forms completed by the same interviewer and from .200 to .922 for different interviewers. Strong relationships existed between rankings of the medications by clinical judgment and rankings of the medications using the AMCI, providing support for criterion validity. Complexity as measured by the AMCI was associated with some measures of adherence, providing partial support for construct validity. Results provide evidence for the reliability and validity of the AMCI when used for research purposes.

Adult↗
PubMed1990

The elderly on dialysis: some considerations in compliance.

Compliance with scheduled treatments, dietary and fluid restrictions, and multiple medications is an important component in the care and well-being of end-stage renal disease (ESRD) patients. Given the rigorus and complex demands of dialysis, it is important to examine the issue of compliance, focusing on a large and ever-increasing segment of our patient population, the elderly. The ESRD literature reflects efforts to define and measure levels of compliance, identify factors that influence and predict compliance, and develop intervention strategies to improve adherence to treatment regimens. While limited attention has been focused specifically on the elderly, there are studies suggesting that age may be a factor associated with improved adherence and that social support may be a significant contributor to compliance in this patient group. In an effort to examine the current status and needs of the dialysis elderly, research is in progress at Chromalloy American Kidney Center, Washington University, which replicates a study of 5 years ago. Eighty-four patients age 60 and over, on dialysis for a minimum of 6 months, were identified. Sociodemographic, treatment, compliance, and functional capacity data were collected; additional mental and psychological testing was completed on patients willing and able to participate. Preliminary data suggest the current elderly population is larger and significantly older than that of 5 years ago. Other sociodemographic data indicate the population is increasingly female, black, and more socioeconomically disadvantaged. In regard to compliance, the vast majority of elderly demonstrate good compliance as measured by serum potassium, fair to good compliance with phosphorus, and fair to poor compliance with fluid restrictions.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗
PubMedDate not supplied

Establishing community pharmacy-based anticoagulation education and monitoring programs.

OBJECTIVE: To determine the process for establishing community pharmacy-based anticoagulation education and monitoring programs using fingerstick capillary whole blood testing. DESIGN: Pilot community-based intervention study using convenience sample of patients. SETTING: Three community pharmacies with pre-established health education centers and laboratories certified for moderate complexity. PARTICIPANTS: 26 patients were referred to the clinics by 2 primary care physicians for each pharmacy, most with a diagnosis of atrial fibrillation. INTERVENTION: Patient assessment, including adherence to prescribed regimens; changes in medication use, including prescription and nonprescription medications, vitamins, health foods, and nutrition supplements; changes in diet and ethanol consumption; assessment of adverse experiences; and needed changes in warfarin dosage. MAIN OUTCOME MEASURES: Percentage of international normalized ratio (INR) values within therapeutic range, major bleeding events, and thrombotic events. RESULTS: A total of 21 patient charts were available for analysis. More than 80% of patients had INR values within their targeted range (+/- 0.2) 60% or more of the time, comparable with values reported for anticoagulation clinics. Of the 235 INR values obtained during the study, 75% were within the individualized targeted therapeutic range (e.g., 2 to 3 +/- 0.2). One patient experienced a major bleeding event related to an underlying cancer. None of the patients experienced a thrombotic event. CONCLUSION: Community pharmacies can effectively implement an anticoagulation education and monitoring program.

Adult↗
PubMed1999

Adherence with referrals for outpatient follow-up from a VA psychiatric emergency room.

This study identifies patient characteristics associated with adherence to outpatient mental health treatment referrals from a VA psychiatric emergency department. Attendance of outpatient appointments was monitored for 12 weeks following emergency department visits (N = 241). Overall attendance of the first appointments was 53%, ranging from 34% of the homeless, to 82% of patients with alcoholism in remission. Characteristics associated with initial adherence included having a place to live and the diagnosis of depression. At twelve weeks, the diagnosis of substance abuse was associated with worse ongoing adherence. The results underscore the need to develop interventions targeting patients at highest risk of poor adherence.

Adult↗
PubMed1998

Implications of HIV treatment advances for behavioral research on AIDS: protease inhibitors and new challenges in HIV secondary prevention.

Protease inhibitor combination therapies can reduce HIV viral load, improve immune system functioning, and decrease mortality from AIDS. These medical developments raise a host of critical new issues for behavioral research on HIV/AIDS. This article reviews developments in HIV combination therapy regimens and behavioral factors involved in these regimens and focuses on four key behavioral research areas: (a) the development of interventions to promote treatment adherence, (b) psychological coping with HIV/AIDS in the context of new treatments for the disease, (c) the possible influence of treatment on continued risk behavior, and (d) behavioral research in HIV prevention and care policy areas. Advances in HIV medical care have created important new opportunities for health psychologists to contribute to the well-being of persons with HIV/AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed2006

The impact of provider knowledge and attitudes toward national asthma guidelines on self-reported implementation of guidelines.

This study determines the impact of provider knowledge and attitude on implementation of guidelines: spirometry, peak flows, patient assessments, action plans, severity assessment, and anti-inflammatories. A self-administered survey conducted in academic family practice sites in Buffalo, NY assessed knowledge, self-reported use, and perceived usefulness. Knowledge was associated with regular use of peak flows (p = 0.048) and anti-inflammatories (p = 0.01). Positive attitude was associated with regular use of spirometry (p = 0.03), peak flows (p < or = 0.001), patient assessments (p = 0.02), action plans (p = 0.046), anti-inflammatories (p < or = 0.001), and severity assessment (p < or = 0.001). Perceived usefulness is critical to implementing asthma guidelines. Interventions to improve provider adherence must address attitude.

Adult↗
PubMed2002

Economic considerations in treating patients with type 2 diabetes mellitus.

Economic considerations in treating patients with type 2 diabetes mellitus are reviewed. Glycemic control, lipid profiles, and adherence to standards of care are less than optimal in many patients with type 2 diabetes mellitus. Diabetes has an enormous economic impact, and its related costs in the United States are expected to increase as the frequency of the disease increases. A substantial portion of diabetes-related health care expenditures is allotted to the treatment of cardiovascular disease, a major complication of diabetes. Significant health care resources are spent in a reactive manner (i.e., after complications have developed), with little emphasis on preventive care. One large study conducted in the United Kingdom demonstrated that providing intensive blood glucose control significantly reduced the risk of microvascular complications, such as retinopathy, nephropathy, and neuropathy, in patients with type 2 diabetes mellitus. Factors to consider in selecting pharmacotherapy for these patients include the magnitude of change in measures of glycemic control provided by the medication, other desired metabolic changes and outcomes (e.g., blood pressure and lipid changes), mechanism of action, adverse effects, contraindications, patient adherence, and cost. Early interventions, such as annual urinalysis and screening for microalbuminemia, annual comprehensive eye examination by an ophthalmologist or optometrist, and screening for neuropathy and foot problems are cost-effective ways of reducing diabetes-related complications. Interventions recommended for reducing the risk for cardiovascular complications in patients with type 2 diabetes mellitus include lipid control, blood pressure control, aspirin therapy, smoking cessation, and weight loss. Achieving and maintaining glycemic control in patients with type 2 diabetes mellitus improves quality of life and is cost-effective, especially among patients with comorbid heart disease, hypertension, or both.

Diabetes Mellitus, Type 2↗
PubMed1993

Treatment adherence difficulties among children with cancer: the role of parenting style.

Investigated the prevalence of treatment adherence problems among children undergoing cancer treatment and explored the relationship of sociodemographic factors, child functional status, and parenting style to these difficulties. Nurse ratings of adherence difficulties encountered during the cancer treatment regimen were completed on 77 children and their caregivers. A subset of caregivers also completed a measure of parenting attitudes and practices. Results indicated that certain adherence difficulties were related to the child's age and functional status, the family's socioeconomic status (SES), and parenting style. The child's age was related to adherence to procedure-related tasks; younger children had more frequent problems with completing these tasks. More functional children had a greater number of adherence problems. Families with a lower SES had more difficulties with timeliness and cancellations/delays of clinic appointments and promptness of reporting of the child's reactions to treatment. Children of caregivers who had a more "supportive" parenting style (were more sensitive to children's input, had a less restrictive attitude towards parenting, and were more nurturant) canceled and delayed fewer appointments, were on time more frequently for appointments, and reported reactions to treatment with less delay. Implications of these findings for future research on treatment adherence and for clinical interventions are discussed.

Adaptation, Psychological↗
PubMed1996

Exercise in treating obesity in children and adolescents.

This paper reviews the use of exercise programs with obese children and adolescents. Studies included for review met two criteria: 1) children or adolescents were defined as obese using objective criteria for obesity, and 2) obese children or adolescents were provided either different types of exercise programs or an exercise program compared with a no-exercise control condition. Thirteen controlled outcome studies were identified. Experimental design, methods, and outcomes are presented and evaluated for each study. Factors that should be considered in research testing exercise interventions are discussed, including adherence, diet, age, gender, and type of exercise. In addition, the potential for exercise programs in the prevention of obesity in childhood and adolescence is discussed. The results support the continued use of exercise in combination with diet for child and adolescent obesity treatment, but the limited number of controlled studies indicates the need for more research in the area. The potential for exercise programs in the prevention of obesity in childhood and adolescence is discussed.

Adolescent↗
PubMed1984

Primary care management of mental illness: medication as a tool.

The central position of the primary care physician in providing mental health services in the United States is emphasized by two amply supported research conclusions: (1) more patients with diagnosable mental disorders are treated by primary care physicians than by all of the classically defined mental health disciplines combined; and (2) the majority of persons seeking care from the primary care system not only have no evidence of organic pathology, but have positive evidence that psychologic factors underlie their complaints. These patients frequently present particularly problematic treatment dilemmas in primary care because they so often have ill-defined but tenaciously defended somatic complaints and resist accepting the psychologic implications of their illnesses. Thus their treatment is often conceptualized in terms of "stress management" and psychopharmacologic interventions are frequently used. Adherence to proposed guidelines may help the primary care physician better integrate this aspect of the treatment of these often difficult patients.

Child↗