Giving patients information on abnormal cytology and human papillomavirus: survey of health providers.

OBJECTIVES: Knowledge of the link between HPV and cervical cancer is low among women. Health providers may be required to give information and counseling on HPV. This study surveyed health providers' comfort in counseling women about HPV. METHODS: Physicians, nurses and midwives attending a lecture on HPV completed a questionnaire (before the lecture) on their comfort level answering questions that a woman with an abnormal Pap may ask her health provider. Comfort level with knowledge was assessed on a 7-point Likert scale, with seven being very comfortable. RESULTS: Of the 96 attendees, 57.3% (55/96) were eligible and completed the questionnaire. Two-thirds of respondents were physicians (61.8%; 34/55), 38.2% were nurses or midwives (21/55). Telling a partner about HPV infection was the question about which the most respondents were very comfortable (69.1% answering 6 or 7) and chances of developing cervical cancer was the item about which the fewest respondents reported being very comfortable (36.4%). CONCLUSIONS: Less than one-half to two-thirds of health providers self-reported being very comfortable answering HPV-related questions that a woman may ask. More information is needed regarding health providers' actual knowledge of HPV and women's wishes for information.

Developing an ethics curriculum for a family practice residency.

PURPOSE: To develop a curriculum in ethics in family practice by studying which ethical issues physicians believe to be important based on frequency of encounter, difficulty in managing the problem, and helpfulness of discussion; to examine whether there are any important differences between faculty and residents and between genders; and to determine the preferred format(s) for teaching these issues. METHOD: Between November 1991 and June 1992 a total of 475 questionnaires were mailed to all the family practice residents (first- and second-year), graduates in their first two years of practice, and the physician faculty of the Department of Family Medicine at the McGill University Faculty of Medicine. Overall, 319 usable questionnaires were returned, for a final response rate of 67%. The questionnaire asked respondents to evaluate 14 ethical dilemmas in order to determine the importance of teaching specific ethical issues as well as to determine the preferred format for teaching. Chi-square tests, analyses of variance, and Student's t-tests were used to test the significance of differences in responses. RESULTS: No consistent pattern of interrelationship was found among frequency of encounter and difficulty and helpfulness of discussion for most items. Overall, there was little difference in how faculty and residents, men and women, perceived the importance of these ethical issues. Women reported encountering ethical issues less frequently than men [F (14,285) = 1.82, p < .04], while at the same time finding them somewhat more difficult and more deserving of discussion. Small-group, case-oriented discussion appears to have been the favored teaching format regardless of the ethical dilemma. CONCLUSION: It is difficult to narrow down the content to be included in a curriculum in ethics in family practice. Frequency of encounter, difficulty in management, and helpfulness of discussion can all be argued to be important factors for consideration; they should all be considered separately or in combination for each teaching situation if time restrictions force a choice between topics.

Panic disorder in coronary artery disease patients with noncardiac chest pain.

In this study we address the following questions: (1) What percentage of coronary artery disease (CAD) patients that present with chest pain, but whose symptoms cannot be fully explained by their cardiac status, suffer from panic disorder (PD)? (2) How do patients with both CAD and PD compare to patients without CAD and to patients without either PD or CAD in terms of psychological distress? Four hundred forty-one consecutive walk-in emergency department patients with chest pain underwent a structured psychiatric interview (ADIS-R) and completed psychological scales. Fifty-seven percent (250 of 441) of these patients were diagnosed as having noncardiac chest pain and constituted this study's sample. A total of 30% (74 of 250) of noncardiac chest pain patients had a documented history of CAD. Thirty-four percent (25 of 74) of CAD patients met criteria for PD. Patients with both PD and CAD displayed significantly more psychological distress than CAD patients without PD and patients with neither CAD nor PD. However, they did not differ from non-CAD patients with PD. PD is highly prevalent in patients with CAD that are discharged with noncardiac diagnoses. The psychological distress in these patients appears to be related to the panic syndrome and not to the presence of the cardiac condition.

School readiness among urban children with asthma.

BACKGROUND: Children with chronic illnesses, including asthma, are at risk for school problems. Developmental problems, however, may begin before school entry, and the developmental status of preschool children with asthma has not been evaluated. OBJECTIVE: To test the hypothesis that urban preschool children with asthma have lower parent-reported developmental scores compared with children without asthma. METHODS: A comprehensive survey of children beginning kindergarten in 1998 in the urban school system in Rochester, NY, collected parent reports of demographic, medical, and developmental data. We compared children with asthma with and without limitation of activity to children without asthma for motor, language, socioemotional, and school readiness skills and the need for extra help with learning. Linear and logistic regression were used to determine associations between asthma and developmental outcomes. RESULTS: Among the 1058 children in this sample, 9% had asthma, including 5% with asthma with limitation of activity. After adjustment for multiple potential confounding variables, the children with asthma with limitation had lower scores on school readiness skills compared with children without asthma (2.0 vs 2.5, P <.001). Further, the parents of children with asthma with limitation were substantially more likely (P <.05) to describe them as needing extra help with learning (74% vs 56%; odds ratio, 3.2; 95% confidence interval, 1.5--7.8). CONCLUSIONS: Urban preschool children with significant asthma had poorer parent-reported school readiness skills and a greater need for extra help with learning compared with children without asthma. This finding suggests that developmental problems for children with asthma may begin before school entry.

Complementary therapy involvement of physicians: implications for practice and learning.

OBJECTIVE: We studied physicians' current and desired clinical role functions within the complementary health paradigm and their perceptions of the necessary educational programs to support them. DESIGN AND SETTING: A questionnaire to determine clinical activities within different complementary therapies was developed and mailed-out to 837 eligible physicians in Hamilton, Ontario, Canada, using a modified Dillman approach. RESULTS: The overall response rate to the mailed survey was 49.8% (417/837), with response rates of 50.2% (115/229) for family physicians and 49.7% (302/608) for specialists. The amount of interactions around complementary therapies between physicians, their patients and complementary therapists appears to be low. At the same time, there is a growing interest among physicians about complementary therapies, particularly with respect to developing their knowledge about efficacy and enhancing their skills in assessment and counselling. CONCLUSIONS: The differential levels of acceptance of different therapies by physicians will influence integration of complementary therapies in mainstream medicine.

Knowledge gained following Neonatal Resuscitation Program courses.

BACKGROUND: This study evaluated the knowledge gained and retained by family practice residents who participated in the Neonatal Resuscitation Program (NRP) course. METHODS: Knowledge attainment and its retention was assessed by the administration of pre-, post-, and 6-month follow-up tests using the standard NRP written examination. Twenty-nine residents from the Department of Family Medicine at McGill University completed the pretests and posttests, and 10 of these completed the follow-up tests. The data were analyzed using repeated measures analysis of variance and Student's t tests. RESULTS: The average score was 60.6% (n = 29) for pretest, 90.7% (n = 29) for posttest, and 75.4% (n = 10) for the follow-up test. A significant improvement was shown in posttest examination scores when compared to pretest scores and in the follow-up test scores when compared to pretest scores. No significant difference existed between the posttest and follow-up test scores. However, small sample size may have prevented detection of significant differences. Further, follow-up scores for some subjects had fallen to below the level required to pass the course. CONCLUSIONS: The results suggest that participation in an NRP course significantly increased knowledge of neonatal resuscitation by family practice residents, but that knowledge may decrease over time.

Retention of neonatal resuscitation skills and knowledge: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: This study compared the effectiveness of two booster strategies designed to improve retention of skills and knowledge in neonatal resuscitation by family practice residents. METHODS: Residents were randomly allocated to one of three groups: video, hands on, or control. Residents in the two experimental groups received a "booster" 3-5 months after the Neonatal Resuscitation Program (NRP) course. All participants completed the follow-up test 6-8 months after taking the course. The main outcome measures consisted of the NRP written examination and the performance checklists. RESULTS: A total of 44 residents completed the study (video, n = 13; hands-on, n = 14; control, n = 17). Overall, participants had significantly lower scores at follow-up than at baseline, indicating deterioration in both neonatal skills and knowledge. Residents in the hands-on booster group made significantly fewer errors across all five checklists in life-supporting but not in lifesaving scores than those allocated to the control and video groups. CONCLUSIONS: The beneficial effect of mannequin practice or video boosters on skills and knowledge retention was less than what had been anticipated, and no benefit could be demonstrated in comparison to the control group. Deteriorating knowledge and skills remain a major concern, since boostering by hands-on or video at 3-5 months do not seem to have an impact on the retention of knowledge or lifesaving skills.

The beginning of the research stream in family medicine residency program at McMaster University.

BACKGROUND: To examine research background, attitudes, knowledge and skills of family medicine residents with regard to primary care research and to compare residents who elected to participate in the research stream with those who did not. METHODS: Mailed survey of Family Medicine residents at McMaster University in 1998, 70% (52/74) of whom responded. The main outcome measures consisted of research background; attitudes towards primary care research and research activities during residency program; knowledge and skills in applying it in biostatistics, epidemiology, and research design. RESULTS: The vast majority of the residents reported previous research experience and/or some training in epidemiology and biostatistics. Residents in the research stream were more likely to be female and were positive towards primary care research: they were more interested in research, more interested in obtaining more research training while a resident, and placed more importance on developing research early in medical education. The research stream residents had stronger views regarding perceived lack of support staff and lack of time for research. There were no statistically significant differences between the research stream and other residents in terms of research knowledge and skills in applying it. CONCLUSIONS: Attitudes towards research rather than research knowledge or skills seemed to distinguish those selecting to be in our new research stream at the inception.

The effect of a peer counseling program on breastfeeding initiation and longevity in a low-income rural population.

Breastfeeding rates among low-income women in the east-south-central United States are among the lowest in the country. This study examined the effect of a peer counseling program on breastfeeding initiation and duration in a low-income rural population in West Tennessee. A postpartum survey and chart review were conducted with WIC clients at nine health departments. Response rate was 99% (291/293). Breastfeeding initiation and duration at 6 weeks were increased in the peer counselor group (n = 156) compared with women in the no-peer counselor group (n = 135) (53% vs. 33%, p < 0.001, and 26% vs. 13%, p = 0.006, respectively). Multivariate analysis revealed that women in the peer counselor group were significantly more likely to initiate breastfeeding (OR = 2.43, 95% CI = 1.23-4.67) and to be breastfeeding at 6 weeks (OR = 2.78, 95% CI = 2.08-9.51), than those in the no-peer counselor group.

Methodology of the 2009 Survey on Living with Chronic Diseases in Canada--hypertension component.

INTRODUCTION: The Survey on Living with Chronic Diseases in Canada--hypertension component (SLCDC-H) is a 20-minute cross-sectional telephone survey on hypertension diagnosis and management. Sampled from the 2008 Canadian Community Health Survey (CCHS), the SLCDC-H includes Canadians (aged ≥ 20 years) with self-reported hypertension from the ten provinces. METHODS: The questionnaire was developed by Delphi technique, externally reviewed and qualitatively tested. Statistics Canada performed sampling strategies, recruitment, data collection and processing. Proportions were weighted to represent the Canadian population, and 95% confidence intervals (CIs) were derived by bootstrap method. RESULTS: Compared with the CCHS population reporting hypertension, the SLCDC-H sample (n = 6142) is slightly younger (SLCDC-H mean age: 61.2 years, 95% CI: 60.8-61.6; CCHS mean age: 62.2 years, 95% CI: 61.8-62.5), has more post-secondary school graduates (SLCDC-H: 52.0%, 95% CI: 49.7%-54.2%; CCHS: 47.5%, 95% CI: 46.1%-48.9%) and has fewer respondents on hypertension medication (SLCDC-H: 82.5%, 95% CI: 80.9%-84.1%; CCHS: 88.6%, 95% CI: 87.7%-89.6%). CONCLUSION: Overall, the 2009 SLCDC-H represents its source population and provides novel, comprehensive data on the diagnosis and management of hypertension. The survey has been adapted to other chronic conditions--diabetes, asthma/chronic obstructive pulmonary disease and neurological conditions. The questionnaire is available on the Statistics Canada website; descriptive results have been disseminated by the Public Health Agency of Canada.

TITRE: Méthodologie de l'Enquête sur les personnes ayant une maladie chronique au Canada ­ composante de l'hypertension de 2009. INTRODUCTION: L'Enquête sur les personnes ayant une maladie chronique au Canada ­ composante de l'hypertension (EPMCC-H) est une enquête téléphonique transversale de 20 minutes sur le diagnostic et la prise en charge de l'hypertension. L'échantillon de l'EPMCC-H, sélectionné à partir des répondants à l'Enquête sur la santé dans les collectivités canadiennes (ESCC) de 2008, était composé de Canadiens (de 20 ans et plus) des dix provinces ayant déclaré avoir reçu un diagnostic d'hypertension. MÉTHODOLOGIE: Le questionnaire a été élaboré au moyen de la technique Delphi et a fait l'objet d'un examen externe ainsi que de tests qualitatifs. Statistique Canada s'est chargé des stratégies d'échantillonnage, du recrutement, de la collecte et du traitement des données. Les proportions ont été pondérées afin de représenter la population canadienne et les intervalles de confiance (IC) à 95 % ont été calculés au moyen de la méthode de rééchantillonnage bootstrap. RÉSULTATS: Si on le compare à la population de l'ESCC ayant déclaré souffrir d'hypertension, l'échantillon de l'EPMCC-H (n = 6 142) est légèrement plus jeune (âge moyen des répondants à l'EPMCC-H : 61,2 ans, IC à 95 % : 60,8 à 61,6; âge moyen des répondants à l'ESCC : 62,2 ans, IC à 95 % : 61,8 à 62,5), comporte plus de détenteurs d'un diplôme d'études postsecondaires (EPMCC-H : 52,0 %, IC à 95 %: 49,7 % à 54,2 %; ESCC : 47,5 %, IC à 95 % : 46,1 % à 48,9 %) et moins de répondants prenant un médicament pour l'hypertension (EPMCC-H : 82,5 %, IC à 95 % : 80,9 % à 84,1 %; ESCC : 88,6 %, IC à 95 % : 87,7 % à 89,6 %). CONCLUSION: Dans l'ensemble, l'EPMCC-H de 2009 est représentatif de sa population source et fournit des données nouvelles et exhaustives sur le diagnostic et la prise en charge de l'hypertension. L'enquête a été adaptée à d'autres maladies chroniques ­ diabète, asthme/maladie pulmonaire obstructive chronique et troubles neurologiques. Le questionnaire est accessible à partir du site Web de Statistique Canada; des résultats descriptifs ont été publiés par l'Agence de la santé publique du Canada.

Perception of uncontrolled blood pressure and behaviours to improve blood pressure: findings from the 2009 Survey on Living with Chronic Diseases in Canada.

Individuals with hypertension should lower and maintain their blood pressure levels through lifestyle modification and/or pharmacotherapy. To determine whether perception of blood pressure control is related to behaviours and intentions for improving blood pressure, data from 6142 Canadians age 20+ years with self-reported hypertension were analysed. Relationships between perception of control, current behaviours for blood pressure control and intentions to improve these behaviours were examined. Although individuals who reported uncontrolled blood pressure were equally likely to report engaging in lifestyle behaviours for blood pressure control, they were more likely to indicate an intention to improve their health, compared with those who reported well-controlled/low blood pressure. These individuals were also less likely to report having enough information to control their blood pressure. In addition, they were less likely to report having been advised to take antihypertensive medication, and to be taking and adhering to medications. Individuals who perceive their blood pressure as uncontrolled have intentions to make health-enhancing changes but may lack the information to do so. The study highlights the potential need for programmes/services to help those with uncontrolled blood pressure make lifestyle changes and/or take appropriate medication.

Blood pressure variability and prevalence of hypertension using automated readings from multiple visits to a pharmacy-based community-wide programme.

Blood pressure (BP) measurements taken outside the routine office context may be a useful adjunct strategy to monitor BP. Community-based BP data can also provide estimates of the prevalence of elevated BP. We compared multiple readings taken on different days in pharmacies using an automated BpTRU device during a cardiovascular health programme targeting community-dwelling older adults. Mean systolic (S) and diastolic (D) BP values were compared over time using repeated measures analysis of variance for all participants with at least three separate sets of readings (n=317). BP variability was then examined among four subgroups based on report of antihypertensive medication or no treatment, and normal or elevated SBP at the initial visit (< or >or=140, or 130 if diabetes reported). Prevalence of elevated BP was compared across visits. Overall, mean SBP decreased between visits 1 and 2 (140.4 vs 137.1 mm Hg; P<0.001). Among participants with normal SBP at the initial visit, SBP did not vary significantly, whether or not antihypertensive treatment was reported. Those with initially elevated SBP experienced a significant decrease between visits 1 and 2, also regardless of treatment status. Prevalence of elevated BP decreased from visits 1 to 2 (55.8 vs 48.9%; P=0.026) and from visits 1 to 3 (55.8 vs 42.9%; P<0.001). Analyses of BP data from a community-based programme using an accurate device showed that initial readings may inflate the population estimate of elevated BP. Findings suggest that more than one set of BP readings measured on different occasions are needed, particularly if the first set is elevated.

Integrating family medicine and pharmacy to advance primary care therapeutics.

The prevalence of suboptimal prescribing of medications is well documented. Patients are often undertreated or not offered therapeutic treatments that are likely to confer benefit. As a result, drug-related hospital admissions are common and often preventable. Improvements to the health-care system are clearly needed in order to maximize the benefits that can be derived from medications. Many countries are changing their primary health-care systems to improve the quality of health-care delivery. One main transformation is the use of multidisciplinary care teams to provide care in a coordinated manner often from the same location or by using the common medical record of the patients. It has been demonstrated that pharmacists can improve prescribing, reduce health-care utilization and medication costs, and contribute to clinical improvements in many chronic medical conditions, such as cardiovascular disease, diabetes, and psychiatric illness. However, the effect of integrating a pharmacist providing general services into a primary care group has not been extensively studied. The Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics (IMPACT) project was designed to provide a real-world demonstration of the feasibility of integrating the pharmacist into primary care office practice. This article provides a description of the IMPACT project participants; the IMPACT practice model and the concepts incorporated in its development; some initial results from the program evaluation; sustainability of the model; and some reflections on the implementation of the practice model.