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BACKGROUND: Behavioural weight loss programs are effective first-line treatments for obesity and are recommended by the US Preventive Services Task Force. Gaining an understanding of intervention components that are found helpful by different demographic groups can improve tailoring of weight loss programs. This paper examined the perceived helpfulness of different weight loss program components. METHODS: Participants (n = 236) from the active intervention conditions of the Practice-based Opportunities for Weight Reduction (POWER) Hopkins Trial rated the helpfulness of 15 different components of a multicomponent behavioural weight loss program at 24-month follow-up. These ratings were examined in relation to demographic variables, treatment arm and weight loss success. RESULTS: The components most frequently identified as helpful were individual telephone sessions (88%), tracking weight online (81%) and coach review of tracking (81%). The component least frequently rated as helpful was the primary care providers' general involvement (50%). Groups such as older adults, Blacks and those with lower education levels more frequently reported intervention components as helpful compared with their counterparts. DISCUSSION: Weight loss coaching delivered telephonically with web support was well received. Findings support the use of remote behavioural interventions for a wide variety of individuals.
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OBJECTIVE: Overweight and obesity are epidemic in populations with serious mental illnesses. We developed and pilot-tested a behavioral weight-loss intervention appropriately tailored for persons with serious mental disorders. METHODS: We conducted a single-arm pilot study in two psychiatric rehabilitation day programs in Maryland, and enrolled 63 overweight or obese adults. The 6-month intervention provided group and individual weight management and group physical activity classes. The primary outcome was weight change from baseline to 6 months. RESULTS: A total of 64% of those potentially eligible enrolled at the centers. The mean age was 43.7 years; 56% were women; 49% were white; and over half had schizophrenia or a schizoaffective disorder. One-third had hypertension and one-fifth had diabetes. In total, 52 (82%) completed the study; others were discharged from psychiatric centers before completion of the study. Average attendance across all weight management sessions was 70% (87% on days participants attended the center) and 59% for physical activity classes (74% on days participants attended the center). From a baseline mean of 210.9 lbs (s.d. 43.9), average weight loss for 52 participants was 4.5 lb (s.d. 12.8) (P<0.014). On average, participants lost 1.9% of body weight. Mean waist circumference change was 3.1 cm (s.d. 5.6). Participants on average increased the distance on the 6-minute walk test by 8%. CONCLUSION: This pilot study documents the feasibility and preliminary efficacy of a behavioral weight-loss intervention in adults with serious mental illness who were attendees at psychiatric rehabilitation centers. The results may have implications for developing weight-loss interventions in other institutional settings such as schools or nursing homes.
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Terapia Comportamental/métodos , Transtornos Mentais/terapia , Obesidade/terapia , Redução de Peso , Adulto , Dieta Redutora , Exercício Físico , Estudos de Viabilidade , Feminino , Humanos , Masculino , Maryland/epidemiologia , Transtornos Mentais/epidemiologia , Transtornos Mentais/reabilitação , Obesidade/epidemiologia , Obesidade/reabilitação , Esforço Físico , Projetos PilotoRESUMO
INTRODUCTION: While behavioral interventions may be viewed as important strategies to improve blood pressure (BP), an evidence-based review of studies evaluating these interventions may help to guide clinical practice. METHODS: We employed systematic review and meta-analysis of the literature (1970-1999) to assess the independent and additive effects of three behavioral interventions on BP control (counseling, self-monitoring of BP, and structured training courses). RESULTS: Of 232 articles assessing behavioral interventions, 15 (4072 subjects) evaluated the effectiveness of patient-centered counseling, patient self-monitoring of BP, and structured training courses. Pooled results revealed that counseling was favored over usual care (3.2 mmHg [95% CI, 1.2-5.3] improvement in diastolic blood pressure [DBP] and 11.1 mmHg [95% CI, 4.1-18.1] improvement in systolic blood pressure [SBP]) and training courses (10 mmHg improvement in DBP [95% CI, 4.8-15.6]). Counseling plus training was favored over counseling (4.7 mmHg improvement in SBP [95% CI, 1.2-8.2]) and afforded more subjects hypertension control (95% [95% CI, 87-99]) than those receiving counseling (51% [95% CI, 34-66]) or training alone (64% [95% CI, 48-77]). CONCLUSIONS: Evidence suggests that counseling offers BP improvement over usual care, and that adding structured training courses to counseling may further improve BP. However, there is not enough evidence to conclude whether self-monitoring of BP or training courses alone offer consistent improvement in BP over counseling or usual care. The magnitude of BP reduction offered by counseling indicates this may be an important adjunct to pharmacologic therapy.
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Hipertensão/terapia , Educação de Pacientes como Assunto/métodos , Determinação da Pressão Arterial , Medicina Baseada em Evidências , Humanos , Hipertensão/prevenção & controle , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Educação de Pacientes como Assunto/organização & administração , AutocuidadoRESUMO
Blacks and women are less likely to undergo invasive cardiac procedures than whites and men in patients with chronic renal disease. We determined the relationship between ethnic and sex differences in access to cardiac procedures as patients progress to ESRD and acquire Medicare insurance. We performed a cohort study of a nationwide random sample of 4,987 patients who progressed to ESRD in 1986 to 1987 and were followed up for 7 years was used. Data were collected from medical charts and Medicare administrative records. Pre-ESRD, the odds of cardiac procedure use were much lower for white women (adjusted odds 0.67 [95% confidence interval (CI) 0.49-0.92]), black men (adjusted odds 0.32 [95% CI 0.20-0.49]), and black women (adjusted odds 0.30 [95%CI 0.18-0.50]) compared with white men. After initiating dialysis therapy, the ethnic and sex differences decreased with odds of receiving a cardiac procedure compared with white men 0.88 (95% CI 0.63-1.21) for white women, 0.66 (95% CI 0.47-0.92) for black men, and 0.75 (95% CI 0.53-1.08) for black women. Patients uninsured pre-ESRD had the largest increase in procedure rates at follow-up. The wide pre-ESRD disparities in cardiac procedure use between white women, black men, and black women compared with white men narrowed substantially with acquisition of Medicare and entry into comprehensive dialysis care. Health insurance contributed to the narrowing of differences. Procedure use for black men still lagged behind the other groups, suggesting the need for closer examination of health needs in this potentially vulnerable group.
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Negro ou Afro-Americano/estatística & dados numéricos , Cardiologia/métodos , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/terapia , Acessibilidade aos Serviços de Saúde/tendências , Falência Renal Crônica/epidemiologia , População Branca/estatística & dados numéricos , Adulto , Idoso , Estudos de Coortes , Comorbidade , Intervalos de Confiança , Doença da Artéria Coronariana/diagnóstico , Feminino , Humanos , Seguro Saúde/economia , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/terapia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Women often are less likely than men to receive diagnostic and therapeutic invasive procedures for coronary disease. OBJECTIVE: To examine the relation between gender, health insurance, and access to cardiovascular procedures over time in persons with chronic illness. RESEARCH DESIGN: Seven-year longitudinal analyses in a cohort from the United States Renal Data System. SUBJECTS: National random sample of women and men who progressed to end-stage renal disease (ESRD) in 1986 to 1987 and were treated at 303 dialysis facilities (n = 4,987). MEASURES: Medical history and utilization records, physical examination, and laboratory data. MAIN OUTCOME MEASURES: Receipt of a coronary catheterization or revascularization procedure before (baseline) and after (follow-up) the development of ESRD and acquisition of Medicare, adjusted for clinical and socioeconomic variables. RESULTS: At baseline, 5.2% of women and 9.2% of men had undergone a cardiac procedure; the odds of women receiving a procedure were one third lower than for men (adjusted odds ratio 0.66 [95% CI 0.49-0.88]). During follow-up, women were just as likely as men to undergo a procedure (adjusted odds ratio 0.94 [95% CI 0.74-1.20]). Compared with men with baseline private insurance, men and women with other and no insurance had 34% to 81% lower odds of receiving procedures at baseline. Women with private insurance had 42% lower odds of having a procedure at baseline compared with men (adjusted odds ratio 0.58 [95% CI 0.42-0.78]) but had the same odds at follow-up (adjusted odds ratio 1.09 [95% CI 0.82-1.45]). At follow-up, gender differences in procedure use were eliminated for groups with baseline Medicaid or no insurance. CONCLUSIONS: Overall gender differences in cardiac procedure use were narrowed markedly after progression of a serious illness, the assurance of health insurance, and entry into a comprehensive care system. Gender disparities in procedure use for different baseline insurance groups were largely equalized in follow-up. These findings suggest that provision of insurance with disease-managed care for a chronic disease can provide equalized access to care for women.
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Doença das Coronárias/epidemiologia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Falência Renal Crônica/epidemiologia , Revascularização Miocárdica/estatística & dados numéricos , Serviços de Saúde da Mulher/estatística & dados numéricos , Adulto , Idoso , Cateterismo Cardíaco/estatística & dados numéricos , Estudos de Coortes , Doença das Coronárias/diagnóstico , Doença das Coronárias/terapia , Progressão da Doença , Feminino , Seguimentos , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Fatores Sexuais , Estados Unidos/epidemiologia , Revisão da Utilização de Recursos de SaúdeRESUMO
BACKGROUND: Black persons historically undergo fewer invasive cardiovascular procedures than white persons. OBJECTIVE: To determine whether acquisition of Medicare health insurance and comprehensive care for severe illness reduce ethnic disparity in use of cardiovascular procedures. DESIGN: 7-year longitudinal analyses in a cohort from the United States Renal Data System. SETTING: Health care institutions in the United States. PATIENTS: Nationwide random sample of 4987 adult black and white patients with incident end-stage renal disease (ESRD) from 303 dialysis facilities in 1986 to 1987. MEASUREMENTS: Medical history and service use records, physical examination, and laboratory data. Main outcome measures were receipt of a coronary catheterization or revascularization procedure before (baseline) and after (follow-up) development of ESRD and acquisition of Medicare, adjusted for clinical and socioeconomic variables. RESULTS: At baseline, 9.9% of white patients and 2.8% of black patients had had a cardiac procedure; the odds were almost three times greater in white than in black patients (adjusted odds ratio, 2.92 [95% CI, 2.04 to 4.18]). During follow-up, white patients were only 1.4 times more likely than black patients to have a procedure (adjusted relative risk, 1.41 [CI, 1.13 to 1.77]); rates were 7.8% for white persons and 8.5% for black persons. In patients with Medicare coverage before development of ESRD, the initial three-fold difference in procedure use was eliminated over follow-up (odds ratio, 1.05 [CI, 0.56 to 1.60]). For procedures after hospital admission for myocardial infarction or coronary disease, no difference between ethnic groups was seen during follow-up (relative risk, 1.12 [CI, 0.68 to 1.85]). CONCLUSIONS: Differences between ethnic groups in use of cardiovascular procedures narrowed markedly once a serious illness (ESRD) developed and adequate insurance coverage was ensured; the disparity was eliminated in patients with previous Medicare insurance or a stronger indication for a procedure. These findings suggest that almost equal access to care is attainable by combining insurance with delivery of comprehensive, clinically appropriate care.