Discussions between medical providers and children/caregivers about the benefits of asthma-control medications.

OBJECTIVES: To describe the content of discussions between general pediatric providers and children and their caregivers about the benefits of asthma-control medication; describe the extent to which these discussions occur; and examine factors that are associated with medication benefit discussions. DESIGN: Cross-sectional secondary analysis of audiotaped medical visits. SETTING: Five primary care pediatric clinics in North Carolina. PARTICIPANTS: 35 pediatric providers and 248 children with persistent asthma and their caregivers. MAIN OUTCOME MEASURES: Presence of discussion about benefits associated with asthma-control medications. RESULTS: Providers discussed benefits associated with asthma-control medications during 56% of medical visits. Benefits were more likely to be discussed when the child was younger and when medication adherence was discussed during the visit. When providers discussed benefits of asthma-control medications, they were most likely to ask questions and make statements regarding symptom control/prevention. CONCLUSION: General pediatric medical providers often do not discuss the benefits of asthma-control medications. Pharmacists could fill this information gap by counseling both children and their caregivers about benefits that a child with asthma can expect as a result of treatment.

Examining the relationship between adjunctive psychotherapy use and antipsychotic persistence and hospitalization.

This study assessed whether the addition of adjunctive psychotherapy to antipsychotic pharmacotherapy improved antipsychotic persistence and reduced the risk of hospitalization among patients with schizophrenia using 2001-2003 Medicaid claims data from four states: Illinois, Kansas, Minnesota, and North Carolina. New antipsychotic users aged 18 or older were included. Our study showed that adjunctive psychotherapy use was associated with increased antipsychotic persistence during the first two months of treatment but was not associated with risk of hospitalization. Further research is needed to understand how to optimize the benefits of psychotherapy in terms of frequency of appointments, duration, and type.

Mixed treatment comparison of the treatment discontinuations of biologic disease-modifying antirheumatic drugs in adults with rheumatoid arthritis.

BACKGROUND: Introduction of biologic disease-modifying antirheumatic drugs (DMARDs) has considerably changed treatment options for rheumatoid arthritis (RA) over the past decade. Very little information is available on comparative discontinuation rates of the biologics. OBJECTIVE: To compare treatment discontinuations for 9 biologic DMARDs in adults with RA. METHODS: We searched electronic databases through May 2012 to retrieve randomized controlled trials (RCTs) of patients with RA that compared biologic DMARDs with placebo or another biologic DMARD. The primary outcome was treatment discontinuation during the blinded phase of the trials, measured as overall withdrawals, withdrawals resulting from lack of efficacy, and withdrawals resulting from adverse events. Random-effects meta-analysis estimated the effect size for individual agents, and adjusted indirect comparisons were made between biologics using mixed treatment comparisons (MTC) meta-analysis. RESULTS: Forty-four trials were included in the analysis. In comparison with placebo, biologics were less likely to be withdrawn because of lack of efficacy (OR 0.22, 95% CI 0.17 to 0.27) and more likely to be withdrawn because of an adverse event (OR 1.41, 95% CI 1.16 to 1.70). Based on the MTC, certolizumab had the most favorable overall withdrawal profile, followed by etanercept and rituximab. Certolizumab had lower relative withdrawal rates resulting from lack of efficacy than adalimumab, anakinra, and infliximab. Anakinra had higher relative withdrawal rates resulting from lack of efficacy than most other biologics. Certolizumab and infliximab had more, while etanercept had fewer, withdrawals because of adverse events than most other drugs. CONCLUSIONS: Based on MTC using data from RCTs, differences in discontinuation rates were observed, generally favoring certolizumab, etanercept, and rituximab over other biologic DMARDs. These potential differences need to be further explored in head-to-head trials or well-conducted observational studies.

Examining external validity in efficacy and secondary articles of home-based depression care management interventions for older adults.

INTRODUCTION: Information on external validity enables public health practitioners to generalize conclusions about an intervention to future or different conditions and is critical to moving research into practice. Prior reviews examining external validity focused on efficacy publications only. Our objective was to determine the extent to which secondary articles could enhance information about external validity presented in efficacy studies. METHODS: We identified a group of interventions recommended by the Guide to Community Preventive Services for home-based depression care management for older adults. We searched online databases for secondary articles using a list of the study authors' names and study acronyms. Five articles were ineligible (intervention was not effective or articles lacked data on external validity) and 14 articles were eligible and reviewed (6 efficacy and 8 secondary articles). We examined 15 elements of external validity based on 4 of the 5 dimensions of the RE-AIM framework: reach, adoption, implementation, and maintenance. RESULTS: The 6 efficacy studies documented 1 or more elements of reach and implementation, and 5 studies included 1 or more elements of maintenance. Secondary articles included 4 to 9 elements on external validity and addressed 1 to 5 unique elements of external validity not reported in the efficacy publications. CONCLUSION: Secondary articles enrich the amount of information about external validity and may be published years before or after the efficacy publication. Reviewing only primary publications of efficacy trials may provide a limited view of external validity, at least for publications describing home-based depression care management.

The quality of care for adults with epilepsy: an initial glimpse using the QUIET measure.

BACKGROUND: We examined the quality of adult epilepsy care using the Quality Indicators in Epilepsy Treatment (QUIET) measure, and variations in quality based on the source of epilepsy care. METHODS: We identified 311 individuals with epilepsy diagnosis between 2004 and 2007 in a tertiary medical center in New England. We abstracted medical charts to identify the extent to which participants received quality indicator (QI) concordant care for individual QI's and the proportion of recommended care processes completed for different aspects of epilepsy care over a two year period. Finally, we compared the proportion of recommended care processes completed for those receiving care only in primary care, neurology clinics, or care shared between primary care and neurology providers. RESULTS: The mean proportion of concordant care by indicator was 55.6 (standard deviation = 31.5). Of the 1985 possible care processes, 877 (44.2%) were performed; care specific to women had the lowest concordance (37% vs. 42% [first seizure evaluation], 44% [initial epilepsy treatment], 45% [chronic care]). Individuals receiving shared care had more aspects of QI concordant care performed than did those receiving neurology care for initial treatment (53% vs. 43%; X(2) = 9.0; p = 0.01) and chronic epilepsy care (55% vs. 42%; X(2) = 30.2; p < 0.001). CONCLUSIONS: Similar to most other chronic diseases, less than half of recommended care processes were performed. Further investigation is needed to understand whether a shared-care model enhances quality of care, and if so, how it leads to improvements in quality.

Recommendations of community pharmacists and health food store employees regarding undiagnosed symptoms of diabetes.

BACKGROUND: Consumers may seek health advice from health food store employees (HFSEs) and pharmacists. Delays in the diagnosis of time-critical illnesses may increase the likelihood of morbidity, mortality and healthcare expenditures. OBJECTIVE: To describe the information provided by HFSEs and pharmacists for symptoms of undiagnosed Type 1 diabetes. DESIGN: A standardized actor portrayed a consumer with symptoms of Type 1 diabetes at eight community pharmacies and 12 health food stores (HFSs) in Pittsburgh, Pennsylvania, and Chapel Hill and Durham, North Carolina. He inquired about potential diagnoses, the need to see a physician, and product recommendations. SUBJECTS: The subjects included twelve HFSEs and eight licensed pharmacists. RESULTS: Four of eight (50%) pharmacists and two of 12 (17%) HFSEs mentioned diabetes as a potential diagnosis. Although six pharmacists recommended urgent physician follow-up, only two HFSEs did so; two HFSEs explicitly advised against a physician visit. One pharmacist recommended a product. Nine HFSEs recommended at least one product (monthly costs, range: $24.70-$209.96). CONCLUSIONS: Even when presented with classic symptoms of Type 1 diabetes, under-recognition of diabetes was common among HFSEs and community pharmacists. Delays in treatment present a health risk to consumers. Further research could confirm these results and inform educational interventions to improve diabetes recognition by both groups.

Engaging communication experts in a Delphi process to identify patient behaviors that could enhance communication in medical encounters.

BACKGROUND: The communication literature currently focuses primarily on improving physicians' verbal and non-verbal behaviors during the medical interview. The Four Habits Model is a teaching and research framework for physician communication that is based on evidence linking specific communication behaviors with processes and outcomes of care. The Model conceptualizes basic communication tasks as "Habits" and describes the sequence of physician communication behaviors during the clinical encounter associated with improved outcomes. Using the Four Habits Model as a starting point, we asked communication experts to identify the verbal communication behaviors of patients that are important in outpatient encounters. METHODS: We conducted a 4-round Delphi process with 17 international experts in communication research, medical education, and health care delivery. All rounds were conducted via the internet. In round 1, experts reviewed a list of proposed patient verbal communication behaviors within the Four Habits Model framework. The proposed patient verbal communication behaviors were identified based on a review of the communication literature. The experts could: approve the proposed list; add new behaviors; or modify behaviors. In rounds 2, 3, and 4, they rated each behavior for its fit (agree or disagree) with a particular habit. After each round, we calculated the percent agreement for each behavior and provided these data in the next round. Behaviors receiving more than 70% of experts' votes (either agree or disagree) were considered as achieving consensus. RESULTS: Of the 14 originally-proposed patient verbal communication behaviors, the experts modified all but 2, and they added 20 behaviors to the Model in round 1. In round 2, they were presented with 59 behaviors and 14 options to remove specific behaviors for rating. After 3 rounds of rating, the experts retained 22 behaviors. This set included behaviors such as asking questions, expressing preferences, and summarizing information. CONCLUSION: The process identified communication tasks and verbal communication behaviors for patients similar to those outlined for physicians in the Four Habits Model. This represents an important step in building a single model that can be applied to teaching patients and physicians the communication skills associated with improved satisfaction and positive outcomes of care.

Improving methods for measuring quality of care: a patient-centered approach in chronic disease.

As health care systems seek to provide patient-centered care as a cornerstone of quality, how to measure this aspect of quality has become a concern. Previous development of quality indicators for treating individual chronic disease has rarely included patient perspectives on quality of care. Using epilepsy as an exemplar, the authors sought to develop an approach to measuring patient-centered quality of care. They conducted six focus groups with adults with epilepsy. Using qualitative methods, the authors initially identified 10 patient-generated quality indicators, 5 of which were subsequently rated, along with literature-based quality indicators, by an expert panel using a modified RAND appropriateness methodology. The authors discuss similarities and differences in aspects of care patients and providers value as essential for good quality. The process presented in this article may serve as a model for incorporating patient perceptions of quality into the future development of quality indicators for chronic diseases.

Novel approach, using end-of-life issues, for identifying items for public health surveillance.

Using end-of-life (EOL) issues to provide context, we introduce a novel approach to identify potential items for public health surveillance. Our method involved an environmental scan of existing EOL surveys and included the following steps: 1) consulting experts for advice on critical EOL topics, 2) identifying a broad sample of EOL surveys, and 3) using an abstraction tool to characterize surveys and survey items. We identified 36 EOL surveys; of these, 10 were state-based surveys. Of the 1,495 EOL items (range, 4 to 126 items per survey), 333 items could be classified in 1 of 11 topic areas of interest. Information on the surveys and these 333 items was entered into a database. As a result of this process, we identified topics for which many EOL items already exist and topics for which items should be developed. We describe the value of this approach and potential next steps for our project.

Completion of a durable power of attorney for health care: what does cognition have to do with it?

PURPOSE: This study examined the association between cognitive functioning and completion of a durable power of attorney for health care. DESIGN AND METHODS: Participants were from the Second Longitudinal Study on Aging (LSOA II), a nationally representative sample of community-dwelling persons who were at least 70 years of age at the time of participation. The sample included 325 older adult respondents (144 men, 181 women) with a mean age of 80.7 years (SE = 0.36) and a mean educational attainment of 11.6 years (SE = 0.18). Researchers measured each respondent's cognitive functioning during follow-up by using an adapted Telephone Interview of Cognitive Status, and a proxy informant indicated whether the respondent completed a durable power of attorney for health care. RESULTS: A durable power of attorney for health care was completed by 60.8% (SE = 2.51) of respondents prior to their death. Logistic regression demonstrated that respondents with the first quartile of global cognitive functioning were 76% less likely to have completed a durable power of attorney (adjusted odds ratio = 0.24, 95% confidence interval = 0.09-0.60) than those with the fourth quartile of cognitive functioning. IMPLICATIONS: The factors associated with completion of durable power of attorney for health care by older adults with lower levels of cognitive functioning should be investigated further. Such data could be used to inform interventions to increase the completion rates of durable power of attorney for health care among this particular group of older adults.

End-of-life content in Comprehensive Cancer Control Plans: a systematic review.

A recent project to define public health priorities for end of life (EOL) recommends incorporating EOL principles in all state/territory/tribe Comprehensive Cancer Control (CCC) Plans. The degree to which EOL content is currently included in CCC Plans was assessed through a systematic review of CCC Plans, examining keywords, definitions, topics, data, goals, and strategies. Forty-five plans (42 state, 3 tribal) were eligible. Forty-one CCC Plans (91%) included the keyword "end-of-life." EOL goals were most often categorized as use of care, access to care, and awareness of EOL issues among patients/public and providers. The top EOL strategies were research, provider education, and patient/public education. The results establish a baseline of EOL content in CCC Plans and should help improve assistance in future CCC planning efforts.

Cost-effectiveness of osteoporosis screening and treatment with hormone replacement therapy, raloxifene, or alendronate.

Recent information about osteoporosis treatments and their nonfracture side effects suggests the need for a new cost-effectiveness analysis. The authors estimate the cost effectiveness of screening women for osteoporosis at age 65 and treating those who screen positive with hormone replacement therapy (HRT), raloxifene, or alendronate. A Markov model of osteoporosis disease progression simulates costs and outcomes of women aged 65 years. Incremental cost effectiveness ratios of screen-and-treat strategies are calculated relative to a no-screen, no-treat (NST) strategy. Disease progression parameters are derived from clinical trials; cost and quality-of-life parameters are based on review of cost databases and cost-effectiveness studies. Women are screened using dual-energy x-ray absorptiometry, and women screening positive are treated with HRT, raloxifene, or alendronate. Screening and treatment with HRT increase costs and lower quality-adjusted life years (QALYs; relative to the NST strategy). The only scenario (of several) in the sensitivity analysis in which HRT increases QALYs is when it is assumed that there are no drug-related (nonfracture) health effects. Raloxifene increases costs and QALYs; its cost-effectiveness ratio is $447,559 per QALY. When prescribed for the shortest duration modeled, raloxifene's cost-effectiveness ratio approached $133,000 per QALY. Alendronate is the most cost-effective strategy; its cost-effectiveness ratio is $72,877 per QALY. Alendronate's cost-effectiveness ratio approaches $55,000 per QALY when treatment effects last for 5 years or the discount rate is set to zero. The authors conclude that screening and treating with alendronate are more cost-effective than screening and treating with raloxifene or HRT. Relative to an NST strategy, alendronate has a fairly good cost-effectiveness ratio.

Development of public health priorities for end-of-life initiatives.

OBJECTIVE: Recently, end-of-life (EOL) issues have captured the attention of the public health community. This study reports a project to help state health departments better understand their potential role in addressing EOL issues and develop initial priorities for EOL activities. METHODS: The project involved two studies. Study 1 (October 2002 to September 2003) involved a concept mapping process to solicit and organize recommendations from key stakeholders. Concept mapping integrates qualitative group processes with multivariate statistical analysis to represent the ideas of stakeholders visually through maps. A key-informant approach was used to identify stakeholder participants with expertise in aging, cancer, public health, and EOL. In two meetings, stakeholders used the maps to develop short-, intermediate-, and long-term recommendations for EOL initiatives. Study 2 (October 2003 to September 2004) involved a modified Delphi process with three iterations to prioritize recommendations for initial action from among a group of short-term recommendations. RESULTS: Study 1 resulted in 103 recommendations for EOL initiatives across nine domains. Study 2 resulted in consensus on five initial recommendations from three domains: identifying an EOL point of contact in state health departments, collecting and analyzing data about EOL, incorporating EOL principles into state comprehensive cancer control plans, educating the public about hospice and palliative care, and educating the public about the importance of advance directives. CONCLUSIONS: Diverse perspectives of key public health stakeholders resulted in a series of short- and longer-term recommendations for EOL action. These recommendations can guide future efforts by state health departments and other public health agencies to address EOL issues.

The long-term effects of a self-management program for inner-city primary care patients with acute low back pain.

BACKGROUND: We evaluated the effect of a self-management program for low-income primary care patients with acute low back pain (ALBP) from inner-city neighborhood health centers. METHODS: We conducted a randomized controlled trial of a self-management program compared with usual care at university-affiliated neighborhood health centers and an emergency department of an inner-city public teaching hospital. We enrolled 211 patients who visited a physician for ALBP (<90 days' duration). The self-management program consisted of 3 group sessions and telephone follow-up that focused on understanding back pain, increasing physical activity, and dealing with fears and frustrations. RESULTS: At baseline, 4 months, and 12 months, blinded interviewers assessed back pain physical function (Roland Disability Questionnaire), health status (Arthritis Impact Measurement Scales), self-efficacy, and time spent in physical activity. Compared with patients receiving usual care, intervention patients reported significantly better scores on the Roland Disability Questionnaire (P =.009), mental functioning (P =.009), self-efficacy to manage ALBP (P =.03), time spent in physical activity (P =.047), and reduced fears of movement/reinjury (P =.005) after 12 months. CONCLUSION: A self-management program can improve and maintain functional status, mental functioning, and self-efficacy to manage future symptoms for 1 year among primary care patients with ALBP living in the urban, inner city.

End of life is a public health issue.

Public health activities to prevent and control disease have produced an extraordinary decline in mortality rates during the last century. This phenomenon has widespread implications, not the least of which is that death often occurs at a later age and frequently after a protracted illness. With a prolonged death due to technological advances now common in developed countries, quality of life at the end of life has become a societal concern. It is logical that public health should embrace the end of life as an area worthy of study and intervention. After all, the end of life has three characteristics of other public health priorities: high burden, major impact, and a potential for preventing the suffering associated with illness. In this paper, we propose three initial roles for the public health profession and a process for developing a public health agenda for the end of life.

Can guidelines impact the ordering of magnetic resonance imaging studies by primary care providers for low back pain?

OBJECTIVE: To compare primary care providers' (PCPs') use of lumbar spine magnetic resonance imaging (MRI) studies and surgical referrals for patients with low back pain (LBP) before and after dissemination of the 1994 Agency for Healthcare Policy and Research (AHCPR) LBP guidelines. DESIGN: Retrospective cohort study. PATIENTS AND METHODS: Computerized audits identified patients with LBP evaluated by PCPs in 1994 or 1996 at a university-affiliated Veterans Affairs medical center who had an MRI order and/or a surgical referral. Research assistants recorded patients' demographic characteristics, LBP-related symptoms, and whether the PCP ordered an MRI and/or a surgery consult. For patients referred to surgery without an MRI, subsequent MRI orders by surgeons were recorded. We compared patient characteristics and utilization patterns for 1994 and 1996 and identified independent predictors of MRI orders. RESULTS: PCPs saw 279 and 261 patients with LBP in 1994 and 1996, respectively. An almost identical number of MRIs were ordered in 1994 (99 by PCPs and 42 by surgeons) and 1996 (105 by PCPs and 32 by surgeons). Nearly 50% of patients meeting AHCPR guidelines underwent an MRI in 1994 or 1996. PCPs more frequently ordered a surgery consult in 1994 than in 1996. Providers were less likely to order an MRI for patients with a previous MRI and more likely to order an MRI for those seen in an urgent visit clinic. Neither year nor meeting AHCPR guidelines predicted MRI ordering. CONCLUSIONS: Orders for MRI did not decrease after education on the guidelines. Limiting MRI orders to only "appropriate" patients would not have changed the observed results.

Provider-caregiver-child discussions about risks associated with asthma control medications: content and prevalence.

OBJECTIVES: The objectives of this study were to: (1) describe the extent to which general pediatric providers discuss risks associated with asthma control medications with families, and (2) examine factors that are associated with risk discussions. STUDY DESIGN: This study was a cross-sectional secondary analysis of audio taped medical visits involving 35 pediatric providers and 248 children with asthma with their caregivers. Transcripts of the visits were coded for discussions about asthma medication risks. Generalized estimating equations were used to analyze the data. RESULTS: Providers discussed asthma control medication risks during 23% of visits. Risks were more likely to be discussed when the visit was longer and when the provider prescribed a new asthma control medication. When providers discussed asthma control medication risks, they were most likely to ask the family general questions and make general statements. Across all of the visits, caregivers asked a total of 16 questions and made a total of 20 statements about risks associated with asthma medications; children asked a total of 3 questions and made two statements about risks associated with asthma control medications. CONCLUSION: Providers discussed risks associated with asthma control medications in less than one-quarter of medical visits. Providers should involve families in discussions about risks associated with medications during every visit to assess potential barriers to medication adherence.

Tumor necrosis factor-α inhibitor treatment and the risk of incident cardiovascular events in patients with early rheumatoid arthritis: a nested case-control study.

OBJECTIVE: To compare the risk of cardiovascular (CV) events between use of tumor necrosis factor-α inhibitors (TNFi) and nonbiologic disease-modifying antirheumatic drugs (DMARD) in patients with early rheumatoid arthritis (RA). METHODS: A nested case-control study was conducted using data from Truven's MarketScan commercial and Medicare claims database for patients with early RA who started treatment with either a TNFi or a nonbiologic DMARD between January 1, 2008, and December 31, 2010. Date of CV event diagnosis for cases was defined as the event date, and 12 age-matched and sex-matched controls were sampled using incidence density sampling. Drug exposure was defined into the following mutually exclusive categories hierarchically: (1) current use of TNFi (with or without nonbiologics), (2) past use of TNFi (with or without nonbiologics), (3) current use of nonbiologics only, and (4) past use of nonbiologics only. Current use was defined as any use in the period 90 days prior to the event date. Conditional logistic regression models were used to derive incidence rate ratios (IRR). RESULTS: From the cohort of patients with early RA, 279 cases of incident CV events and 3348 matched controls were identified. The adjusted risk of CV events was not significantly different between current TNFi users and current nonbiologic users (IRR 0.92, 95% CI 0.59-1.44). However, past users of nonbiologics showed significantly higher risk compared to current nonbiologic users (IRR 1.47, 95% CI 1.04-2.08). CONCLUSION: No differences in the CV risk were found between current TNFi and current nonbiologic DMARD treatment in patients with early RA.