The challenges to ophthalmologic follow-up care in at-risk pediatric populations.

PURPOSE: To identify barriers to ophthalmological follow-up in high-risk children who are identified by vision screening and eye examination. METHODS: The records of patients identified as needing follow-up through two free eye care programs (organized optometric and ophthalmologic screening sessions aimed at identifying and treating ocular pathology) targeted toward inner-city youths of low socioeconomic status were reviewed. Parents were contacted by phone, and a questionnaire on barriers to follow-up was administered. Callers attempted to schedule appointments at that time. Data were assessed by means of descriptive analysis. RESULTS: Of 93 patients, 54 (58%), were successfully contacted. Of these, 23 (25%) were eventually scheduled. Five (5%) patients elected follow-up elsewhere. Twenty (22%) with working phones were still unable to be scheduled. Additional obstacles included families' lack of awareness of the need for follow-up (13%), assumption by families that they would be contacted (5%), scheduling conflicts (4%), concerns about insurance, and difficulty finalizing referrals (2%). A total of 39 patients (42%) were not successfully contacted because of inoperable phone services, and none of the families responded to the mailed questionnaire. CONCLUSIONS: Inability to contact families was the greatest barrier to follow-up. Our findings suggest that immediate arrangement of follow-up care, on-site visual assessment, and a program director may be useful in increasing follow-up for high-risk children.

Serious psychological distress and diabetes care among California adults.

OBJECTIVE: To evaluate three aspects of diabetes care (foot checks, eye examinations, and hemoglobin A 1 C checks by a physician) among California adults with Type 2 diabetes and serious psychological distress (SPD). METHOD: Data were from the population-based 2005 California Health Interview Survey. Estimates were that in 2005, 1,516,171 Californians (5.75% of all adults) had a physician-given diabetes diagnosis, and of those, 108,621 (7.16%) had co-morbid SPD. RESULTS: Among Californians with Type 2 diabetes, SPD was associated with fewer physician foot checks (odds ratio = 0.56, 95% Confidence Interval = 0.32 to 0.97) but not with fewer eye examinations or hemoglobin A 1 C checks. CONCLUSIONS: The findings highlight a specific area--foot complication evaluation and prevention--for improving the quality of diabetes care among adult Californians with Type 2 diabetes and SPD.

Mental health, binge drinking, and antihypertension medication adherence.

OBJECTIVES: To evaluate the relationship between self-reported mental health and binge drinking, as well as health status, sociodemographic, social support, economic resource, and health care access indicators to antihypertension medication adherence. METHOD: Analysis of 2003 California Health Interview Survey data. RESULTS: Having poor mental health days predicted medication nonadherence, whereas binge drinking did not. Nonadherence predictors included younger age, Latino, non-US citizen, uninsured, less education, and no regular medical care. Adherence predictors were older age, African American, having prescription insurance, a college degree, poor health, comorbid diabetes or heart disease, and overweight or obese. CONCLUSION: Better mental health may improve medication adherence among hypertensive individuals.

Physician and patient communication training in primary care: effects on participation and satisfaction.

OBJECTIVE: To assess the effects of a communication skills training program for physicians and patients. DESIGN: A randomized experiment to improve physician communication skills was assessed 1 and 6 months after a training intervention; patient training to be active participants was assessed after 1 month. Across three primary medical care settings, 156 physicians treating 2,196 patients were randomly assigned to control group or one of three conditions (physician, patient, or both trained). MAIN OUTCOME MEASURES: Patient satisfaction and perceptions of choice, decision-making, information, and lifestyle counseling; physicians' satisfaction and stress; and global ratings of the communication process. RESULTS: The following significant (p < .05) effects emerged: physician training improved patients' satisfaction with information and overall care; increased willingness to recommend the physician; increased physicians' counseling (as reported by patients) about weight loss, exercise, and quitting smoking and alcohol; increased physician satisfaction with physical exam detail; increased independent ratings of physicians' sensitive, connected communication with their patients, and decreased physician satisfaction with interpersonal aspects of professional life. Patient training improved physicians' satisfaction with data collection; if only physician or patient was trained, physician stress increased and physician satisfaction decreased. CONCLUSION: Implications for improving physician-patient relationship outcomes through communication skills training are discussed.

Binge drinking, poor mental health, and adherence to treatment among California adults with asthma.

Binge drinking and poor mental health may affect adherence to treatment for individuals with asthma. The purposes were to (a) examine the relationship of self-reported binge drinking and mental health to adherence to daily asthma control medications and (b) identify other demographic and health-related factors associated with asthma control medication adherence. Secondary analyses of 2003 adult California Health Interview Survey data were undertaken, and these analyses identified 3.2 million California adults who had been told by a physician they had asthma. Of these, approximately 1.7 million were symptomatic. Binge drinking significantly predicted medication nonadherence among California adults with symptomatic asthma (OR = .63, 95% CI = .45-.89), whereas poor mental health did not. Other predictors of nonadherence (odds ratios < 1, p < .05) included being overweight, younger age, having some college education, being a current smoker, and having no usual source of medical care. Predictors of adherence (odds ratios > 1, p < .05) were older age, more frequent asthma symptoms, more ER visits, more missed work days, being African American, and being a non-citizen. Intervention efforts could be directed toward improving medication adherence among adult asthma patients who engage in risky health behaviors such as binge drinking. Also at risk for medication nonadherence and therefore good targets for asthma control medication management interventions are adults who are overweight, younger (18-44 age range), have some college education, and no usual source of medical care.

The therapeutic effects of the physician-older patient relationship: effective communication with vulnerable older patients.

There is growing evidence that the outcomes of health care for seniors are dependent not only upon patients' physical health status and the administration of care for their biomedical needs, but also upon care for patients' psychosocial needs and attention to their social, economic, cultural, and psychological vulnerabilities. Even when older patients have appropriate access to medical services, they also need effective and empathic communication as an essential part of their treatment. Older patients who are socially isolated, emotionally vulnerable, and economically disadvantaged are particularly in need of the social, emotional, and practical support that sensitive provider-patient communication can provide. In this review paper, we examine the complexities of communication between physicians and their older patients, and consider some of the particular challenges that manifest in providers' interactions with their older patients, particularly those who are socially isolated, suffering from depression, or of minority status or low income. This review offers guidelines for improved physician-older patient communication in medical practice, and examines interventions to coordinate care for older patients on multiple dimensions of a biopsychosocial model of health care.

Health beliefs, disease severity, and patient adherence: a meta-analysis.

BACKGROUND: A large body of empirical data exists on the prediction of patient adherence from subjective and objective assessments of health status and disease severity. This work can be summarized with meta-analysis. OBJECTIVES: Retrieval and summary analysis of r effect sizes and moderators of the relationship between patient adherence and patients': (1) beliefs in disease threat; (2) rated health status (by physician, self, or parent); and (3) objective disease severity. METHODS: Comprehensive search of published literature (1948-2005) yielding 116 articles, with 143 separate effect sizes. Calculation of robust, generalizable random effects model statistics, and detailed examination of study diversity with moderator analyses. RESULTS: Adherence is significantly positively correlated with patients' beliefs in the severity of the disease to be prevented or treated ("disease threat"). Better patient adherence is associated with objectively poorer health only for patients experiencing disease conditions lower in seriousness (according to the Seriousness of Illness Rating Scale). Among conditions higher in seriousness, worse adherence is associated with objectively poorer health. Similar patterns exist when health status is rated by patients themselves, and by parents in pediatric samples. CONCLUSIONS: Results suggest that the objective severity of patients' disease conditions, and their awareness of this severity, can predict their adherence. Patients who are most severely ill with serious diseases may be at greatest risk for nonadherence to treatment. Findings can contribute to greater provider awareness of the potential for patient nonadherence, and to better targeting of health messages and treatment advice by providers.

The challenge of patient adherence.

Quality healthcare outcomes depend upon patients' adherence to recommended treatment regimens. Patient nonadherence can be a pervasive threat to health and wellbeing and carry an appreciable economic burden as well. In some disease conditions, more than 40% of patients sustain significant risks by misunderstanding, forgetting, or ignoring healthcare advice. While no single intervention strategy can improve the adherence of all patients, decades of research studies agree that successful attempts to improve patient adherence depend upon a set of key factors. These include realistic assessment of patients' knowledge and understanding of the regimen, clear and effective communication between health professionals and their patients, and the nurturance of trust in the therapeutic relationship. Patients must be given the opportunity to tell the story of their unique illness experiences. Knowing the patient as a person allows the health professional to understand elements that are crucial to the patient's adherence: beliefs, attitudes, subjective norms, cultural context, social supports, and emotional health challenges, particularly depression. Physician-patient partnerships are essential when choosing amongst various therapeutic options to maximize adherence. Mutual collaboration fosters greater patient satisfaction, reduces the risks of nonadherence, and improves patients' healthcare outcomes.