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Purpose of Review: Efficacious pharmacologic treatments are available for the management of hypertension, yet only about 50% of patients treated with antihypertensive medications have their blood pressure controlled. A key factor contributing to poor blood pressure control is suboptimal adherence to prescribed therapy. Despite numerous studies conducted over the last 50 years to identify the best method for increasing patient compliance, no single intervention has emerged as superior to the others. This article reviews the effectiveness of methods to improve antihypertensive medication adherence, discusses the effect of drug benefit caps on compliance, and proposes a framework for future clinical and research directions., Recent Findings: Several recent systematic reviews and meta-analyses have attempted to quantify the effectiveness of various methods to improve adherence. As a result of the multiple factors influencing medication adherence, a patient-centered approach that tailors interventions aimed at overcoming barriers to adherence may be necessary., Summary: Physicians and other health care professionals should consider nonadherence to medication when evaluating a patient with poor blood pressure control. In selecting an intervention to improve compliance to medications, clinicians should consider engaging the patient in an intervention that overcomes patient-specific barriers. Future research should target development of adherence models, which simultaneously examine the effects and interactions of social, psychological, and biologic variables on antihypertensive medication adherence.

Objective: With respect to obesity prevention and treatment, to determine pediatricians' 1) treatment self-efficacy; 2) perceived barriers and relationships to management self-efficacy; 3) desired resources; and 4) willingness to be involved in advocacy., Methodology: A cross-sectional, self-administered mail survey queried members of the North Carolina Pediatrics Society and the American Academy of Pediatrics who were practicing routine care., Results: The adjusted response rate was 71% (n = 356). Only 12% of respondents reported high self-efficacy in obesity management, yet 39% believed that physicians could potentially be effective. The most frequently encountered barriers to obesity management included availability of fast food (97%) and soft drinks (95%). However, some practice-based barriers were most strongly associated with self-efficacy. Odds of high self-efficacy were lower for respondents who reported lack of non-MD staff reimbursement (odds ratio [OR] = 0.73; 95% confidence interval [CI] = 0.58, 0.92), lack of on-site dietitian (OR = 0.65; 95% CI = 0.50, 0.83), or lack of patient educational materials (OR = 0.67; 95% CI = 0.50, 0.89), compared with those who reported encountering these barriers infrequently. Respondents chose better counseling tools (96%) as the most helpful clinical resource for obesity management. Most (89%) were willing to take at least a small role in advocacy efforts., Conclusions: Most pediatricians reported feeling ineffective in their ability to treat obesity. Some practice-based barriers were specifically associated with low self-efficacy. However, pediatricians welcomed multiple clinical resources for obesity management and expressed willingness to advocate for policy change. Practice-based tool kits and efforts to engage willing participants in advocacy may help pediatricians combat this epidemic.

Objectives: To investigate a new method for evaluating counselling performance of staff in community pharmacies and to assess the quality of patient counselling., Method: Trained pseudo customers, instructed to play their role according to two different self-medication scenarios, visited voluntarily participating community pharmacies in Berlin. After documenting the counselling process, immediately after each visit, outside the pharmacy on an assessment form, the pseudo customer re-entered the pharmacy and gave detailed performance feedback to the counsellor and the pharmacist in charge in order to provide support for improving counselling skills and practice behaviour, when appropriate. This was followed with a written summary of the general performance of all participating pharmacies and additional individual feedback and suggestions for improvement. Educational needs were identified for subsequent performance-based educational strategies such as group-workshops, team-training and on-site team-coaching., Results: Forty-nine community pharmacies in Berlin volunteered to participate in this pilot study. Ninety-eight per cent of the participating pharmacies offered advice. However, in 36% of the cases, advice was only given on request. The different types of scenarios--presentation of a symptom or request for a specific product--made a great difference to the spontaneity of questions and advice. At least one question to check on accuracy of self-diagnosis was asked in 95% of the cases of symptom presentation but in only 47% of the cases of specific product request. Information on appropriate self-medication was provided on at least one item in 74% of pseudo customer visits, but most of the time the information was not sufficient. Communication skills (nonverbal elements, comprehensibility etc.) were very good or good in 54% of the visits. Potential for improvement was mainly in relation to the use of open-ended questions to gain more information and on counselling about appropriate self-medication. Direct feedback was given in 96% of the pharmacies (one person refused to accept feedback and one feedback had to be postponed because of time shortage). All of the participants regarded counselling as an important subject in pharmacy practice., Conclusion: The pseudo customer method was successfully used in this study of German community pharmacies. It was shown that pseudo customer visits and performance feedback following the counselling process, were feasible in daily practice and well accepted by the participants. A training program, focussing on areas in most need of improvement, has been developed. The promising results have led to the Federal Chamber of Pharmacists in Germany adopting this method as part of a continuous quality improvement program in community pharmacies.

Radiologists face substantial challenges in the timely and appropriate communication of diagnostic test results. As with other systems in health care delivery, the radiology reporting system is not designed to be optimally safe, timely, and patient centered. To improve the quality of care, there must be a new commitment to organizing services around patients' needs, including the reporting of diagnostic test results directly from radiologists to patients. The rationale for this change is that if both referring physicians and patients are given imaging examination results from radiologists immediately after their interpretation, it would be less likely that important diagnostic information would be lost or overlooked. The results would be provided to all stakeholders in a more timely fashion, the potential for important information to "fall through the cracks" would be diminished, and safety would be improved. Providing these results to patients directly online would also allow radiologists to facilitate increased patient satisfaction and patient-centered care by treating patients as "co-customers" and equal partners with referring physicians with regard to access to information and shared decision making.

The incidence of kidney failure treatment in the United States increased 57% from 1991 to 2000. Chronic kidney disease (CKD) prevalence was 11% among U.S. adults surveyed in 1988 to 1994. The objective of this study was to estimate awareness of CKD in the U.S. population during 1999 to 2000 and to determine whether the prevalence of CKD in the United States increased compared with 1988 to 1994. Analysis was conducted of nationally representative samples of noninstitutionalized adults, aged 20 yr and older, in two National Health and Nutrition Examination Surveys conducted in 1988 to 1994 (n = 15,488) and 1999 to 2000 (n = 4101) for prevalence +/- SE. Awareness of CKD is self-reported. Kidney function (GFR), kidney damage (microalbuminuria or greater), and stages of CKD (GFR and albuminuria) were estimated from calibrated serum creatinine, spot urine albumin to creatinine ratio (ACR), age, gender, and race. GFR was estimated using the simplified Modification of Diet in Renal Disease Study equation. Self-reported awareness of weak or failing kidneys in 1999 to 2000 was strongly associated with decreased kidney function and albuminuria but was low even in the presence of both conditions. Only 24.3 +/- 6.4% of patients at GFR 15 to 59 ml/min per 1.73 m(2) and albuminuria were aware of CKD compared with 1.1 +/- 0.3% at GFR of 90 ml/min per 1.73 m(2) or greater and no microalbuminuria. At moderately decreased kidney function (GFR 30 to 59 ml/min per 1.73 m(2)), awareness was much lower among women than men (2.9 +/- 1.6 versus 17.9 +/- 5.9%; P = 0.008). The prevalence of moderately or severely decreased kidney function (GFR 15 to 59 ml/min per 1.73 m(2)) remained stable over the past decade (4.4 +/- 0.3% in 1988 to 1994 and 3.8 +/- 0.4% in 1999 to 2000; P = 0.23). At the same time, the prevalence of albuminuria (ACR >/= 30 mg/g) in single spot urine increased from 8.2 +/- 0.4% to 10.1 +/- 0.7% (P = 0.01). Overall CKD prevalence was similar in both surveys (9% using ACR > 30 mg/g for persistent microalbuminuria; 11% in 1988 to 1994 and 12% in 1999 to 2000 using gender-specific ACR cutoffs). Despite a high prevalence, CKD awareness in the U.S. population is low. In contrast to the dramatic increase in treated kidney failure, overall CKD prevalence in the U.S. population has been relatively stable.

The paper describes nowadays information technology skills in the Czech Republic. It focuses on informatics education using Internet, ECDL concept and the links between computer literacy among health care professionals and quality of health care. Everyone understands that the main source of wealth of any nation is information management and the efficient transformation of information into knowledge. There appear completely new decisive factors for the economics of the near future based on circulation and exchange information. It is clear that modern health care cannot be built without information and communication technologies. We discuss several approaches how to contribute to some topics of information society in health care, namely the role of electronic health record, structured information, extraction of information from free medical texts and sharing knowledge stored in medical guidelines.

This study evaluated British Columbian primary care physicians' use of sexually transmitted disease (STD) and HIV counseling guidelines. The authors sought to assess barriers to integrated HIV and STD testing and counseling, with the objective of developing and revising practice guidelines to meet the needs of primary care physicians in diverse settings. The BC College of Physicians and Surgeons membership of general practice/family medicine practitioners was stratified by practitioner location; 1200 physicians were randomly selected to receive a mailed self-administered questionnaire. Four hundred seven completed questionnaires were returned. Female physicians reported better adherence to practice guidelines on many items than their male counterparts. A minority of primary care physicians routinely integrated HIV and STD testing and counseling. Physicians in nonurban areas were more likely to report that they lacked sufficient information on HIV and STD risk and prevention. Although male primary care physicians in British Columbia were more likely to provide care for people with HIV infection, female physicians were more likely to undertake ongoing screening for sexual risk behavior and sexually transmitted infections (STIs) among their HIV-positive patients. Clinical practice guidelines are theoretically equally available to all physicians, but they are not universally used. Physicians may not receive adequate training in sexual health during their medical education; continuing education opportunities may be limited to physicians outside of urban centres. Accessible and relevant continuing medical education in novel formats are needed to address the gap between ideal and actual practice in HIV and STD prevention, treatment, and care in Canada.

Many underserved patients in Utah lack insurance coverage for health care and prescription drugs but are provided medical care in community health centers (CHCs). Before June 2000, comprehensive pharmacy services were not provided to these patients at a Utah CHC. As part of a Health Resources and Services Administration grant, a collaborative agreement between the University of Utah College of Pharmacy and Utah CHCs was established so that a faculty clinician who is a certified diabetes educator (CDE) could provide diabetes education and care to underserved patients. The College of Pharmacy faculty clinician (pharmacist CDE) collaborated with physicians and midlevel practitioners to provide diabetes education and care for 176 patients. In addition to initial diabetes education, the pharmacist CDE provided continuing disease management by providing information and feedback to patients and recommendations to providers. The pharmacist CDE conducted continuing chart reviews to track certain parameters, such as laboratory test results for hemoglobin A 1c (A1C) and lipid levels, and blood pressure. Patients were followed for 1-3 years. The same outcome data were also collected for 176 patients with diabetes mellitus in another CHC clinic to provide a comparison group. Total cholesterol, low-density lipoprotein cholesterol, A1C, and triglyceride levels declined significantly from baseline at both sites. However, more patients who were provided care by the pharmacist CDE reached the American Diabetes Association A1C target goal of below 7%.

Background: In the last 5 years, several treatments have become available for erectile dysfunction (ED). During this same period, consumer use of the Internet for health information has increased rapidly. In traditional direct-to-consumer advertisements, viewers are often referred to a pharmaceutical company Web site for further information., Objective: To evaluate the accessibility and informational content of 5 pharmaceutical company Web sites about ED treatments., Methods: Using 10 popular search engines and 1 specialized search engine, the accessibility of the official pharmaceutical company-sponsored Web site was determined by searching under brand and generic names. One company also manufactures an ED device; this site was also included. A structured, explicit review of information found on these sites was conducted., Results: Of 110 searches (1 for each treatment, including corresponding generic drug name, using each search engine), 68 yielded the official pharmaceutical company Web site within the first 10 links. Removal of outliers (for both brand and generic name searches) resulted in 68 of 77 searches producing the pharmaceutical company Web site for the brand-name drug in the top 10 links. Although all pharmaceutical company Web sites contained general information on adverse effects and contraindications to use, only 2 sites gave actual percentages. Three sites provided references for their materials or discussed other treatment or drug options, while 4 of the sites contained profound advertising or emotive content. None mentioned cost of the therapy., Conclusions: The information contained on pharmaceutical company Web sites for ED treatments is superficial and aimed primarily at consumers. It is largely promotional and provides only limited information needed to effectively compare treatment options.

In 1998, the German Federal Ministry of Education and Research (BMBF) and the German pension insurance scheme established a funding programme for research in rehabilitation. This "Rehabilitation Sciences" research funding programme comprises eight regional research networks for eight years in two periods (1998-2002, 2001-2005). In our paper we review the findings of the first funding period in five of the research fields: patient education, need for and access to rehabilitation, vocational training in medical rehabilitation to enhance return to work, comorbid mental disorders in patients with somatic diseases, and gender differences. Several activities aimed at transferring research findings into practice are outlined. Finally, the impact of the funding programme is summarized and perspectives for further funding are given.

Aims: To determine the nature, extent, and quality of information provided by general practitioners (GPs) and hospital emergency departments to people after mild traumatic brain injury (MTBI)., Method: A survey was distributed throughout New Zealand to a representative sample of GPs and emergency departments (EDs)., Results: 244 valid surveys were returned, (229 from GPs and 15 from EDs), giving a return rate of 50.1%. Included with the returned surveys were 145 samples of information that these agencies typically provide after MTBI. Overall, 45.9% of respondents (93.4% of EDs and 42.8% of GPs) provided an information sheet to patients with a confirmed or suspected MTBI. These generally covered signs and symptoms; when to seek medical attention; and advice about pain relief, driving, alcohol, and rest. Of the information sheets provided by EDs, 92.9% had a FRE score of over 61 (the level recommended to be able to be read by 70% of the population), compared to 56% of those provided by GPs. Information sheets ranged in length from half a page to 10 pages, with those provided by EDs generally longer than those provided by GPs (mean 33.6 compared to 12.9 sentences)., Conclusions: Less than half of the GPs who returned questionnaires routinely provided information sheets about head injury and what to expect. Of the sample information sheets that were returned, just under half did not meet the criteria for being able to be read by 70% of the population.

Objective: The Internet provides an enormous amount of patient-orientated information on colorectal cancer. This study examined its accessibility and quality., Methods: Sites were identified using two search engines (Google and Hotbot) and the search terms 'bowel cancer' and 'colon and rectal cancer'. The first 100 sites in each search were visited and classified. Sites that contained patient information were assessed using the 'Discern' instrument for reliability and quality of information on treatment choices., Results: Google identified 55,700 sites for the search term 'colorectal cancer' and 214,000 for 'bowel cancer'. Hotbot produced 27,700 and 190,000, respectively. Four hundred sites were studied. Only 25 (6%) sites were duplicated in the searches. One hundred and eighteen (30%) provided information, 70 (18%) were lists of links, 27 (7%) were adverts, 22 (6%) promoted medical centres, 51 (13%) were dead links, 15 (4%) were message boards. Of the 118 that provided information 73 (62%) advised on treatment and 73 (62%) were designed for patients. The sources of information were clear in 55 (47%) and the date when this information was reported was given in only 63 (53%). By adapting the Discern instrument, sites were classified as excellent 18 (15.3%), very good 19 (16.1%), good 28 (23.7%), fair 8 (6.8%) and poor 45 (38.1%)., Conclusions: The Internet provides a wealth of information on colorectal cancer but the best sites are difficult for patients to distinguish from the thousands of sites returned by search engines. Clinicians should guide patients to quality sites to avoid confusion and misinformation.

As the use of disease management and preventive care expands, people ages 45 or older are seeing their doctor more often, according to a CDC survey. With an aging population, experts believe physicians will be challenged by patients with multiple chronic conditions and will rely more heavily on information technology innovations.

This study investigated the prevalence of back pain, disability, and, of most importance, the presence of misconceptions about low back pain (LBP), its diagnosis and treatment in a bicultural community sample (Belgium). Using the Graded Chronic Pain Scale [Pain 50 (1992) 133] persons were classified according to pain intensity and disability in five subgroups. The interrelationship between LBP beliefs and these five subgroups was also investigated. In our sample (n=1624) the 6-month prevalence of low back pain was 41.8%. Only in 8.2% back pain was disabling. Misconceptions about back pain were widespread, even in the group reporting no back pain. The least misconceptions were found to exist in participants with mild LBP without disability. It is suggested that recovery from an episode of acute low back pain is an active process that involves a correction of beliefs about harm, about the need to restrict physical activities and about medical diagnosis and cure. Finally, it is argued that community actions may be useful to correct LBP myths in order to prevent the development of long-term disability due to LBP.

The field of pharmacogenetics will soon celebrate its 50th anniversary. Although science has delivered an impressive amount of information in these 50 years, pharmacogenetics has suffered from lack of integration into clinical practice. There are several reasons for this, including the unmet need for education at medical schools and the lack of awareness about the impact of genetic medicine on healthcare in the community. Recently, the FDA announced that it considers pharmacogenomics one of three major opportunities on the critical path to new medical products. This notion by the FDA is filling the regulatory void that existed between drug developers and drug users. However, in order to bring pharmacogenetic testing to the prescription pad successfully, healthcare professionals and policy makers, as well as patients, need to have the necessary background knowledge for making educated treatment decisions. To effectively move pharmacogenetics into everyday medicine, it is therefore imperative for scientists and teachers in the field to take on the challenge of disseminating pharmacogenetic insights to a broader audience.

Background: Before any invasive procedure, physicians have a legal obligation to inform patients. Traditionally, this involves a discussion with a physician, supplemented by written leaflet information directed at the specific procedure., Objective: Comparison of the use and effectiveness of computer-based visualization opposed to standardized conversation for providing patients with information of forthcoming procedures (coronary catheters or endoscopy procedures)., Methods: Prospective, randomized trial with 56 participants allocated in two different groups: Visualization Group (standardized information supported by a tool for displaying two-dimensional pictures to explain medical facts as well as informative leaflet) or Control Group (standardized information and informative leaflet only). Detailed information was given about the indication, the probable complications and the details of the forthcoming procedures (coronary catheters or endoscopy procedures). All participants had to reach a Karnofsky Score of 70 points and be able to understand German or English. Main outcome measures were patient's satisfaction with physician-patient conversation, patient's acquired knowledge and duration of the intervention as described above., Results: Patients of the Visualization Group were more satisfied with the conversation and had higher knowledge scores after the conversation. A Mann-Whitney-U-Test between the two groups showed that these differences in satisfaction (P<0.001) and knowledge (P= or <0.006) were statistically significant. Length of time needed for the conversation was slightly higher in the Visualization Group, but this difference was not statistically significant (25 versus 23 min; P= 0.441). No differences could be found due to differing age or educational level in the results of the Visualization and the Control Group., Conclusions: Using computerized visualization increased the satisfaction and knowledge of the patients. The presentation of the visualized information in the Visualization Group did not demand significantly more time than the standard conversation in the Control Group.

The fate and management of 50 patients with epilepsy is described whilst they undertook varied gap year experiences in various countries. Despite initial apprehension on my part almost all had no change in their epilepsy (or had actual improvement) and it turned out to be a positive experience for all. With the ready availability of email it is suggested that the home clinic keeps in touch with gap year students whilst they are away and provides them with basic information and an assessment before they go, information which they can then take with them.

The DNA Board of Directors met to consider the particular challenges confronting the dermatology nurse and the patient care team today. The following mega issues are the result of our combined efforts to identify those factors having the greatest impact on how we practice today and tomorrow: bio-nuclear terrorism; health care provider shortage; the provision of quality patient; education literature authored by nurses; emerging role and specialized educational needs of nurses in dermatology; and evolving therapeutic modalities.

Purpose/objectives: To obtain detailed information about the preferences of patients with cancer and their need for information about side effects of cancer treatment to design an interactive multimedia educational program., Design: Qualitative., Setting: Regional rural academic medical center., Sample: 51 patients and 14 spouses of patients who either currently were undergoing or recently had completed chemotherapy or radiation therapy for cancer., Methods: Focus groups., Main Research Variables: Information needs and common and distressing symptoms., Findings: Patients wanted information about the process of getting treatment, specific side effects that might occur, and the impact of treatment on their lives. Patients sought information from a variety of sources, but many found that other patients were the most helpful source. Although most patients wanted as much information as possible so they would be prepared for whatever happened, some patients preferred to avoid information about possible side effects. Several obstacles related to information were reported, including access to providers, communication difficulties with providers, informational overload, and problems with retention., Conclusions: Several aspects regarding information needs confirmed previous findings, and new aspects were illuminated. This led to a conclusion that multimedia technology offered many advantages to meet these informational needs., Implications for Nursing: New approaches to patient education that will meet the needs of patients as well as clinicians and educators need to be developed.

Objective: To assess the impact of a community pharmacy-based bone mineral density (BMD) screening and education program and determine the feasibility of providing such a service in community pharmacies., Design: Uncontrolled study using convenience sample combined with economic feasibility analysis., Setting: Two independent and four chain community pharmacies., Participants: Women age 18 years and older., Intervention: Pharmacy patrons were invited to a free BMD screening. Demographic information was collected, and patients were screened using an ultrasound BMD analyzer. BMD results were reviewed with the participant during an education session and forwarded to primary care providers. Questionnaires were completed at baseline and after 3 months., Main Outcome Measures: Time spent with each participant, project costs, and willingness to pay for screenings were used to estimate feasibility; questionnaire responses assessed impact of the intervention on participants' health care decisions, lifestyle modifications, and communications with their prescribers about osteoporosis., Results: Of the 140 women screened at baseline, 82% indicated the screening was "very useful" for making health care decisions, and 91% believed it encouraged them to talk with their physicians about osteoporosis. At 3 months, 11% of patients reported having improved exercise habits, and 30% had increased their calcium and vitamin D intake. A total of 41% of respondents indicated a willingness to pay dollar 20 or more for the BMD screening service. The average screening time was 23 minutes. Based on fixed costs of the screening device and materials and variable costs associated with personnel time, a community pharmacy could generate a positive net income with a BMD screening program. Cost of the BMD analyzer could be recovered through revenue generated in 24-35 screening days, depending on the fees charged., Conclusion: A community pharmacy osteoporosis program had a positive impact on patient health care by influencing lifestyle modifications, increasing use of medications, and encouraging participants to discuss osteoporosis with their physician. Patients are willing to pay for this service; feasibility varies depending on available resources and patient population served.

Objective: To review the available literature on psychoeducation and cognitive-behavioral therapy (CBT) in bipolar disorder (BD) and to give an integral view of these therapies., Method: Studies were identified through Medline searches in English language publications between 1971 and 2003. This was supplemented by a hand search and the inclusion of selected descriptive articles on good clinical practice., Results: A number of studies demonstrate that psychoeducation enhances adherence to treatment, and one finds that it improves outcome in BD. Other studies find that CBT diminishes depressive symptoms and improves quality of life in BD. Occasionally some adverse effects may occur with psychotherapy and, although they are sporadic, should not be overlooked., Conclusion: When combined with pharmacological treatment, psychoeducation helps to improve adherence. Training in the identification of early manic symptoms helps to improve outcomes and decreases the number of manic relapses in BD.

Between 50 and 100 million Americans have used the Internet to obtain health information. Breast cancer is one of the most common diagnoses sought online, and breast oncologists are likely to encounter more and more patients who have used the Internet. The effects that this is having on patients and on the clinical encounter in oncology are unclear. Here, the author reviews recent research about the growing importance of online health information and the small amount of literature on breast cancer and the Internet. Other recent developments, such as efforts to recruit patients to clinical trials via the Internet and online support groups for cancer patients, also are reviewed. Finally, the author offers his views on how best to manage patients' growing interest in Internet information.

Training of hypertensive patients is a widely disputable problem. It is shown that education of hypertensive patients and population at risk can effectively prevent hypertension both at population and individual levels. The authors believe that programs designed for the education of hypertensive patients and population have marked drawbacks as they lack consistency, vary in strategy (group or individual learning), methods of teaching (interactive multimedia presentation of the material, self-education according to certain recommendations, video- and audio materials), evaluation of short- and long-term effects (6 and 24 months), patients management, etc. This explains the necessity of further studies into the problem of the approaches to education of the patients and population concerning hypertension.

One of the major challenges for general practitioners is to manage individuals with acute low back pain appropriately to reduce the risk of chronicity. A prospective study was designed to assess the actual management of acute low back pain in one primary care setting and to determine whether existing practice patterns conform to published guidelines. Twenty-four family physicians from public primary care centers of the Basque Health Service in Bizkaia, Basque Country (Spain), participated in the study. A total of 105 patients aged 18-65 years presenting with acute low back pain over a 6-month period were included. Immediately after consultation, a research assistant performed a structured clinical interview. The patients' care provided by the general practitioner was compared with the Agency for Health Care Policy and Research (AHCPR) guidelines and guidelines issued by the Royal College of General Practitioners. The diagnostic process showed a low rate of appropriate use of history (27%), physical examination (32%), lumbar radiographs (31%), and referral to specialized care (33%). Although the therapeutic process showed a relatively high rate of appropriateness in earlier mobilization (77%) and educational advice (65%), only 23% of patients were taught about the benign course of back pain. The study revealed that management of acute low back pain in the primary care setting is far from being in conformance with published clinical guidelines.

Background: Topical corticosteroids are commonly used in dermatological practice. The aim of this study was to assess the baseline level of knowledge about topical steroids in a group of dermatology patients and to evaluate the impact of educational materials on patients' level of information., Methods: A 10-item questionnaire was developed, and 126 patients who were prescribed topical steroids for several dermatologic diseases were asked mostly about side-effects of the drugs. Three different educational methods were used in parallel to the questionnaire: verbal (n = 42), written (n = 42) or verbal and written (n = 42). The same questions were asked again 1 or 2 weeks later., Results: Only 7.1% of the study group mentioned that they were informed by doctors about the side-effects of topical steroids before they were administered. The baseline information scores about topical corticosteroids were higher in high school and college graduates and in those who noted side-effects or who were informed about side-effects before administration. A statistically significant difference was detected between pre- and posteducation scores of patients in the whole group and within the three groups of different educational methods (P < 0.001). Posteducation scores of the combined verbal- and written-educated group were higher than the written-educated group or the verbal-educated group., Conclusion: The present study indicated that patient knowledge is enhanced by any kind of educational method, and particularly written information supported by verbal instructions given in dermatology outpatient departments. Moreover, we conclude that the 10-item questionnaire can be used in Turkey to assess patients' knowledge about topical corticosteroids.

Background: The objective of the study was to determine physicians' views of the effects of Direct-to-Consumer Advertising (DTCA) on health service utilization, quality of care, and the doctor-patient relationship., Methods: Cross-sectional survey of a nationally representative sample of US physicians to determine their perceptions of the effects of patients discussing information from DTCA on time efficiency; requests for specific interventions; health outcomes; and the doctor-patient relationship., Results: Physicians reported that more than half (56%) of patients who discussed information from DTCA in a visit did so because they wanted a specific intervention, such as a test, change in medication, or specialist referral. The physician deemed 49% of these requests clinically inappropriate. Physicians filled 69% of requests they deemed clinically inappropriate; 39% of physicians perceived DTCA as damaging to the time efficiency of the visit, and 13% saw it as helpful. Thirty-three percent of physicians thought discussing DTCA had improved the doctor-patient relationship; 8% felt it had worsened it. The effect on the relationship was strongly associated with doing what the patient wanted., Conclusions: DTCA can have good and bad effects on quality of care, the doctor-patient relationship, and health service utilization. The benefits might be maximized, and the harms minimized, by increasing the accuracy of information in advertisements; enhancing physicians' communication and negotiation skills; and encouraging patients to respect physicians' clinical expertise.

Background: In 1998 the Swedish noncommercial public health service Infomedica opened an Ask the Doctor service on its Internet portal. At no charge, anyone with Internet access can use this service to ask questions about personal health-related and disease-related matters., Objective: To study why individuals choose to consult previously-unknown doctors on the Internet., Methods: Between November 1, 2001, and January 31, 2002 a Web survey of the 3622 Ask the Doctor service users, 1036 men (29%) and 2586 (71%) women, was conducted. We excluded 186 queries from users. The results are based on quantitative and qualitative analysis of the answers to the question "Why did you choose to ask a question at Infomedica's 'Ask the Doctor' service?", Results: 1223 surveys were completed (response rate 36 %). Of the participants in the survey 322 (26%) were male and 901 (74%) female. As major reasons for choosing to consult previously-unknown doctors on the Internet participants indicated: convenience (52%), anonymity (36%), "doctors too busy" (21%), difficult to find time to visit a doctor (16%), difficulty to get an appointment (13%), feeling uncomfortable when seeing a doctor (9%), and not being able to afford a doctors' visit (3%). Further motives elicited through a qualitative analysis of free-text answers were: seeking a second opinion, discontent with previous doctors and a wish for a primary evaluation of a medical problem, asking embarrassing or sensitive questions, seeking information on behalf of relatives, preferring written communication, and (from responses by expatriates, travelers, and others) living far away from regular health care., Conclusions: We found that that an Internet based Ask the Doctor service is primarily consulted because it is convenient, but it may also be of value for individuals with needs that regular health care services have not been able to meet.

Background: More people than ever are turning to the Internet for health-related information, and recent studies indicate that the information patients find online directly affects the decisions they make about their health care. Little is known about the information needs or actual search behavior of people who use the Internet for health information., Objective: This study analyzes what people search for when they use a health-education Web site offering information about arthritis, orthopaedics, and sports-medicine topics. Additionally, it determines who is performing these searches: is it patients, friends or relatives of patients, or neither? Finally, it examines the similarities and differences among questions submitted by Web site visitors from different countries., Methods: Content analysis was performed on 793 free-text search queries submitted to a patient-education Web site owned and operated by the Department of Orthopaedics and Sports Medicine at the University of Washington Medical Center. The 793-query data set was coded into 3 schemes: (1) the purpose of the query, (2) the topic of the query, and (3) the relationship between the asker of the query and the patient. We determined the country from which each query was submitted by analyzing the Internet Protocol addresses associated with the queries., Results: The 5 most frequent reasons visitors searched the Web site were to seek: (1) information about a condition, (2) information about treatment, (3) information about symptoms, (4) advice about symptoms, and (5) advice about treatment. We were able to determine the relationship between the person submitting the query and the patient in question for 178 queries. Of these, the asker was the patient in 140 cases, and the asker was a friend or relative of the patient in 38 cases. The queries were submitted from 34 nations, with most coming from the United States, Australia, the United Kingdom, and Canada. When comparing questions submitted from the United States versus those from all other countries, the 3 most frequent types of questions were the same for both groups (and were the top 3 question types listed above)., Conclusions: These results provide the University of Washington Department of Orthopaedics and Sports Medicine, as well as other organizations that provide health-information Web sites, with data about what people around the world are seeking when they turn to the Internet for health information. If Web site managers can adapt their health-information Web sites in response to these findings, patients may be able to find and use Internet-based health information more successfully, enabling them to participate more actively in their health care.

Purpose/objectives: To provide a description of the inception and evolution of the Breast Cancer Education and Risk Assessment Program., Data Sources: Computerized database (e.g., Personal Family History Risk Assessment Model, Knowledge Assessment Tool, risk perception, evaluation form) and author experience., Data Synthesis: A total of 749 women participated in the group education and risk-assessment program from March 1999 through March 2002. Advanced practice nurses provided information about calculated risks, corrected misperceptions among participants, and highlighted options available to decrease breast cancer risk. Knowledge scores improved, and, in general, participants were very satisfied with the content and comprehensibility of the educational session., Conclusions: Results from the evaluation of the Breast Cancer Education and Risk Assessment Program suggest that group education is a viable and acceptable way to bring new advances in breast cancer prevention to large groups of women. The data sources support the conclusion that women can be effectively taught general breast cancer risk information in a group setting and be placed into specific risk categories to streamline discussion of risk-management options and relevant research studies., Implications for Nursing: Advanced practice nurses are a vital link in the assessment of women at high risk for breast cancer, education, and appropriate referrals for management options and relevant clinical trials.

One percent of the UK population suffers from rheumatoid arthritis (RA), with a female to male ratio of 3:1. The disease has a major influence on employment and disability rates. About 15% are classified as having serious illness, which prognostically is equivalent to 3-vessel coronary artery disease. Overall life expectancy for those with RA is reduced on average by 5 years. Financial costs are enormous. Per-patient, each year, direct and indirect costs total about 7000 pounds sterling. Costs escalate with disease severity. In a specialist rheumatology clinic, about 12% of new referrals have RA, and these patients account for more than 40% of the followup workload. The approach to management is changing, with emphasis on earlier, more aggressive intervention. This is acknowledged to improve outcome. For the severe disease, management has been revolutionized by the introduction of biologic agents. RA is managed by a multidisciplinary team, and there are active patient support groups. Advances in knowledge about genetic and immunological mechanisms of disease hold promise for further progress. Never was there a greater need for a successful alliance to deliver effective, high quality services involving government, professionals, patients, and their advocates.

Background: Patient adherence affects treatment efficacy, and surprisingly, adherence is frequently associated with reductions in mortality for those receiving placebo., Methods: This study considers the role of trial adherence for men (N = 12,338) in the Multiple Risk Factor Intervention Trial (MRFIT), a prospective study of 9-year follow-up mortality following randomization to Special Intervention (SI) or Usual Care (UC). Annual visit attendance rates were used as a measure of adherence., Results: A significant Adherence x Group Assignment interaction (p =.002) revealed that SI significantly reduced cardiovascular disease (CVD) mortality for highly adherent participants, RR =.91 (95% confidence interval [CI] =.84-.99) but significantly increased CVD mortality for poorly adherent participants, RR = 1.28 (95% CI = 1.05-1.57) when compared to UC. These associations remained after controlling for baseline characteristics (e.g., income), reported illness, or occurrence of a nonfatal CVD event during the trial. The beneficial effect of SI among the adherent participants was partly due to reduced smoking and diastolic blood pressure levels during the trial., Conclusions: SI significantly reduced the risk of CVD mortality for participants adherent with the MRFIT, and this effect was accounted for by positive changes in CVD risk factors. These findings suggest a method for evaluating treatment efficacy in subgroups determined by patient responses (e.g., adherence to annual assessment visits) to the treatment program after randomization.

Musculoskeletal conditions (MSC) are among the most frequent in adults in France, with over 20% of the population experiencing bone, joint, and muscle disorders. MSC are an increasing health concern in France, growing in importance on the public health agenda. Some of the present governmental plans are connected with MSC (Pain, the Disabled, Nutrition, Geriatrics). An overview of the present situation in France is provided, regarding the burden, the present situation, and steps forward. Scientific societies and patient groups are actively involved in campaigning in several fields; 2 examples are described: osteoporosis and rheumatoid arthritis and spondyloarthropathies. The Bone and Joint Decade initiative, officially endorsed by the French Government on June 20, 2000, provides the opportunity to develop more coordinated actions through the national network and international partnership as well (including the European League Against Rheumatism) to finally improve the health-related quality of life for people with MSC.

Background: Public use of the Internet for health information is increasing but its effect on health care is unclear. We studied physicians' experience of patients looking for health information on the Internet and their perceptions of the impact of this information on the physician-patient relationship, health care, and workload., Methods: Cross-sectional survey of a nationally-representative sample of United States physicians (1050 respondents; response rate 53%)., Results: Eighty-five percent of respondents had experienced a patient bringing Internet information to a visit. The quality of information was important: accurate, relevant information benefited, while inaccurate or irrelevant information harmed health care, health outcomes, and the physician-patient relationship. However, the physician's feeling that the patient was challenging his or her authority was the most consistent predictor of a perceived deterioration in the physician-patient relationship (OR = 14.9; 95% CI, 5.5-40.5), in the quality of health care (OR = 3.4; 95% CI, 1.1-10.9), or health outcomes (OR = 5.6; 95% CI, 1.7-18.7). Thirty-eight percent of physicians believed that the patient bringing in information made the visit less time efficient, particularly if the patient wanted something inappropriate (OR = 2.5; 95% CI, 1.5-4.4), or the physician felt challenged (OR = 3.6; 95% CI, 1.8-7.2)., Conclusions: The quality of information on the Internet is paramount: accurate relevant information is beneficial, while inaccurate information is harmful. Physicians appear to acquiesce to clinically-inappropriate requests generated by information from the Internet, either for fear of damaging the physician-patient relationship or because of the negative effect on time efficiency of not doing so. A minority of physicians feels challenged by patients bringing health information to the visit; reasons for this require further research.

Background: Unlike many patients of the past, today's health-care users want to become more informed about their illnesses, and they want the most current information. The Internet has become a popular way to access current information, and since its introduction more people are turning to it to find medical information. Studies report that anywhere from 36% to 55% of the American population that use the Internet is using the Internet to research medical information, and these percentages have been rising. Cancer is 1 of the top 2 diseases about which people seek information on the Internet. Some studies have specifically asked whether breast cancer patients access the Internet for medical information; estimates range from 10% to 43% of breast cancer patients who use the Internet, with higher usage being associated with more education, greater income, and younger age., Objective: To identify where breast cancer patients find medical information about their illness and to track changes over time, from active treatment to survivorship status., Methods: Participants were 224 women who had been recently diagnosed with Stage I, Stage II, or Stage III breast cancer. Each woman was contacted approximately 8 months and 16 months after diagnosis and was asked about 10 different information sources they could have used to obtain information or support about their breast cancer., Results: Eight months after diagnosis, the top 3 information sources used by women were books (64%), the Internet (49%), and videos (41%). However, at follow-up (16 months after diagnosis), the most frequently cited information source was the Internet (40%), followed by books (33%), and the American Cancer Society (17%). We found that women continued to use the Internet as a means of gathering information even after their treatment ended. Significant unique predictors of Internet use were more years of formal education and younger ages. Cancer stage was not a significant predictor of Internet use., Conclusions: Previous research has been mixed about the percentage of cancer patients who use the Internet to gather information about their illnesses. The results of the present study corroborate 2 other data sets of breast cancer patients, as just over 44% of the women reported using the Internet after diagnosis. Sixteen months after diagnosis, the percentage of women using the Internet dropped slightly, but other chief sources dropped sharply at that time. The Internet continues to play an important role for cancer survivors after medical treatment has ended, and health professionals can use this knowledge to provide their patients with Internet advice.

Background: Despite evidence that men believe the general practitioner is an appropriate person to assist with sexual health issues, few men actually access medical practitioners for such assistance. Raising community awareness of male sexual and reproductive health issues is expected to generate a clinical demand for men's health services., Objective: The aim of this study was to determine GP perceptions of their own education needs and those of the community in the area of men's health., Discussion: A total of 27 GPs from four Victorian divisions of general practice (three metropolitan and one rural) participated in three focus groups. Key themes from the data were identified after analysis of the data by three researchers. General practitioners indicated that a clinical demand for men's health services needed to be generated in order for GPs to be interested in professional development. They suggested community education providing general information to men about sexual and reproductive health issues and emphasising the importance of accessing their GP for health checks. However, due to a lack of information for GPs about some areas of male sexual and reproductive health, e.g., androgen deficiency and male infertility, a case based practical approach to GP education was recommended. General practitioners also requested concrete information, current specialist recommendations and details of locally available services working in men's health.

A knowledge, attitude and practice study on vaccinations was undertaken among Irish parents and healthcare professionals between May and August 2001. Parents expressed fear of vaccine side effects, mistrust of health services, and felt poorly informed on the vaccination issues. According to group discussions, health professionals felt they lack time and user-friendly materials to properly inform the parents.

Background: Although easy access to the Internet can provide much information for patients, the quality and accuracy of information are uncertain. This investigation evaluated information concerning laparoscopic bariatric surgery available via the Internet., Methods: Searches on the six most popular search engines and two metasearch engines were performed. The first 20 "hits" for each separate search were included in the study., Results: A total of 602 "hits" were found. Only 119 unique Web sites were found. Although 63 of the 119 sites discussed some procedure related to laparoscopic obesity surgery, 18 of the 63 had biased or misleading information, 30 did not discuss the details of the procedure, 37 did not discuss other procedures, 30 did not discuss complications, 37 did not discuss death as a risk, and 7 did not discuss laparoscopic procedure as an option. Only 89 of the original 602 "hits" led to Web sites that discussed laparoscopic obesity surgery, details of the procedure, and complications in an unbiased manner., Conclusions: A large amount of information is available via the Internet. However, it is difficult for the patient to identify the unbiased information. The Internet is not a dependable source of information for patients.