Search

PURPOSE: To assess factors that influence adolescent asthma responsibility and how patient- and parent-reported asthma responsibility changes over a 12-month period. METHODS: One hundred sixty-four adolescents and their parents completed questionnaires at baseline and 12 months, including the asthma responsibility questionnaire, in which higher scores indicate greater adolescent responsibility. Multiple linear regression was used to assess how baseline asthma responsibility, self-efficacy, outcome expectations, and demographic characteristics were associated with 12-month asthma responsibility. RESULTS: Asthma responsibility as reported by both adolescents and parents shifted significantly toward the adolescent over the study period (p

The glaucoma question prompt list/video intervention was well received by patients. Eighty-seven percent of patients recommended that other patients should watch the educational video before their visits, and 89% said that other patients should complete the question prompt list before visits.The objectives of this study were to (a) describe patient feedback on a glaucoma question prompt list/video intervention designed to motivate African American patients to be more engaged during visits and (b) examine patient demographics associated with acceptance of the intervention.We are conducting a randomized controlled trial of a glaucoma question prompt list/video intervention. African American patients with glaucoma were enrolled and assigned to a control group or an intervention group where they watched a video emphasizing the importance of asking questions and received a prompt list to complete before visits. All patients were interviewed after visits and are being followed up for 12 months.One hundred eighty-nine African American patients with glaucoma were enrolled into the larger trial. Of the 93 patients randomized to the intervention group, 89% said that patients should complete the prompt lists before visits, and 87% recommended that patients should watch the video before visits. Older patients were significantly less likely to believe that other patients should watch the video before their visits (t = -3.7, P = .04). Patients with fewer years of education were significantly more likely to rate the video as being more useful than patients with more years of education (Pearson correlation, -0.27; P = .01). Patients who reported being less adherent on the visual analog scale were more likely to rate the video as being more useful (Pearson correlation, -0.23; P = .03).This study demonstrates that the question prompt list/video was accepted by the majority of African American patients who received the intervention.

Introduction Although rates of cigarette smoking among U.S. adolescents have declined, rates of vaping (i.e., using e-cigarettes) have increased. We conducted a secondary analysis of 359 transcripts of medical visits of adolescents with asthma to examine communication about caregiver and adolescent smoking and vaping. Method Adolescents aged 11–17 years with persistent asthma and their parents were enrolled from four pediatric clinics in 2015–2017. Youth were randomized to the intervention or usual care groups. Intervention group adolescents watched a video and then completed an asthma question prompt list before their visits. Results Forty providers and 359 patients participated. Providers, adolescents, and caregivers discussed smoking during 38.2% of their visits. Vaping was never discussed. Discussion There is room to improve how often providers in a primary care setting discuss smoking and vaping. Further investigation might focus on how a smoking and vaping prompt list for adolescents could increase tobacco discussions during visits.

The purpose of this study was to investigate the extent to which adolescent asthma management self-efficacy, outcome expectations, and asthma responsibility were associated with asthma control and quality-of-life. Adolescent self-efficacy and outcome expectations are important components of social cognitive theory, which guided this research.English- and Spanish-speaking adolescents ages 11-17 with persistent asthma were recruited at four pediatric clinics. Adolescents were interviewed and parents completed questionnaires. Multiple linear regression was used to analyze the data.Three hundred and fifty-nine adolescents were recruited. Older adolescent age, male gender, and higher adolescent asthma management self-efficacy were significantly associated with higher adolescent responsibility; outcome expectations were not significantly associated with responsibility. Adolescent ratings of their own responsibility were higher than parent ratings of their child's responsibility for almost all asthma management tasks. Adolescents with higher reported asthma management self-efficacy were significantly more likely to have better quality-of-life and controlled asthma. Adolescents with more positive outcome expectations were significantly more likely to have controlled asthma. Being Native American was associated with worse quality-of-life and asthma not being controlled. Being Black was associated with asthma not being controlled.Parents and providers should work to improve adolescent self-efficacy in managing their asthma because it is associated with asthma responsibility, asthma control, and quality-of-life. Providers need to especially work with Native American and Black adolescents to improve quality-of-life and asthma control.

Purpose The effectiveness of an asthma question prompt list with video intervention to increase question-asking during pediatric office visits among youth who reported medication problems was evaluated. Methods English- or Spanish-speaking youth age 11-17 years with persistent asthma and their caregivers were enrolled from 4 pediatric clinics in a randomized controlled trial. Youth were randomized to intervention or usual care groups. Youth in the intervention group watched an educational video with their caregivers on an iPad. The youth then received a 1-page asthma question prompt list to complete before their visits. The audio of all baseline medical visits was recorded. Youth were interviewed and caregivers completed questionnaires at baseline and 6 months later. Results A total of 40 providers and 359 of their patients participated. Youth who reported at least 1 medication problem who were in the intervention group were significantly more likely to ask 1 or more questions about medications during their visits than youth in the usual care group (odds ratio = 3.1, 95% confidence interval = 2.0, 4.1). Seventy-four percent of youth and 71% caregivers who reported the youth had problems using asthma medications at baseline still reported 1 or more problems 6 months later. Conclusion Among youth who reported 1 or more problems with using their asthma medications, the intervention significantly increased youth question-asking. Many youth- and caregiver-reported problems with using asthma medications persisted over time.

Despite the authority to dispense naloxone, pharmacists have been reluctant to offer and dispense it, often due to discomfort communicating about the sensitive topic of opioid overdose. Because existing online naloxone trainings do not sufficiently address how to communicate effectively with patients about naloxone, Nalox-Comm, a training module designed to improve pharmacists' self-efficacy to engage in naloxone discussions, was developed.To describe the study protocol to evaluate the effectiveness of the Nalox-Comm training module on naloxone dispensing rates.A randomized controlled trial, which began in July 2021, is used to evaluate the pre-post Nalox-Comm training intervention. Sixty pharmacists are being recruited from 62 pharmacies part of a single grocery store chain in rural counties of the southeastern United States. After completing a baseline survey, pharmacists are observed by simulated patients (SPs) who rate the quality of their pre-training naloxone communication. Pharmacists are then invited to complete either a basic online naloxone training module (control group) or a newly developed Nalox-Comm training (experimental group), after which they complete a post-training survey and are observed a second time by SPs. Three months post-training, study participants complete a final follow-up survey. Naloxone dispensing records are obtained from each participating pharmacy to assess change in naloxone dispensing rates.Informed by rural pharmacist stakeholders, the Nalox-Comm training module addresses communication barriers specific to rural communities. Compared to those in the control group, we hypothesize that pharmacies in the experimental group will dispense more naloxone in the three months post-training intervention.

OBJECTIVE: We examined how an asthma question prompt list with video intervention influenced discussion of and provider education about asthma triggers. METHODS: English or Spanish-speaking adolescents ages 11-17 with persistent asthma and their caregivers were enrolled from four pediatric clinics. Adolescents were randomized to the intervention or usual care groups. Adolescents in the intervention group watched the video on an iPad and then completed a one-page asthma question prompt list before their visits. All visits were audio-recorded. Generalized Estimating Equations were used to predict the number of trigger areas discussed and the number of areas providers educated adolescents about during visits. RESULTS: Forty providers and 359 patients participated. Triggers were discussed during 89% of intervention group visits and 81% of usual care visits; providers educated adolescents about triggers during 59% of intervention group visits and 46% of usual care visits. More triggers were significantly more likely to be discussed and providers educated about more trigger areas during visits of adolescents in the intervention group and when adolescents asked one or more questions during visits. More trigger areas were significantly more likely to be discussed if the adolescent was White and male. Providers were significantly more likely to educate adolescents whose family spoke Spanish at home about more trigger areas than adolescents who spoke English at home. CONCLUSIONS: More trigger areas were significantly more likely to be discussed and providers educated about more trigger areas during visits of adolescents who received the intervention and when adolescents asked one or more questions.

Objective We conducted a pragmatic randomized controlled trial to test the effectiveness of an asthma question prompt list with video intervention to increase youth question-asking and provider education during visits. Methods English or Spanish-speaking youth ages 11–17 with persistent asthma and their parents were enrolled from four rural and suburban pediatric clinics. Youth were randomized to the intervention or usual care groups. Intervention group adolescents watched the video on an iPad and then completed an asthma question prompt list before their visits. Generalized estimating equations were used to analyze the data. Results Forty providers and 359 patients participated. Intervention group youth were significantly more likely to ask one or more questions about medications, triggers, and environmental control than usual care youth. Providers were significantly more likely to educate intervention group youth about rescue medications, triggers, and environmental control. Intervention group caregivers were not significantly more likely to ask questions. Conclusion The intervention increased youth question-asking and provider education about medications, triggers, and environmental control. The intervention did not impact caregiver question-asking. Practice implications Providers/practices should consider having youth complete question prompt lists and watch the video with their parents before visits to increase youth question-asking during visits.

Background: Many factors affect youth adherence to asthma medications. Better understanding of the relationship between problems reported by youth in using asthma medications, self-efficacy, outcome expectations, and adherence is needed. Objective: The study examined the relationship between youth and caregiver problems in using asthma medications, asthma management self-efficacy, outcome expectations, and youth- and caregiver-reported adherence to asthma controller medications. Methods: Adolescents with persistent asthma and their caregivers were recruited at 4 pediatric practices. Youth were interviewed after their medical visit while caregivers completed a questionnaire. Multivariable linear regression was used to analyze the data. Results: Of 359 participating youth, 319 were on controller medications. Youth reported 60% average adherence, whereas caregivers reported 69%. Youth who reported difficulty using their inhaler correctly and youth who reported difficulty remembering to take their medications were significantly less likely to be adherent. Caregivers who reported that it was hard to remember when to give the asthma medications were significantly less likely to report their child being adherent. Both youth and caregivers with higher outcome expectations were significantly more likely to self-report being adherent. Conclusions: Pharmacists and other health care providers should consider asking youth and caregivers about problems in using asthma medications, self-efficacy in managing asthma, and outcome expectations for following treatment regimens, so that they can help youth overcome difficulties they might have in managing their asthma.

Background: Atrial fibrillation (AF) is the most common coronary artery bypass graft (CABG) post-operative arrhythmia. This complication can increase the patient’s chances for a more extended hospital stay, stroke, or death; resulting in additional healthcare costs. Prescribing statins (3-hydroxy-3-methylglutaryl COA reductase inhibitors) to reduce the risk of postoperative AF (POAF) is well studied, as they provide an anti-inflammatory and antioxidant benefit within hours of initiation. However, whether the statin type or dose is the origin for these benefits remains unknown; as research is conflicted. Methods: This ten-year retrospective observational study at a single institution, included all patients who underwent an isolated CABG; between January 1, 2005 - December 31, 2015 (n=3,226). For multiple CABG procedure cases, only the first incidence was included. Cases with a pacemaker, history of AF before CABG, or inflammatory disease that requires chronic steroid therapy, were excluded. The final population totaled 1,842 (non-AF n=867; AF n=975) cases, respectively. We analyzed the data using two-sample t-tests and chi-square tests to identify which patient characteristics were significantly associated with having POAF. To keep a representative sample of our study population, variables missing more than 80% of values were excluded. Multiple logistic regression was used to identify which combination of characteristics were most significant and then statin dose and type were each added to the model, individually and together. These two variables were highly correlated, thus for our final model, we used a professional statin dose comparison resource guide to create a dose-intensity variable that considered the type of statin and dose. Patients prescribed no statin was classified as a no dose group, while those prescribed statins were classified into a low, medium or high-intensity dose group. Results: The characteristics associated with a risk of POAF were age, history of vascular disease, and cardiomegaly. While, history of carotid disease, IV heparin within 24 hours of pre-op, and aspirin use were associated with a lower risk of POAF. Patients receiving a high-intensity dose had the lowest rate of POAF (46% vs. 67% for no statin, 57% for low and 53% for moderate, p Conclusion: According to this CABG population analysis, a history of carotid disease, IV heparin within 4 hours of pre-op, and aspirin use were associated with a lower risk of POAF and both statin dose and type are essential factors in POAF prevention. High-intensity dose statins had the lowest rate of POAF, and a one day shorter hospital stay whereas simvastatin had the lowest and atorvastatin had the highest incidence of POAF.

Many adolescents do not obtain the maximum benefit from their asthma medications. Improving patient-provider communication may improve adolescents' asthma knowledge, adherence, and clinical outcomes.To determine how a question prompt list and educational video intervention affect youth- and caregiver-reported medication adherence and self-reported medication problems.Adolescents with persistent asthma (n = 359; 56.4% with moderate to severe asthma) and their caregivers were enrolled in a randomized controlled trial at 4 pediatric clinics. Intervention group families received a question prompt list and watched a short video before seeing the provider; control families received usual care. Youth- and caregiver-reported medication adherence was measured with a Visual Analog Scale, ranging from 0 to 100. Generalized estimating equations were used to determine how the intervention and covariates were associated with medication adherence and reported problems at 12 months.The intervention was not a significant predictor of medication adherence at 12 months. Higher caregiver education was associated with higher youth-reported adherence (β = 1.1; 95% CI = 0.1, 2.1; P = 0.036) and caregiver-reported adherence (β = 1.2; 95% CI = 0.3, 2.0; P = 0.006). The intervention was associated with fewer caregiver-reported problems at 12 months (β = -0.32; 95% CI = -0.48, -0.16; P0.001).A question prompt list and educational video decreased the number of caregiver-reported medication problems, but did not significantly affect medication adherence. Further research is needed to develop more effective interventions to improve medication adherence and outcomes.

OBJECTIVES: The purpose of this study was to: (a) describe the types of medication problems/concerns youth with asthma and their caregivers reported and (b) examine the association between socio-demographic characteristics and youth and caregiver reported medication problems/concerns. METHODS: English-and Spanish-speaking youth ages 11–17 with persistent asthma were recruited at four pediatric clinics. Youth were interviewed and caregivers completed questionnaires about reported asthma medication concerns/problems. Multiple logistic regression was used to analyze the data. RESULTS: Three hundred and fifty-nine youth were recruited. Eighty percent of youth and 70% of caregivers reported one or more problems in using asthma medications. The most commonly reported problems by youth were: (a) hard to remember when to take the asthma medication (54%) and (b) hard to use asthma medication at school (34%). Younger children were significantly more likely to report difficulty in understanding their asthma medication’s directions and difficulty reading the print on the medication’s package. Caregivers’ top-reported problem was that it is hard for their child to remember to take their asthma medications (49%). Caregivers without Medicaid were significantly more likely to express difficulty paying for their child’s asthma medications. CONCLUSIONS: Difficulty remembering to take asthma medication was a significant problem for youth and their caregivers. Providers should work with youth and their caregivers to identify asthma medication problems and discuss strategies to address those problems.

We examined whether six patient-provider communication behaviors directly affected the intraocular pressure (IOP) of glaucoma patients or whether patient medication adherence and eye drop technique mediated the relationship between self-efficacy, communication, and IOP.During an 8-month, longitudinal study of 279 glaucoma patients and 15 providers, two office visits were videotape-recorded, transcribed, and coded for six patient-provider communication behaviors. Medication adherence was measured electronically and IOP was extracted from medical records. We ran generalized estimating equations to examine the direct effects of communication on IOP and used bootstrapping to test whether medication adherence and eye drop technique mediated the effect of communication on IOP.Provider education about medication adherence (B=-0.50, p0.05) and inclusion of patient input into the treatment plan (B=-0.35, p0.05) predicted improved IOP. There was no evidence of significant mediation.The positive effects of provider education and provider inclusion of patient input in the treatment plan were not mediated by adherence and eye drop technique.Providers should educate glaucoma patients about the importance of medication adherence and include patient input into their treatment plan.

Objectives The objective of this study was to examine the extent to which patient characteristics, eye drop technique self-efficacy, and ophthalmologist–patient communication about eye drop administration are associated with glaucoma patients' ability to instil a single drop, have the drop land in the eye, and avoid touching the applicator tip of the medication bottle to the eye or face while self-administering eye drops. Methods Glaucoma patients (n = 279) were recruited from six ophthalmology clinics. Medical visits were videotape-recorded. Afterwards, patients were interviewed and demonstrated administering an eye drop on a videotaped-recording. Generalized estimating equations were used to analyse the data. Key findings Ophthalmologists provided eye drop administration instruction to 40 patients. Patients with more years of education were significantly more likely to both instil a single drop (P = 0.017) and have the drop land in their eye (P = 0.017). Women were significantly more likely to touch the applicator tip to their eyes or face (P = 0.014). Patients with severe glaucoma (P = 0.016), women (P = 0.026), and patients who asked at least one eye drop administration question (P = 0.001) were significantly less likely to instil a single drop. Patients with arthritis were significantly less likely to have the drop land in their eye (P = 0.008). African American patients were significantly less likely to touch the applicator tip to their eyes or face (P = 0.008). Conclusions Some glaucoma patients have a difficult time self-administering eye drops. As so few patients received eye drop administration instruction from their providers, there is an opportunity for pharmacists to complement care.

To examine the associations of provider-patient communication, glaucoma medication adherence self-efficacy, and outcome expectations with glaucoma medication adherence.Prospective, observational cohort study.Two hundred seventy-nine patients with glaucoma who were newly prescribed or taking glaucoma medications were recruited at 6 ophthalmology clinics.Patients' visits were video recorded and communication variables were coded using a detailed coding tool developed by the authors. Adherence was measured using Medication Event Monitoring Systems for 60 days after their visits.The following adherence variables were measured for the 60-day period after their visits: whether the patient took 80% or more of the prescribed doses, percentage of the correct number of prescribed doses taken each day, and percentage of the prescribed doses taken on time.Higher glaucoma medication adherence self-efficacy was associated positively with better adherence with all 3 measures. Black race was associated negatively with percentage of the correct number of doses taken each day (β = -0.16; P0.05) and whether the patient took 80% or more of the prescribed doses (odds ratio, 0.37; 95% confidence interval, 0.16-0.86). Physician education about how to administer drops was associated positively with percentage of the correct number of doses taken each day (β = 0.18; P0.01) and percentage of the prescribed doses taken on time (β = 0.15; P0.05).These findings indicate that provider education about how to administer glaucoma drops and patient glaucoma medication adherence self-efficacy are associated positively with adherence.

We applied the ecologic model of communication in medical consultations to examine how patient, physician, and situational/contextual factors are associated with whether patients ask one or more questions about glaucoma and glaucoma medications during visits to ophthalmologists. Patients with glaucoma who were newly prescribed or already on glaucoma medications were recruited at six ophthalmology clinics. Patients' visits with their doctors were video-recorded and patients were interviewed after visits. Generalized estimating equations were used to analyze the data. Two hundred and seventy-nine patients participated. Patients asked one or more questions about glaucoma during 59% of visits and about glaucoma medications during 48% of visits. Patients who were newly prescribed glaucoma medications were significantly more likely to ask one or more questions about glaucoma and glaucoma medications. Whether providers asked patients if they had questions was not significantly associated with patient question-asking. Patients were significantly more likely to ask older providers questions about glaucoma medications and female providers questions about glaucoma. Eye care providers should encourage glaucoma patients to ask questions during their medical visits.

Objective. The purpose of this study was to examine how patient, physician, and situational factors are associated with the extent to which providers educate patients about glaucoma and glaucoma medications, and which patient and provider characteristics are associated with whether providers educate patients about glaucoma and glaucoma medications.Methods. Patients with glaucoma who were newly prescribed or on glaucoma medications were recruited and a cross-sectional study was conducted at six ophthalmology clinics. Patients’ visits were videotape recorded and patients were interviewed after visits. Generalized estimating equations were used to analyze the data.Results. Two hundred and seventy-nine patients participated. Providers were significantly more likely to educate patients about glaucoma and glaucoma medications if they were newly prescribed glaucoma medications. Providers were significantly less likely to educate African American patients about glaucoma. Providers were significantly less likely to educate patients of lower health literacy about glaucoma medications.Conclusion. Eye care providers did not always educate patients about glaucoma or glaucoma medications.Practice Implications. Providers should consider educating more patients about what glaucoma is and how it is treated so that glaucoma patients can better understand their disease. Even if a patient has already been educated once, it is important to reinforce what has been taught before.

Our objectives were to examine whether providers engage children with asthma in treatment-related discussions at the level children prefer (engagement concordance) and to determine whether engagement concordance is related to child, caregiver, and provider characteristics. Children with asthma ( n = 296) aged 8–16 years were recruited at five pediatric practices in North Carolina. Using audiotaped medical visit transcripts, we documented the number of treatment-related questions the providers asked the children. Children reported their preferred level of provider engagement. A logistic generalized estimating equation was used to determine which variables predicted engagement concordance. Most children (96.6%) wanted to be involved in treatment-related discussions. One-third of the providers did not ask children any treatment-related questions. Only 36.1% of provider–child dyads were concordant. Most discordant dyads were under-engaged (83.1%). Better engagement concordance was observed among older children (odds ratio (OR) = 1.19, 95% confidence interval (CI) (1.07, 1.33)), male children (OR = 1.67, 95% CI (1.03, 2.70)), and among providers with fewer years in practice (OR = .97, 95% CI (.94, .99)). Providers engaged in treatment-related discussions with younger children and females less frequently than these children preferred. Providers should ask children how much they want to be involved in treatment-related discussions and then attempt to engage children at the level they prefer.

ObjectivesThe objectives of the study were to describe the extent to which lay caregivers and children who reported asthma medication problems asked medication questions during their medical visits.MethodsChildren with asthma ages 8 through 16 years and their caregivers were recruited at five paediatric practices and their medical visits were audiotape recorded. Children were interviewed after their medical visits and caregivers completed questionnaires. A home visit was conducted 1 month later. Generalized estimating equations were used to analyse the data.Key findingsTwo hundred and ninety six families participated. Among those caregivers who reported asthma medication problems, only 35% had asked at least one medication question during the visit. Among children who reported asthma medication problems, only 11% had asked at least one medication question during their consultation. Caregivers and children who reported a problem with their asthma medications were significantly more likely to have asked medication questions if providers had asked more questions about control medications. Children who reported higher asthma management self-efficacy were significantly more likely to have asked an asthma medication question.ConclusionsOnly one in three caregivers and one in 10 children who reported an asthma medication problem asked a question during their medical visits and many still reported these problems 1 month later. Pharmacists should encourage caregivers and children to report problems they may be having using their asthma medications.

Objective The objectives of this study were to: (a) describe teen feedback on an asthma question prompt list/video intervention designed to motivate teens to be more engaged during visits and (b) examine teen demographics associated with teen acceptance of the intervention. Methods Two hundred and fifty-nine teens ages 11 to 17 with persistent asthma were enrolled into a randomized, controlled trial and assigned to either a standard care or an intervention group where they watched an educational video with their parents and received a prompt list to complete before visits. Teens were interviewed after visits. Results Of the 185 teens randomized to the intervention group: 93% said teens should complete the prompt lists before visits; 95% recommended teens should watch the video before visits; teens with moderate/severe persistent asthma were significantly more likely to find the prompt list useful; non-White teens were significantly more likely to find the prompt list and video more useful. Conclusions Teens exposed to the question prompt list/video had very positive feedback about the intervention. Practice implications Providers/practices should consider having teens complete question prompt lists during pre-visit wait time for use during visits and watch the video with their parents before visits.

Our objective was to develop a series of short educational videos for teens and parents to watch before pediatric visits to motivate teens to be more actively involved during their visits.The development of the short educational videos was theoretically guided by Social Cognitive Theory. First we conducted four focus groups with teens (ages 11 to 17) with asthma, four focus groups with the teens' parents, and seven focus groups with pediatric providers from four clinics. The research team, which included two teens with asthma and their parents, analyzed the focus group transcripts for themes and then developed the initial video script. Next, a visual storyboard was reviewed by focus groups with parents and four with teens to identify areas of the script for improvement. The English videos were then produced. Focus groups with Hispanic parents and teens were then conducted for advice on how to modify the videos to make a more culturally appropriate Spanish version.Based on focus group results, teen newscasters narrate six one- to two-minute videos with different themes: (a) how to get mom off your back, (b) asthma triggers, (c) staying active with asthma, (d) tracking asthma symptoms, (e) how to talk to your doctor and (f) having confidence with asthma. Each video clip has three key messages and emphasizes how teens should discuss these messages with their providers.Teens, parents, and providers gave us excellent insight into developing videos to increase teen involvement during medical visits.

This study investigated how provider demonstration of and assessment of child use of asthma medication devices and certain aspects of provider-patient communication during medical visits is associated with device technique 1 month later.Two hundred and ninety-six children aged 8-16 years with persistent asthma and their caregivers were recruited at five North Carolina pediatric practices. All of the medical visits were audio-tape recorded. Children were interviewed 1 month later and their device technique was observed and rated.If the provider asked the child to demonstrate metered dose inhaler technique during the medical visit, then the child was significantly more likely to perform a greater percentage of inhaler steps correctly 1 month later. Children with higher asthma management self-efficacy scores were significantly more likely to perform a greater percentage of diskus steps correctly. Additionally, children were significantly more likely to perform a greater percentage of diskus steps correctly if the provider discussed a written action plan during the visit. Children were significantly more likely to perform a greater percentage of turbuhaler steps correctly if they asked more medication questions.Providers should ask children to demonstrate their inhaler technique during medical visits so that they can educate children about proper technique and improve child asthma management self-efficacy. Providers should encourage children to ask questions about asthma medication devices during visits and they should discuss asthma action plans with families.

Objective To examine the frequency with which medication costs are discussed, and the predictors of these discussions, during visits between rheumatologists and their patients with rheumatoid arthritis (RA). Methods Audiotapes of medical visits, patient questionnaires, medical records, and physician questionnaires were collected from March 2003 to December 2005. Data were collected from 200 RA patients from 4 rheumatology clinics. Audiotapes were coded for the presence of communication about medication costs using a detailed coding instrument. The final analysis sample included 193 patients and 8 rheumatologists. Stepwise multivariable logistic regression was used to examine the role of patient, physician, medication, and relationship characteristics on discussions of medication costs. Results Despite medication changes being made in more than 50% of the visits, only 34% of those visits included discussions of medication-related costs; 48% of these discussions were initiated by patients. In multivariable logistic regression models, communication about medication costs occurred more often when patients were white (compared with nonwhite) and reported an annual income of $20,000–$59,999 (compared with those earning ≥$60,000). Discussions about medication costs also were more common when physicians were white. Conclusion Although medication changes were common, medication costs were only discussed in one-third of the visits. Communication about medication costs was more common among patients who were white and in a middle income category. Disparities in communication about medication costs have the potential to negatively impact prescribing and subsequent medication use. Further research should examine potential disparities in communication about medication costs.

The objectives of the study were to (a) describe the different types of problems that patients in southern India reported having when taking their glaucoma medications and (b) examine the relationship between patient reported-problems in taking their glaucoma medications and the self-reported patient adherence. A survey was conducted by clinical staff on 243 glaucoma patients who were on at least one glaucoma medication in an eye clinic in southern India. We found that 42% of patients reported one or more problems in using their glaucoma medications. Approximately 6% of patients reported being less than 100% adherent in the past week. Unmarried patients and patients who reported difficulty squeezing the bottle and difficulty opening the bottle were significantly more likely to report nonadherence.

Objectives The objectives of the study are: (a) to describe the sources of glaucoma patient's medication information and instruction, and (b) to examine the influence of patient characteristics on the sources of medication information and instruction obtained. Setting Four geographically distinct ophthalmology practices in the US. Method A survey assessing receipt of information and instruction on how to use eye drops was completed by 324 patients. Multivariable logistic and ordinal regression were used to analyse the data. Key findings Fifteen per cent of patients stated that no-one gave them information about their glaucoma medications, and 20% of patients stated that no-one showed them how to use their glaucoma medications. Ophthalmologists were the individuals most likely and ophthalmic technicians were the second-most likely to give the patients information and instruction on how to use their medications. Fourteen per cent of patients stated that pharmacists gave them information about their eye drops. Patients very rarely reported pharmacists or primary care physicians showing them how to use their glaucoma medications. Fourteen per cent of patients reported going to the internet for information. Younger patients were significantly more likely to receive information about glaucoma and glaucoma medications from the internet than older patients. Conclusion Patients are receiving information about glaucoma medications from numerous sources, yet almost one out of five glaucoma patients reported receiving no instruction on the instillation of their eye drops. Pharmacists have the opportunity to educate glaucoma patients about using their medications by giving them information and showing them how to administer the medications correctly.

Objective To examine whether rheumatologists and rheumatoid arthritis (RA) patients with depressive symptoms communicate about depression. Methods The data used in this study came from a randomized controlled trial to improve provider-patient communication about patients' agendas. The current secondary analysis used data collected at baseline, before any intervention occurred. A total of 200 RA patients from 4 rheumatology clinics participated in the study. Patient medical visits were audiotape recorded and patients were interviewed after their medical visits. Physicians recorded patients' American College of Rheumatology (ACR) functional status after their visits. Results Twenty-one (11%) patients were scored as having moderately severe to severe symptoms of depression. Patients who were rated by their physicians as having worse ACR functional status were more than twice as likely to have moderately severe to severe symptoms of depression (odds ratio 2.23, 95% confidence interval 1.1–4.6). Only 4 (19%) of the 21 patients who were scored as having moderately severe to severe symptoms of depression discussed depression during their medical visits, and patients initiated the discussion each time. Conclusion Rheumatologists should consider assessing depressive symptoms among their patients, especially among those with worse functional status.

Education about how to administer eye drops may improve a patient’s ability to instill his or her eye drops correctly. Our objectives were to (a) document the methods providers use to educate glaucoma patients about eye drop technique; (b) determine whether eye drop technique education varies by provider and patient characteristics; and (c) evaluate whether education predicts improved patient technique. We conducted an 8-month longitudinal study of 279 glaucoma patients and 15 providers in which we recorded on videotape the content of glaucoma office visits at two time points (baseline and 4- to 6-week follow-up) and videotaped patient eye drop technique at three time points (baseline, 4- to 6-week follow-up, and 8-month follow-up). Mann–Whitney rank sum tests were used to determine whether education was associated with improved patient eye drop technique over time. Ninety-four patients (34%) received technique education at either visit; 31% received verbal education and 10% received a technique demonstration. Only 24 patients (47%) who were new to eye drops received technique education at the baseline visit. Patients who were new to drops at baseline (p = .008) and patients who asked a question about drops (p < .001) were more likely to receive technique education. Education was not associated with improved technique. Eye drop technique education occurs infrequently during glaucoma office visits. Future studies should compare the effectiveness of different educational methods, such as patient demonstration versus provider verbal instruction, to determine which method is best at improving patient eye drop technique.

Little is known about how ophthalmologist-patient communication over time is associated with glaucoma patient long-term adherence. The purpose of our study was to examine the association between provider use of components of the resources and supports in self-management model when communicating with patients and adherence to glaucoma medications measured electronically over an 8-month period. In this longitudinal prospective cohort study, the main variables studied were ophthalmologist communication-individualized assessment, collaborative goal setting and skills enhancement. Patients with glaucoma who were newly prescribed or on glaucoma medications were recruited from six ophthalmology clinics. Patients' baseline and next follow-up visits were videotape-recorded. Patients were interviewed after their visits. Patients used medication event monitoring systems (MEMS) for 8 months after enrollment into the study, and adherence was measured electronically using MEMS for 240 days after their visits. Two hundred and seventy-nine patients participated. Patient race and regimen complexity were negatively associated with glaucoma medication adherence over an 8-month period. Provider communication behaviors, including providing education and positive reinforcement, can improve patient adherence to glaucoma medications over an 8-month period.

For handling missing data, newer methods such as those based on multiple imputation are generally more accurate than older ones and entail weaker assumptions. Yet most do assume that data are missing at random (MAR). The issue of assessing whether the MAR assumption holds to begin with has been largely ignored. In fact, no way to directly test MAR is available. We propose an alternate assumption, MAR+, that can be tested. MAR+ always implies MAR, so inability to reject MAR+ bodes well for MAR. In contrast, MAR implies MAR+ not universally, but under certain conditions that are often plausible; thus, rejection of MAR+ can raise suspicions about MAR. Our approach is applicable mainly to studies that are not longitudinal. We present five illustrative medical examples, in most of which it turns out that MAR+ fails. There are limits to the ability of sophisticated statistical methods to correct for missing data. Efforts to try to prevent missing data in the first place should therefore receive more attention in medical studies than they have heretofore attracted. If MAR+ is found to fail for a study whose data have already been gathered, extra caution may need to be exercised in the interpretation of the results.

Background Inflammatory processes at the mucosal surface may play a role in maintenance of asthma pathophysiology. Cross-sectional studies in asthmatic patients suggest that chemokines such as interleukin 8 (IL-8) are overproduced by respiratory epithelium. Objective To test the hypothesis that chemokine levels are persistently elevated in the respiratory secretions of asthmatic children at a stable baseline. Methods We measured nasal lavage fluid (NLF) levels of chemokines and other mediators at 3- to 4-month intervals in a longitudinal study of asthmatic children, with nonasthmatic siblings as controls. Results In a linear mixed-model analysis, both family and day of visit had significant effects on nasal mediators. Thus, data for 12 asthmatic-nonasthmatic sibling pairs who had 3 or more same-day visits were analyzed separately. For sibling pairs, median eosinophil cationic protein levels derived from serial measurements in NLF were elevated in asthmatic patients compared with nonasthmatic patients, with a near-significant tendency for elevation of total protein and eotaxin levels as well. However, no significant differences were found for IL-8 or several other chemokines. Ratios of IL-13 or IL-5 to interferon-γ released by house dust mite antigen-stimulated peripheral blood mononuclear cells, tested on a single occasion, were significantly increased for asthmatic patients. Conclusions Substantial temporal and family-related variability exists in nasal inflammation in asthmatic children. Although higher levels of eosinophil cationic protein are usually present in NLF of patients with stable asthma compared with patients without asthma, chemokines other than eotaxin are not consistently increased. Eosinophil activation at the mucosal surface is a more consistent predictor of asthmatic symptoms than nonspecific elevation of epithelium-derived inflammatory chemokine levels.

The authors sought to determine the prevalence of diastolic heart failure (DHF) in patients hospitalized with their first stroke, transient ischemic attack, or new onset of peripheral vascular disease. A total of 216 prospective consecutive stroke, transient ischemic attack, and peripheral vascular disease patients (vascular group) were identified at their first noncardiac presentation to a hospital and compared with 164 age-matched control patients (nonvascular group). DHF was clinically defined as the presence of left ventricular ejection fraction>or=45% on echocardiography. DHF occurred in 40% and 73% of vascular and control patients, respectively, with symptomatic heart failure. Overall, it was found in 12% of vascular (10% of stroke/transient ischemic attack, 16% of peripheral vascular disease) and 11% of control patients. Advancing age and female gender were independently associated with the presence of DHF in vascular patients (p

The purpose of the study was to examine the relationship between ethnicity, the presence of moderate to severe symptoms of depression, and communication about emotions and feelings during prenatal visits. The purpose was also to describe women's perceptions of the barriers to communicating with providers, family, and friends about their emotions or feelings and how to overcome these barriers. Seventy-three women were recruited and interviewed by a bilingual research assistant between June and September 2002 after a prenatal visit occurring between 12- and 32-week gestation. Nineteen percent of women screened as having moderate to severe symptoms of depression. Quality of social relationships had a significant negative relationship with whether women had moderate to severe symptoms of depression. Almost 29% of women reported discussing their emotions or feelings with their providers and this did not differ significantly by ethnicity. Women who discussed their emotions or feelings with their providers did have significantly higher scores on the Beck Depression Inventory-II (BDI-II) than those who did not. Thirty-four percent of women stated that there were barriers to expectant or new mothers communicating with their providers. Women who felt that there were barriers to expectant or new mothers discussing their emotions with their providers did have significantly higher BDI-II scores than those women who did not. Thirty-seven percent of women believed that there were barriers to expectant or new mothers communicating with their family about their emotions. Women felt that providers and families could try to develop trust with them and try to make them feel more comfortable discussing their feelings.

African American, Hispanic, and White women between 12 and 32 weeks gestation were recruited to examine their depression treatment preferences. The 73 women who participated were interviewed after their prenatal visit. Nineteen percent of women had symptoms of moderate or severe depression. Women with moderate or severe symptoms of depression were more likely to believe that antidepressants were an acceptable treatment than those without symptoms or with only minor depression symptoms. There were only small differences among the three ethnic groups for antidepressant use preference but most women found them to be unacceptable. In contrast, approximately half of the White women felt that herbal medicines were acceptable compared with 16 and 22 percent for African Americans and Hispanics, respectively. Only 44 percent of African American women felt that counseling from a mental health professional was an acceptable treatment for depression compared to 68 percent for White and 61 percent for Hispanic women. Similarly, African American women were less likely to believe that waiting and getting over depression symptoms naturally was acceptable compared to Hispanic and White women.

Background: Prior studies have produced conflicting results on whether N-acetylcysteine (NAC) reduces the incidence of contrast-induced nephropathy (CIN) in patients undergoing coronary angiography (CA). The dosing regimens of NAC in these studies seemed impractical for everyday clinical practice. Objective:We studied the effect of NAC, with a novel dosing strategy, on serum creatinine concentration (SCr), and the incidence of CIN, in patients who were undergoing CA and/or percutaneous coronary intervention (PCI). Methods: Twenty-five subjects with baseline renal insufficiency who were undergoing CA and/or PCI were randomized to either NAC or placebo.The treatment schedule was 800 mg of NAC 12 h prior to angiography, 600 mg of NAC 2 h prior to angiography, and 600 mg of NAC 6 h after angiography or matching placebo. All subjects were hydrated with 1 ml/kg of 0.45% saline and received non-ionic contrast for angiography. The primary endpoint was change in SCr and the secondary endpoint was the incidence of CIN as defined by an increase of 0.5 mg/dl or 25% in SCr at 48 h. Results:The average SCr at enrollment was 1.7 mg/dl and average dye exposure was 171 ml. The average change in SCr in the NAC and placebo groups was 0.14 and 0.06 mg/dl, respectively (p = 0.60). The incidence of CIN was 18 and 14% in the NAC and placebo groups, respectively (p = 1.0). Conclusion: In this small study, there was no significant difference in the change inSCr nor the incidence of CIN in patients with baseline renal insufficiency undergoing CA and/or PCI who were treated with NAC or placebo.

The prevalence of nontuberculous mycobacteria (NTM) is high (approximately 13%) in sputum of patients with cystic fibrosis (CF), but the impact on lung disease is unknown. We followed 60 incident NTM-positive and 99 culture-negative patients with CF for 15 months and assessed clinical impact of NTM by FEV 1 and high-resolution computed tomography (HRCT) of the chest. Mycobacterium avium complex was seen in 75% of NTM-positive subjects. The annual rate of decline in FEV 1 was not different among control versus NTM-positive subjects who did not, or did, meet American Thoracic Society microbiologic criteria for NTM disease (3 ± 1, 3 ± 2, and 5 ± 2%, respectively). More subjects with three or more positive cultures for NTM had two or more characteristic findings on entry HRCT (60%, 9/15) as compared with subjects with two positive cultures or less (32%) or negative cultures (19%; p < 0.02). All subjects with three or more positive cultures and exit HRCTs (n = 6) showed progression of HRCT findings, whereas only 17% of subjects with two positive cultures or less had progression (p = 0.0006). In summary, no significant short-term effect on FEV 1 was detected in patients with multiple positive NTM cultures, but an abnormal HRCT was predictive of progression. Patients with CF and multiple positive NTM cultures, characteristic HRCT findings, and progression of HRCT changes should be monitored closely and considered for antimycobacterial therapy.

Purpose Glaucoma medications can improve clinical outcomes when patients adhere to their medication regimen. Providers often ask patients with glaucoma to self-report their adherence, but the accuracy of self-reporting has received little scientific attention. The purpose of this article was to compare a self-reported medication adherence measure with adherence data collected from Medication Event Monitoring Systems (MEMS) electronic monitors. An additional goal was to identify which patient characteristics were associated with overreporting adherence on the self-reported measure. Methods English-speaking adult patients with glaucoma were recruited from 6 ophthalmology practices for this observational cohort study. Patients were interviewed after their initial visit and were given MEMS contains, which recorded adherence over a 60-day period. MEMS percent adherence measured the percentage of the prescribed number of doses taken. MEMS-measured timing adherence assessed the percent doses taken on time. Patients self-reported adherence to their glaucoma medications on a visual analog scale (VAS) ~60 days after the baseline visit. Bivariate analyses and logistic regressions were used to analyze the data. Self-reported medication adherence on the VAS was plotted against MEMS adherence to illustrate the discrepancy between self-reported and electronically monitored adherence. Findings The analyses included 240 patients who returned their MEMS containers and self-reported medication adherence at the 60-day follow-up visit. Compared with MEMS-measured percent adherence, 31% of patients (n = 75) overestimated their adherence on the VAS. Compared with MEMS-measured timing adherence, 74% (n = 177) of patients overestimated their adherence. For the MEMS-measured percent adherence, logistic regression revealed that patients who were newly prescribed glaucoma medications were significantly more likely to overreport adherence on the VAS (odds ratio, 3.07 [95% CI, 1.22–7.75]). For the MEMS-measured timing adherence, being male (χ 2 test, 6.78; P = 0.009) and being prescribed glaucoma medications dosed multiple times daily (χ 2 test, 4.02; P = 0.045) were significantly associated with patients overreporting adherence. However, only male sex remained a significant predictor of overreporting adherence in the logistic regression (odds ratio, 4.05 [95% CI, 1.73–9.47]). Implications Many patients with glaucoma, especially those newly diagnosed, overestimated their medication adherence. Because patients were likely to overreport the percent doses taken and timing adherence, providers may want to ask patients additional questions about when they take their glaucoma medications to potentially detect issues with taking these medications on time.

Objective. To examine how often providers discussed asthma action plans with children and their caregivers and child, clinical, and provider characteristics that were associated with those discussions. Method. This was a cross-sectional analysis of audio-recorded visits between 35 general pediatric providers and 260 children (8-16 years old) with asthma and their caregivers. The visits were transcribed into text. The transcripts were coded for discussions about written asthma action plans. Results. Providers discussed written asthma action plans with 21.0% of children and caregivers. Providers were significantly more likely to discuss asthma action plans when the child was enrolled in Medicaid, the visit was asthma related, the visit was longer, the provider was not White, or more provider education. Conclusion. In our sample, providers rarely discussed action plans with children and their caregivers. Providers should discuss asthma action plans with every child with persistent asthma and their caregivers and revise them regularly.

Current survival techniques do not provide a good method for handling clinical trials with a large percent of censored observations. This research proposes using time-dependent surrogates of survival as outcome variables, in conjunction with observed survival time, to improve the precision in comparing the relative effects of two treatments on the distribution of survival time. This is in contrast to the standard method used today which uses the marginal density of survival time, T. only, or the marginal density of a surrogate, X, only, therefore, ignoring some available information. The surrogate measure, X, may be a fixed value or a time-dependent variable, X(t). X is a summary measure of some of the covariates measured throughout the trial that provide additional information on a subject's survival time. It is possible to model these time-dependent covariate values and relate the parameters in the model to the parameters in the distribution of T given X. The result is that three new models are availabl...

OBJECTIVE: Our objectives were to examine how certain aspects of provider-patient communication recommended by national asthma guidelines (ie, provider asking for child and caregiver input into the asthma treatment plan) were associated with child asthma medication adherence 1 month after an audio-taped medical visit. METHODS: Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at 5 pediatric practices in nonurban areas of North Carolina. All medical visits were audio-tape recorded. Children were interviewed 1 month after their medical visits, and both children and caregivers reported the child’s control medication adherence. Generalized estimating equations were used to determine if communication during the medical visit was associated with medication adherence 1 month later. RESULTS: Children (n = 259) completed a home visit interview ∼1 month after their audio-taped visit, and 216 of these children were taking an asthma control medication at the time of the home visit. Children reported an average control medication adherence for the past week of 72%, whereas caregivers reported the child’s average control medication adherence for the past week was 85%. Child asthma management self-efficacy was significantly associated with both child- and caregiver-reported control medication adherence. When providers asked for caregiver input into the asthma treatment plan, caregivers reported significantly higher child medication adherence 1 month later. CONCLUSIONS: Providers should ask for caregiver input into their child’s asthma treatment plan because it may lead to better control medication adherence.

Background. Few studies have explored how providers communicate about control medications during pediatric asthma visits.Objectives. The purpose of this study was to: (a) describe the extent to which providers discuss, educate, and ask children and their caregivers questions about control medications and (b) examine how child, caregiver, and provider characteristics are associated with provider communication about control medications during pediatric asthma visits.Methods. Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at five pediatric practices in nonurban areas of North Carolina. After audio-tape recording medical visits, caregivers completed questionnaires and children were interviewed. Generalized estimating equations were used to analyze the data.Results. Providers educated families about control medications during 61% of the visits, and they asked questions about control medications during 67% of visits. Providers were significantly more likely to discuss control medications if a child was taking a control medication, if the child had moderate to severe persistent asthma, and if the child was present for an asthma-related visit.Conclusion. Providers need to educate and ask more questions of families about side effects and how well control medications are working.

OBJECTIVE: The purposes of this study were to (a) describe the extent to which children use metered dose inhalers, turbuhalers, diskuses, and peak flow meters correctly, and (b) investigate how often providers assess and demonstrate use of metered dose inhalers, turbuinhalers, diskuses, and peak flow meters during pediatric asthma visits. PATIENTS AND METHODS: Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at 5 pediatric practices in nonurban areas of North Carolina. All of the medical visits were audiotape-recorded. Children were interviewed after their medical visits, and their device technique was observed and rated by the research assistants. RESULTS: Of the patients, 296 had useable audiotape data. Only 8.1% of children performed all of the metered dose inhaler steps correctly. Older children were more likely to get more of the metered dose inhaler steps correct. Of the children, 22% performed all of the diskus steps correctly, 15.6% performed all of the turbuhaler steps correctly, and 24% performed all of the peak flow meter steps correctly. The majority of providers did not demonstrate or assess child use of metered dose inhalers, turbuhalers, diskuses, or peak flow meters during pediatric asthma visits. CONCLUSIONS: There is a need for providers to demonstrate proper asthma medication and monitoring device techniques to children and to have children demonstrate to proficiency. The 2007 National Heart, Lung, and Blood Institute expert panel report on the diagnosis and management of asthma encourages providers to educate children on these techniques.