An office-based intervention to maintain parent-adolescent teamwork in diabetes management. Impact on parent involvement, family conflict, and subsequent glycemic control.
(9/982)
OBJECTIVE: To design and evaluate an office-based intervention aimed at maintaining parent-adolescent teamwork in diabetes management tasks without increasing diabetes-related family conflict. RESEARCH DESIGN AND METHODS: There were 85 patients (aged 10-15 years, mean 12.6 years) with type 1 diabetes (mean duration 5.5 years; mean HbA1c 8.5%) who were randomly assigned to one of three study groups--teamwork, attention control, and standard care--and followed for 24 months. At each visit, parent involvement in insulin administration and blood glucose monitoring was assessed. The teamwork and attention control interventions were integrated into routine ambulatory visits over the first 12 months (four medical visits). Measures of diabetes-related family conflict were collected at baseline and after 12 months. All patients were followed for an additional 12 months with respect to glycemic control. RESULTS: In the teamwork group, there was no major deterioration (0%) in parent involvement in insulin administration, in contrast to 16% major deterioration in the combined comparison (attention control and standard care) group (P < 0.03). Similarly, no teamwork families showed major deterioration in parent involvement with blood glucose monitoring versus 11% in the comparison group (P < 0.07). On both the Diabetes Family Conflict Scale and the Diabetes Family Behavior Checklist, teamwork families reported significantly less conflict at 12 months. An analysis of HbA1c over the 12- to 24-month follow-up period indicated that more adolescents in the teamwork group (68%) than in the comparison group (47%) improved their HbA1c (P < 0.07). CONCLUSIONS: The data demonstrate that parent involvement in diabetes management tasks can be strengthened through a low-intensity intervention integrated into routine follow-up diabetes care. Moreover, despite increased engagement between teen and parent centered around diabetes tasks, the teamwork families showed decreased diabetes-related family conflict. Within the context of a broader cultural recognition of the protective function of parent involvement in the lives of adolescents, the findings of this study reinforce the potential value of a parent-adolescent partnership in managing chronic disease. (+info)
Clinic visits and hospital admissions for care of acid-related upper gastrointestinal disorders in women using alendronate for osteoporosis.
(10/982)
CONTEXT: About 1 in 3 women taking alendronate for osteoporosis report gastrointestinal symptoms, a rate much higher than that found during clinical trials. OBJECTIVE: To establish the frequency of outpatient visits and hospital admissions for acid-related upper gastrointestinal disorder (ARD) among women taking alendronate and to identify potential risk factors. METHODS: A retrospective database analysis identified 812 women with osteoporosis who had filled one or more 10-mg alendronate prescriptions from October 1995 through October 1996. RESULTS: One hundred (12.3%) of the 812 women received healthcare for ARD, a clinical encounter rate of 28.5 per 100 person-years. A reference group of 362,109 women from the same health plan had 17.6 ARD encounters per 100 person-years. Excluding women who had ARDs before receiving alendronate, alendronate users were 1.6 (95% CI = 1.2, 2.7) times more likely to have an ARD encounter than nonusers. Risk of having ARD increased with age [users aged 70 years and older had a relative risk of 1.5 (95% confidence interval (CI) 1.0-2.30) compared with younger women] and with concurrent use of nonsteroidal anti-inflammatory drugs (NSAIDS) (relative risk 1.7, 95% CI 1.1-2.6). CONCLUSIONS: Elderly alendronate users or those concurrently taking NSAIDS should be carefully monitored because of their high risk of having ARD. Cost/benefit analyses of alendronate treatment for osteoporosis should include costs of treating ARD. (+info)
When should this patient be seen again?
(11/982)
CONTEXT: The decision about when to ask a patient to return to the clinic for his or her next visit is common to all outpatient encounters in longitudinal care. It directly affects provider workloads and has a potentially great impact on health care costs and outcomes. GENERAL QUESTION: What are the effects of lengthening or shortening revisit intervals (the recommended period between one visit and the next) on health status and health care costs? SPECIFIC RESEARCH CHALLENGE: How can we change the average revisit interval while preserving provider input for individual patients? PROPOSED APPROACH: Patients could be randomly assigned to either short or long revisit intervals. So that provider input would be preserved, providers would select from among three discrete categories of revisit intervals: near-term (1 to 2 months); intermediate-term (2 to 4 months); and long-term (4 to 8 months). On the basis of randomization, patients would receive appointments at either the lower or the upper bound of the category selected. POTENTIAL DIFFICULTIES: Because blinding would be almost impossible, providers might "game" randomization at subsequent visits. ALTERNATE APPROACHES: A comparison of shorter and longer revisit intervals might be achieved with less direct approaches. In one such approach, patients would be randomly assigned to 1) having an appointment made immediately after the initial visit or 2) calling back for an appointment according to the interval recommended by the provider. In another approach, patient panel size would be held constant and providers would be randomly assigned to either an increased or a reduced number of clinic sessions. (+info)
Treatment of type 2 diabetes mellitus.
(12/982)
Type 2 diabetes mellitus (formerly called non-insulin-dependent diabetes) causes abnormal carbohydrate, lipid and protein metabolism associated with insulin resistance and impaired insulin secretion. Insulin resistance is a major contributor to progression of the disease and to complications of diabetes. Type 2 diabetes is a common and underdiagnosed condition that poses treatment challenges to family practitioners. The introduction of new oral agents within the past three years has expanded the range of possible combination regimens available for treating type 2 diabetes. Despite the choice of pharmacologic agents, physicians must stress the nonpharmacologic approaches of diet modification, weight control and regular exercise. Pharmacologic approaches must be based on patient characteristics, level of glucose control and cost considerations. Combinations of different oral agents may be useful for controlling hyperglycemia before insulin therapy becomes necessary. A stepped-care approach to drug therapy may provide the most rational, cost-efficient approach to management of this disease. Pharmaco-economic analyses of clinical trials are needed to determine cost-effective treatment strategies for management of type 2 diabetes. (+info)
Characteristics of nurse-midwife patients and visits, 1991.
(13/982)
OBJECTIVES: This study describes the patient populations served by and visits made to certified nurse-midwives (CNMs) in the United States. METHODS: Prospective data on 16,729 visits were collected from 369 CNMs randomly selected from a 1991 population survey. Population estimates were derived from a multistage survey design with probability sampling. RESULTS: We estimated that approximately 5.4 million visits were made to nearly 3000 CNMs nationwide in 1991. Most visits involved maternity care, although fully 20% were for care outside the maternity cycle. Patients considered vulnerable to poor access or outcomes made 7 of every 10 visits. CONCLUSIONS: Nurse-midwives substantially contribute to the health care of women nationwide, especially for vulnerable populations. (+info)
Access to care for the uninsured: is access to a physician enough?
(14/982)
OBJECTIVES: This study examined a private-sector, statewide program (Kentucky Physicians Care) of care for uninsured indigent persons regarding provision of preventive services. METHODS: A survey was conducted of a stratified random sample of 2509 Kentucky adults (811 with private insurance, 849 Medicaid recipients, 849 Kentucky Physicians Care recipients). RESULTS: The Kentucky Physicians Care group had significantly lower rates of receipt of preventive services. Of the individuals in this group, 52% cited cost as the primary reason for not receiving mammography, and 38% had not filled prescribed medicines in the previous year. CONCLUSIONS: Providing free access to physicians fills important needs but is not sufficient for many uninsured patients to receive necessary preventive services. (+info)
Reduced utilization and cost of primary care clinic visits resulting from self-care education for patients with osteoarthritis of the knee.
(15/982)
OBJECTIVE: To determine the extent to which the cost of an effective self-care intervention for primary care patients with knee osteoarthritis (OA) was offset by savings resulting from reduced utilization of ambulatory medical services. METHODS: In an attention-controlled clinical trial, 211 patients with knee OA from the general medicine clinic of a municipal hospital were assigned arbitrarily to conditions of self-care education (group E) or attention control (group AC). Group E (n = 105) received individualized instruction and followup emphasizing nonpharmacologic management of joint pain. Group AC (n = 106) received a standard public education presentation and attention-controlling followup. A comprehensive clinical database provided data concerning utilization and cost of health services during the following year. RESULTS: Only 25 subjects (12%) were lost to followup. The 94 subjects remaining in group E made 528 primary care visits during the year following intervention, compared with 616 visits by the 92 patients remaining in group AC (median visits 5 versus 6, respectively; P < 0.05). Fewer visits translated directly into reduced clinic costs in group E, relative to controls (median costs [1996 dollars] $229 versus $305, respectively; P < 0.05). However, self-care education had no significant effects on utilization and costs of outpatient pharmacy, laboratory, or radiology services over the ensuing year. The cost per patient to deliver the self-care intervention was estimated to be $58.70. CONCLUSION: Eighty percent of the cost of delivering effective self-care education to the knee OA patients in this study was offset within 1 year by the reduced frequency and costs of primary care visits. For >50% of patients receiving the intervention, the savings associated with fewer primary care visits exceeded the cost of self-care education. (+info)
Black-white differences in disability and morbidity in the last years of life.
(16/982)
To assess black-white differences in disability and morbidity in the last years of life, the authors analyzed data from the National Health Interview Survey from 1986 to 1994, with mortality follow-up through December 1995. A baseline household interview was conducted for 10,187 decedents aged 50 years and over within 2 years before death. Data collected included long-term limitation of activity, number of chronic conditions, number of bed days, doctor visits, and days of short hospital stay during the year preceding the interview. For both blacks and whites, educational attainment was inversely associated with disability/morbidity indices. Black decedents had greater morbidity compared with whites, and this difference was consistent across educational levels. Adjustment for education reduced the black-white difference in limitation of activity score by 32%, bed days by 59%, and hospital stay days by 40%. This study from a national representative US sample indicates that black decedents experienced greater disability/morbidity and worse quality of life through their last few months or years of life. Educational attainment was associated with morbidity before death and accounted for much of the black-white difference. (+info)