Exposure to Tobacco Smoke and Chronic Asthma Symptoms

The objective was to determine if tobacco exposure is associated with year-round asthma symptoms. We analyzed baseline data from a multistate survey of 896 pediatric patients with asthma participating in a randomized controlled trial. Daytime symptoms, nocturnal symptoms, and limitations in activity because of asthma tend to increase during the winter season (p < 0.05 for all comparisons, except spring to winter daytime symptoms). One hundred forty of 896 (16%) children had year-round symptoms (i.e., active asthma symptoms during every season). Using separate multivariate analyses, we found that having a parent who smokes (odds ratio [OR]: 2.22; 95% confidence interval [CI]: 1.35, 3.64) or a member of the household who smokes (OR: 1.94; 95% CI: 1.29, 2.93) was associated with a higher likelihood of year-round symptoms, controlling for region of residence, insurance status, and use of a daily controller medication. Asthma symptoms are more likely to increase in the winter season. In anticipation of these patterns, clinicians should consider initiating controller medication therapy or reinforcing asthma education prior to these time periods for those patients at risk for seasonal exacerbations. Exposure to tobacco smoke is associated with year-round asthma symptoms, highlighting the importance of health care providers identifying and counseling about smoking cessation, especially for children with year-round asthma symptoms. (Pediatr Asthma Immunol 2005; 18[4]:180–188.)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63404/1/pai.2005.18.180.pd

Pediatricians' perspectives on the impact of MRSA in primary care: a qualitative study

<p>Abstract</p> <p>Background</p> <p>The incidence of skin and soft-tissue infections (SSTIs) has rapidly increased among children in primary care settings since the emergence of community-associated methicillin-resistant <it>Staphylococcus aureus </it>(CA-MRSA). Recent treatment recommendations emphasize CA-MRSA as the primary cause, performing incision and drainage (I&D) as the primary therapy, and not prescribing antibiotics for uncomplicated cases. It is unknown how this epidemic has impacted primary care pediatricians in terms of their practice patterns and barriers they face to providing recommended therapies.</p> <p>Methods</p> <p>3 Focus groups among 29 primary care pediatricians in the San Francisco Bay Area were conducted. Transcripts were reviewed and coded into major themes by two investigators using modified grounded theory.</p> <p>Results</p> <p>Substantial changes in clinical practice have occurred since the emergence of CA-MRSA. These include increased office visits for SSTIs, patients with multiple recurrences and transmission within households. Additionally, our participants reported increased visits for mild skin problems due to media reports contributing to fears about CA-MRSA. Participants routinely prescribed antibiotics for SSTIs, however, few performed I&D. Few were aware of recent SSTI treatment recommendations. Barriers to prescribing antibiotics with CA-MRSA activity included concerns about side-effects and lack of local epidemiologic data showing that it is the primary etiology. Barriers to performing I&D included lack of training, resources and skepticism about its necessity. Important clinical challenges included increased time demands for follow-up visits and patient education along with the lack of evidence-based strategies for preventing recurrent inections and household transmission.</p> <p>Conclusion</p> <p>CA-MRSA has influenced the presentation and treatment of SSTIs especially in terms of case numbers and recurrences. Barriers to providing recommended therapies can be addressed through improved dissemination of treatment guidelines and epidemiologic data. Studies are urgently needed toimprove theevidence-base for treatment and prevention strategies.</p

Patient attitudes toward using computers to improve health services delivery

BACKGROUND: The aim of this study was to examine the acceptability of point of care computerized prompts to improve health services delivery among a sample of primary care patients. METHODS: Primary data collection. Cross-sectional survey. Patients were surveyed after their visit with a primary care provider. Data were obtained from patients of ten community-based primary care practices in the spring of 2001. RESULTS: Almost all patients reported that they would support using a computer before each visit to prompt their doctor to: "do health screening tests" (92%), "counsel about health behaviors (like diet and exercise)" (92%) and "change treatments for health conditions" (86%). In multivariate testing, the only variable that was associated with acceptability of the point of care computerized prompts was patient's confidence in their ability to answer questions about their health using a computer (beta = 0.39, p = .001). Concerns about data security were expressed by 36.3% of subjects, but were not related to acceptability of the prompts. CONCLUSIONS: Support for using computers to generate point of care prompts to improve quality-oriented processes of care was high in our sample, but may be contingent on patients feeling familiar with their personal medical history

Prioritizing WHO normative work on maternal and perinatal health: a multicountry survey

<p>Abstract</p> <p>Background</p> <p>WHO develops evidence-based guidelines for setting global standards and providing technical support to its Member States and the international community, as a whole. There is a clear need to ensure that WHO guidance is relevant, rigorous and up-to date. A key activity is to ascertain the guidance needs of the countries. This study provides an international comparison of priority guidance needs for maternal and perinatal health. It incorporates data from those who inform policy and implementation strategies at a national level, in addition to targeting those who use and most need the guidance at grassroot level.</p> <p>Methods</p> <p>An online multi-country survey was used to identify WHO guidance priorities for the next five years in the field of maternal and perinatal health. WHO regional and country offices were requested to respond the survey and obtain responses from Ministries of Health around the world. In addition, the survey was disseminated through other networks and relevant electronic forums.</p> <p>Results</p> <p>A total of 393 responses were received, including 56 from Ministries of Health and 54 from WHO/UN country offices. 75% of responses were from developing countries and 25% from developed countries. Guidance on strategies focusing on 'quality of care' issues to reduce all-cause maternal/perinatal mortality was considered the most important domain to target, which includes for instance guidance to improve access, dissemination, implementation of effective practices and health professionals' education.</p> <p>Conclusions</p> <p>This study provides a panorama of international priority guidance needs for maternal and perinatal health. Although clinical guidance remains a priority, there are other areas related to health systems guidance, which seem to be even more important. Overall, the domain ranked highest in terms of greatest need for guidance was around quality of care, which included questions related to educational needs, access to and implementation of guidance.</p

Partner randomized controlled trial: study protocol and coaching intervention

<p>Abstract</p> <p>Background</p> <p>Many children with asthma live with frequent symptoms and activity limitations, and visits for urgent care are common. Many pediatricians do not regularly meet with families to monitor asthma control, identify concerns or problems with management, or provide self-management education. Effective interventions to improve asthma care such as small group training and care redesign have been difficult to disseminate into office practice.</p> <p>Methods and design</p> <p>This paper describes the protocol for a randomized controlled trial (RCT) to evaluate a 12-month telephone-coaching program designed to support primary care management of children with persistent asthma and subsequently to improve asthma control and disease-related quality of life and reduce urgent care events for asthma care. Randomization occurred at the practice level with eligible families within a practice having access to the coaching program or to usual care. The coaching intervention was based on the transtheoretical model of behavior change. Targeted behaviors included 1) effective use of controller medications, 2) effective use of rescue medications and 3) monitoring to ensure optimal control. Trained lay coaches provided parents with education and support for asthma care, tailoring the information provided and frequency of contact to the parent's readiness to change their child's day-to-day asthma management. Coaching calls varied in frequency from weekly to monthly. For each participating family, follow-up measurements were obtained at 12- and 24-months after enrollment in the study during a telephone interview.</p> <p>The primary outcomes were the mean change in 1) the child's asthma control score, 2) the parent's quality of life score, and 3) the number of urgent care events assessed at 12 and 24 months. Secondary outcomes reflected adherence to guideline recommendations by the primary care pediatricians and included the proportion of children prescribed controller medications, having maintenance care visits at least twice a year, and an asthma action plan. Cost-effectiveness of the intervention was also measured.</p> <p>Discussion</p> <p>Twenty-two practices (66 physicians) were randomized (11 per treatment group), and 950 families with a child 3-12 years old with persistent asthma were enrolled. A description of the coaching intervention is presented.</p> <p>Trial registration</p> <p>ClinicalTrials.gov identifier <a href="http://www.clinicaltrials.gov/ct2/show/NCT00860834">NCT00860834</a>.</p

Management of abnormal uterine bleeding by northern, rural and isolated primary care physicians: PART II: What do we need?

BACKGROUND: Abnormal uterine bleeding (AUB) is a common problem that affects one in five women during the pre-menopausal years. It is frequently managed by family physicians, especially in northern, rural and isolated areas where severe shortages of gynecologists exist. METHODS: We surveyed 194 family physicians in northern, rural and isolated areas of Ontario, Canada to determine their educational and resource needs for the management of AUB, with a specific focus on the relevance and feasibility of using clinical practice guidelines (CPGs). RESULTS: Most physicians surveyed did not use CPGs for the management of AUB because they did not know that such guidelines existed. The majority were interested in further education on the management of AUB through mailed CPGs and locally held training courses. A major theme among respondents was the need for more timely and effective gynecological referrals. CONCLUSION: A one-page diagnostic and treatment algorithm for AUB would be easy to use and would place minimal restrictions on physician autonomy. As the majority of physicians had Internet access, we recommend emailing and web posting in addition to mailing this algorithm. Local, hands-on courses including options for endometrial biopsy training would also be helpful for northern, rural and isolated physicians, many of whom cannot readily take time away from their practices