Asthma is a chronic disorder that causes significant morbidity and mortality and requires ongoing chronic care. Approximately two‐thirds of people with asthma are receiving care from a primary care clinician, such as an internist, family practitioner, nurse practitioner, or pediatrician. The other one‐third of patients are obtaining treatment and ongoing care from specialists, including allergists or pulmonologists. The outcomes of asthma care are a subject of intense investigation. Many studies focus on pharmacotherapy, allergen control, and asthma education as interventions to reduce the morbidity and costs associated with asthma. Fewer studies have explored the differences in outcomes between asthmatic patients cared for by specialists compared with generalists. Even fewer have explored the practice differences between generalists and specialists that may relate to outcomes of care. With the advent of national asthma guidelines and the high prevalence of asthma seen in primary care settings, it is important to investigate the knowledge, attitudes, and practices of primary care physicians with regard to asthma.
OBJECTIVE To describe the predictive relationships of selected sociodemographic, biomedical, and psychosocial variables to reluctance to use insulin among patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 178 patients with type 2 diabetes participated in this cross-sectional, observational study. Data were obtained by patient interview using validated measures of diabetes attitude, knowledge, self-efficacy, care communication, and perceived barriers to treatment, as well as sociodemographic and biomedical data. RESULTS Women and ethnic minorities with type 2 diabetes have more psychological barriers to insulin treatment (P < 0.05). The final regression model showed that individuals who believed in the value of tight glucose control, had strong self-efficacy, and had better interpersonal processes with their healthcare providers were less reluctant to use insulin treatment (R2 = 0.403; P < 0.0001). CONCLUSIONS Diabetes self-efficacy and better interaction with clinicians were important in decreasing patients' reluctance to use insulin, known as psychological insulin resistance.
The objective of this work was to describe the incidence of chronic breathing problems, particularly asthma-related breathing problems, in a cross-section of the United States population and to assess the perceived impact of these problems on daily living. An initial screening survey was used in a nationwide panel of 30,000 households; an in-depth follow-up questionnaire was sent to a random sample of respondents who reported a breathing problem. A sample (n = 2685) of respondents who reported persistent cough, shortness of breath, or wheezing within the previous 2 years were sent a newly developed questionnaire. A subsample (n = 723) of respondents reported a primary diagnosis of asthma and of these, 59.4% were female and 90.2% were white. Their mean age was 37.4 years. Respondents (n = 723) characterized their level of perceived asthma control as completely controlled, well controlled, somewhat controlled, or poorly/not controlled. At least 31% of those with a perception of some control and 59% of those with a perception of poor/no control reported their breathing problems had increased in the last year. Those who perceived their asthma-related breathing problems as poorly controlled reported significantly greater symptom frequency, activity restriction, fears and concerns about their breathing difficulties, less helpful coping strategies, and less confidence in their doctor's ability to care for them. Responses to many of the questions indicated that the worst levels of disease control were associated with poorer quality of life and a more negative perception of the disease and its effects on daily living. A significant portion of the U.S. population appears to suffer from chronic breathing problems; this requires confirmation and further exploration to reduce the potential mortality and morbidity due to asthma in the United States.
Bory de Saint-Vincent’s set As well as offering her exsiccata for sale, Libert gave away sets to friends as gifts. One such she presented to Bory. A letter from Libert bestowing the third fascicle on Bory is transcribed and translated into English here for the first time (Fig. 3, Appendix 3).1 The letter is written in carefully formed copperplate hand-writing, and in a highly formal tone. Thanking Bory for a ‘present magnifique’ (magnificent present) which she does not identify, Libert claims that the fascicle is a token of her esteem and respect for Bory, and ‘toute l’ardeur de mon zele [sic] pour vous obliger’ (all my desire to oblige you). So anxious was Libert to fulfill what she saw as a duty to Bory, that she apologises for not sending the fascicle sooner owing to ‘un accident survenu a mon relieur’ (an accident that occurred to my bookbinder). Libert does not name Bory in her letter, referring to him only as ‘Monsieur le Colonel’. We have identified ‘the Colonel’ as Bory on the basis of Libert’s known contacts with him, and because Bory held the rank of ‘Colonel’ in the French army under the leadership of Napoleon Bonaparte (Lauzun 1908). Bory’s set at MEL Bory’s set of Libert’s exsiccata probably remained in his personal herbarium during his lifetime. In 1847, a year after his death, Botanische Zeitung announced the forthcoming sale of Bory’s herbarium, exclaiming ‘Plus riche ni plus belle collection cryptogamique n’a jamais ete offerte aux amateurs’ (a richer or more
Effective asthma treatment requires long-term inflammation control. Patient adherence to corticosteroid treatment regimens remains problematic. Leukotriene modifiers, a newer drug class, add to the pharmacologic approaches to asthma management. Here, we review the role of leukotrienes in asthma pathogenesis and appropriate uses for leukotriene modifiers in asthma management.
The HITECH Act signed into law in 2009 requires hospitals to provide patients with electronic access to their health information through an electronic personal health record (ePHR) in order to receive Medicare/Medicaid incentive payments. Little is known about who uses these systems or the impact these systems will have on patient outcomes in HIV care. The health care empowerment model provides rationale for the hypothesis that knowledge from an electronic personal health record can lead to greater patient empowerment resulting in improved outcomes. The objective was to determine the patient characteristics and patient activation, empowerment, satisfaction, knowledge of their CD4, Viral Loads, and antiretroviral medication, and medication adherence outcomes associated with electronic personal health record use in Veterans living with HIV at the San Francisco VA Medical Center. The participants included HIV-Infected Veterans receiving care in a low volume HIV-clinic at the San Francisco VA Medical Center, divided into two groups of users and non-users of electronic personal health records. The research was conducted using in-person surveys either online or on paper and data abstraction from medical records for current anti-retroviral therapy (ART), CD4 count, and plasma HIV-1 viral load. The measures included the Patient Activation Measure, Health Care Empowerment Inventory, ART adherence, provider satisfaction, current CD4 count, current plasma viral load, knowledge of current ART, knowledge of CD4 counts, and knowledge of viral load. In all, 40 participants were recruited. The use of electronic personal health records was associated with significantly higher levels of patient activation and levels of patient satisfaction for getting timely appointments, care, and information. ePHR was also associated with greater proportions of undetectable plasma HIV-1 viral loads, of knowledge of current CD4 count, and of knowledge of current viral load. The two groups differed by race and computer access. There was no difference in the current CD4, provider satisfaction, Health Care Empowerment Inventory score, satisfaction with provider-patient communication, satisfaction with courteous and helpful staff, knowledge of ART, or ART adherence. The use of electronic personal health records is associated with positive clinical and behavioral characteristics. The use of these systems may play a role in improving the health of people with HIV. Larger studies are needed to further evaluate these associations.
Objective. To describe what adult patients with asthma report about their experiences with their own self-management behavior and working with their clinicians to control asthma. Methods. The study sample consisted of 104 patients with persistent asthma participating in a clinical trial on asthma monitoring. All subjects were seen by primary care clinicians of a large, academic medical center. This qualitative post hoc analysis examined the views of adults with asthma about their asthma-related health care. Patients attended monthly visits as part of their study participation, during which data were derived from semistructured interviews. All patients included in this analysis participated in the study for 1 year. At the end of study participation, patients were asked to complete an evaluation of their clinician's communication behavior. All study clinicians were also asked to complete a self-evaluation of their own communication behavior. Results. Five major themes of barriers to successful self-management were identified, including personal constraints, social constraints, communication failures, medication issues, and health care system barriers to collaboration with their clinicians. Patients most frequently reported lack of communication surrounding issues relating to day-to-day management of asthma (31%) and home management of asthma (24%). Clinicians generally rated themselves well for consistency in showing nonverbal attentiveness (89%) and maintaining interactive conversations (93%). However, only 30% of clinicians reported consistency in helping patients make decisions about asthma management and only 33% of clinicians reported consistency in tailoring medication schedules to the patient's routines. Conclusion. These findings emphasize the difficulties of establishing and maintaining a therapeutic partnership between patients and clinicians. The results underscore the need for system-wide interventions that promote the success of a therapeutic patient-clinician relationship in order to achieve long-term success in chronic disease management.
The prevalence of asthma among working adults continues to rise each year. The California Department of Health Services conducts surveillance of work related asthma (WRA) to classify each work related exposure using Doctor's First Reports of Occupational Illness and Injury (DFRs). Using a cross-sectional, descriptive, comparative design, additional interviews were conducted and medical records were reviewed to explore workers' and providers' perceptions of follow up care. Two cohorts were compared: workers with WRA who belonged to a large, single HMO (n = 79) and workers with WRA who underwent follow up outside this HMO (n = 76). The interview asked about providers seen, tests ordered, and the impact of asthma on work. The HMO clients were significantly more likely than the non-HMO clients to see occupational medicine specialists (p = .004) and have pulmonary function testing (p = .049) during initial treatment. Twenty-four percent of clients currently working reported missed workdays caused by asthma in the past 6 months. The findings indicate management of WRA varies by health care system in California.
