Nevertheless, if we accept that the conclusions are correct, the study suggests that successful follow-up is determined not so much by who performs it than by what is done. First, the diagnosis should be confirmed. In the study Nathan et al, the diagnosis of nearly 10% of patients who were apparently hospitalized for asthma was not confirmed, although the correct diagnoses for those patients are not presented. Second, studies have documented that the following factors, which could be addressed on a follow-up appointment, are related to an increased risk of asthma-related emergency department visits or hospitalizations: inadequate asthma knowledge; not having an action plan; incorrect use of me-tered-dose inhalers; adverse environmental exposures, especially regarding environmental tobacco smoke and mites’; and adverse psychosocial circumstances.
Category Archives: Asthma
Forty-seven intervention patients were randomized to follow-up by one pediatric respirologist, and 48 patients continued to receive regular care from their family physician or pediatrician. Intervention subjects had less school absenteeism than control subjects (mean, 10.7 vs 16.0 days, respectively; p = 0.04), but there were no significant differences in the rates of hospitalizations or emergency department visits during the study year. However, fewer days were spent in the hospital by the intervention patients compared to control patients (mean, 3.7 vs 11.2 days, respectively; p = 0.02). Castro et al reported the results of a nurse specialist intervention program in asthmatic patients with a history of frequent health-care use. The intervention group consisted of 50 patients, and 46 patients who continued their usual care with their private primary care physician were assigned to the control group. canadian health care mall
Asthma caused an average of 467,000 hospitalizations per year between 1995 and 2002. Most asthma hospitalizations are preceded by an emergency department visit (Emergency Medicine Network; unpublished data), and asthma accounts for a total of nearly 1.8 million emergency department visits per year. Although exact figures are not available, many of these emergency asthma visits are preventable. Since a prior asthma hospitalization or emergency department visit is the strongest risk factor for subsequent emergency hospital utiliza-tion, follow-up after an asthma hospitalization or emergency department visit presents a golden opportunity for tertiary prevention. However, there are substantial knowledge gaps regarding the type of follow-up that will significantly improve asthma outcomes.
Participants highlighted a number of points that they believed formed the basis of patient-focused care (Table 3). Patients are more likely to be motivated to follow treatment advice if they perceive the recommendations to be a common sense approach to maintaining health, and if they have a clear appreciation of the nature of their illness and an understanding of treatment risks and benefits. It is also important to consider that the management of chronic disease differs from that of an acute illness, so clinicians must be prepared to work in an ongoing partnership with patients to ensure that they are offered a clear rationale as to why inhaled corticosteroids are necessary, and to address their concerns about potential adverse effects. This approach, the basis of which is a detailed examination of patients’ perspectives on asthma and its treatment, and an open, nonjudgmental manner on the part of the clinician, is consistent with the idea of concordance. It also fits in with other recent initiatives, such as the “expert patient,” and shared decision making.
The effectiveness of this approach has been demonstrated in the development of an asthma center specifically developed to target patients with diffi-cult-to-control asthma. Adult patients with more than two emergency department visits within the last 6 months were referred by their primary care pro-vider. Interventions included an initial evaluation by asthma center personnel, spirometry and skin allergy testing, the development of treatment and follow-up plans after discussion of the patient by team members, extensive patient education, and establishment of a relationship with one of the asthma center nurses and physicians. Statistical analysis was not presented in this abstract report, but some of the results have obvious clinical and economic relevance. An analysis of 125 patients found that 90% rated their visit to the asthma center “very good” or “excellent.” Based on prescriptions filled, there was a reduction in the ratio of (3-agonist use vs inhaled corticosteroid use (ratio of 1.65 before vs 1.05 after). website
This study was a qualitative retrospective assessment of depositions and indicated that the decision to litigate was often associated with a perceived lack of caring and/or collaboration in the delivery of healthcare. Problematic relationship issues between the doctor and patient were identified in 71% of the depositions. These could be categorized by four themes: deserting the patient (32%), devaluing patient and/or family views (29%), delivering information poorly (26%), and failing to understand the patient and/or family perspective (13%). The postoutcome consulting specialist was named in 71% of the depositions in which malpractice was alleged. These results imply that if more attention had been focused on the physician/patient interaction, particularly at the postoutcome consultation, litigation could have been avoided in many of these cases. this
Pulmonary disease has one of the lowest levels of patient adherence for any area of medicine. In a meta-analysis of 569 studies, pulmonary disease ranked fifteenth out of 17 different disease conditions for adherence, with a mean adherence rate of 68.8%. Only diabetes (67.5%) and sleep disorders (65.5%) ranked worse. Adherence is discussed in detail elsewhere in this Supplement (see the article by Horne). However, as an example of the importance of patient-focused care to adherence, it is worth mentioning that in the Medical Outcomes Study, general adherence and adherence to medication, exercise, and diet recommendations in diabetic, hypertensive, and heart disease patients were related to the following: physician job satisfaction (general adherence), number of patients seen per week (medication), scheduling a follow-up appointment (medication), tendency to answer patients’ questions (exercise), number of tests ordered (diet), seriousness of illness (diet), physician specialty (medication, diet), and patient health distress (medication, exercise). All of these factors, except physician specialty and seriousness of illness, can be influenced within the framework of patient-focused care.
In asthma, there is evidence that a patient-focused approach can be learned and applied to improve both parents’ view of physicians’ behavior and health outcomes. Clark et al evaluated the long-term impact of an interactive physician seminar based on the principles of patient self-regulation, clinician behavior, children’s use of asthma services, and parents’ evaluations of physician performance. The seminar focused on the development of physician communication and teaching skills, and used the therapeutic recommendations from the National Asthma Education and Prevention Program guidelines. Follow-up assessment of 34 physicians completing the program and 33 control subjects was accomplished by self-administered surveys, telephone interviews with parents of their patients, and review of patients’ medical records. Figure 2 shows the impact of the education program on physician behavior approximately 2 years after intervention. fully
The effect of patient centeredness and a positive approach on patient satisfaction and health outcomes was evaluated in a UK study of 661 patients who completed a postconsultation questionnaire. The goals of the study were to determine the importance of patient centeredness to patient satisfaction, patient enablement, and symptom burden 1 month after the consultation. Independent predictors of high patient satisfaction were communication and partnership (p < 0.001) and a positive approach from the physician (p < 0.001). High patient enablement was independently predicted by the patients’ perception of the doctors’ interest in the effect of the problem on their lives (p = 0.001), health promotion (p < 0.001), and a positive approach (p < 0.001). At 1 month after consultation, patient-assessed symptom burden was improved with a positive approach (p = 0.004). The authors concluded that patients want a patient-centered, positive approach, and if they receive this approach they are more satisfied, have greater enablement, and have greater improvement in their symptom burden. sildenafil citrate pink
Levenstein et al introduced the concept of a “patient agenda” as playing a pivotal role in physician understanding. The physician’s agenda is the explanation of the patient’s illness in terms of a taxonomy of disease and prescription of treatment as necessary. In a disease-centered model, only this agenda is addressed. However, in a patient-focused model, the patient’s agenda should be elicited and addressed as well. Patients may not actively voice their agendas, and the physician needs to be receptive to cues from patients and to enact behavior that encourages them to express their feelings, beliefs, and concerns. However, physicians are not always skilled in eliciting patients’ agendas. For example, Barry et al interviewed 35 patients prior to a primary care consultation to determine their agendas and evaluated the consultation as to whether the patients’ agendas were actually voiced. There was a total of 188 agenda items expressed in the preconsultation interviews, 73 of which were unvoiced during the interview (38.8%). All patients had more than one agenda item, and most had five or more items, and only four patients (11.4%) voiced all of their agenda items. The frequency of voiced vs unvoiced agenda items is shown in Figure 1. Most of the unvoiced agenda items were psychosocial, but some patients failed to mention symptoms and other biomedical information. canadian health&care mall