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Integrating Web-based computer cases into a required clerkship: development and evaluation.

Purpose To evaluate a five-year experience (1995–2000) developing and integrating computer cases into a required clerkship. Method In Study 1, 54 volunteer students were randomly assigned to study articles, a paper case, or a computer case on low back pain/kidney stones. Students were given an exam immediately after the exercise and one week later. In Study 2, 325 clerkship students were asked to select and complete two computer cases or to prepare assignments on unrelated topics. Among the cases offered were two test cases on low back pain/kidney stones and pneumonia. Questions specific to the computer test cases (CC) and other noncomputer cases (NCC) were in the final exam. Exam scores related to CC questions and NCC questions were compared between the groups of students who did and did not complete the computer cases. Students also rated the computer cases on a questionnaire. Results In Study 1, reading articles required the most time and received the most negative comments. The students who completed the computer case scored the best on the exam one week later. In Study 2, the students who completed the two computer cases scored significantly higher on the CC questions than did students who studied only one or none of the computer cases (p < .001). There was no difference among groups for the NCC scores (p = .76). Students rated the computer cases with a mean of 6 on a seven-point scale (7 = strongly agree). Conclusion Computer cases are effective learning tools, are well-received by students, and can be successfully integrated into existing clerkships.

Diabetes nurse case management and motivational interviewing for change (DYNAMIC): results of a 2-year randomized controlled pragmatic trial.

The aim of the present study was to determine whether the addition of nurse case managers (NCMs) trained in motivational interviewing (MI) to usual care would result in improved outcomes in high‐risk type 2 diabetes patients.

A Positive Deviance Approach to Understanding Key Features to Improving Diabetes Care in the Medical Home

PURPOSE The medical home has gained national attention as a model to reorganize primary care to improve health outcomes. Pennsylvania has undertaken one of the largest state-based, multipayer medical home pilot projects. We used a positive deviance approach to identify and compare factors driving the care models of practices showing the greatest and least improvement in diabetes care in a sample of 25 primary care practices in southeast Pennsylvania. METHODS We ranked practices into improvement quintiles on the basis of the average absolute percentage point improvement from baseline to 18 months in 3 registry-based measures of performance related to diabetes care: glycated hemoglobin concentration, blood pressure, and low-density lipoprotein cholesterol level. We then conducted surveys and key informant interviews with leaders and staff in the 5 most and least improved practices, and compared their responses. RESULTS The most improved/higher-performing practices tended to have greater structural capabilities (eg, electronic health records) than the least improved/lower-performing practices at baseline. Interviews revealed striking differences between the groups in terms of leadership styles and shared vision; sense, use, and development of teams; processes for monitoring progress and obtaining feedback; and presence of technologic and financial distractions. CONCLUSIONS Positive deviance analysis suggests that primary care practices’ baseline structural capabilities and abilities to buffer the stresses of change may be key facilitators of performance improvement in medical home transformations. Attention to the practices’ structural capabilities and factors shaping successful change, especially early in the process, will be necessary to improve the likelihood of successful medical home transformation and better care.

Effects of a Web-Based Patient Activation Intervention to Overcome Clinical Inertia on Blood Pressure Control: Cluster Randomized Controlled Trial

Background Only approximately half of patients with hypertension have their blood pressure controlled, due in large part to the tendency of primary care providers (PCPs) not to intensify treatment when blood pressure values are elevated. Objective This study tested the effect of an intervention designed to help patients ask questions at the point of care to encourage PCPs to appropriately intensify blood pressure treatment. Methods PCPs and their patients with hypertension (N=500) were recruited by letter and randomized into 2 study groups: (1) intervention condition in which patients used a fully automated website each month to receive tailored messages suggesting questions to ask their PCP to improve blood pressure control, and (2) control condition in which a similar tool suggested questions to ask about preventive services (eg, cancer screening). The Web-based tool was designed to be used during each of the 12 study months and before scheduled visits with PCPs. The primary outcome was the percentage of patients in both conditions with controlled blood pressure. Results Of 500 enrolled patients (intervention condition: n=282; control condition: n=218), 418 (83.6%) completed the 12-month follow-up visit. At baseline, 289 (61.5%) of participants had controlled blood pressure. Most (411/500, 82.2%) participants used the intervention during at least 6 of 12 months and 222 (62.5%) reported asking questions directly from the Web-based tool. There were no group differences in asking about medication intensification and there were no differences in blood pressure control after 12 months between the intervention condition (201/282, 71.3%) and control condition (143/218, 65.6%; P=.27) groups. More intervention condition participants discussed having a creatinine test (92, 52.6% vs 49, 35.5%; P=.02) and urine protein test (81, 44.8% vs 21, 14.6%; P<.001), but no group differences were observed in the rate of testing. The control condition participants reported more frequent discussions about tetanus and pneumonia vaccines and reported more tetanus (30, 13.8% vs 15, 5.3%; P=.02) and pneumonia (25, 11.5% vs 16, 5.7%; P=.02) vaccinations after 12 months. Conclusions The use of an interactive website designed to overcome clinical inertia for hypertension care did not lead to improvements in blood pressure control. Participant adherence to the intervention was high. The control intervention led to positive changes in the use of preventive services (eg, tetanus immunization) and the intervention condition led to more discussions of hypertension-relevant tests (eg, serum creatinine and urine protein). By providing patients with individually tailored questions to ask during PCP visits, this study demonstrated that participants were likely to discuss the questions with PCPs. These discussions did not, however, lead to improvements in blood pressure control. Trial Registration ClinicalTrials.gov NCT00377208; http://clinicaltrials.gov/ct2/show/NCT00377208 (Archived by WebCite at http://www.webcitation.org/6IqWiPLon).

Relationship between Depression and Treatment Satisfaction among Patients with Type 2 Diabetes

BACKGROUND: Depression has been shown to adversely affect glycemic control. The purpose of this study is to examine the association between depression and treatment satisfaction in patients with diabetes. MATERIALS AND METHODS: Baseline data was collected on 545 patients with poorly controlled type 2 diabetes enrolled in a study that examined the effectiveness of diabetes nurse case managers. Depression was measured using the Center for Epidemiologic Studies Depression (CES-D) questionnaire, and treatment satisfaction, using the Diabetes Treatment Satisfaction Questionnaire (DTSQ). RESULTS: The majority of participants (59%) were female, with a high percentage (41%) of Hispanic/Latino participants with a mean HbA1C of 8.4%. The prevalence of depression in this population was 35.6%. High CES-D scores were associated with elevated levels of HbA1C and LDL cholesterol (p<0.001). The relationship between depression and treatment satisfaction was significant (p<0.001), indicating that as depression increases, treatment satisfaction decreases. DISCUSSION: We identified a significant relationship between depression and treatment satisfaction in this group of poorly controlled type 2 diabetes patients. Although causation cannot be determined, it is possible that patients who are depressed are less likely to be satisfied with their treatment. This could lead to decreased patient adherence, ultimately resulting in poor glycemic control.

Vanished Twins and Misdiagnosed Sex: A Case Report with Implications in Prenatal Counseling Using Noninvasive Cell-Free DNA Screening

Cell-free DNA testing is a recently introduced method for screening pregnant women for fetal trisomy, which is associated with some common significant genetic diseases, as well as the sex of the fetus. The case described here demonstrates the connection between the ultrasound “vanishing twin” phenomenon and the misdiagnosis of prenatal sex using cell-free DNA testing.