Cynthia Willey

Stages of change for reducing dietary fat to 30% of energy or less

OBJECTIVE To develop an algorithm that defines a persons stage of change for fat intake < or = 30% of energy. The Stages of Change Model describes when and how people change problem behaviors; change is defined as a dynamic variable with five discrete stages. DESIGN A stage of change algorithm for determining dietary fat intake < or = 30% of energy was developed using one sample and was validated using a second sample. SUBJECTS Sample 1 was a random sample of 614 adults who responded to mailed questionnaires. Sample 2 was a convenience sample of 130 faculty, staff, and graduate students. STATISTICS Subjects in sample 1 were initially classified in a stage of change using an algorithm based on their behavior related to avoiding high-fat foods. Dietary markers were selected for a Behavioral algorithm using logistic regression analyses. Sensitivity, specificity, and predictive value of the Behavioral algorithm were determined, then compared between samples using the Z test. RESULTS The following dietary markers predicted intake < or = 30% of fat (chi 2 = 131; P < .0001): low-fat cheese, breads without added fat, chicken without skin, low-calorie salad dressing, and vegetables for snacks. The specificity of the Behavioral algorithm was validated; the algorithm classified subjects consuming > 30% of energy from fat with 93% specificity in sample 1 and 87% in sample 2 (Z = 1.36; P > .05). Predictive value was also validated; 64% and 58% of subjects meeting the behavioral criteria had fat intakes < or = 30% of energy (Z = 1.1; P > .05). The algorithm was not sensitive, however; most subjects with fat intakes < or = 30% of energy from fat failed to meet the behavioral criteria. The sensitivity differed between samples 1 and 2 (44% and 27%, respectively; Z = 3.84; P < .0001). APPLICATIONS The Behavioral algorithm determines stage of change for fat reduction to < or = 30% of energy in populations with high fat intakes. The algorithm could be used in dietary counseling to tailor interventions to a patients stage of change.

An academic detailing intervention to disseminate physician-delivered smoking cessation counseling: smoking cessation outcomes of the Physicians Counseling Smokers Project.

BACKGROUND Little is known about the effectiveness of interventions to disseminate smoking cessation interventions among a population of primary care physicians. This studys objective was to determine the effect of a community-based academic detailing intervention on the quit rates of a population-based sample of smokers. METHODS This community-based, quasi-experimental study involved representative samples of 259 primary care physicians and 4295 adult smokers. An academic detailing intervention was delivered to physicians in intervention areas over a period of 15 months. Analyses were performed on the data from the 2346 subjects who reported at least one physician visit over 24 months. Multivariate regression analyses were conducted to determine the impact of the intervention on self-reported smoking quit rates, reported by adjusted odds ratios. RESULTS Among smokers reporting a physician visit during the study period, there was a borderline significant effect for those residing in intervention areas versus control areas (OR = 1.35; 95% CI.99-1.83; P = 0.057). Among a subgroup of 819 smokers who reported a visit with an enrolled physician, we observed a significant effect for those residing in intervention areas (OR = 1.80; 95% CI 1.16-2.75; P = 0.008). CONCLUSION An academic detailing intervention to enhance physician delivered smoking cessation counseling is an effective strategy for disseminating smoking cessation interventions among community-based practices.

Compliance-Related Problems in the Ambulatory Population

When prescription drugs are taken in the correct dose and the correct manner, they have great potential for improving the quality of medical care, but inappropriate and incorrect administration of these drugs can lead to severe health problems. Risk factors for problems related to prescription drug compliance were examined in a cross-sectional retrospective study (n = 1017) of ambulatory individuals who had undergone a Brown Bag Prescription Evaluation Program consultation. A pharmacist interviewer assessed drug-related problems such as duplication of drug product, overutilization and underutilization of medication, drug interactions, and side effects. Associations between specific medication-related problems and patient characteristics (demographics, medical history, and insurance status) were studied. Factors that appear to be associated with compliance problems include a patients level of understanding of both medication instructions and the drug therapy, length of time since last physician visit, length of time on medication, total number of medications, and number of drug allergies. The class of medication taken was also found to be a significant predictor of excess risk. The age and sex of an individual appear to have little association with the development of compliance-related problems. The study reinforces the need for frequent patient contact with a health care professional and the value of educating the patient about the medication regimen.

Assessing the transtheoretical model of change constructs for physicians counseling smokers.

Baseline data from a population-based sample of 259 primary care physicians were used to examine the interrelations of 3 central constructs of the Transtheoretical Model of Change (TTM; stages of change, self-efficacy, and decisional balance) in regard to smoking cessation counseling behavior. In this article we explore the potential use of the TTM for future interventions to help understand and guide physicians ’ behavior change toward increasing adoption of smoking cessation interventions with their patients. It was hypothesized that self-efficacy and the decisional balance of counseling would be significantly related to physicians’ stages of change, which in turn would be related to self-reported physician counseling behavior. Principal components analyses were conducted to examine the self-efficacy and decisional balance constructs. Coefficient alphas were .90 for self-efficacy and .84 and. 78 for the pros and cons scales, respectively. Consistent with the TTM, analyses of variance revealed that later stages of physicians ’ readiness to provide smoking cessation counseling were associated with higher self-efficacy scores. Earlier stages showed significantly higher cons and lower pros of smoking cessation counseling. Structural equation modeling procedures supported the hypothesized path analysis model in which 3 constructs related to stage of readiness, which in turn related to reported physicians ’ counseling behavior.

Prevalence of autosomal dominant polycystic kidney disease in the European Union.

Background Autosomal dominant polycystic kidney disease (ADPKD) is a leading cause of end-stage renal disease, but estimates of its prevalence vary by >10-fold. The objective of this study was to examine the public health impact of ADPKD in the European Union (EU) by estimating minimum prevalence (point prevalence of known cases) and screening prevalence (minimum prevalence plus cases expected after population-based screening). Methods A review of the epidemiology literature from January 1980 to February 2015 identified population-based studies that met criteria for methodological quality. These examined large German and British populations, providing direct estimates of minimum prevalence and screening prevalence. In a second approach, patients from the 2012 European Renal Association‒European Dialysis and Transplant Association (ERA-EDTA) Registry and literature-based inflation factors that adjust for disease severity and screening yield were used to estimate prevalence across 19 EU countries (N = 407 million). Results Population-based studies yielded minimum prevalences of 2.41 and 3.89/10 000, respectively, and corresponding estimates of screening prevalences of 3.3 and 4.6/10 000. A close correspondence existed between estimates in countries where both direct and registry-derived methods were compared, which supports the validity of the registry-based approach. Using the registry-derived method, the minimum prevalence was 3.29/10 000 (95% confidence interval 3.27-3.30), and if ADPKD screening was implemented in all countries, the expected prevalence was 3.96/10 000 (3.94-3.98). Conclusions ERA-EDTA-based prevalence estimates and application of a uniform definition of prevalence to population-based studies consistently indicate that the ADPKD point prevalence is <5/10 000, the threshold for rare disease in the EU.

Development of Stage of Readiness and Decisional Balance Instruments: Tools to Enhance Clinical Decision-Making for Adherence to Antiretroviral Therapy

This study presents the development of Stage of Readiness (SOR) and decisional balance instruments based on the Transtheoretical Model of Behavior Change (TTM) to improve adherence to antiretroviral therapy (ART). These instruments were tested on HIV positive women who enrolled in an adherence support study at a womens HIV clinic at a mid-western medical school. The decisional balance instrument was analyzed and 8 of 11 items were retained. These items were validated by follow-up administration of the instrument. Baseline stage of change and decisional balance scores prospectively predicted 1-year viral load level, thus identifying participants in need of adherence support interventions. Use of these instruments can give a provider added objective data on which to base a decision to either prescribe ART immediately or to first implement an intervention tailored to enhance this patients readiness to adhere.

Stages of change for adherence to antiretroviral medications.

Providers do not predict reliably which of their HIV-positive patients are having difficulty adhering to antiretroviral therapy (ART). The transtheoretical, or stages of change model, may be a useful tool to help providers identify patients who are having difficulty with ART adherence. The objective of the current study was to determine the relationship between stages of change and ART adherence among patients who were actively taking ART. Data from a randomized trial of a provider-focused intervention were used to examine the relationship between the stages of change and adherence, measured using electronic monitoring devices in the 30 days following the stages of change assessment. Individuals were eligible for inclusion if they were taking ART and had detectable plasma viral load (HIV-RNA). Repeated measures analysis of covariance was used to determine the impact of stages of change on adherence after controlling for potential confounders. The sample of 137 participants was 22% female, 48% white, 28% African-American, with a mean age of 42 years. Fifty-eight percent reported sex with a man as an HIV risk factor, while 13% reported sex with a woman, 14% reported injecting drugs and 15% reported other risk factors. In adjusted models, those in earlier stages of change (i.e., contemplation and preparation) had significantly lower adherence (-9.8%, p=0.04) compared to those in the action and maintenance phases. No demographic characteristics predicted adherence. The stages of change model may function as a screening tool for clinicians to discover patients at-risk of lower adherence.

Distinguishing Between the Fit and Frail Elderly, and Optimising Pharmacotherapy

SummaryFrail older patients are at risk for adverse consequences from medications or other external stresses. No single marker, such as age or physical disability, or laboratory test can identify this group of patients. As a result, screening questionnaires have been developed and successfully used by nurses to help identify frail older patients upon admission to a hospital. A very short, 7-item screen with questions concerning cognitive ability, physical mobility, nutrition, number of medications used and hospitalisation within the previous month, was able to identify those patients who were more likely to be discharged to a nursing home, die, or incur a large hospitalisation cost for the institution.While the number of medications used was not an independent predictor of the outcome measures studied (e.g. discharge to a nursing home), data from the literature show that the number of medications prescribed is related to iatrogenic complications in older patients, and specific impairments in mobility and cognition. The proper choice and prescribed dose of a medication is extremely important in frail older patients who, for instance, are at increased risk from hip fracture with some benzodiazepines, and who have markedly diminished clearance of some drugs. A systematic approach is suggested for the prescription of medications in frail older persons which will help achieve optimal pharmacotherapy by using a limited number of medications, thoughtfully selecting medications which will not impair function, and prescribing an appropriate dose based on pharmacodynamic and pharmacokinetic changes that occur with age.

Patient education provided to asthmatic children: a historical cohort study of the implementation of NIH recommendations

NIH guidelines for treatment of childhood asthma emphasize educating both patients and family about avoiding triggers and providing information to support self-management of asthma. To determine the extent to which primary care providers had implemented these recommendations, we examined the patient education provided to a cohort of asthmatic children (n = 331) between January and December 1994. During 1994 education of any type was documented for less than half the children. Provision of education was associated with asthma severity: An action plan for exacerbations was discussed with the majority with moderate or severe asthma (61%). Avoiding triggers (aOR: 2.38, 95% CI: 1.37–4.12) and treatment goals (aOR: 3.14, 95% CI: 1.46–6.75), were more likely to be discussed with children who were prescribed inhaled anti-inflammatory medication, after adjustment for asthma severity and age. Limited implementation of the NIH recommendations by primary care providers in our study may have reduced their impact on the management of childhood asthma.

Changing Trends in Antihypertensive Therapy in Two New England Communities During the 1980s

The prevalence rates and correlates of antihypertensive drug use among individuals with hypertension were determined using data derived from five biennial population‐based surveys conducted between 1981 and 1990 in two New England communities. Point prevalence estimates were determined for nine categories of antihypertensive agents at five time points, and were analyzed by age and sex using multiple logistic regression. In the first cross‐sectional survey, the prevalence of use per 1000 individuals with hypertension was 235.4 for diuretics, 57.1 for β‐blockers, 65.5 for combination products, 29.2 for central α‐agonists, 2.8 for peripheral α‐antagonists, and 8.4 each for adrenergic blockers and direct vasodilators. The prevalence rates for calcium channel blockers and angiotensin‐converting enzyme inhibitors increased sharply between the third and fourth survey cycles. Significant age‐ and sex‐related differences in antihypertensive use were detected.