Julie Wright

Impact of Health Literacy on Health Outcomes in Ambulatory Care Patients: A Systematic Review

Objective To examine the relationship between low health literacy and disease state control and between low health literacy medication adherence in the primary caro setting. Data Sources: The following databases were searched for relevant articles from date of inception to April 2008: The Cochrane Database of Systematic Reviews, Cumulative Index to Nursing & Allied Health Literature, EMBASE, Education Resources Information Center, PsyclNFO, International Pharmaceutical Abstracts, and Iowa Drug Information Service. MEDLINE was searched from 1966 to April 2008. Key words included literacy, health literacy, health education, educational status, disease outcomes, health outcomes, adherence, medication adherence, and patient compliance. Additional articles were identified by reviewing reference sections of retrieved articles. Study Selection And Data Extraction: Studies using a validated measure of health literacy and performing statistical analysis to evaluate the relationship between health literacy and disease state control or medication adherence were evaluated. Data Synthesis: Eleven evaluations, including 10 discrete studies, met eligibility criteria. Six studies evaluated the relationship between health literacy and disease state control, 3 evaluated health literacy and medication adherence, and 1 study evaluated health literacy and both outcomes. A quality rating of poor, fair, or good was assigned to each study based on the study question, population, outcome measures, statistical analysis, and results. Eight studies had good quality, 1 was fair, and 2 were poor. Two high-quality studies demonstrated statistically significant relationships with health literacy, 1 with disease state control and 1 with medication adherence. Limitations of the other studies included inadequate sample size, underrepresentation of patients with low health literacy, use of less objective outcome measures, and insufficient statistical analysis. Conclusions: There may be a relationship between health literacy and disease state control and health literacy and medication adherence. Future research, with adequate representation of patients with low health literacy, is needed to further define this relationship and explore interventions to overcome the impact that low health literacy may have on patient outcomes.

Mexiletine in the Symptomatic Treatment of Diabetic Peripheral Neuropathy

OBJECTIVE: To evaluate the efficacy and safety of mexiletine in the symptomatic treatment of diabetic peripheral neuropathy (DPN). METHODS: In this prospective, double-blind study, 29 patients were randomized to receive mexiletine 600 mg/d or matching placebo for 3 weeks. A four-item symptom score (FIS), which rated pain, dysesthesias, paresthesias, and nightly exacerbations of symptoms, and a 100-mm visual analog scale (VAS), which rated pain intensity, were completed by patients before and after treatment. At the end of treatment independent patient and investigator global assessments were made. Patients reported adverse effects after 1 and 3 weeks of treatment. RESULTS: Treatment groups were similar at baseline. The difference between the median changes in FIS scores (mexiletine = 5.5, placebo = 2) was not statistically significant. Overall symptom response was similar in both treatment groups as demonstrated by both global assessments (p = 0.19). The mean change in VAS score from baseline to posttreatment was determined for both groups and the difference between these mean scores was 16.5 mm (95% CI, −7.1 to 40.2 mm) (p = 0.16). Inadequate statistical power (1 — β = 0.40) may have resulted from small sample size, small magnitude of effect, or variability in the measured effect. Adverse effects were more common in the mexiletine group, though not statistically significant. One patient receiving mexiletine was hospitalized for palpitations. CONCLUSIONS: Because of conflicting reports of mexiletines efficacy in the treatment of symptomatic DPN, this drug should be reserved for patients unresponsive or intolerant to standard therapy, without evidence of heart disease, and with sensations of burning, heat, formication, or stabbing pain.

Nsaid Use and Efficacy in the Emergency Department: Single Doses of Oral Ibuprofen versus Intramuscular Ketorolac:

OBJECTIVE: To compare the clinical efficacy of single doses of intramuscular ketorolac and oral ibuprofen in the emergency department (ED) treatment of acute pain. DESIGN: A retrospective analysis of data collected during a prospective survey of pain management efficacy. The design was noninterventional, and therapy was selected by the treating physician independent of the trial. SETTING: Urban teaching hospital adult patient emergency department. PARTICIPANTS: A convenience sample of ED patients in acute pain. INTERVENTIONS: Patients received ibuprofen 800 mg po (n=95), or ketorolac 60 mg im (n=30) as a single dose. Therapy was selected by the treating physician and was not influenced by the study. RF.8ULTS: Data collected were a 100-mm visual analog pain scale at patient arrival and discharge, verbal description of pain relief, patient demographics, pain management data, and discharge diagnosis. Baseline pain intensity was higher in patients receiving ketorolac (77 mm median) than in those receiving ibuprofen (65 mm, p=0.02). Pain relief was similar (p=0.29) with either treatment when assessed by visual analog scale or patient definition of pain relief. CONCLUSIONS: A single dose of either nonsteroidal antiinflammatory drug produced similar pain relief in the general ED population during clinical treatment of pain. Ketorolac should not necessarily be considered a more effective analgesic than ibuprofen in these commonly used doses.

Review of the symptomatic treatment of diabetic neuropathy.

References were selected from a MEDLINE search from 1966–1993 for literature evaluating the drug therapy of diabetic peripheral neuropathy (DPN). The search was limited to studies evaluating symptomatic treatment, and methods were developed to include only well‐designed clinical trials. Many recommendations for the symptomatic treatment of DPN appear in the medical literature, but are frequently based on case reports, information extrapolated from other neuropathic pain syndrome models, or treatment protocols lacking scientific methods. These recommendations include antidepressants, sodium channel antagonists, topical capsaicin, and miscellaneous agents. Antidepressants are considered to be the first choice in these patients. Factors to consider in establishing a regimen are interpretation of studies, adverse drug effects, drug‐drug and drug‐disease interactions, convenience of administration, and cost of therapy. Potentially effective alternatives were determined from the reviewed trials.

Psychosocial Characteristics and Sexual Behaviors of People in Care for HIV Infection: An Examination of Men Who Have Sex with Men, Heterosexual Men and Women

Few studies have examined the psychosocial factors associated with sexual transmission behaviors among HIV-positive men who have sex with men (MSM), heterosexual men (MSW) and women. We enrolled 1,050 sexually active HIV-positive patients at seven HIV clinics in six US cities as part of a clinic-based behavioral intervention. We describe the sexual transmission behaviors and examine demographic, clinical, psychosocial, and clinic prevention variables associated with unprotected anal or vaginal intercourse (UAVI). Twenty-three percent of MSM, 12.3% of MSW and 27.8% of women engaged in UAVI with partners perceived to be HIV-negative or of unknown serostatus. Among MSM and MSW, having multiple partners and lower self-efficacy were associated with increased odds of UAVI. Self-rating one’s health status as excellent/very good was a risk factor for UAVI among MSM. Among women, binge drinking and stressful life events were associated with UAVI. These findings identify variables that warrant attention in targeted interventions.

Autonomous Regulation and Locus of Control as Predictors of Antiretroviral Medication Adherence

The purpose of the current study was to examine the interrelationships between autonomous regulation (AR) and locus of control (LOC) and their prediction of Antiretroviral Therapy (ART) adherence among 189 HIV+ patients. Path analyses revealed that neither AR nor LOC directly predicted adherence although AR was indirectly related when mediated by self-efficacy. AR was positively related to internal and doctors LOC, but not related to chance or others LOC. Overall, results support Self-determination Theorys conceptualization of AR and indicate that AR may be a more robust predictor of medication adherence than LOC variables.

Current Strategies for the Prevention and Treatment of Disseminated Mycobacterium avium Complex Infection in Patients with AIDS

Disseminated Mycobacterium avium complex (MAC) infection is a common opportunistic disease in patients with acquired immunodeficiency syndrome and is associated with significant morbidity and mortality. Macrolides effectively prevented and treated the disease in clinical trials. In general, prophylaxis with clarithromycin or azithromycin is indicated for patients with CD4 cell counts below 50 cells/mm3. Treatment of disseminated MAC infection is lifelong and must include two agents with antimycobacterial activity. Clarithromycin plus ethambutol is considered the standard regimen. Potential alternatives are azithromycin, rifabutin, ciprofloxacin, clofazamine, and amikacin. Several factors influence drug selection, such as the patients immune status, evidence of treatment safety and efficacy, drug interactions, and potential for resistance.

Economic Burden of Adult Pharyngitis: The Payer's Perspective

OBJECTIVES Although not recommended by practice guidelines, physicians frequently prescribe an antibiotic for adults with viral pharyngitis. The financial burden of this practice, from the payers perspective, has not been previously evaluated. The purpose of this study was to estimate those expenditures. METHODS A cost-of-illness study was performed to estimate annual expenditures of pharyngitis management from the payers perspective. National Ambulatory Care Survey data were used to represent current patterns of ambulatory care visits and antibiotic prescriptions for adult pharyngitis. Direct and antibiotic resistance costs were summed to estimate total expenditures for pharyngitis management. Resistance costs were calculated using a model linking the effect of antibiotic consumption to the cost consequences of resistant Streptococcus pneumoniae infection. Sensitivity analyses compared cost outcomes of current practice, adherence to pharyngitis management guidelines from the Infectious Diseases Society of America (IDSA), and nonantibiotic treatment. RESULTS In the base-case analysis, reflecting current practice patterns, total expenditures were

Implementation and evaluation of a clinic-based behavioral intervention: positive steps for patients with HIV.

1.2 billion with antibiotic resistance contributing 36% (

Improved prevention counseling by HIV care providers in a multisite, clinic-based intervention: positive steps.

426 million). IDSA guideline adherence decreased costs to