Patient participation in the consultation process: a structured review of intervention strategies

OBJECTIVE: To describe the range and effectiveness of intervention strategies designed to enhance patient participation in the consultation process. METHODS: A systematic review of published literature (1976-2004) was undertaken. Controlled trials in English were included. Data regarding study design, intervention characteristics, patient populations and study results were extracted. RESULTS: One hundred and forty-six articles describing 137 trials were reviewed. A pragmatic categorisation of intervention strategies and study outcomes supported data synthesis. Patient-targeted coaching and educational materials, and provider-targeted communication skills training have a substantial impact on communication. Information feedback to providers from patient-reported outcome measures (PROMs) benefits provider diagnosis and management of patient conditions. Communication and provider diagnosis and management benefit most from the reviewed interventions. Although patient satisfaction and health status were two of the most frequently measured outcomes, overall, the interventions appeared to have less impact on patient self-efficacy, attitudes and behaviours, patient satisfaction, health status and resource use. CONCLUSION: Evidence is insufficient to strongly advocate one approach to enhancing patient participation in the consultation process. More rigorous research design with clearly specified intervention strategies and appropriately defined outcomes assessed over both the short and long term is required. PRACTICE IMPLICATIONS: Although limited and inconclusive, the most extensive and most encouraging evidence to enhance patient participation in the consultation process is available for three patient-targeted intervention strategies (coaching, educational materials and PROMs feedback to providers) and one provider-targeted intervention strategy (communication skills training).     

Effects of a Web-based intervention for adults with chronic conditions on patient activation: online randomized controlled trial

Background

With almost one-half of Americans projected to have at least one chronic condition before 2020, a vital role of the health care system is to develop informed, engaged individuals who are effective self-managers of their health. Self-management interventions (SMIs) delivered face-to-face or by telephone (traditional SMIs) are associated with improved self-management knowledge, skills, and self-efficacy, which are expressed by the composite construct of patient activation, a predictor of health outcomes. Web-based interventions to support self-management across the spectrum of chronic diseases have the potential to reach a broader population of patients for extended periods than do traditional SMIs. However, evidence of the effectiveness of Web-based interventions on patient activation is sparse. High-quality studies featuring controlled comparisons of patients with different chronic conditions are needed to explore the interaction of Web-based interventions and patient activation.

Objective

To explore the effect of a Web-based intervention on the patient activation levels of patients with chronic health conditions, measured as attitudes toward knowledge, skills, and confidence in self-managing health.

Methods

For this 12-week study, prospective participants were selected from the patient panel of a regional health care system in the United States. The 201 eligible participants were randomly assigned to two groups. Intervention group participants had access to MyHealth Online, a patient portal featuring interactive health applications accessible via the Internet. Control participants had access to a health education website featuring various topics. Patient activation was assessed pre- and posttest using the 13-item patient activation measure. Parametric statistical models (t test, analysis of variance, analysis of covariance) were applied to draw inferences.

Results

The Web-based intervention demonstrated a positive and significant effect on the patient activation levels of participants in the intervention group. A significant difference in posttest patient activation scores was found between the two groups (F _1,123 = 4.438, P = .04, r = .196). Patients starting at the most advanced development of patient activation (stage 4) in the intervention group did not demonstrate significant change compared with participants beginning at earlier stages.

Conclusions

To our knowledge, this is the first study to measure change in patient activation when a Web-based intervention is used by patients living with different chronic conditions. Results suggest that Web-based interventions increase patient activation and have the potential to enhance the self-management capabilities of the growing population of chronically ill people. Activated patients are more likely to adhere to recommended health care practices, which in turn leads to improved health outcomes. Designing Web-based interventions to target a specific stage of patient activation may optimize their effectiveness. For Web-based interventions to reach their potential as a key component of chronic disease management, evidence is needed that this technology produces benefits for a sustained period among a diverse population.     

Participation and outcome in manualized self-help for bulimia nervosa and binge eating disorder — A systematic review and metaregression analysis

There is a growing body of research on manualized self-help interventions for bulimia nervosa (BN) and binge eating disorder (BED). Study and treatment dropout and adherence represent particular challenges in these studies. However, systematic investigations of the relationship between study, intervention and patient characteristics, participation, and intervention outcomes are lacking. We conducted a systematic literature review using electronic databases and hand searches of relevant journals. In metaregression analyses, we analyzed study dropout as well as more specific measures of treatment participation in manualized self-help interventions, their association with intervention characteristics (e.g. duration, guidance, intervention type [bibliotherapy, CD-ROM or Internet based intervention]) and their association with treatment outcomes. Seventy-three publications reporting on 50 different trials of manualized self-help interventions for binge eating and bulimia nervosa published through July 9th 2012 were identified. Across studies, dropout rates ranged from 1% to 88%. Study dropout rates were highest in CD-ROM interventions and lowest in Internet-based interventions. They were higher in samples of BN patients, samples of patients with higher degrees of dietary restraint at baseline, lower age, and lower body mass index. Between 6% and 88% of patients completed the intervention to which they had been assigned. None of the patient, study and intervention characteristics predicted intervention completion rates. Intervention outcomes were moderated by the provision of personal guidance by a health professional, the number of guidance sessions as well as participants' age, BMI, and eating disorder related attitudes (Restraint, Eating, Weight and Shape Concerns) at baseline (after adjusting for study dropout and intervention completion rates). Guidance particularly improved adherence and outcomes in samples of patients with bulimia nervosa; specialist guidance led to higher intervention completion rates and larger intervention effects on some outcomes than non-specialist guidance. Self-help interventions have a place in the treatment of BN and BED, especially if the features of their delivery and indications are considered carefully. To better determine who benefits most from what kind and “dosage” of self-help interventions, we recommend the use of consistent terminology as well as uniform standards for reporting adherence and participation in future self-help trials.     

Randomized trial of a question prompt list to increase patient active participation during interactions with black patients and their oncologists

ObjectiveCommunication during racially-discordant interactions is often of poor quality and may contribute to racial treatment disparities. We evaluated an intervention designed to increase patient active participation and other communication-related outcomes during interactions between Black patients and non-Black oncologists.MethodsParticipants were 18 non-Black medical oncologists and 114 Black patients at two cancer hospitals in Detroit, Michigan, USA. Before a clinic visit to discuss treatment, patients were randomly assigned to usual care or to one of two question prompt list (QPL) formats: booklet (QPL-Only), or booklet and communication coach (QPL-plus-Coach). Patient-oncologist interactions were video recorded. Patients reported perceptions of the intervention, oncologist communication, role in treatment decisions, and trust in the oncologist. Observers assessed interaction length, patient active participation, and oncologist communication.ResultsThe intervention was viewed positively and did not increase interaction length. The QPL-only format increased patient active participation; the QPL-plus-Coach format decreased patient perceptions of oncologist communication. No other significant effects were found.ConclusionThis QPL booklet is acceptable and increases patient active participation in racially-discordant oncology interactions. Future research should investigate whether adding physician-focused interventions might improve other outcomes.Practice implicationsThis QPL booklet is acceptable and can improve patient active participation in racially-discordant oncology interactions.     

Spanish-Language Consumer Health Information Technology Interventions: A Systematic Review

BackgroundAs consumer health information technology (IT) becomes more thoroughly integrated into patient care, it is critical that these tools are appropriate for the diverse patient populations whom they are intended to serve. Cultural differences associated with ethnicity are one aspect of diversity that may play a role in user-technology interactions.ObjectiveOur aim was to evaluate the current scope of consumer health IT interventions targeted to the US Spanish-speaking Latino population and to characterize these interventions in terms of technological attributes, health domains, cultural tailoring, and evaluation metrics.MethodsA narrative synthesis was conducted of existing Spanish-language consumer health IT interventions indexed within health and computer science databases. Database searches were limited to English-language articles published between January 1990 and September 2015. Studies were included if they detailed an assessment of a patient-centered electronic technology intervention targeting health within the US Spanish-speaking Latino population. Included studies were required to have a majority Latino population sample. The following were extracted from articles: first author’s last name, publication year, population characteristics, journal domain, health domain, technology platform and functionality, available languages of intervention, US region, cultural tailoring, intervention delivery location, study design, and evaluation metrics.ResultsWe included 42 studies in the review. Most of the studies were published between 2009 and 2015 and had a majority percentage of female study participants. The mean age of participants ranged from 15 to 68. Interventions most commonly focused on urban population centers and within the western region of the United States. Of articles specifying a technology domain, computer was found to be most common; however, a fairly even distribution across all technologies was noted. Cancer, diabetes, and child, infant, or maternal health were the most common health domains targeted by consumer health IT interventions. More than half of the interventions were culturally tailored. The most frequently used evaluation metric was behavior/attitude change, followed by usability and knowledge retention.ConclusionsThis study characterizes the existing body of research exploring consumer health IT interventions for the US Spanish-speaking Latino population. In doing so, it reveals three primary needs within the field. First, while the increase in studies targeting the Latino population in the last decade is a promising advancement, future research is needed that focuses on Latino subpopulations previously overlooked. Second, preliminary steps have been taken to culturally tailor consumer health IT interventions for the US Spanish-speaking Latino population; however, focus must expand beyond intervention content. Finally, the field should work to promote long-term evaluation of technology efficacy, moving beyond intermediary measures toward measures of health outcomes.     

Impact of mHealth Chronic Disease Management on Treatment Adherence and Patient Outcomes: A Systematic Review

Background

Adherence to chronic disease management is critical to achieving improved health outcomes, quality of life, and cost-effective health care. As the burden of chronic diseases continues to grow globally, so does the impact of non-adherence. Mobile technologies are increasingly being used in health care and public health practice (mHealth) for patient communication, monitoring, and education, and to facilitate adherence to chronic diseases management.

Objective

We conducted a systematic review of the literature to evaluate the effectiveness of mHealth in supporting the adherence of patients to chronic diseases management (“mAdherence”), and the usability, feasibility, and acceptability of mAdherence tools and platforms in chronic disease management among patients and health care providers.

Methods

We searched PubMed, Embase, and EBSCO databases for studies that assessed the role of mAdherence in chronic disease management of diabetes mellitus, cardiovascular disease, and chronic lung diseases from 1980 through May 2014. Outcomes of interest included effect of mHealth on patient adherence to chronic diseases management, disease-specific clinical outcomes after intervention, and the usability, feasibility, and acceptability of mAdherence tools and platforms in chronic disease management among target end-users.

Results

In all, 107 articles met all inclusion criteria. Short message service was the most commonly used mAdherence tool in 40.2% (43/107) of studies. Usability, feasibility, and acceptability or patient preferences for mAdherence interventions were assessed in 57.9% (62/107) of studies and found to be generally high. A total of 27 studies employed randomized controlled trial (RCT) methods to assess impact on adherence behaviors, and significant improvements were observed in 15 of those studies (56%). Of the 41 RCTs that measured effects on disease-specific clinical outcomes, significant improvements between groups were reported in 16 studies (39%).

Conclusions

There is potential for mHealth tools to better facilitate adherence to chronic disease management, but the evidence supporting its current effectiveness is mixed. Further research should focus on understanding and improving how mHealth tools can overcome specific barriers to adherence.     

The development of a health information exchange to enhance care and improve patient outcomes among HIV+ individuals in rural North Carolina

BackgroundThe Regional Health Information Integration Project (RHIIP) has developed the Carolina HIV Information Cooperative regional health information organization (CHIC RHIO). The CHIC RHIO was implemented to improve patient care and health outcomes by enhancing communication among geographically disconnected networks of HIV care providers in rural North Carolina. CHIC RHIO comprises one medical clinic and five AIDS Service Organizations (ASOs) serving clients in eight rural counties.MethodsCommunication among the CHIC RHIO members is facilitated by CAREWare software. The RHIIP team assessed organizational readiness to change, facilitated relationship-building for CHIC RHIO, created the CHIC RHIO and used both qualitative and quantitative approaches to evaluate the process-related effects of implementing a data-sharing intervention.ResultsWe found the CHIC RHIO member organizations were ready to engage in the IT intervention prior to its implementation, which most likely contributed to its successful adoption. The qualitative findings indicate that CHIC RHIO members personally benefited – and perceived their clients benefited – from participation in the information exchange. The quantitative results echoed the qualitative findings; following the CHIC RHIO intervention, quality improvements were noted in the ASO and medical clinic relationships, information exchange, and perceived level of patient care. Furthermore, hopes for what data sharing would accomplish were overly high at the beginning of the project, thus requiring a recalibration of expectations as the project came to a close.ConclusionsInnovative strategies for health information exchange can be implemented in rural communities to increase communication among providers. With this increased communication comes the potential for improved health outcomes and, in turn, healthier communities.     

Patient-centered interventions to improve medication management and adherence: A qualitative review of research findings

Objective

Patient-centered approaches to improving medication adherence hold promise, but evidence of their effectiveness is unclear. This review reports the current state of scientific research around interventions to improve medication management through four patient-centered domains: shared decision-making, methods to enhance effective prescribing, systems for eliciting and acting on patient feedback about medication use and treatment goals, and medication-taking behavior.

Methods

We reviewed literature on interventions that fell into these domains and were published between January 2007 and May 2013. Two reviewers abstracted information and categorized studies by intervention type.

Results

We identified 60 studies, of which 40% focused on patient education. Other intervention types included augmented pharmacy services, decision aids, shared decision-making, and clinical review of patient adherence. Medication adherence was an outcome in most (70%) of the studies, although 50% also examined patient-centered outcomes.

Conclusions

We identified a large number of medication management interventions that incorporated patient-centered care and improved patient outcomes. We were unable to determine whether these interventions are more effective than traditional medication adherence interventions.

Practice Implications

Additional research is needed to identify effective and feasible approaches to incorporate patient-centeredness into the medication management processes of the current health care system, if appropriate.     

Provider-patient interaction in diabetes care: effects on patient self-care and outcomes. A systematic review

A systematic review of the research literature using Medline, Embase, Psyclit/Psycinfo and the Cochrane Library files 1980 through 2001, identified only eight publications based on well-designed studies involving randomised controlled trials (RCTs)--testing the effects of modification of provider-patient interaction and provider consulting style on patient diabetes self-care and diabetes outcomes, in general practice or hospital outpatient settings. Review of these publications leads to the tentative conclusion that focusing on patient behaviour--directly enhancing patient participation i.e. by assistant-guided patient preparation for visits to doctors, empowering group education, group consultations, or automated telephone management--is more effective than focusing on provider behaviour to change their consulting style into a more patient-centred one. The latter proves hard to sustain, needs intensive support, and is not very effective in improving patient self-care and health outcomes when executed alone. Patient behaviour focused interventions show good efficacy and efficiency, and improve patient self-care and diabetes outcomes. More well-designed intervention studies focusing on enhancing patient participation in primary and hospital outpatient diabetes care are needed.     

Psychological and quality-of-life outcomes from a comprehensive stress reduction and lifestyle program in patients with coronary artery disease: results of a randomized trial

BACKGROUND: Stress reduction and comprehensive lifestyle modification programs have improved atherosclerosis and cardiac risk factors in earlier trials. Little is known about the impact of such programs on quality-of-life (QoL) and psychological outcomes. Given recent significant improvements in cardiac care, we evaluated the current benefit of stress reduction/lifestyle modification on QoL and emotional distress in patients with coronary artery disease (CAD). METHODS: 101 patients (59.4 +/- 8.6 years, 23 female) with CAD were randomized to a 1-year lifestyle/stress management program (n = 48) or written advice (n = 53). QoL and psychological outcomes were assessed with the SF-36, Beck Depression, Spielberger State/Trait Anxiety, Spielberger State/Trait Anger and Perceived Stress Inventories. Group repeated-measures analyses of variance were performed for all measures. RESULTS: Adherence to the program was excellent (daily relaxation practice 39 +/- 5 vs. 5 +/- 8 min, respectively; p < 0.001). Both groups improved comparably in most dimensions of QoL, and significantly greater improvements for the lifestyle group were found for physical function and physical sum score (p = 0.046 and p = 0.045). Depression, anxiety, anger and perceived stress were reduced similarly in both groups. However, intervention x gender interaction effects revealed greater benefits among women in the lifestyle intervention vs. advice group for depression and anger (p = 0.025 and p = 0.040), but no effects for men. CONCLUSIONS: A comprehensive lifestyle modification and stress management program did not improve psychological outcomes in medically stable CAD patients. The program did appear to confer psychological benefits for women but not men. Further trials should investigate gender-related differences in coronary patient responses to behavioral interventions.     

Does improving patient–practitioner communication improve clinical outcomes in patients with cardiovascular diseases? A systematic review of the evidence

Objective

To conduct a systematic literature review appraising the effects of interventions to improve patient–practitioner communication on cardiovascular-related clinical outcomes.

Methods

Databases were searched up to March 27, 2013 to identify eligible studies that included interventions to improve patient and/or practitioner communication skills and assessment of a cardiovascular-related clinical outcome in adults ≥18 years of age.

Results

Fifteen papers were reviewed: the primary focus in seven studies was the patient; seven included a practitioner-focused intervention and one targeted both. Two patient-focused and two practitioner-focused studies demonstrated a beneficial effect of the intervention compared to a control group. Patient-focused studies were designed to improve patients’ information-seeking and question-asking skills with their practitioner. Practitioner-focused studies were designed to either improve practitioner's general patient-centered communication or risk communication skills.

Conclusion

Few interventions targeting patient–practitioner communication have assessed the impact on cardiovascular-related clinical outcomes, limiting the ability to determine effectiveness. Additional rigorous research supported by theoretical frameworks and validated measurement is needed to understand the potential of patient–practitioner communication to improve cardiovascular-related clinical outcomes.

Practice implications

Investments in communication skills trainings in medical education and practice are needed in order to attain the full potential of patient-centered care on cardiovascular-related clinical outcomes.     

Motivational interviewing to promote interconception health: A scoping review of evidence from clinical trials

BackgroundPromoting interconception health can improve birth outcomes and long-term women’s health. Motivational Interviewing (MI) is an evidence-based behavior change strategy that can address interconception health behaviors and health care engagement.ObjectiveThis scoping review assessed the evidence for using MI to promote interconception health and assessed features of successful MI interventions.MethodsWe searched PubMed, CHINAL, and Cochrane databases for clinical trials that involved an MI intervention and at least one comparison group published by 8/31/2021. Interventions occurred during pregnancy or within three months postpartum and outcomes were measured between birth and one year postpartum. We abstracted data on trial characteristics including outcome, population, interventionist training, MI fidelity monitoring, intervention dose, and comparison condition. We examined whether trials that demonstrated statistically significant improvement in outcomes had common features.ResultsThere were 37 included studies. Interventions addressed breastfeeding, teen contraception, tobacco, alcohol, or substance use, vaccine acceptance, nutrition, physical activity, and depression. No trials addressed more than one topic. Nineteen studies demonstrated improved outcomes. Interventions during the perinatal or postnatal periods were more likely to demonstrate improved interconception outcomes than interventions in the prenatal period. No other trial characteristics were consistently associated with demonstrating improved outcomes.DiscussionMI has been applied to a variety of interconception health behaviors, with some promising results, particularly for interventions in the perinatal or postpartum period. Outcomes were not clearly attributable to any other differences in intervention or study design. Further exploring context or implementation may help maximize the potential of MI in interconception health promotion.Practical valueMI may be implemented across a range of clinical settings, patient groups, and time points around pregnancy. Interventions on health topics relevant to the interconception period should incorporate perinatal or postpartum components.     

The Effect of Technology-Based Interventions on Pain,Depression, and Quality of Life in Patients With Cancer: A Systematic Review of Randomized Controlled Trials

BackgroundThe burden of cancer is increasing; projections over the next 2 decades suggest that the annual cases of cancer will rise from 14 million in 2012 to 22 million. However, cancer patients in the 21st century are living longer due to the availability of novel therapeutic regimens, which has prompted a growing focus on maintaining patients’ health-related quality of life. Telehealth is increasingly being used to connect with patients outside of traditional clinical settings, and early work has shown its importance in improving quality of life and other clinical outcomes in cancer care.ObjectiveThe aim of this study was to systematically assess the literature for the effect of supportive telehealth interventions on pain, depression, and quality of life in cancer patients via a systematic review of clinical trials.MethodsWe searched PubMed, EMBASE, Google Scholar, CINAHL, and PsycINFO in July 2013 and updated the literature search again in January 2015 for prospective randomized trials evaluating the effect of telehealth interventions in cancer care with pain, depression, and quality of life as main outcomes. Two of the authors independently reviewed and extracted data from eligible randomized controlled trials, based on pre-determined selection criteria. Methodological quality of studies was assessed by the Cochrane Collaboration risk of bias tool.ResultsOf the 4929 articles retrieved from databases and relevant bibliographies, a total of 20 RCTs were included in the final review. The studies were largely heterogeneous in the type and duration of the intervention as well as in outcome assessments. A majority of the studies were telephone-based interventions that remotely connected patients with their health care provider or health coach. The intervention times ranged from 1 week to 12 months. In general, most of the studies had low risk of bias across the domains of the Cochrane Collaboration risk of bias tool, but most of the studies had insufficient information about the allocation concealment domain. Two of the three studies focused on pain control reported significant effects of the intervention; four of the nine studies focus on depression reported significant effects, while only the studies that were focused on quality of life reported significant effects.ConclusionsThis systematic review demonstrates the potential of telehealth interventions in improving outcomes in cancer care. However, more high-quality large-sized trials are needed to demonstrate cogent evidence of its effectiveness.     

Designing and evaluating a web-based selfmanagement site for patients with type 2 diabetes - systematic website development and study protocol

ABSTRACT: BACKGROUND: Given that patients provide the majority of their own diabetes care, patient self-management training has increasingly become recognized as an important strategy with which to improve quality of care. However, participation in self management programs is low. In addition, the efficacy of current behavioural interventions wanes over time, reducing the impact of self-management interventions on patient health. Web-based interventions have the potential to bridge the gaps in diabetes care and self-management. OBJECTIVE: To improve self-efficacy, quality of life, self-care, blood pressure, cholesterol and glycemic control and promote exercise in people with type 2 diabetes through the rigorous development and use of a web-based patient self-management intervention. METHODS: This study consists of five phases: (1) intervention development; (2) feasibility testing; (3) usability testing; (4) intervention refinement; and (5) intervention evaluation using mixed methods. We will employ evidence-based strategies and tools, using a theoretical framework of self-efficacy, then elicit user feedback through focus groups and individual user testing sessions. Using iterative redesign the intervention will be refined. Once finalized, the impact of the website on patient self-efficacy, quality of life, self-care, HbA1c, LDL-cholesterol, blood pressure and weight will be assessed through a non-randomized observational cohort study using repeated measures modeling and individual interviews. DISCUSSION: Increasing use of the World Wide Web by consumers for health information and ongoing revolutions in social media are strong indicators that users are primed to welcome a new era of technology in health care. However, their full potential is hindered by limited knowledge regarding their effectiveness, poor usability, and high attrition rates. Our development and research agenda aims to address these limitations by improving usability, identifying characteristics associated with website use and attrition, and developing strategies to sustain patient use in order to maximize clinical outcomes.     

Audio-taping the oncology treatment consultation: a literature review

An increased amount of research has been conducted to evaluate interventions for improving the quality of communication between cancer patients and health care providers. One of these interventions involves providing patients with audiotapes of their consultations with oncologists. Given that effective patient-physician communication has been linked to beneficial health outcomes, an examination of studies that have evaluated the effects of audiotape provision appears warranted. This article provides a critical review of this literature. The audiotape intervention has been examined in uncontrolled studies and randomized trials, and the primary outcome variables have included psychological well-being, information recall, and patient satisfaction. The empirical literature is unclear as to the efficacy of providing patients with taped recordings of cancer consultations. Overall, the findings suggest that the majority of patients benefit from receiving the audiotape, but the utility of this intervention in improving patient-physician communication requires further examination. Replication studies and well-controlled experimental designs applied to a variety of health care providers in diverse oncology settings are needed to confirm the validity of the empirical findings to date, and to facilitate further development of interventions aimed at enhancing patient-physician communication.     

Educational intervention for older people with asthma: A randomised controlled trial

ObjectivesTo improve the asthma control and adherence to asthma preventer medication of older people using the Patient Asthma Concerns Tool (PACT) to identify and address unmet needs and patient concerns.MethodsCommunity dwelling adults over 55 years, living in Victoria or New South Wales were recruited into a single-blind, parallel design, randomised-controlled trial comparing person-centred education including device technique, versus written information-only education. Fifty-eight participants randomised to the intervention group and 56 to the control completed participation. Outcome measures: asthma control, adherence to preventer medication, asthma related quality of life, asthma exacerbations and written action plan ownership were assessed at baseline, and 3 and 12 months post intervention.ResultsIntervention participants experienced improvements in asthma control, adherence to asthma preventer medication, reduced exacerbations, improved quality of life and an increase in asthma action plan ownership at 3 and 12 months.ConclusionAsthma outcomes in older people can be significantly improved by delivering tailored education that identifies specific patient concerns and unmet needs.Practical implicationsUse of the PACT to identify patient concerns and unmet needs will assist health professionals to improve the health literacy of patients by addressing gaps in their knowledge and perceptions of asthma control.     

Preconception Care Education for Women With Diabetes: A Systematic Review of Conventional and Digital Health Interventions

BackgroundWorldwide, 199.5 million women have diabetes mellitus (DM). Preconception care (PCC) education starting from adolescence has been recommended as an effective strategy for safeguarding maternal and child health. However, traditional preconception care advice provided by health care professionals (HCPs) within clinic settings is hindered by inadequate resources, suboptimal coverage, and busy clinics. Electronic health (eHealth), which is instrumental in solving problems around scarce health resources, could be of value in overcoming these limitations and be used to improve preconception care and pregnancy outcomes for women with DM.ObjectiveThe objectives were to: (1) identify, summarize, and critically appraise the current methods of providing PCC education; (2) examine the relationship between PCC educational interventions (including use of technology as an intervention medium) on patient and behavioral outcomes; and (3) highlight limitations of current interventions and make recommendations for development of eHealth in this field.MethodsElectronic databases were searched using predefined search terms for PCC education in women with type 1 or 2 DM for quantitative studies from 2003 until June 2016. Of the 1969 titles identified, 20 full papers were retrieved and 12 papers were included in this review.ResultsThe reviewed studies consistently reported that women receiving educational interventions via health care professionals and eHealth had significantly improved levels of glycosylated hemoglobin (P<.001) with fewer preterm deliveries (P=.02) and adverse fetal outcomes (P=.03). Significant improvements in knowledge (P<.001) and attitudes toward seeking PCC (P=.003) were reported along with reduced barriers (P<.001).ConclusionsPCC has a positive effect on pregnancy outcomes for women with DM. However, uptake of PCC is low and the use of eHealth applications for PCC of women with DM is still in its infancy. Initial results are promising; however, future research incorporating mobile phones and apps is needed. Clearly, there is much to be done if the full potential of eHealth PCC to improve obstetric outcomes for women with DM is to be realized.     

Physical activity counseling in primary care: who has and who should be counseling?

OBJECTIVE: To examine the physical activity (PA) counseling literature in primary care in order to identify which intervention provider has been used to date and their relative effectiveness for increasing PA. METHOD: MEDLINE and PsycINFO databases were searched for PA intervention studies in primary care settings. RESULTS: Of the 19 studies, 37% were conducted solely by physicians, 37% by allied health professionals, while 26% were combined-provider interventions. There was a decline in the number of physician-only interventions and a shift towards interventions offered by allied health professionals as adjuncts or alone. Interventions across all provider categories generated some improvements in physical activity behavior, however, it appears that allied health professionals as adjuncts or alone produced the best results in the long-term (>6 months). There was substantial variation in the location and counseling approach employed by allied health professionals. CONCLUSION: We argue for an interdisciplinary model in which physicians recommend PA and provide referrals to allied health professionals such as physical activity counselors. PRACTICE IMPLICATIONS: With physical activity counselors' specialized training and greater time available to the patient, they may provide more intensive and effective counseling required for behavior change and maintenance.     

Implementing decision and communication aids to facilitate patient-centered care in breast cancer: A case study

ObjectiveDecision Services (DS) provide support for breast cancer patients at the University of California, San Francisco to help ensure patient-centered care.MethodsWe examined a case study to explore whether our program practices matched our program theory, and what the patient in the case thought was effective and ineffective about our decision support interventions.ResultsThe patient relied on a decision aid to educate her husband about her condition; felt that her question list contributed to a productive and efficient consultation with her oncologist; credited an audio-recording with helping her remember to follow-up with a genetic counselor; and reviewed the consultation summary 30 days into treatment in order to reflect on her decision. The patient rated the interventions highly on surveys, and experienced desirable reductions in decisional conflict, and improvements in knowledge. However, the question-prompting intervention was associated with a small decrease in self-efficacy, and the patient criticized the decision aid for omitting mention of a prognostic test.ConclusionThis case illustrates how decision support interventions can be deployed to promote patient-centered care.Practice implicationsBreast care centers should consider distributing decision aids and assisting patients in listing questions, recording consultations, and obtaining written consultation summaries.