The effectiveness of web-based patient education and action and coping plans as an adjunct to patient treatment in physiotherapy: A randomized controlled trial

ABSTRACT

Objective: The study investigated: (1) the effect of combining web-based patient education (WBPE) with action and coping plans on patients’ adherence to physiotherapy and their subsequent functional outcomes; and (2) the participants’ satisfaction with the WBPE program. Methods: One hundred and eight participants enrolled in this 8-week two group randomized controlled trial. They were allocated to either the WBPE planning group or the attention-control group. The WBPE group made action and coping plans and were familiarized with their web-based program. The attention control group was given access to a web-based neutral information program about shoulder injuries and physiotherapy rehabilitation. Throughout the 8-week study physiotherapists measured the participants’ clinic-based adherence and participants recorded their home-based adherence using a self-report diary. Functional outcomes for all participants were measured at the beginning and end of the study. Participants provided feedback about their respective websites. Results: The intervention group had a significantly higher clinic based adherence than the control group (p < 0.04). Both groups had a significant improvement in shoulder function but there was no significant difference between them. Participants in the intervention group were highly satisfied with the WBPE program. The preferred delivery of physiotherapy by 87% of the intervention group was a combination of face-to-face appointments and WBPE. Control participants indicated that they would have appreciated information about shoulder exercises and the shoulder complex in their program. Discussion: The WBPE program was an effective adjunct to physiotherapy in terms of patient satisfaction and clinic-based treatment adherence.     

Prevalence and causes of persistent use of hormone replacement therapy among postmenopausal women: a follow-up study

In a previous study analyzing data from September 2002 to February 2003, we showed that, despite the Women's Health Initiative trial results, many women still remained on hormone replacement therapy (HRT) in an internal medicine practice. However, it is not known whether such use has persisted over time. We performed a retrospective chart analysis of 1000 postmenopausal women seen at the same internal medicine practice from January 2004 to May 2004 to establish whether the prevalence of HRT use had declined, remained stable, or increased when compared with our previous data and to determine the reasons for continued HRT use. Among 1000 postmenopausal women, mean age 66+/-9 years, 116 (12%) remained on HRT (HRT users) in 2004. The prevalence of HRT users declined from 16% to 12% (P<0.01) over a period of 15 months. Among HRT users, the main reasons for continued use were severe menopausal symptoms in 39 (34%), patient preference in 17 (15%), osteoporosis or osteopenia in 14 (12%), failed attempt at discontinuation in 13 (11%), taper in progress in 12 (10%), gynecologist recommendation in 10 (9%), not documented in 8 (7%), and other reasons in 3 (3%). The use of HRT declined over time in an internal medicine clinic since the publication of the Women's Health Initiative study. However, 12% of the women still remained on HRT in 2004. The severity of menopausal symptoms, patient preference, and osteoporosis or osteopenia played a prominent role in the decision to remain on HRT.     

The readability of printed education materials regarding hormone replacement therapy

In summary, HRT is a preventative medication that has been shown to decrease the incidence of heart disease and osteoporosis. It also has been shown to reduce symptoms of menopause and to increase the quality of life of users. Choosing to begin and maintain HRT is a personal and complicated decision. In evaluating the risks and benefits of HRT for any one woman, that woman and her primary care provider must individualize her past and current medical history, her family history, and her lifestyle. Together they must come to a decision that best represents the health, social needs, and desires of the patient. Individualizing HRT is difficult for a woman to do on her own, and it is time-consuming for a practitioner. Using PEMs to clarify the benefits and risks of HRT can be very beneficial to a woman considering such therapy. PEMs, however, are not a substitute for one-on-one education, and especially are not appropriate for teaching if their level of technical difficulty is beyond the scope of a patient's comprehension. This study suggests that many of the PEM's provided to women on the subject of HRT are failing to reach their target audiences because of their level of reading difficulty. A stated objective identified in the national initiative Healthy People 2000 (U.S. Department of Health and Human Services, 1997) is to "Increase to at least 90% the proportion of perimenopausal women who have been counseled about the benefits and risks of hormone replacement therapy for the prevention of osteoporosis." PEMs are one way to reach this objective, provided they are understandable to the clientele of focus.     

Overuse of mammography during the first round of an organized breast cancer screening programme

Objectives  We examined the frequency of mammography screening among women who had had a screening mammogram recently and therefore generally did not need to repeat the examination.
Methods  A population-based sample of 50- to 69-year-old women were surveyed immediately before and 8 months after they received an invitation to participate in the first round of screening of the newly organized mammography screening programme in Geneva, Switzerland. These women also received a booklet that included the recommendation to have screening mammograms at 2-year intervals.
Results  The baseline survey identified 660 women who had had a mammogram within the previous 12 months. Of these, 23.2% [95% confidence interval (CI), 20.0–26.6] had an opportunistic mammogram and 4.1% (95% CI, 2.7–5.9) had an organized mammogram during follow-up. Women who had had their last mammogram 6–12 months prior to baseline (vs. more recently), intended to have a mammogram within the next 6 months, wished to receive more information on mammography screening, and had a history of surgical breast biopsy were more likely to have an unnecessary screening mammogram (either organized or opportunistic) during follow-up. Compared with women who had an opportunistic mammogram, women who had an organized mammogram were more likely to be of lower socioeconomic status, to have made their own screening decision and to have anticipated the date of their next mammogram by no more than a few months.
Conclusions  Opportunistic mammography screening in excess of recommendation is common, and persists despite explicit advice about recommended screening frequency.     

Effect of feedback in promoting adherence to an exercise programme: a randomized controlled trial

Objective We investigated whether providing participants in an exercise programme with regular feedback on their exercise progress affected their adherence to the programme regimen. Method We conducted a randomized controlled trial. Adult men and women with borderline hypertension and a body mass index ≥ 25.0 were randomized to two intervention groups (groups A and B) and one control group (group C) and were prescribed regular aerobic exercise. During the 12‐week study period, group A was provided with both feedback information on their exercise progress and a health letter, while group B was provided with the health letter only. The main outcome measure was exercise performance, per cent achievement of target exercise level (%) defined as the number of weeks during which the exercise target was reached divided by the number of weeks in the programme. Results were compared using the Kruskal–Wallis test. Results A total of 105 study subjects were randomized into three groups (A, n = 37; B, n = 37 and C, n = 31). Per cent achievement of target exercise level during the 12‐week period was highest in group A (26.5%), followed by groups B (22.9%) and C (17.4%) (P = 0.36). Subjects who received regular feedback during the exercise programme tended to have higher exercise performance. Conclusions In improving adherence to exercise intervention, the provision of regular feedback to participants in an exercise programme may be an effective intervention.     

Testing an Intervention for Preventing Osteoporosis in Postmenopausal Breast Cancer Survivors

Purpose: To test a 12-month multicomponent intervention for preventing or treating osteoporosis in 21 postmenopausal women who had completed treatment (except Tamoxifen) for breast cancer, and for whom hormone replacement therapy (HRT) was contraindicated.
Design: Pilot intervention study.
Methods: The intervention consisted of home-based strength and weight training exercises, 5 or 10 mg alendronate per day, 1500 mg calcium per day, 400 IU vitamin D per day, education on osteoporosis, and facilitative strategies to promote adherence to the intervention. Outcome measures were: adherence to the intervention, dynamic balance, muscle strength, and bone mineral density (BMD) of the hip, spine, and forearm.
Findings and Conclusions: Adherence to calcium, vitamin D, and alendronate therapy was above 95%, and adherence to strength training exercises was above 85%. Over the 12 months, the 21 participants had significant improvements in dynamic balance, muscle strength for hip flexion, hip extension, and knee flexion, and BMD of the spine and hip. Participants had a significant decrease in BMD of the forearm. Three of the 21 women who had measurable bone loss at baseline had normal BMD after 12 months of the intervention.     

Impact of a Multifaceted Intervention on Promoting Adherence to Screening Colonoscopy Among Persons in HIV Primary Care: A Pilot Study

HIV‐positive patients have lower colon cancer screening rates and are at increased risk for colon adenocarcinoma. We tested a transdisciplinary prevention model to increase provider and patient adherence to screening colonoscopy. Of 1,339 HIV‐positive patients with scheduled clinic appointments during the period September to November 2009, we identified 400 records of eligible patients ≥50 years and retrospectively reviewed for screening colonoscopy referral; if never referred, flagged for referral at next visit. Providers referred 43.5% (174/400) patients and 36.2% (63/174) kept appointment. Within 6 months before the study, 337 patients attended clinic and providers referred 18%. Note that 211/226 patients with flagged records attended clinic at least once during the study 6‐month period and providers referred (43.6%). The referral rate for flagged records was significantly different from that for the prior 6 months (p < 0.0001). A randomized trial compared the efficacy of patient decision support versus usual care on screening adherence. Among patients randomized to intervention 17 (51.5%) compared to usual care only 16 (48.5%), intervention group showed significant adherence of 70.6% (12/17) versus 29.4% (5/16), (p = 0.024). In addition, intervention patients had good bowel preparation of 76.9% (10/13) versus usual care 23.1% (3/13), (p = 0.05). This transdisciplinary intervention model significantly increased provider and patient screening colonoscopy behavior.     

Effects of an exercise intervention on other health behaviors in overweight/obese post-menopausal women

BACKGROUND: Little is known about whether initiating physical activity induces change in other health-related behaviors. If other behaviors do change with increasing physical activity, this would complicate interpretation of differences in study outcomes in exercise intervention trials. DESIGN: Randomized controlled trial. SETTING/PARTICIPANTS: 173 sedentary, overweight (body mass index between 24.0 and 25.0 kg/m2 with body fat>33% or BMI>or=25.0 kg/m2), postmenopausal women, ages 50 to 75 years, not using hormone therapy, and living in the Seattle, WA area. INTERVENTION: Participants were randomly assigned to an exercise intervention (n=87) or a stretching-control group (n=86). The exercise intervention included facility and home-based moderate-intensity exercise. MAIN OUTCOME MEASURES: Changes in dietary intake, alcohol consumption, and medication and supplement use were compared from baseline to 3- and 12-month follow-up between exercise and control groups, and by tertiles of exercise adherence. Data were collected between January 1998 and July 2001. RESULTS: In general, changes in dietary intake between the exercise and control group were not statistically different. The exercise group had a greater increase in the proportion of participants who used multivitamins (+5%) compared to the control group (-10%) at 3 months (p-interaction=0.04), but not at 12 months (p-interaction=0.58). Furthermore, there were few differences when comparing changes in health behaviors across exercise adherence tertiles. CONCLUSIONS: Our results suggest that participation in a year-long exercise intervention trial among post-menopausal women has little effect on other health behaviors. These findings suggest that additional behavior changes in exercise trials are minimal and unlikely to bias primary study results.     

A Controlled Pilot Trial of PainTracker Self-Manager,a Web-Based Platform Combined With Patient Coaching,to Support Patients' Self-Management of Chronic Pain

The objective of this study was to develop and pilot test a chronic pain empowerment and self-management platform, derived from acceptance and commitment therapy, in a pain specialty setting. A controlled, sequential, nonrandomized study design was used to accommodate intervention development and to test the efficacy of the PainTracker Self-Manager (PTSM) intervention (Web-based educational modules and outcome tracking combined with tailored patient coaching sessions and provider guidance). Generalized estimating equations evaluated changes over time (baseline, 3 months, 6 months) in pain self-efficacy (primary outcome), chronic pain acceptance (activity engagement and pain willingness), perceived efficacy in patient–provider interactions, pain intensity and interference, and overall satisfaction with pain treatment (secondary outcomes) between intervention (n?=?48) and usual care control groups (n?=?51). The full study sample (N?=?99) showed greater improvements over time (significant Group × Time interactions) in pain self-efficacy and satisfaction with pain treatment. Among study completers (n?=?82), greater improvement in activity engagement as well as pain intensity and interference were also observed. These preliminary findings support the efficacy of the PTSM intervention in a pain specialty setting. Further research is needed to refine and expand the PTSM intervention and to test it in a randomized trial in primary care settings.

Determinants of adherence to exercise in women treated for breast cancer

We describe adherence to a three group randomised controlled trial that involved aerobic exercise therapy (N=34) and exercise-placebo intervention (N=36) or usual care (N=38) in women treated for breast cancer. We also investigated relationships between routes of trial recruitment, socio-economic characteristics, health behaviours, cancer treatment regimen(s) and subsequent adherence to the interventions. Women who had completed breast cancer treatment 12-36 months previously were randomised to one of the groups. The intervention groups attended an exercise facility three times per week for eight weeks. A total of 77% of the aerobic exercise therapy and 88.9% of the exercise-placebo groups attended at least 70% of prescribed sessions. The percentage of women achieving 30min of aerobic exercise per session steadily increased during the intervention but many women were not able to achieve this goal. Routes of trial recruitment, socio-economic characteristics, health behaviours and cancer treatment regimen(s) were not related to intervention. Exercise therapy participants were able to comply with the progressive nature of the aerobic exercise intervention, although some women were not able to achieve 30min of aerobic exercise per session by intervention completion. Research is still required to tease out all the potential determinants of exercise in this population.     

The veterans' study to improve the control of hypertension (V-STITCH): design and methodology

BACKGROUND: Among the 60 million Americans with hypertension, only approximately 31% have their blood pressure (BP) under control (<140/90 mm Hg). Despite the damaging impact of hypertension and the availability of evidence-based target values for BP, interventions to improve BP control have had limited success. OBJECTIVES: A randomized controlled health services intervention trial with a split-plot design is being conducted to improve BP control. This 4-year trial evaluates both a patient and a provider intervention in a primary care setting among diagnosed hypertensive veterans. METHODS: In a cluster-randomization, 30 primary care providers in the Durham VAMC Primary Care Clinic were randomly assigned to receive the provider intervention or control. The provider intervention is a patient-specific electronically generated hypertension decision support system (DSS) delivering guideline-based recommendations to the provider at each patient's visit, designed to improve guideline-concordant therapy. For these providers, a sample of their hypertensive patients (n=588) was randomly assigned to receive a telephone-administered patient intervention or usual care. The patient intervention incorporates patients' need assessments and involves tailored behavioral and education modules to promote medication adherence and improve specific health behaviors. All modules are delivered over the telephone bi-monthly for 24 months. In this trial, the primary outcome is the proportion of patients who achieve a BP < or =140/90 mm Hg at each outpatient clinic visit over 24 months. CONCLUSION: Despite the known risk of poor BP control, a majority of adults still do not have their BP controlled. This study is an important step in testing the effectiveness of a patient and provider intervention to improve BP control among veterans in the primary care setting.     

Factors influencing quality of life in older women with heart disease

BACKGROUND: Better understanding of factors influencing the quality of life (QOL) of cardiac patients can guide treatment decisions. OBJECTIVES: To describe the impact of clinical and psychosocial factors on the QOL of older women with heart disease. RESEARCH DESIGN: Baseline and 12-month data from women participating in an intervention study. SUBJECTS: Eligible participants, identified from medical records, were female, > or = 60 years of age, and diagnosed with cardiac disease. A volunteer sample of 570 women (87% white) completed baseline interviews, with 485 women completing the 12-month assessment. MEASURES: Utilizing Wilson and Cleary's conceptual framework (1995), measures of clinical, psychosocial, and functional status were examined for their associations with QOL. RESULTS: At baseline, General Health Perceptions and Symptom Status accounted for 38% and 26%, respectively, of the variation in the QOL rating. Using logistic regression models, seven measures were significant predictors (P < 0.05) of maintenance/improvement versus decline in QOL over 12 months: baseline QOL rating; baseline value and change in satisfaction with social activities over 12 months; change in satisfaction with physical activities; change in satisfaction with mental activities; and baseline value and change in perceived stress. For women who maintained or improved their satisfaction with social activities, the odds for also maintaining or improving QOL were 4.5 times the odds for women whose satisfaction with social activities deteriorated. CONCLUSIONS: Satisfaction with social activities and perceived stress are important predictors of subsequent QOL. Consideration of the impact of treatments on these factors may help to prevent deterioration of QOL among older female cardiac patients.     

Feasibility of using a computer-assisted intervention to enhance the way women with breast cancer communicate with their physicians

This study was conducted to evaluate the feasibility of using a computer intervention to enhance communication between healthcare professionals and women with breast cancer. Additional aims were to measure the extent to which women achieved their preferred decisional roles and satisfaction with the clinical medical appointment. This two-arm randomized clinical trial design included a convenience sample of 749 women with breast cancer attending 3 urban Canadian outpatient oncology clinics. Most women were older than 50 years and had a high school diploma or greater (57%). Women in the control group completed measures of decision preference before their clinic appointments. Women in the intervention group were encouraged to use the information and decision preference profiles generated by the computer program at their clinic appointments. Levels of involvement in decision making and satisfaction were measured after the clinic appointments. Results showed that although the majority of women in both groups did assume their preferred roles in decision making, a significantly higher proportion of women in the intervention group reported playing a more passive role than originally planned. Both groups reported high satisfaction levels. Future research is required to study how this computer intervention could be used by clinicians to provide information and decision support to these women.     

Evaluation of a 12-week home-based walking intervention for breast cancer survivors

Goals of work To evaluate a 12-week home-based walking intervention among breast cancer survivors and to quantify changes in physical activity (PA) behaviors, body weight, and body composition in response to the intervention. Patients and methods Breast cancer survivors that were in the posttreatment period were randomized to intervention (n=23) or wait-list usual care (n=13). PA was assessed by self-report, and in a study subsample (n=23), by an accelerometer. Intention to treat principles were employed to estimate the intervention effect on PA behaviors, body weight, and body composition. Intervention adherence was calculated as the proportion of exercise sessions completed relative to the number of exercise sessions recommended, as reported each week on walking logs. Main results Thirty-four of 36 women randomized (94%) completed the study. Average intervention adherence over 12 weeks was 94%. Intervention participants reported a significantly greater increase in walking for exercise [+11.9 metabolic equivalent (MET)-h/week] over time than did usual care participants (+1.7 MET-h/week, p=0.01). Objective measures of activity also indicated that intervention participants increased their activity levels over time as compared to usual care participants [i.e., counts/min/day and steps/day (p≤0.04)]. No significant changes in body weight or composition were observed. Conclusion We found that a 12-week home-based walking intervention was safe and effective for increasing short-term PA levels in breast cancer survivors. Future studies are needed to assess the ability of brief interventions to facilitate the maintenance of increased activity levels and to produce favorable quality of life and risk factor outcomes.     

Cardiopulmonary responses and adherence to exercise in women newly diagnosed with breast cancer undergoing adjuvant therapy

Cardiopulmonary responses to an 8-week moderate-intensity aerobic exercise intervention and adherence to exercise during and after intervention were assessed in 41 women newly diagnosed with breast cancer undergoing adjuvant therapy. The intervention was primarily aimed at minimizing deconditioning. Women were randomly assigned to the intervention or control group, completed graded exercise tests before and after intervention, and encouraged to continue their exercise postintervention. Over time, only the intervention group showed significant decreases in resting heart rate, resting systolic blood pressure (SBP), P <.05 each, and maximum SBP, P <.02, and an increase in VO2 peak, P <.001, although resting SBP was higher in the intervention group at both timepoints, P <.05. The adherence rate to 8-week exercise intervention was 78.3% with average weekly attendance of 2.4 sessions and 42.7 minutes (27.8 minutes within target heart rate) exercise per session. Overall physical activity levels over 16 weeks postintervention did not differ between 2 groups. However, the within-group analysis indicated that only the intervention group showed a significant increase in voluntary activity, P < .02, and energy expenditure, P < .02, and a decrease in sedentary activity, P < .02. These findings indicate that moderate-intensity aerobic exercise is beneficial in reducing deconditioning of cardiopulmonary responses in newly diagnosed breast cancer women undergoing adjuvant therapy.     

Nurse Practitioner Communication and Treatment Adherence in Hypertensive Patients

In hypertensive patients, treatment adherence is improved with patient-centered communication (PTC), leading to better outcomes. Many barriers to PTC should be overcome, including patient background characteristics, provider time constraints, and provider discomfort. Using patient-centered education increases patient awareness of choices and builds a partnership between the provider and patient. Nurse practitioners should adhere to PTC by discussing the disease of hypertension, treatment, and self-monitoring. Overcoming communication barriers will lead to better patient understanding, trust, satisfaction, improved treatment plans, greater adherence, and improved blood pressure.     

Quality Improvement: Using Teach-Back to Improve Patient Satisfaction during Discharge in the Emergency Department

IntroductionPatients discharged in the emergency department often have poor understanding of their discharge instructions. Teach-back is a communication method that involves asking patients to explain in their own words what a health care provider just told them. The purpose of this project was to determine whether nurse-led teach-back at discharge could improve patient satisfaction with discharge information.MethodsA teach-back method was used to educate patients on what to do if they do not feel better after leaving, using a single site quality improvement design. Patient satisfaction was measured using a standardized benchmark question on whether providers explained what to do if they did not feel better after leaving. The department goal for this question was established as achieving a response of “Yes, definitely” for 64.4% or more of the satisfaction surveys. Patient satisfaction data were collected before and after intervention through a survey given to patients within 24 hours after their visit. A statistical process chart was used to analyze whether the observed improvements coincided with implementation of the teach-back intervention.ResultsAlthough there was an overall increase in post-intervention scores (61%) from baseline scores (59%), there were no special cause variations signaling that the intervention had a significant impact.DiscussionTeach-back may improve patient satisfaction with discharge information. Future implementation with measures of intervention adoption, fidelity, accountability, and sustainability are needed.     

The effect of hormone replacement therapy and/or exercise on skeletal muscle attenuation in postmenopausal women: a yearlong intervention

Hormone replacement therapy (HRT) has been reported to exert a positive effect on preserving muscle strength following the menopause, however, the mechanism of action remains unclear. We examined whether the mechanism involved preservation of muscle composition as determined by skeletal muscle attenuation. Eighty women aged 50-57 years were randomly assigned to either: HRT, exercise (Ex), HRT+exercise (ExHRT), and control (Co) for 1 year. The study was double-blinded with subjects receiving oestradiol and norethisterone acetate (Kliogest) or placebo. Exercise included progressive high-impact training for the lower limbs. Skeletal muscle attenuation in Hounsfield units (HU) was determined by computed tomography of the mid-thigh. Areas examined were the quadriceps compartment (includes intermuscular adipose tissue), quadriceps muscles, the posterior compartment and posterior muscles. Muscle performance was determined by knee extensor strength, vertical jump height, and running speed over 20 m. Fifty-one women completed the intervention. Vertical jump height and running speed improved in the HRT and ExHRT groups compared with Co (interaction, P<0.01). For both the quadriceps compartment and quadriceps muscles, HU significantly increased (interaction, P相似文献   

Short-term aerobic training and circulatory function in women: age and hormone-replacement therapy

The physiological basis of training responses in women, and particularly older women, is not well understood. Short-term aerobic training (STAT) was used to probe the effects of age and hormone-replacement therapy (HRT) on women's ability to rapidly change peak uptake ( VO(2max)), plasma volume and cardiac function. A total of 39 females participated in the STAT programme: 15 younger (Y; aged 19-29 years), 12 postmenopausal women undergoing HRT and 12 non-medicating postmenopausal (PM) women (aged 60-75 years). Training consisted of ten sessions of cycling over a 2-week period, which progressed in duration from 20 to 60 min and in intensity from 60-75% of maximum heart rate. Plasma volume (PV; as determined by Evan's Blue dye dilution), VO(2max) (cycle ergometry) and cardiac function (radionuclide ventriculography) were analysed using analysis of covariance or repeated measures ANOVA. All groups demonstrated similar increase in VO(2max) (Y, 13%; PM, 17%; HRT, 13%), but without a significant change in left-ventricular ejection fraction and diastolic function or volumes during supine exercise. PV expansion was observed among the Y group (7%; P <0.05) but not the PM group (2%; P >0.05) or women undergoing HRT (1%; P >0.05). Age and hormone-replacement status did not affect the magnitude of VO(2max) change. This study suggests that STAT improves VO(2max), independent of central adaptations.