Overcoming Barriers to Eye Care: Patient Response to a Medical Social Worker in a Glaucoma Service

This paper investigates the patient response to a medical social worker in a glaucoma clinic. The literature suggests that medical social workers are effective in a variety of health care settings, yet the efficacy of a medical social worker in an adult ophthalmic setting has not been studied. We present the results of a retrospective chart review of 50 patients with glaucoma referred to a medical social worker between January 5, 2015 and June 31, 2015 in an outpatient clinic of an urban eye hospital. Clinical and demographic data, as well as the data from a quality of care questionnaire, were collected for each patient. Patients rated their interaction with the medical social worker as highly positive (mean = 4.75, 5-point Likert scale), and nearly 90 % of patients expressed interest in future contact with the social worker. Additionally, most patients reported that the social worker resolved the issues they were facing (61.1 %), supported them in seeing their ophthalmologist (70.6 %), and helped them to manage their glaucoma (69.7 %). Reported barriers to glaucoma care were emotional distress; cost of office visits and medications; lack of medical insurance; transportation; poor medication adherence; impairment of daily activities; follow-up adherence; and language. As vision loss from glaucoma is irreversible, it is important to detect and treat patients at early stages of the disease. Therefore, it is imperative for patients to regularly visit their eye care providers and adhere to treatment and follow-up recommendations. This study suggests that a medical social worker could play a pivotal role in helping patients with glaucoma overcome barriers to treatment and facilitate disease management.     

Predictors of the use of healthcare services in children and adolescents in Spain

Objective

To assess medium to long term predictors of healthcare services use in a population-based sample of children/adolescents in Spain.

Methods

A sample of children and adolescents aged 8–18 and their parents were evaluated at baseline (2003) and follow-up (2006). Total use of healthcare services and visits to specialist and dentists at the follow-up were analyzed.

Results

Four hundred fifty-four children/adolescents completed baseline and follow-up assessments (response rate 54 %). 90 % of respondents reported at least one visit during the 12 months previous to the follow-up. Low socioeconomic status (beta coefficient = 0.30; 95 % CI = 0.02–0.57), double healthcare coverage (0.41; 0.17–0.66), parental use of services, poor mental health and activity limitation were associated to the total number of visits. Access to specialist was associated to double healthcare coverage (OR = 1.77; 1.01–3.07) and parental primary level of education (OR = 0.51; 0.32–0.81). Age and low family affluence predicted visits to dentists (OR = 0.38; 0.19–0.73).

Conclusion

No barriers to healthcare services use were found. Family level of education, family affluence and double healthcare coverage predicted the use of specialists and dentists.     

Improved Diabetes Control Through a Provider-Based Disease Management Program

Objective: The primary aim of this study was to evaluate the effectiveness of a newly implemented hospital-based diabetes mellitus disease management program. A secondary aim was to determine if relationships existed among variables.Design and setting: Effectiveness was evaluated in terms of glycemic control, post-program acute care resource utilization, adherence with American Diabetes Association (ADA) standards of care, and health-related quality of life. Participants in the Diabetes LifeCare program (DLC) received all standards of care which included diabetes self-management education, medical management by a primary care provider (PCP) supported by an evaluation and recommendations by an Advanced Practice Registered Nurse (APRN), nutritional counseling and at minimum, quarterly follow-up appointments for 1 year.Patients: Patients who were aged ≥18 years and referred to the DLC program with new a diagnosis or history of type 1 or 2 diabetes mellitus.Main outcome measures and results: Results demonstrated that at 3 months after enrollment in the DLC, participants in the study with available data (n = 142) had a mean decrease in predominant glycosylated hemoglobin (HbA_1c) values from 9.31 to 7.21 (p < 0.001). The HbA_1c value for participants with data at the 6-month visit (n = 66) decreased from 9.23 to 7.22 at 3 months and to 6.80 at 6 months (p < 0.001). At baseline, 52 of the 142 participants (36.5%) had HbA1c values less than 8.0, compared with 107 patients (75.4%) at 3 months (p < 0.0001). A total of 185 of 227 patients (81.5%) received eye examinations as per ADA guidelines. A total of 225 of 227 patients (99.1%) were in compliance with the ADA guidelines for nutritional counseling as a result of participation in the program. On the Physical Component Summary, their mean scores were 42.75 [standard deviation (SD) = 11.17] at enrollment, compared with 45.12 (SD = 10.52) at 3 months (p < 0.001). The Mental Component Summary score increased from 47.52 (SD = 11.90) to 50.83 (SD = 10.47) [p < 0.001]. Regarding resource utilization, during the follow-up period only 3 of 227 patients had emergency room visits and there were no inpatient visits for acute problems related to diabetes.Conclusions: Our results show that, in the short term, significant improvement in glycemic control can be achieved through a comprehensive program of patient education and management, that includes collaborative efforts with the patient’s primary care provider. High rates of eye and foot examination can also be attained by reinforcing patient involvement and admissions for acute metabolic complications can be minimized.     

Racial Disparities at the Point of Care for Urban Children with Persistent Asthma

Little is known about disparities in preventive asthma care delivery at the time of an office visit. Our objective was to better understand what treatments are delivered at the point of care for urban children with asthma, and whether there are racial disparities. We enrolled 100 Black and 77 White children (2–12 years) with persistent asthma from 6 primary care practices. We evaluated how frequently providers delivered guideline-based asthma actions at the index visit. We also assessed asthma morbidity prior to the index visit and again at 2 month follow-up. Black children had greater symptom severity and were less likely to report having a preventive medication at baseline, but were no more likely to report a preventive medication action at the time of an office visit. Symptoms persisted for Black children at follow-up, suggesting additional preventive actions were needed. Further efforts to promote consistent guideline-based preventive asthma care are critical.     

What Circumstances Prompt a Workplace Discussion in Medical Evaluations for Back Pain?

Purpose: To determine how frequently workplace topics emerge in the interactions between patients and providers in an evaluation for low back pain (LBP) and to determine its association with patient and provider characteristics. Methods: Adults with work-related LBP (N = 97; 64 % male; median age = 38) completed a demographic questionnaire and a survey of disability risk factors, then agreed to audio-taping of their visits with a participating occupational healthcare provider (n = 14). Utterance-level verbal exchanges were categorized by trained coders using the Roter interaction analysis system. In addition, coders flagged any instance of workplace discussion between patients and providers. Results: Workplace discussions occurred in 51 % of visits, and the most frequent topic was physical job demands. Workplace discussions were more frequent among the oldest and youngest patients and when patients were seen by providers who were more patient-centered and made more efforts to establish patient rapport and engagement. However, patients reporting numerous disability risk factors and workplace concerns in the pre-visit questionnaire were no more likely to discuss workplace topics with their providers (p > 0.05). Only the patient-centered orientations of providers and patients remained statistically significant predictors in multivariate modeling (p < 0.05). Conclusions: Workplace discussions are facilitated by a patient-centered orientation and by efforts to establish patient engagement and rapport, but workplace discussions are no more frequent among patients with the most significant workplace concerns. Screening questionnaires and other assessment tools may be helpful to foster workplace discussions to overcome possible barriers for returning to work.     

Characteristics of Patients Who Report Confusion After Reading Their Primary Care Clinic Notes Online

Patient access to online electronic medical records (EMRs) is increasing and may offer benefits to patients. However, the inherent complexity of medicine may cause confusion. We elucidate characteristics and health behaviors of patients who report confusion after reading their doctors’ notes online. We analyzed data from 4,528 patients in Boston, MA, central Pennsylvania, and Seattle, WA, who were granted online access to their primary care doctors’ clinic notes and who viewed at least one note during the 1-year intervention. Three percent of patients reported confusion after reading their visit notes. These patients were more likely to be at least 70 years of age (p < .0001), have fewer years of education (p < .0017), be unemployed (p < .0001), have lower levels of self-reported health (p < .0043), and worry more after reading visit notes (relative risk [RR] 4.83; confidence interval [CI] 3.17, 7.36) compared to patients who were not confused. In adjusted analyses, they were less likely to report feeling more in control of their health (RR 0.42; CI 0.25, 0.71), remembering their care plan (RR 0.26; CI 0.17, 0.42), and understanding their medical conditions (RR 0.32; CI 0.19, 0.54) as a result of reading their doctors’ notes compared to patients who were not confused. Patients who were confused by reading their doctors’ notes were less likely to report benefits in health behaviors. Understanding this small subset of patients is a critical step in reducing gaps in provider–patient communication and in efforts to tailor educational approaches for patients.     

A Randomized Clinical Trial of Trans-Dermal Nicotine Replacement in Pregnant African-American Smokers

We compared acceptability, adherence and efficacy of trans-dermal nicotine patches and cognitive behavioral therapy (Group 1) to cognitive behavioral therapy alone (Group 2) in minority pregnant smokers. This is a randomized controlled trial. 52 women were recruited during pregnancy with a mean gestational age 18.5 ± 5.0 weeks and followed through delivery. Randomization was by site and initial cotinine levels. Interventionists and interviewers were blinded to group assignment. Two different nicotine replacement therapy dosing regiments were administered according to the baseline salivary cotinine level. A process evaluation model summarized patient adherence. The main outcome measure was self-report of cessation since last visit, confirmed by exhaled carbon monoxide. Analyses of categorical and continuous measures were conducted as well as linear trend tests of salivary cotinine levels. Women lost to follow-up were considered treatment failures. Participants were on average 27.5 ± 5.4 years old, 81 % were single, 69 % unemployed and 96 % were Medicaid eligible. A process evaluation indicated patients in both groups were adherent to scheduled program procedures through Visit 4, but not for Visits 5 and 6. Confirmed quit rates were: at visit 3, 23 (Group 1) and 0 % (Group 2) (p = 0.02); at visits 4 and 5, no difference; at visit 6, 19 (Group 1) and 0 % (Group 2) (p = 0.05). Group 1 delivered infants with a mean gestational age of 39.4 weeks versus 38.4 weeks in Group 2 (p = 0.02). 73 % (52/71) of the eligible smokers agreed to participate and 65 % (17/26) of Group 1 completed the protocol (i.e. attended 6 visits). A comparison of Group 1 and 2 quit rates confirmed a non-significant difference.     

The effect of physician office visits on CHD risk factor modification as part of a worksite cholesterol screening program

BACKGROUND: Elevated serum cholesterol is a major risk factor for CHD. Primary prevention through behavioral modification has been designated first-line treatment for patients with elevated cholesterol. In this study, we assessed the impact of a physician office visit after a worksite cholesterol screening on self-reported changes in diet, weight loss, exercise, and smoking. We hypothesized that those individuals who had a physician office visit regarding cholesterol would make more changes in CHD risk factors than those who did not have such a visit. METHODS: A cohort of 4,928 participants from 33 work-sites in Massachusetts and Rhode Island had baseline CHD risk factors evaluated at a cholesterol screening and 4,473 were available at follow-up 6 months later by telephone interview. A total of 1,957 had elevated cholesterol levels (>/=200 mg;/dl) and were instructed to visit their physician, in addition to receiving educational materials related to CHD risk factor modification. RESULTS: Most individuals with elevated cholesterol levels had other prevalent self-reported CHD risk factors at baseline: 58% consumed high-fat diets (>30% fat), 43% were overweight, 60% had a sedentary lifestyle (sweat-related physical activity <3 x per week), and 22% were cigarette smokers. After 6 months of follow-up, 74% of participants with high-fat diets reported eating a lower fat diet, 71% of overweight participants reported weight loss, 53% of sedentary participants attempted to increase physical activity, and 38% of smokers decreased or quit cigarette smoking. Thirty-five percent of participants completed the referral for a physician office visit to discuss their elevated cholesterol determined at the baseline worksite screening. However, these individuals showed only a modest change (which was not statistically significant) in self-reported CHD risk factors compared with those who did not have follow-up physician visits after adjusting for age, sex, race, education, occupation, medical insurance, time since last doctor visit, diabetes, and hypertension. Objective measurements of serum cholesterol, body mass index, and dietary score were likewise modestly improved and not statistically significant. CONCLUSIONS: In 6 months of follow-up, high absolute levels of CHD risk factor modification were observed after a worksite cholesterol screening. A physician office visit added only a modest but not statistically significant benefit for further CHD risk factor modification. These findings indicate that the follow-up cholesterol-related physician visit had little added clinical benefit over the screening intervention alone.     

What Do Chaplains Really Do? I. Visitation in the New York Chaplaincy Study

The current study presents findings from the New York Chaplaincy Study about chaplain visits with patients and their families in 13 healthcare institutions in the Greater New York City area during 1994–1996. It documents the distribution of 34,279 clinical visits by religious affiliation, population served (patients, family and friends), and type of healthcare setting (acute care and non-acute care), and analyzes the number and duration of visits with patients by their medical status. Chaplains in acute settings tended to make less frequent but longer visits with patients than chaplains in non-acute settings. On average, chaplains spent less time with patients who were alone than they did during visits with patients whose family was present during the visit or visits with only family members. Average visit duration was positively related to the percentage of visits in each of the 13 facilities that were made in response to referrals (r = .65, p < .05), and the average duration of referred visits was significantly longer (p < .001) than that of non-referred visits (p < .001). The findings are intended to provide a general picture of what these particular chaplains did in these particular institutions over this particular time-period and are not intended to represent a standard of what chaplains should be doing.     

Improving access to specialty care

BACKGROUND: Waits and delays plague health care systems worldwide, and wait times for most specialists exceed those for primary care practices. In office-based practices, the provider office presence is not diluted by competing indispensable activities, and the demand for service is most often for a single type, or stream, of office-based appointment demand. In the more complex specialty practices, however, the demand streams for office visits and other services compete for provider time and dilute the supply of office visits. SEVEN FLOW STRATEGIES, WITH A FOCUS ON THE INITIAL APPOINTMENT: Seven strategies for reduction of delay can be applied, not only at all steps in patient flow and for all demand streams but also at all steps (for example, office visit, diagnostic procedure, surgery, follow-up) and within all specialty care types and ranges of practice. Each specialty care practice will need to discover how to use the basic principles and implement customized solutions within its own unique environment. Although it is ultimately critical to eliminate the delays in all streams of service, the focus is on the application of change strategies at the initial step between primary care and all specialty care practice types. The strategies are (1) balance supply and demand at each step in the chain, (2) work down the backlog, (3) reduce appointment types, (4) independent contingency planning for all variation, (5) reduce the demand for visits, (6) increase the supply, and (7) improve the efficiency of the office work flow. SUMMARY: Specialists support various, distinct demand streams that require demand/supply balance to achieve optimal system performance. If demand/supply balance exists within any stream, waits can be minimized, and the practice can choose time frames within which to balance workload.     

National Ambulatory Medical Care Survey: 2001 summary

OBJECTIVE: This report describes ambulatory care visits made to physician offices in the United States. Statistics are presented on selected characteristics of the physician's practice, the patient, and the visit. Results highlighting new items on continuity of care are presented. They include whether the visit was the first or a followup for a problem, number of visits to this provider in the past 12 months for established patients, and whether other physicians shared care for the patient's problem. The report also highlights estimates of practice characteristics for office-based physicians. METHODS: The data presented in this report were collected from the 2001 National Ambulatory Medical Care Survey (NAMCS). NAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization by various types of providers. NAMCS is a national probability sample survey of visits to office-based physicians in the United States. Sample data are weighted to produce annual national estimates. Selected trends from the 1992 and 1997 NAMCS are also presented. RESULTS: During 2001, an estimated 880.5 million visits were made to physician offices in the United States, an overall rate of 314.4 visits per 100 persons. From 1992 through 2001, the visit rate for persons 45 years of age and over increased by 17%, from 407.3 to 478.2 visits per 100 persons. The mean age of patients at each office visit has steadily increased from 1992 through 2001 as has the mean number of diagnoses rendered and the overall drug mention rate. The visit rate to physician offices in metropolitan statistical areas (MSAs) (338.3 visits per 100 persons) was significantly larger than the rate in non-MSAs (218.0 visits per 100 persons). Females had a higher visit rate compared with males, and white persons had a higher rate than black or African-American persons. Half of all office visits were to the patient's primary care physician (PCP). Of the visits to physicians other than the patient's PCP, about one-third (32.6 percent) were referrals. About 1 in 10 office visits were made by new patients (11.8 percent), down 20% since 1992. More than one physician shared the care for the patient's condition at about one-fifth of the office visits. Of all visits made to offices in 2001, 58.8 percent listed private insurance as the primary expected source of payment, followed by Medicare (21.8 percent) and Medicaid and/or State Children's Health Insurance Program (7.2 percent). For preventive care visits, the female visit rate was over 75% higher than the rate for males (67.1 versus 37.7 visits per 100 persons). Essential hypertension, arthropathies, acute upper respiratory infection, and diabetes mellitus were the leading illness-related primary diagnoses. There were an estimated 99.8 million injury-related visits in 2001, or 35.6 visits per 100 persons. Diagnostic and screening services were ordered or provided at 82.8 percent of visits, therapeutic and preventive services were ordered or provided at 41.4 percent of visits, and medications were prescribed or provided at 61.9 percent of visits. On average, 2.4 medications were ordered or provided at each office visit with any mention of a medication. The leading therapeutic class for drugs mentioned at office visits included cardiovascular-renal drugs (14.7 percent of mentions) and pain-relieving drugs (12.1 percent of mentions). A physician was seen at a majority of visits (95.8 percent), and a registered or licensed practical nurse was seen at 31.3 percent of visits. From 1992 through 2001, changes were observed in the leading diagnoses, therapeutic drug classes, and drug mentions. Physician estimates revealed that primary care physicians were twice as likely as specialists to make home visits during an average week of work; when they conducted them, they made twice as many (6 versus 2-3 visits per week) as specialists. Approximately 3 in 10 physicians reported not accepting new capitated, privately insured patients, whereas only 6.8 percent did not accept noncapitated, privately insured patients.     

Effectiveness of Community Health Workers in Providing Outreach and Education for Colorectal Cancer Screening in Appalachian Kentucky

The purpose of this study was to examine the effectiveness of a community health worker (CHW)–delivered cancer education program designed to increase knowledge and awareness of colorectal cancer screening options. The study population was an extremely vulnerable and medically underserved geographic region in Appalachian Kentucky. CHWs enrolled participants in face-to-face visits, obtained informed consent, and administered a baseline assessment of knowledge of colorectal cancer risks and the benefits of screening and screening history. An educational intervention was then provided and participants were re-contacted 6 months later when a posttest was administered. The mean score of the 637 participants increased from 4.27 at baseline to 4.57 at follow-up (p < .001). Participants who reported asking their health care provider about colorectal cancer screening increased from 27.6% at baseline to 34.1% at follow-up (p?=?.013). Results suggest that CHWs were very effective at maintaining the study population; no loss to follow-up occurred. The results also showed increased knowledge and awareness about colorectal cancer screening education. Implications for social work practice, policy and research are discussed.     

Confronting Disparities in Diabetes Care: The Clinical Effectiveness of Redesigning Care Management for Minority Patients in Rural Primary Care Practices

CONTEXT: Diabetes mellitus and its complications disproportionately affect minority citizens in rural communities, many of whom have limited access to comprehensive diabetes management services. PURPOSE: To explore the efficacy of combining care management and interdisciplinary group visits for rural African American patients with diabetes mellitus. METHODS: In the intervention practice, an advanced practice nurse visited the practice weekly for 12 months and facilitated diabetes education, patient flow, and management. Patients participated in a 4-session group visit education/support program led by a nurse, a physician, a pharmacist, and a nutritionist. The control patients in a separate practice received usual care. FINDINGS: Median hemoglobin A1c (HbA1c) was not significantly different at baseline in the intervention and control groups but was significantly different at the end of the 12-month follow-up period (P < .05). In the intervention group, median HbA1c at baseline was 8.2 +/- 2.6%, and median HbA1c at an average follow-up of 11.3 months was 7.1 +/- 2.3%, (P < .0001). In the control group, median HbA1c increased from 8.3 +/- 2.0% to 8.6 +/- 2.4% (P < .05) over the same time period. In the intervention group, 61% of patients had a reduction in HbA1c, and the percentage of patients with a HbA1c of less than 7% improved from 32% to 45% (P < 05). CONCLUSIONS: These findings suggest that a redesigned care management model that combines nurse-led case management with structured group education visits can be successfully incorporated into rural primary care practices and can significantly improve glycemic control.     

Effectiveness and Cost of a Personalized Reminder Intervention to Improve Adherence to Glaucoma Care

Background

Glaucoma is the leading cause of irreversible blindness in the USA. Glaucomatous vision loss is preventable with proper eye care, including appointment adherence. Therefore, interventions that improve appointment adherence can reduce the number of patients with more severe glaucoma.

Objectives

The primary study aim was to determine the efficacy and cost-effectiveness of a multifaceted personal reminder intervention, which included a customized letter and personal telephone outreach, in improving appointment adherence of patients with glaucoma. A secondary study aim was to identify patient characteristics that were associated with non-adherence.

Methods

This prospective, randomized, controlled study included a cost-effectiveness analysis completed using a decision analytic model. The subjects included 256 patients with glaucoma. Study measures included appointment adherence and incremental cost effectiveness ratios.

Results

Patients in the intervention group were more likely to adhere to appointments (82.31 vs. 69.05 %; RR 1.23; 95 % CI 1.04–1.37, p < 0.012) than patients in the usual care group. Patients in the intervention group were 23 % more likely to adhere to appointments (RR 1.23; 95 % CI 1.08–1.41, p < 0.0021) than patients in the usual care group, when adjusting for age, secondary insurance, primary open angle glaucoma diagnosis, number of previous visits at Wills Eye Hospital, and follow-up recommendation using Poisson regression. Per-patient cost of the program was US$11.32, and cost per follow-up attended within the adherence window was US$73.56.

Conclusions

A low cost reminder intervention consisting of a personalized letter and telephone outreach significantly improved appointment adherence of patients with glaucoma.

     

Physician assessment of patient motivation: influence on disposition for follow-up care.

This study of 3,318 outpatient visits evaluated the influence of the physician-assessed level of patient motivation on the level of physician involvement in follow-up care. Data collected included patient demographics, health risk factors, physician-assessed level of patient motivation, and the disposition for follow-up care (return office visit or self-care). Physicians more frequently scheduled patients for a return office visit, regardless of assessed level of patient motivation, when they presented with a traditional biomedical problem. Patients with health promotion-disease prevention problems were more frequently relegated to self-care; patients physicians judged to be poorly motivated were four times as likely to be relegated to self-care. We discuss the implications of physician overuse of self-care strategies on the health status of poorly motivated patients. Factors influencing such physician behavior may include prior unrewarding experiences with poorly motivated patients, perceived lack of skill in affecting behavior change, time constraints, lack of reimbursement for preventive care services, and the actual process of physician education and professional socialization.     

Empowering Low-Income Parents with Skills to Reduce Excess Pediatric Emergency Room and Clinic Visits through a Tailored Low Literacy Training Intervention

In this article, we evaluate the impact of a health literacy intervention to decrease emergency room and doctor's office visits for common childhood illness symptoms. Our education model trained low-income parents of young children (9,240 families) at 55 Head Start sites on the use of a low-literacy health book to respond to common childhood illnesses. The overall strategic framework required each Head Start site to create a Health Improvement Project to plan, successfully train, monitor, and keep the momentum through a strong follow-up with families regarding their health care decisions. The study was conducted from 2003 to 2006. Each family was tracked for 3 months prior to the training using self-report, and for 6 months afterward. The average number of emergency room and doctor visits among parents decreased 58% and 41% respectively (p < .001). Further, work days missed by the primary caretaker per year decreased 42%, and school days missed per year decreased 29% (p < .001). During the health literacy intervention, emergency room and doctor visits reported among parents decreased, as well as the number of work days and school days missed per year. Significant cost savings for the health care system can be anticipated through thoughtful broad dissemination of this training model.     

Food Insecurity and Health Care Utilization Among Older Adults in the United States

This study examined the relationships between food insecurity and utilization of four health services among older Americans: office visits, inpatient hospital nights, emergency department visits, and home health care. Nationally representative data from the 2011 and 2012 National Health Interview Survey were used (N = 13,589). Nearly 83.0% of the sample had two or more office visits, 17.0% reported at least one hospital night, 23.0% had at least one emergency room visit, and 8.1% used home health care during the past 12 months. Adjusting for confounders, food-insecure older adults had higher odds of using more office visits, inpatient hospital nights, and emergency department visits than food-secure older adults, but similar odds of home health care utilization. The findings of this study suggest that programs and policies aimed at reducing food insecurity among older adults may have a potential to reduce utilization of health care services.     

Dietary Satisfaction Correlated with Adherence in the Modification of Diet in Renal Disease Study

Objective To measure satisfaction with modified protein eating patterns and the relationship of satisfaction to adherence and sociodemographic factors in a clinical trial.Design Participants completed the Dietary Satisfaction Questionnaire at baseline, at 6-month follow-up visits, at annual visits, and at the final visit. Satisfaction with diet was rated on a visual analog scale from 1 (dislike extremely) to 5 (like very much). Adherence to protein goals was assessed using urine urea nitrogen excretion from monthly 24-hour urine samples.Subjects 840 adults with chronic renal disease.Intervention Individual participants, randomly assigned to a usual-protein, low-protein, or very-low-protein group, received monthly counseling from a dietitian for an average of 26 months.Statistics Analyses of variance and two-sample t tests compared, among study/diet groups, satisfaction with diet, its relationship to adherence and sociodemographic characteristics, and changes in satisfaction over time. Paired t tests compared changes within diet groups from baseline to final visit.Results From the baseline visit to the final visit, satisfaction with the prescribed eating pattern increased slightly in the usual-protein group, declined slightly in the low-protein group, and declined significantly in the very-low-protein group. Participants in all of the eating pattern groups who were more satisfied at the final visit had mean protein intakes closer to their assigned protein goals. This relationship was significant in the low-protein group (P<.05). In men, satisfaction with diet declined significantly from baseline to the final follow-up visit in the very-low-protein group.Applications The Modification of Diet in Renal Disease Study Dietary Satisfaction Questionnaire may be useful in other research and clinical settings to assess and enhance dietary adherence. J Am Diet Assoc. 1995; 95:1301-1306.     

Development of a psychosocial concern index from videotaped interviews of nurse practitioners and family physicians

The delivery of primary health care involves a complex interactive process between the provider and patient. One important feature of this interaction is provider concern for psychosocial issues. A study was undertaken to examine provider's actions with the patient and to describe the factors influencing the provider's concern with psychosocial issues. A total of 412 provider-patient clinic visits, including 276 with physicians and 136 with nurse practitioners, were videotaped and analyzed using a provider psychosocial concern index developed specifically for this study. Data from exit and follow-up interviews with patients plus a provider questionnaire were analyzed to identify factors associated with a provider's psychosocial concern. The results show that an interactional analysis focusing on clinician activities can be useful in describing important process-outcome relationships such as psychosocial concern. Factors such as type of visit, visit history, type of provider, and sex of patient and provider were associated with the amount of psychosocial concern displayed by providers and perceived by patients.