Web-based self-management support training for health professionals: A pilot study

Objective

To evaluate a web-based self-management training for health professionals. Patients spend 99% of their time outside the healthcare system. Thus self-management support from health professionals is central to optimal care. Our objective was to teach health professionals the skills to provide this support.

Methods

Primary care residents and practicing providers enrolled in six groups. Each group received four web-based interactive training sessions derived from self-efficacy theory. Retrospective-pre/post assessed changes in self-management beliefs and confidence. Wilcoxon signed-rank tests with Bonferroni correction compared responses. Focus groups solicited qualitative feedback.

Results

Fifty-seven residents and providers across the United States enrolled. Residents demonstrated positive changes on all belief questions (P 0.001–0.012). Practicing providers had a non-significant positive change on one and significant changes on the remainder (P 0.001–0.018). Both types of participants demonstrated significant increases on confidence questions regarding their ability to support self-management (P < 0.01 for all). Participants described learned techniques as being useful, reducing burnout, and increasing acceptance of patient involvement in care planning.

Conclusion

The web-based self-management support training for health professionals was feasible and changed beliefs and confidence.

Practice implications

The program may maximize patient self-management by increasing provider self-efficacy and skill for self-management support.     

An Easily Accessible Web-Based Minimization Random Allocation System for Clinical Trials

Background

Minimization as an adaptive allocation technique has been recommended in the literature for use in randomized clinical trials. However, it remains uncommonly used due in part to a lack of easily accessible implementation tools.

Objective

To provide clinical trialists with a robust, flexible, and readily accessible tool for implementing covariate-adaptive biased-coin randomization.

Methods

We developed a Web-based random allocation system, MinimRan, that applies Pocock–Simon (for trials with 2 or more arms) and 2-way (currently limited to 2-arm trials) minimization methods for trials using only categorical prognostic factors or the symmetric Kullback–Leibler divergence minimization method for trials (currently limited to 2-arm trials) using continuous prognostic factors with or without categorical factors, in covariate-adaptive biased-coin randomization.

Results

In this paper, we describe the system’s essential statistical and computer programming features and provide as an example the randomization results generated by it in a recently completed trial. The system can be used in single- and double-blind trials as well as single-center and multicenter trials.

Conclusions

We expect the system to facilitate the translation of the 3 validated random allocation methods into broad, efficient clinical research practice.     

Reporting of informed consent and ethics committee approval in clinical trials

Context  To determine whether journals have improved their disclosure of ethical protections in clinical trials. Methods  Comparison of clinical trials published before and after 1997 (July 1995 to December 1996 and January 1998 to June 1999) in Annals of Internal Medicine, BMJ, JAMA, The Lancet, and The New England Journal of Medicine. Sixty articles per journal per period were randomly selected and assessed for rate of reporting on informed consent and on ethics committee approval. Results  Informed consent was not described in 79 articles (26%) published before 1997 vs 53 (18%) published after 1997 (P = .01), and ethics committee approval was not mentioned in 93 (31%) before 1997 vs 54 (18%) after 1997 (P<.001). Neither protection was described in 48 articles (16%) published before 1997 vs 28 (9%) after 1997 (P = .01). In subgroup analyses, those journals with the worst initial rates generally improved the most. BMJ did not describe informed consent in 25 articles (42%) before 1997 vs 15 (25%) after 1997 (P = .05), and JAMA did not describe ethics committee approval in 25 (42%) before 1997 vs 13 (22%) after 1997 (P = .02). BMJ, JAMA, and Annals had the lowest initial rates of reporting on both protections in the same article, with 25 (42%), 32 (53%), and 34 (57%), respectively, but improved markedly to 38 (63%), 43 (72%), and 45 (75%) (P = .02, .04, and .03, respectively). Conclusions  Major medical journals have improved their reporting on informed consent and ethics committee approval; however, 9% of studies still report neither.      

Abnormal diurnal weight gain among institutionalized patients with manic-depressive spectrum disorders

We found diurnal weight gain to be abnormal among 41 institutionalized patients with manic-depressive spectrum disorders. They were weighed at 7 AM and 4 PM weekly for three weeks. We normalized the diurnal weight gain (NDWG) as a percentage by subtracting the 7 AM weight from the 4 PM weight, multiplying the difference by 100, and then dividing the result by the 7 AM weight. NDWG was 2.216 +/- 1.513 percent for the study population, .631 +/- .405 percent for 16 young, newly admitted controls, and .511 +/- .351 percent for 29 normals. Abnormal NDWG may be an additional feature of manic-depressive spectrum disorders.     

Diurnal variation of urinary excretion for patients with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome)

Ten patients [8 men and 2 women, mean age (SD) 37.6 +/- 6.5 years] with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome) underwent serial determinations at 6:00 AM, 12 noon, 6:00 PM, and 12 midnight of levels of urinary creatinine concentration (UCR), urinary specific gravity (SPGR), and urinary osmolality (UOSM) on 8 consecutive Thursdays. Diurnal variation (p less than 0.015) was present in the case of each parameter of urinary excretion (UCR, SPGR, and UOSM). These three parameters remained very low throughout the day (mean UCR 19.0 mg/dl, mean SPGR 1.0033, and mean UOSM 112.6 mosmol/kg), which is consistent with severe and persistent hyposthenuria, and each parameter correlated well with the other two parameters (r between 0.78 and 0.93, p less than 0.001). The 6:00 PM (UC6PM) value for UCR correlated best with the daily mean UCR (UCM), providing the simple linear regression UCM = 0.7615 X UC6PM + 6.1503 (r = 0.912, p = 0.0005) for the 10 PIP patients. Twenty-four-hour urinary volume (24UV) could then be estimated using UCM and values of 17.5 and 12.5 mg creatinine/kg body weight for male and female PIP patients, respectively, to calculate the daily urinary excretion of urinary creatinine. The group mean 24UV was 6963 ml, with a range of 4934-9884 ml. We hope that information about the diurnal variation of urinary excretion (21.6%, 20.5%, 27.4%, and 30.4% of 24UV excreted in consecutive quartiles commencing with the 12 midnight to 6:00 AM quartile), coupled with the utilization of the equation UCM = 0.7615 X UC6PM + 6.1503 (r = 0.912, p = 0.0005) to estimate UCM as an index of 24UV in the PIP syndrome, will provide tools to better elucidate the relationship between psychosis and water dysregulation.     

Systems approaches in mental health administration: Linking state and community programs

Approaches to state-community linkage include capitation financing, utilization review, performance contracts, continuous treatment teams, and regional mental health authorities. Several states' experience in developing integrated systems of care, utilizing these approaches, are presented and analyzed from a systems perspective as the process of creating mechanisms of couple two organizational systems in a mutually beneficial manner.     

Diurnal variation in water homeostasis among schizophrenic patients subject to water intoxication

Among seven schizophrenic patients subject to water intoxication (six men and one woman, mean age 39.1 +/- 6.9 years), we measured serum sodium, plasma arginine vasopressin, and urine osmolality at 7 a.m. and 4 p.m. on eight consecutive Thursdays. On the days of greatest diurnal change in serum sodium, the 7 a.m. serum sodium was 141.1 +/- 1.8 mEq/l and the 4 p.m. value was 129.9 +/- 3.2 mEq/l. Plasma vasopressin also tended to be lower at 4 p.m. but, in many cases, was inadequately suppressed for the level of hyponatremia. The urine was dilute at both 7 a.m. and 4 p.m. and mean urine osmolality did not differ at the two times. In three patients, urine osmolality was consistently subnormal relative to plasma vasopressin at both 7 a.m. and 4 p.m. This abnormality was consistent with nephrogenic diabetes insipidus secondary to lithium and, possibly, phenytoin which the patients received to protect them against hyponatremia. We conclude that the combination of polydipsia and abnormal osmoregulation of vasopressin secretion contributes importantly to the afternoon hyponatremia found in schizophrenic patients subject to water intoxication.     

Abnormal diurnal weight gain among chronically psychotic patients contrasted with acutely psychotic patients and normals

We found diurnal weight gain to be abnormal among 28 institutionalized chronically psychotic patients. They were weighed daily for 15 days at 7 a.m. and 4 p.m. We normalized the diurnal weight gain (NDWG) as a percentage by subtracting the 7 a.m. weight from the 4 p.m. weight, multiplying the difference by 100, and then dividing the result by the 7 a.m. weight. NDWG was 2.8 +/- 1.3% for the 28 study patients, 0.631 +/- 0.405% for 16 acutely psychotic controls, and 0.511 +/- 0.351% for 29 normals. Ninety-three per cent of the study sample had NDWG values above the upper limit of normal. Sex, diagnosis, smoking, baseline weight, blood pressure, and pulse did not explain these observations. NDWG related (N = 28, r = 0.552, P = 0.002) to antipsychotic drug dose. The implications of our findings are discussed.     

Abnormal diurnal weight gain among long-term patients with schizophrenic disorders

We found diurnal weight gain to be abnormal among 65 long-term patients with schizophrenic disorders. Patients were weighed at 7 a.m. and 4 p.m. serially and diurnal weight gain was normalized (NDWG) as a percentage by subtracting the 7 a.m. weight from the 4 p.m. weight, multiplying the difference by 100, and then dividing the result by the 7 a.m. weight. NDWG was 2.2 +/- 1.5% for 47 male patients compared (P = 0.001) with 0.6 +/- 0.4% for 11 male controls. NDWG was 1.7 +/- 0.7% for 18 female patients compared (P less than 0.0001) with 0.5 +/- 0.3% for 14 female controls. We hypothesize that NDWG may be an index of both the severity and duration of the schizophrenic disorder.