Context: Most older adults with dementia will be cared for by primary care physicians, but the primary care practice environment presents important challenges to providing quality care. Objective: To test the effectiv...Context: Most older adults with dementia will be cared for by primary care physicians, but the primary care practice environment presents important challenges to providing quality care. Objective: To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease. Design, Setting, and Patients: Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were randomized by physician to receive collaborative care management (n=84) or augmented usual care (n=69)-at primary care practices within 2 US university-affiliated health care systems from January 2002 through August 2004. Eligible patients (identified via screening or medical record) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver. Intervention: Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient’s family caregiver and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacological management. Main Outcome Measures: Neuropsychiatric Inventory (NPI)-administered at baseline and at 6, 12, and 18 months. Secondary outcomes included the Cornell Scale for Depression in Dementia (CSDD), cognition, activities of daily living, resource use, and caregiver’s depression severity. Results: Initiated by caregivers’reports, 89%of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocols. Intervention patients were more likely to receive cholinesterase inhibitors (79.8%vs 55.1%; P=.002) and antidepressants (45.2%vs 27.5%; P= .03). Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months (mean difference, -5.6; P= .01) and at 18 months (mean difference, -5.4; P=.01). Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months; at 18 months, caregivers showed improvement in depression as measured by the Patient Health Questionnaire-9. No group differences were found on the CSDD, cognition, activities of daily living, or on rates of hospitalization, nursing home placement, or death. Conclusions: Collaborative care for the treatment of Alzheimer disease resulted in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics. Trial Registration: clinicaltrials.gov Identifier: NCT00246896.展开更多
Objective. To examine the implementation of a protocol for the assessment of attention-deficithyperactivity disorder (ADHD)-in rural pediatric practices. The protocol was designed to provide an efficient means for ped...Objective. To examine the implementation of a protocol for the assessment of attention-deficithyperactivity disorder (ADHD)-in rural pediatric practices. The protocol was designed to provide an efficient means for pediatricians to learn and use the ADHD guidelines put forth by the American Academy of Pediatrics (AAP). Methods. Primary care staff (physicians, nurses, etc) from 2 rural pediatric practices were trained to use the ADHD-assessment protocol. Medical records for 101 patients were reviewed from 1 to 2 years before the introduction of the protocol and for 86 patients during the subsequent 2 to 3 years to assess compliance with the AAP guidelines. In addition, 34%of the scales scored by the staff were rescored to check for scoring accuracy. Results. Before the availability of the AAP guidelines and the implementation of the assessment protocol, neither primary care site was consistently collecting the comprehensive information that is now recommended for an ADHD assessment. Parent andor teacher rating scales were collected for only 0%to 21%of assessments across sites. When provided with brief training and supporting materials, medical records reflected significant improvement in the ascertainment of clinically necessary ADHD information, with parent and teacher rating scales present 88%to 100%of the time. Staff demonstrated an ability to score rating scales with a high degree of accuracy. The integrity of protocol collection and management was maintained 2 to 3 years after training. Conclusions. An efficient system for conducting ADHD assessments according to AAP guidelines in rural pediatrics clinics can be initiated and maintained with integrity. Additional research is needed to determine if this system improves diagnostic decision-making and patient outcomes.展开更多
Background. Despite growing evidence of the benefits of prolonged breastfeeding for mother and infant health, the rate of breastfeeding at infant age of 6 months remains below the Healthy People 2010 goal. The greates...Background. Despite growing evidence of the benefits of prolonged breastfeeding for mother and infant health, the rate of breastfeeding at infant age of 6 months remains below the Healthy People 2010 goal. The greatest decrease in the breastfeeding rate occurs during the first 4 postpartum weeks. Mothers who discontinue breastfeeding early aremore likely to report lack of confidence in their ability to breastfeed, problems with the infant latching or suckling, and lack of individualized encouragement from their clinicians in the early postdischarge period. Observational studies suggest that primary care physicians can increase breastfeeding rates through specific advice and practices during routine preventive visits. However, robust scientific evidence based on randomized, controlled trials is currently lacking. Objective. The purpose of this study was to determine whether attending an early, routine, preventive, outpatient visit delivered in a primary care physician’s office would improve breastfeeding outcomes. Design. The study was a prospective, randomized, parallel-group, open trial. Setting. Participants were recruited at a level 3 maternity facility, with an average of 2000 births per year, in France. Participants. A total of 231 mothers who had delivered a healthy singleton infant (gestational age: ≥37 completed weeks) and were breastfeeding on the day of discharge were recruited and randomized (116 were assigned to the intervention group and 115 to the control group) between October 1, 2001, and May 31, 2002; 226 mother-infant pairs (112 in the intervention group and 114 in the control group) contributed data on outcomes. Intervention. Support for breastfeeding in the control group included the usual verbal encouragement provided by the maternity ward staff members, a general health assessment and an evaluation for evidence of successful breastfeeding behavior by the pediatrician working in the obstetrics department on the day of discharge, provision of the telephone number of a peer support group, mandatory routine, preventive, outpatient visits at 1, 2, 3, 4, 5, and 6 months of infant age, and 10 weeks of paid maternity leave (extended to 18 weeks after the birth of the third child). In addition to the usual predischarge and postdischarge support, the mothers in the intervention group were invited to attend an individual, routine, preventive, outpatient visit in the office of 1 of the 17 participating primary care physicians (pediatricians or family physicians) within 2 weeks after the birth. The participating physicians received a 5-hour training program on breastfeeding, delivered in 2 parts in 1 month, before the beginning of the study. Outcome Measures. The primary outcome was the prevalence of exclusive breastfeeding reported at 4 weeks (defined as giving maternal milk as the only food source, with no other foods or liquids, other than vitamins or medications, being given). The secondary outcomes included any breastfeeding reported at 4 weeks, breastfeeding duration, breastfeeding difficulties, and satisfaction with breastfeeding experiences. Classification into breastfeeding categories reported at 4 weeks was based on 24-hour dietary recall. Results. Ninety-two mothers (79.3%) assigned to the intervention group and 8 mothers (7.0%) assigned to the control group reported that they had attended the routine, preventive, outpatient visit in the office of 1 of the 17 primary care physicians participating in the study. Mothers in the intervention group were more likely to report exclusive breastfeeding at 4 weeks (83.9%vs 71.9%; hazard ratio: 1.17; 95%confidence interval CI : 1.01-1.34) and longer breastfeeding duration (median: 18 weeks vs 13 weeks; hazard ratio: 1.40; 95%CI: 1.03-1.92). They were less likely to report any breastfeeding difficulties (55.3%vs 72.8%; hazard ratio: 0.76; 95%CI: 0.62-0.93). There was no significant difference between the 2 groups with respect to the rate of any breastfeeding at 4 weeks (89.3%vs 81.6%; hazard ratio: 1.09; 95%CI: 0.98-1.22) and the rate of mothers fairly or very satisfied with their breastfeeding experiences (91.1%vs 87.7%; hazard ratio: 1.04; 95%CI: 0.95-1.14). Conclusions. Although we cannot exclude the possibility that findings might differ in other health care systems, this study provides preliminary evidence of the efficacy of breastfeeding support through an early, routine, preventive visit in the offices of trained primary care physicians. Our findings also suggest that a short training program for practicing physicians might contribute to improving breastfeeding outcomes. Multifaceted interventions aiming to support breastfeeding should involve primary care physicians.展开更多
文摘Context: Most older adults with dementia will be cared for by primary care physicians, but the primary care practice environment presents important challenges to providing quality care. Objective: To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease. Design, Setting, and Patients: Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were randomized by physician to receive collaborative care management (n=84) or augmented usual care (n=69)-at primary care practices within 2 US university-affiliated health care systems from January 2002 through August 2004. Eligible patients (identified via screening or medical record) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver. Intervention: Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient’s family caregiver and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacological management. Main Outcome Measures: Neuropsychiatric Inventory (NPI)-administered at baseline and at 6, 12, and 18 months. Secondary outcomes included the Cornell Scale for Depression in Dementia (CSDD), cognition, activities of daily living, resource use, and caregiver’s depression severity. Results: Initiated by caregivers’reports, 89%of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocols. Intervention patients were more likely to receive cholinesterase inhibitors (79.8%vs 55.1%; P=.002) and antidepressants (45.2%vs 27.5%; P= .03). Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months (mean difference, -5.6; P= .01) and at 18 months (mean difference, -5.4; P=.01). Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months; at 18 months, caregivers showed improvement in depression as measured by the Patient Health Questionnaire-9. No group differences were found on the CSDD, cognition, activities of daily living, or on rates of hospitalization, nursing home placement, or death. Conclusions: Collaborative care for the treatment of Alzheimer disease resulted in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics. Trial Registration: clinicaltrials.gov Identifier: NCT00246896.
文摘Objective. To examine the implementation of a protocol for the assessment of attention-deficithyperactivity disorder (ADHD)-in rural pediatric practices. The protocol was designed to provide an efficient means for pediatricians to learn and use the ADHD guidelines put forth by the American Academy of Pediatrics (AAP). Methods. Primary care staff (physicians, nurses, etc) from 2 rural pediatric practices were trained to use the ADHD-assessment protocol. Medical records for 101 patients were reviewed from 1 to 2 years before the introduction of the protocol and for 86 patients during the subsequent 2 to 3 years to assess compliance with the AAP guidelines. In addition, 34%of the scales scored by the staff were rescored to check for scoring accuracy. Results. Before the availability of the AAP guidelines and the implementation of the assessment protocol, neither primary care site was consistently collecting the comprehensive information that is now recommended for an ADHD assessment. Parent andor teacher rating scales were collected for only 0%to 21%of assessments across sites. When provided with brief training and supporting materials, medical records reflected significant improvement in the ascertainment of clinically necessary ADHD information, with parent and teacher rating scales present 88%to 100%of the time. Staff demonstrated an ability to score rating scales with a high degree of accuracy. The integrity of protocol collection and management was maintained 2 to 3 years after training. Conclusions. An efficient system for conducting ADHD assessments according to AAP guidelines in rural pediatrics clinics can be initiated and maintained with integrity. Additional research is needed to determine if this system improves diagnostic decision-making and patient outcomes.
文摘Background. Despite growing evidence of the benefits of prolonged breastfeeding for mother and infant health, the rate of breastfeeding at infant age of 6 months remains below the Healthy People 2010 goal. The greatest decrease in the breastfeeding rate occurs during the first 4 postpartum weeks. Mothers who discontinue breastfeeding early aremore likely to report lack of confidence in their ability to breastfeed, problems with the infant latching or suckling, and lack of individualized encouragement from their clinicians in the early postdischarge period. Observational studies suggest that primary care physicians can increase breastfeeding rates through specific advice and practices during routine preventive visits. However, robust scientific evidence based on randomized, controlled trials is currently lacking. Objective. The purpose of this study was to determine whether attending an early, routine, preventive, outpatient visit delivered in a primary care physician’s office would improve breastfeeding outcomes. Design. The study was a prospective, randomized, parallel-group, open trial. Setting. Participants were recruited at a level 3 maternity facility, with an average of 2000 births per year, in France. Participants. A total of 231 mothers who had delivered a healthy singleton infant (gestational age: ≥37 completed weeks) and were breastfeeding on the day of discharge were recruited and randomized (116 were assigned to the intervention group and 115 to the control group) between October 1, 2001, and May 31, 2002; 226 mother-infant pairs (112 in the intervention group and 114 in the control group) contributed data on outcomes. Intervention. Support for breastfeeding in the control group included the usual verbal encouragement provided by the maternity ward staff members, a general health assessment and an evaluation for evidence of successful breastfeeding behavior by the pediatrician working in the obstetrics department on the day of discharge, provision of the telephone number of a peer support group, mandatory routine, preventive, outpatient visits at 1, 2, 3, 4, 5, and 6 months of infant age, and 10 weeks of paid maternity leave (extended to 18 weeks after the birth of the third child). In addition to the usual predischarge and postdischarge support, the mothers in the intervention group were invited to attend an individual, routine, preventive, outpatient visit in the office of 1 of the 17 participating primary care physicians (pediatricians or family physicians) within 2 weeks after the birth. The participating physicians received a 5-hour training program on breastfeeding, delivered in 2 parts in 1 month, before the beginning of the study. Outcome Measures. The primary outcome was the prevalence of exclusive breastfeeding reported at 4 weeks (defined as giving maternal milk as the only food source, with no other foods or liquids, other than vitamins or medications, being given). The secondary outcomes included any breastfeeding reported at 4 weeks, breastfeeding duration, breastfeeding difficulties, and satisfaction with breastfeeding experiences. Classification into breastfeeding categories reported at 4 weeks was based on 24-hour dietary recall. Results. Ninety-two mothers (79.3%) assigned to the intervention group and 8 mothers (7.0%) assigned to the control group reported that they had attended the routine, preventive, outpatient visit in the office of 1 of the 17 primary care physicians participating in the study. Mothers in the intervention group were more likely to report exclusive breastfeeding at 4 weeks (83.9%vs 71.9%; hazard ratio: 1.17; 95%confidence interval CI : 1.01-1.34) and longer breastfeeding duration (median: 18 weeks vs 13 weeks; hazard ratio: 1.40; 95%CI: 1.03-1.92). They were less likely to report any breastfeeding difficulties (55.3%vs 72.8%; hazard ratio: 0.76; 95%CI: 0.62-0.93). There was no significant difference between the 2 groups with respect to the rate of any breastfeeding at 4 weeks (89.3%vs 81.6%; hazard ratio: 1.09; 95%CI: 0.98-1.22) and the rate of mothers fairly or very satisfied with their breastfeeding experiences (91.1%vs 87.7%; hazard ratio: 1.04; 95%CI: 0.95-1.14). Conclusions. Although we cannot exclude the possibility that findings might differ in other health care systems, this study provides preliminary evidence of the efficacy of breastfeeding support through an early, routine, preventive visit in the offices of trained primary care physicians. Our findings also suggest that a short training program for practicing physicians might contribute to improving breastfeeding outcomes. Multifaceted interventions aiming to support breastfeeding should involve primary care physicians.
