A website to improve asthma care by suggesting patient questions for physicians: qualitative analysis of user experiences

Optimizing the design and implementation of question prompt lists to support person-centred care: A scoping review

INTRODUCTION

Question prompt lists (QPLs) are lists of questions that patients may want to discuss with clinicians. QPLs support person-centred care and have been associated with many beneficial outcomes including improved patient question-asking, and the amount and quality of the information provided by clinicians. The purpose of this study was to review published research on QPLs to explore how QPL design and implementation can be optimized.

METHODS

We performed a scoping review by searching MEDLINE, EMBASE, Scopus, CINAHL, Cochrane Library and Joanna Briggs Database from inception to 8 May 2022, for English language studies of any design that evaluated QPLs. We used summary statistics and text to report study characteristics, and QPL design and implementation.

RESULTS

We included 57 studies published from 1988 to 2022 by authors in 12 countries on a range of clinical topics. Of those, 56% provided the QPL, but few described how QPLs were developed. The number of questions varied widely (range 9-191). Most QPLs were single-page handouts (44%) but others ranged from 2 to 33 pages. Most studies implemented a QPL alone with no other accompanying strategy; most often in a print format before consultations by mail (18%) or in the waiting room (66%). Both patients and clinicians identified numerous benefits to patients of QPLs (e.g., increased patient confidence to ask questions, and patient satisfaction with communication or care received; and reduced anxiety about health status or treatment). To support use, patients desired access to QPLs in advance of clinician visits, and clinicians desired information/training on how to use the QPL and answer questions. Most (88%) studies reported at least one beneficial impact of QPLs. This was true even for single-page QPLs with few questions unaccompanied by other implementation strategies. Despite favourable views of QPLs, few studies assessed outcomes amongst clinicians.

CONCLUSION

This review identified QPL characteristics and implementation strategies that may be associated with beneficial outcomes. Future research should confirm these findings via systematic review and explore the benefits of QPLs from the clinician's perspective.

PATIENT/PUBLIC CONTRIBUTION

Following this review, we used the findings to develop a QPL on hypertensive disorders of pregnancy and interviewed women and clinicians about QPL design including content, format, enablers and barriers of use, and potential outcomes including beneficial impacts and possible harms (will be published elsewhere).

Clinical inertia in the treatment of heart failure: a major issue to tackle

Despite an enormous improvement in heart failure management during the last decades, the hospitalization and mortality rate of heart failure patients still remain very high. Clinical inertia, defined as the lack of treatment intensification in a patient not at evidence-based goals for care, is an important underlying cause. Clinical inertia is extensively described in hypertension and type 2 diabetes mellitus, but increasingly recognized in heart failure as well. Given the well-established guidelines for the management of heart failure, these are still not being reflected in clinical practice. While the absolute majority of patients were treated by guideline-directed heart failure drugs, only a small percentage of these patients reached the correct guideline-recommended target dose of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta-blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors. This considerable under-treatment leads to a large number of avoidable hospitalizations and deaths. This review discusses clinical inertia in heart failure and explains its major contributing factors (i.e., physician, patient, and system) and touches upon some recommendations to prevent clinical inertia and ameliorate heart failure treatment.

Using digital interventions for self-management of chronic physical health conditions: A meta-ethnography review of published studies

OBJECTIVES

To understand the experiences of patients and healthcare professionals (HCPs) using self-management digital interventions (DIs) for chronic physical health conditions.

METHODS

A systematic search was conducted in 6 electronic databases. Qualitative studies describing users' experiences of self-management DIs were included, and authors' interpretations were synthesised using meta-ethnography.

RESULTS

30 papers met the inclusion criteria, covering a range of DIs and chronic conditions, including hypertension, asthma and heart disease. The review found that patients monitoring their health felt reassured by the insight this provided, and perceived they had more meaningful consultations with the HCP. These benefits were elicited by simple tele-monitoring systems as well as multifaceted DIs. Patients appeared to feel more reliant on HCPs if they received regular feedback from the HCP. HCPs focused mainly on their improved clinical control, and some also appreciated patients' increased understanding of their condition.

CONCLUSIONS

Patients using self-management DIs tend to feel well cared for and perceive that they adopt a more active role in consultations, whilst HCPs focus on the clinical benefits provided by DIs.

PRACTICE IMPLICATIONS

DIs can simultaneously support patient condition management, and HCPs' control of patient health. Tele-monitoring physiological data can promote complex behaviour change amongst patients.

Impact of online patient reminders to improve asthma care: A randomized controlled trial

Importance

Asthma is one of the most burdensome chronic illnesses in the US. Despite widespread dissemination of evidence-based guidelines, more than half of the adults with asthma have uncontrolled symptoms.

Objective

To examine the efficacy of an online tool designed to improve asthma control.

Design

12-month single blind randomized controlled trial of the online tool (Intervention condition, IC) versus an active control tool (CC).

Setting

Patients enrolled in an insurance plan.

Participants

Participants were 408 adults (21–60 years of age) with persistent asthma.

Intervention

At least once each month and before provider visits, participants in the IC answered questions online about their asthma symptoms, asthma medications and asthma care received from providers, such as an asthma management plan. The tool then provided tailored feedback to remind patients 1) to ask health care providers specific questions that may improve asthma control (e.g., additional controller medications) and 2) to consistently perform specific self-care behaviors (e.g., proper inhaler technique). Participants in the CC received similar questions and feedback, yet focused instead on preventive services unrelated to asthma control (e.g., cancer screening).

Main outcome measures

The main outcome measure was asthma control, as assessed by the 5-question Asthma Control Test (ACT). Secondary outcomes included quality of life, medication use and healthcare utilization (e.g., emergency department visits).

Results

After 12 months, 323 participants completed follow-up measures (79.2%). Participants in the IC reported a greater mean improvement in the ACT score than participants in the CC (2.3 vs. 1.2; p = 0.02) and 9 of 11 individual asthma control survey items showed non-significant improvements favoring the IC. No differences were observed in medication adherence, number of asthma controller medications or health care utilization.

Conclusion and relevance

Simple and brief online patient reminders improved asthma control among insured patients. Although future studies are needed to understand the mechanism of the improvement, the magnitude of the effect on asthma control was similar to the addition of an additional controller medication. Given the widespread use of the Internet, simple tools such as this may be useful for improving the control of other chronic diseases as well.

Trial registration

This study is registered at clinicaltrials.gov, NCT00921401, “Improving the Quality of Asthma Care Using the Internet”

Evaluation of the efficacy of a web-based work-related asthma educational tool

BACKGROUND

Work-related asthma (WRA) has been estimated to account for 15-20% of adult asthma cases. Studies have indicated that a substantial number of asthma patients have inadequate knowledge of work-related effects on their disease, which may contribute to suboptimal asthma control. A Canadian web-based educational tool on WRA was developed to address this knowledge gap in the population.

OBJECTIVE

To evaluate the effectiveness of this web-based tool.

METHODS

Participants were recruited prior to a routine visit at a tertiary care asthma clinic in Toronto. A brief WRA knowledge questionnaire was developed and administered immediately before and after using of the web-based educational tool, and one year later.

RESULTS

The study sample (N = 34) was mostly female (68%) with a mean age of 50.7 (SD, 17.2). Participants demonstrated significant improvement in questionnaire scores following interaction with the tool. The mean score increased from 76% (SEM = 2.1) to 84% (SEM = 1.7) (p = 0.001). On average, scores improved on 12 of the 13 questionnaire items. A 1-year follow-up of a sample of 19 participants demonstrated a slight reduction in mean scores, from 86% (SEM = 1.9) to 84% (SEM = 1.9), but still demonstrated a trend towards a higher score than the baseline (78%; SEM = 2.9; p = 0.08).

CONCLUSIONS

Our findings suggest that the educational tool has a positive effect on WRA knowledge, and that knowledge may be retained long-term. Future studies are needed in non-tertiary care clinic populations which may possess less baseline knowledge of WRA.

The use of behavior change theory in Internet-based asthma self-management interventions: a systematic review

Background

The high prevalence rate of asthma represents a major societal burden. Advancements in information technology continue to affect the delivery of patient care in all areas of medicine. Internet-based solutions, social media, and mobile technology could address some of the problems associated with increasing asthma prevalence.

Objective

This review evaluates Internet-based asthma interventions that were published between 2004 and October 2014 with respect to the use of behavioral change theoretical frameworks, applied clinical guidelines, and assessment tools.

Methods

The search term (Asthma AND [Online or Internet or Mobile or Application or eHealth or App]) was applied to six bibliographic databases (Ovid MEDLINE, PubMed, BioMed Central, ProQuest Computing, Web of Knowledge, and ACM Digital Library) including only English-language articles published between 2004 and October 2014. In total, 3932 articles matched the priori search terms and were reviewed by the primary reviewer based on their titles, index terms, and abstracts. The matching articles were then screened by the primary reviewer for inclusion or exclusion based on their abstract, study type, and intervention objectives with respect to the full set of priori inclusion and exclusion criteria; 331 duplicates were identified and removed. A total of 85 articles were included for in-depth review and the remaining 3516 articles were excluded. The primary and secondary reviewer independently reviewed the complete content of the 85 included articles to identify the applied behavioral change theories, clinical guidelines, and assessment tools. Findings and any disagreement between reviewers were resolved by in-depth discussion and through a consolidation process for each of the included articles.

Results

The reviewers identified 17 out of 85 interventions (20%) where at least one model, framework, and/or construct of a behavioral change theory were applied. The review identified six clinical guidelines that were applied across 30 of the 85 interventions (35%) as well as a total of 21 assessment tools that were applied across 32 of the 85 interventions (38%).

Conclusions

The findings of this literature review indicate that the majority of published Internet-based interventions do not use any documented behavioral change theory, clinical guidelines, and/or assessment tools to inform their design. Further, it was found that the application of clinical guidelines and assessment tools were more salient across the reviewed interventions. A consequence, as such, is that many Internet-based asthma interventions are designed in an ad hoc manner, without the use of any notable evidence-based theoretical frameworks, clinical guidelines, and/or assessment tools.

Using qualitative methods to evaluate a family behavioral intervention for type 1 diabetes

INTRODUCTION

The objectives of this study were to qualitatively evaluate a dyadic adolescent-parent type 1 diabetes (T1D) program developed to prevent deterioration in diabetes care among adolescents with T1D and provide recommendations for program refinement.

METHOD

Thirteen adolescent-parent dyads who participated in the larger randomized controlled trial, the TeamWork Project, were interviewed regarding their perceptions of their participation in the program and current T1D challenges. Interviews were transcribed and coded to establish broad themes.

RESULTS

Adolescents and parents thought the TeamWork Project sessions were helpful and taught them new information. Five themes catalog findings from the qualitative interviews: TeamWork content, TeamWork structure, transition of responsibility, current and future challenges, and future intervention considerations.

DISCUSSION

Addressing T1D challenges as a parent-adolescent dyad via a behavioral clinic program is helpful to families during adolescence. Findings highlight the utility of qualitative evaluation to tailor interventions for the unique challenges related to pediatric chronic illness.

Factors associated with clinical inertia: an integrative review

Failure to initiate or intensify therapy according to evidence-based guidelines is increasingly being acknowledged as a phenomenon that contributes to inadequate management of chronic conditions, and is referred to as clinical inertia. However, the number and complexity of factors associated with the clinical reasoning that underlies the decision-making processes in medicine calls for a critical examination of the consistency of the concept. Indeed, in the absence of information on and justification of treatment decisions that were made, clinical inertia may be only apparent, and actually reflect good clinical practice. This integrative review seeks to address the factors generally associated with clinical inaction, in order to better delineate the concept of true clinical inertia.

Single-centre experience with Renal PatientView, a web-based system that provides patients with access to their laboratory results

BACKGROUND

Renal PatientView (RPV) is a novel, web-based system in the UK that provides patients with access to their laboratory results, in conjunction with patient information.

AIM

To study how renal patients within our centre access and use RPV.

METHODS

We sent out questionnaires in December 2011 to all 651 RPV users under our care. We collected information on aspects such as the frequency and timing of RPV usage, the parameters viewed by users, and the impact of RPV on their care.

RESULTS

A total of 295 (45 %) questionnaires were returned. The predominant users of RPV were transplant patients (42 %) followed by pre-dialysis chronic kidney disease patients (37 %). Forty-two percent of RPV users accessed their results after their clinic appointments, 38 % prior to visiting the clinic. The majority of patients (76 %) had used the system to discuss treatment with their renal physician, while 20 % of patients gave permission to other members of their family to use RPV to monitor results on their behalf. Most users (78 %) reported accessing RPV on average 1-5 times/month. Most patients used RPV to monitor their kidney function, 81 % to check creatinine levels, 57 % to check potassium results. Ninety-two percent of patients found RPV easy to use and 93 % felt that overall the system helps them in taking care of their condition; 53 % of patients reported high satisfaction with RPV.

CONCLUSION

Our results provide interesting insight into use of a system that gives patients web-based access to laboratory results. The fact that 20 % of patients delegate access to relatives also warrants further study. We propose that online access to laboratory results should be offered to all renal patients, although clinicians need to be mindful of the 'digital divide', i.e. part of the population that is not amenable to IT-based strategies for patient empowerment.

A personalised eHealth programme reduces the duration until return to work after gynaecological surgery: results of a multicentre randomised trial

OBJECTIVE

To evaluate the effectiveness of an eHealth intervention on recovery and return to work, after gynaecological surgery.

DESIGN

Randomised multicentre trial that ran from March 2010 until September 2011.

SETTING

Secondary care in seven general and university hospitals in The Netherlands.

POPULATION

A cohort of 215 women (aged 18-65 years) who had a hysterectomy and/or laparoscopic adnexal surgery for a benign indication.

METHODS

The women were randomly assigned to the intervention group (n = 110) or the control group (n = 105). The intervention group received an eHealth programme that provided personalised tailor-made pre- and postoperative instructions on the resumption of daily activities, including work, and tools to improve self-empowerment and to identify recovery problems. The control group was provided with access to a control website.

MAIN OUTCOME MEASURES

The primary outcome was the duration of sick leave until a full sustainable return to work. Secondary outcome measures were quality of life, general recovery, and pain intensity.

RESULTS

In intention-to-treat analysis the eHealth intervention was effective on time to return to work (hazard ratio 1.43; 95% confidence interval 1.003-2.040; P = 0.048). The median duration of sick leave until a full sustainable return to work was 39 days (interquartile range 20-67 days) in the intervention group and 48 days (interquartile range 21-69 days) in the control group. After 26 weeks pain intensity was lower (visual analogue scale, cumulative odds ratio 1.84; 95% confidence interval 1.04-3.25; P = 0.035) and quality of life was higher (Rand-36 health survey, between-group difference 30, 95% confidence interval 4-57; P = 0.024) in the intervention group, compared with the control group.

CONCLUSIONS

The use of the eHealth intervention by women after gynaecological surgery results in a faster return to work, with a higher quality of life and less pain.

Evaluation of internet use for health information by parents of asthmatic children attending pediatric clinics in Riyadh, Saudi Arabia

BACKGROUND AND OBJECTIVES

Internet use by patients raises awareness about their conditions, while its use by physicians assists their ability to make evidence-based decisions. This study aimed at assessing the extent, sources and effects of Internet use by parents of asthmatic children in Riyadh, Saudi Arabia.

DESIGN AND SETTING

A cross-sectional design to collect data from two pediatric pulmonology clinics (public, private) for asthma management in Riyadh, Saudi Arabia, during the period of January to May 2011.

SUBJECTS AND METHODS

A specially designed tool was used to collect data from a random sample of 500 parents of asthmatic children. This tool included questions on demographic data (parents, child) and internet use (sources, frequency, purposes).

RESULTS

Most children (77%) in our study sample were diagnosed with asthma before their third birthday, by a treating physician (78%). Among Internet user parents (n=400), 53% used it for 10 to < 30 minutes or < 10 minutes (22%). Reported reasons for internet use were reassurance, clarification, online consulting, and new management schemes. Reported limitations for Internet use for managing asthma included the nonavailability of Arabic information and highly technical information. Parents suggested the need for the availability of the following online services: consulting/chatting with treating physician, receiving updates on asthma, booking appointments, and being directed to specific websites on asthma. Multivariate analysis showed that the most important predictors for internet use were: "higher mother education" (OR=7.02), followed by "higher father education" (OR=3.04) and "non-health related mother occupation" (OR=2.6).

CONCLUSION

The application of the findings of this study may assist clinicians in the patient-centered shared management of asthmatic children.

eHealth program to empower patients in returning to normal activities and work after gynecological surgery: intervention mapping as a useful method for development

BACKGROUND

Full recovery after gynecological surgery takes much longer than expected regardless of surgical technique or the level of invasiveness. After discharge, detailed convalescence recommendations are not provided to patients typically, and postoperative care is fragmented, poorly coordinated, and given only on demand. For patients, this contributes to irrational beliefs and avoidance of resumption of activities and can result in a prolonged sick leave.

OBJECTIVE

To develop an eHealth intervention that empowers gynecological patients during the perioperative period to obtain timely return to work (RTW) and prevent work disability.

METHODS

The intervention mapping (IM) protocol was used to develop the eHealth intervention. A literature search about behavioral and environmental conditions of prolonged sick leave and delayed RTW in patients was performed. Patients' needs, attitudes, and beliefs regarding postoperative recovery and resumption of work were identified through focus group discussions. Additionally, a literature search was performed to obtain determinants, methods, and strategies for the development of a suitable interactive eHealth intervention to empower patients to return to normal activities after gynecological surgery, including work. Finally, the eHealth intervention was evaluated by focus group participants, medical doctors, and eHealth specialists through questionnaires.

RESULTS

Twenty-one patients participated in the focus group discussions. Sufficient, uniform, and tailored information regarding surgical procedures, complications, and resumption of activities and work were considered most essential. Knowing who to contact in case of mental or physical complaints, and counseling and tools for work reintegration were also considered important. Finally, opportunities to exchange experiences with other patients were a major issue. Considering the determinants of the Attitude-Social influence-self-Efficacy (ASE) model, various strategies based on a combination of theory and evidence were used, resulting in an eHealth intervention with different interactive functionalities including tailored convalescence recommendations and a video to communicate the most common pitfalls during the perioperative period to patients and employers. Fifteen patients in the focus groups, 11 physicians, and 3 eHealth specialists suggested points for improvement to optimize the usability of the eHealth intervention and judged it an approachable, appropriate, and attractive eHealth intervention to empower gynecological patients.

CONCLUSIONS

The IM protocol was a useful method to develop an eHealth intervention based on both theory and evidence. All patients and stakeholders judged the eHealth intervention to be a promising tool to empower gynecological patients during the perioperative period and to help them to return to normal activities and work.

Triaging patients at risk of influenza using a patient portal

Vanderbilt University has a widely adopted patient portal, MyHealthAtVanderbilt, which provides an infrastructure to deliver information that can empower patient decision making and enhance personalized healthcare. An interdisciplinary team has developed Flu Tool, a decision-support application targeted to patients with influenza-like illness and designed to be integrated into a patient portal. Flu Tool enables patients to make informed decisions about the level of care they require and guides them to seek timely treatment as appropriate. A pilot version of Flu Tool was deployed for a 9-week period during the 2010-2011 influenza season. During this time, Flu Tool was accessed 4040 times, and 1017 individual patients seen in the institution were diagnosed as having influenza. This early experience with Flu Tool suggests that healthcare consumers are willing to use patient-targeted decision support. The design, implementation, and lessons learned from the pilot release of Flu Tool are described as guidance for institutions implementing decision support through a patient portal infrastructure.

Active assistance technology for health-related behavior change: an interdisciplinary review

Background

Information technology can help individuals to change their health behaviors. This is due to its potential for dynamic and unbiased information processing enabling users to monitor their own progress and be informed about risks and opportunities specific to evolving contexts and motivations. However, in many behavior change interventions, information technology is underused by treating it as a passive medium focused on efficient transmission of information and a positive user experience.

Objective

To conduct an interdisciplinary literature review to determine the extent to which the active technological capabilities of dynamic and adaptive information processing are being applied in behavior change interventions and to identify their role in these interventions.

Methods

We defined key categories of active technology such as semantic information processing, pattern recognition, and adaptation. We conducted the literature search using keywords derived from the categories and included studies that indicated a significant role for an active technology in health-related behavior change. In the data extraction, we looked specifically for the following technology roles: (1) dynamic adaptive tailoring of messages depending on context, (2) interactive education, (3) support for client self-monitoring of behavior change progress, and (4) novel ways in which interventions are grounded in behavior change theories using active technology.

Results

The search returned 228 potentially relevant articles, of which 41 satisfied the inclusion criteria. We found that significant research was focused on dialog systems, embodied conversational agents, and activity recognition. The most covered health topic was physical activity. The majority of the studies were early-stage research. Only 6 were randomized controlled trials, of which 4 were positive for behavior change and 5 were positive for acceptability. Empathy and relational behavior were significant research themes in dialog systems for behavior change, with many pilot studies showing a preference for those features. We found few studies that focused on interactive education (3 studies) and self-monitoring (2 studies). Some recent research is emerging in dynamic tailoring (15 studies) and theoretically grounded ontologies for automated semantic processing (4 studies).

Conclusions

The potential capabilities and risks of active assistance technologies are not being fully explored in most current behavior change research. Designers of health behavior interventions need to consider the relevant informatics methods and algorithms more fully. There is also a need to analyze the possibilities that can result from interaction between different technology components. This requires deep interdisciplinary collaboration, for example, between health psychology, computer science, health informatics, cognitive science, and educational methodology.

Understanding reactions to an internet-delivered health-care intervention: accommodating user preferences for information provision

Background

It is recognised as good practice to use qualitative methods to elicit users' views of internet-delivered health-care interventions during their development. This paper seeks to illustrate the advantages of combining usability testing with 'theoretical modelling', i.e. analyses that relate the findings of qualitative studies during intervention development to social science theory, in order to gain deeper insights into the reasons and context for how people respond to the intervention. This paper illustrates how usability testing may be enriched by theoretical modelling by means of two qualitative studies of users' views of the delivery of information in an internet-delivered intervention to help users decide whether they needed to seek medical care for their cold or flu symptoms.

Methods

In Study 1, 21 participants recruited from a city in southern England were asked to 'think aloud' while viewing draft web-pages presented in paper format. In Study 2, views of our prototype website were elicited, again using think aloud methods, in a sample of 26 participants purposively sampled for diversity in education levels. Both data-sets were analysed by thematic analysis.

Results

Study 1 revealed that although the information provided by the draft web-pages had many of the intended empowering benefits, users often felt overwhelmed by the quantity of information. Relating these findings to theory and research on factors influencing preferences for information-seeking we hypothesised that to meet the needs of different users (especially those with lower literacy levels) our website should be designed to provide only essential personalised advice, but with options to access further information. Study 2 showed that our website design did prove accessible to users with different literacy levels. However, some users seemed to want still greater control over how information was accessed.

Conclusions

Educational level need not be an insuperable barrier to appreciating web-based access to detailed health-related information, provided that users feel they can quickly gain access to the specific information they seek.

Health information needs of childhood cancer survivors and their family

BACKGROUND

Knowledge about past disease, treatment, and possible late effects has previously been shown to be low in survivors of childhood cancer and their relatives. This study investigated the information needs of childhood cancer survivors and their parents and explored possible determinants for differences in information need and health-related Internet use.

PROCEDURE

Childhood cancer survivors or their parents were contacted to complete a questionnaire about their characteristics, Internet use and requirements/expectations of a website on late effects (N = 160).

RESULTS

One-hundred forty-five questionnaires (90.6%) were returned. Of the 69 respondents (49.3%) who had visited a late effects outpatient clinic prior to the survey, 20 (29.0%) had questions left after the consult. The large majority of the population had home access to Internet and 71 respondents (49.3%) used Internet for medical questions. Only 15 respondents (10.5%) used Internet to look for information on late effects of childhood cancer and only 4 survivors found what they were looking for. Main information items requested were information about recognizing late effects, personalized information on late effects treatment and information on self-care. Only six respondents (4.2%) stated they would not visit a late effects website if it would be available.

CONCLUSIONS

The need for late effects information showed to be of high priority by the majority of respondents, as was their interest in visiting a late effects website. In the development of a late effects website, attention should be given to patient information tailored to the personal situation of the website's users.

Using Qualitative Research to Inform the Development of a Comprehensive Outcomes Assessment for Asthma

BACKGROUND: Qualitative research can inform the development of asthma patient-reported outcome (PRO) measures and user-friendly technologies through defining measurement constructs, identifying potential limitations in measurement and sources of response error, and evaluating usability. OBJECTIVE: The goal of the current study was to inform the development of a comprehensive asthma PRO assessment with input from patients and clinical experts. METHOD: Self-reported adult asthma sufferers recruited from a 3,000 member New England-area research panel participated in either one of three focus groups (N=21) or individual cognitive item debriefing interviews (N=20) to discuss how asthma impacts their health-related quality of life (HRQOL), and provide feedback on a preliminary set of asthma impact survey items and prototype patient report. Focus groups and cognitive interviews were conducted using traditional research principles (e.g., semi-structured interview guide, probing, and think aloud techniques). An Expert Advisory Panel (N=12) including asthma clinical specialists and measurement professionals was convened to review results from the focus group and cognitive interview studies and make recommendations for final survey and report development. RESULTS: Domains of health impacted by asthma included physical (recreation, play, competitive sports, and exercise), social (activities, family relationships), emotional (anger, upset, frustration, anxiety, worry), sleep, role (recreational/leisure activities; work), and sexual functioning. Most items in the impact survey were easily understood, covered important content, and included relevant response options. Items with contradictory examples and multiple concepts were difficult to comprehend. Suggestions were made to expand survey content by including additional items on physical and sexual functioning, sleep, self-consciousness, stigma, and finances. Reports were considered useful and participants saw value in sharing the results with their doctor. Graphic presentation of scores was not always understood; participants preferred tabular presentation of score levels with associated interpretative text. Display of inverse scores for different measures (higher scores equaling better health on one scale and worse health on another) shown on a single page was confusing. The score history section of the report was seen as helpful for monitoring progress over time, particularly for those recently diagnosed with asthma. Expert panelists agreed that displaying inverse scores in a single summary report may be confusing to patients and providers. They also stressed the importance of comprehensive interpretation guidelines for patients, with an emphasis on what they should do next based on scores. Panelists made recommendations for provider and aggregate-level reports (e.g., "red flags" to indicate significant score changes or cut-points of significance; identification of subgroups that have scored poorly or recently gotten worse). CONCLUSION: Incorporating input from patients, clinicians, and measurement experts in the early stages of product development should improve the construct validity of this PRO measure and enhance its practical application in healthcare.

The effects of a computer-tailored message on secondary prevention in type 2 diabetes: a randomized trial

The purpose of this study was to test the effect of computer-generated, tailored feedback on the quality of chronic disease management for type 2 diabetes when provided to a patient prior to a scheduled physician visit. A stand-alone computer application was developed to provide tailored feedback aimed at empowering patients to engage more actively in their diabetes management. Adults with type 2 diabetes (n = 203) were randomly assigned to groups receiving either efficacy (positive) messages (n = 68), risk (negative) messages (n = 67), or to a delayed treatment control group (n = 68). The intervention was delivered prior to a patient's visit with his or her physician so that patients would have the opportunity to discuss the messages at the clinical appointment. Although there were no significant differences in the percentage of participants who received intensified care or routine tests between the control and intervention groups, we learned that more directive messaging may be needed to help patients effectively manage their diabetes. Patients may benefit from directive feedback, providing them with specific questions to ask their physician that can lead to improved care, rather than receiving general and educational informational messages.

Empowerment of disability benefit claimants through an interactive website: design of a randomized controlled trial

BACKGROUND

Individuals claiming a disability benefit after long-term sickness absence, have to undergo medical disability assessments. These assessments, often carried out by specialized physicians, can be complicated by wrong expectations or defensive attitudes of disability benefit claimants. It is hypothesized that empowerment of these claimants will enhance the physician-patient relationship by shifting claimants from a passive role to a more active and constructive role during disability assessments. Furthermore, empowerment of claimants may lead to a more realistic expectation and acceptance of the assessment outcome among claimants and may lead to a more accurate assessment by the physician.

METHODS/DESIGN

In a two-armed randomized controlled trial (RCT), 230 claimants will be randomized to either the intervention or control group. For the intervention group, an interactive website was designed http://www.wiagesprek.nl using an Intervention Mapping procedure. This website was tested during a pilot study among 51 claimants. The final version of the website consists of five interactive modules, in which claimants will be prepared and empowered step-by-step, prior to their upcoming disability assessment. Other website components are a forum, a personal health record, a personal diary, and information on disability assessment procedures, return to work, and coping with disease and work disability. Subjects from the control group will be directed to a website with commonly available information only. Approximately two weeks prior to their disability assessment, disability claimants will be recruited through the Dutch Workers Insurance Authority (UWV). Outcomes will be assessed at five occasions: directly after recruitment (baseline), prior to disability assessment, directly after disability assessment as well as 6 and 16 weeks after the assessment. The study's primary outcome is empowerment, measured with the Vrijbaan questionnaire. Secondary outcomes include claimants' satisfaction, perceived justice, coping strategy, and knowledge. A process evaluation will also be conducted.

DISCUSSION

This study evaluates the effectiveness of an interactive website aimed at empowerment of disability claimants. It is hypothesized that by increasing empowerment, the physician-patient relationship may be enhanced and claimants' satisfaction and perceived justice can be improved. Results are expected in 2010.

TRIAL REGISTRATION

NTR-1414.

Pacifier use: a systematic review of selected parenting web sites

INTRODUCTION

The purpose of this study was to explore and describe content related to pacifier use on parenting Web sites.

METHODS

Sixteen parenting Web sites met the inclusion criteria of the study. Two checklists were used to evaluate and describe different aspects of the Web sites. The first checklist provided a quality assessment of the Web sites. The second checklist was constructed to identify content categories of pacifier use.

RESULTS

The majority of sites met quality assessment criteria. Eleven content categories regarding pacifier use were identified. Nine of the 16 sites contained eight or more of the 11 content areas. The most common types of Web pages containing pacifier information included pacifier specific (articles), questions and answer pages, and related content pages.

DISCUSSION

Most of the parenting Web sites met the quality measures for online information. The content categories reflected the current controversies and information regarding pacifier use found in the expert literature. The findings of this study suggest the need to establish pacifier recommendations in the United States to guide parents and health care providers with decision making.