Treating asthma by the guidelines: developing a medication management information system for use in primary care

The aim of this study was to develop, implement, and assess an automated asthma medication management information system (MMIS) that provides patient-specific evaluative guidance based on 1997 NAEPP clinical consensus guidelines. MMIS was developed and implemented in primary care settings within a pediatric asthma disease management program. MMIS infrastructure featured a centralized database with Internet access. MMIS collects detailed patient asthma medication data, evaluates pharmacotherapy relative to practitioner-reported disease severity, symptom control and model of guideline-recommended severity-appropriate medications and produces a patient-specific "curbside consult" feedback report. A system algorithm translates actual detailed medication data into actual severity-specific medication-class combinations. A table-driven computer program compares actual medication-class combinations to a guideline-based medication-class combinations model. Methodology determines whether the patient was prescribed a "severity-appropriate" amount or an amount "more" or "less" medication than indicated for patient's reported severity. Feedback messages comment on comparison. Missing data, unrecognized amounts of controller medication or unrecognized medication combinations create error cases. Post hoc review analyzed error cases to determine prevalence of non-guideline medicating practices among these practitioners. Proportion of valid and error cases across two clinical visits before and after post hoc clinical review were measured, as well as proportion of severity-appropriate, out-of-severity and non-guideline medications. MMIS produced a valid feedback report for 83% of patient visits. Missing data accounted for 60% of error cases. Practitioners used severity-appropriate medications for 60% of cases. When non-severity-appropriate medications were used they tended to be "too much" rather than "too little" (22%, 5%), suggesting appropriate use of guideline-recommended "step down" therapy by these practitioners.

Evaluating family practice residencies: a new method for qualitative assessment

BACKGROUND AND OBJECTIVES

This study reports on a novel qualitative method for evaluating family practice training programs. Previous evaluation techniques have generally been quantitative in nature and have limited their scope to a few isolated elements of residency education.

METHODS

A guest faculty, working in conjunction with local faculty, conducted a site analysis of an East Coast and a West Coast family practice residency. Multiple qualitative techniques were used, including participant observation, focus groups, long interviews, and analysis of key texts. Program strengths and weaknesses were analyzed, and a discrepancy model was used to compare program goals and ideals to the actual training realities. The analysis used a process of immersion/crystallization, and triangulation of the multiple data sources was achieved through repeated comparisons.

RESULTS

This report focuses on the process of the evaluations, rather than on their content. In general, the sites have achieved most of their objectives, but notable limitations are present at both programs. This is particularly apparent in terms of multiple demands on faculty, the lack of a shared vision, and program isolation.

CONCLUSIONS

Significant lessons were learned from these initial assessments, which can be used to further refine the method. Comprehensive qualitative reviews may provide unexpected insights and identify program limitations and strengths.

Serious technology assessment for health care information technology

United States health care is engaged in an ambitious project to make its clinical and administrative records "100% electronic." Substantial benefits are expected in both clinical care delivery and medical research (especially for public health surveillance and outcomes/effectiveness studies). Substantial costs also potentially accrue, beyond the large outlays for an expanded computer and telecommunications infrastructure. Privacy and confidentiality are obviously at risk if such systems cannot be made secure. Limited empirical evidence currently available suggests health information systems security may not be very good, at least in the "average" institutional setting. Privacy-focused critics of electronic record-keeping are sometimes accused of taking Luddite stands, insufficiently attentive to IT's benefits. It may also be fair to worry about a certain Panglossian tendency in "industry" commentary, insufficiently attentive to potential problems. Better federal and state laws structuring health data use will help; the industry must also attend more candidly to the technical uncertainties.

Injury prevention: the time has come

Although cancer, heart disease and stroke occupy much of society's attention to health matters, injuries account for more potential years of life lost before age 65 than all these diseases combined. The time has come to set the record straight and to give injury its rightful place on the health policy agenda. Contrary to popular belief, most injuries are no accident. More than 90% of injuries are both predictable and preventable. Injury prevention, a multidisciplinary effort, is coming of age in Canada. Education alone is not enough. New technology, innovative approaches to safety education and the mobilization of community resources can help to change behaviour and legislation to decrease the risk of injury. Physicians have an important role to play in this process.

Survey of construction workers repeatedly exposed to chlorine over a three to six month period in a pulpmill: I. Exposure and symptomatology

OBJECTIVE

The admission to hospital of three construction workers with acute respiratory distress caused by inhalation of chlorine gas prompted the inspection of a building site located in a kraft pulpmill. The accidental emissions had taken place in the bleach plant and the construction workers assigned there were surveyed to uncover possible large scale health effects.

DESIGN AND PARTICIPANTS

A questionnaire was presented to 281 workers (participation rate = 97%); 257 workers reported an average of 24 exposure episodes to chlorine and derivatives over a three to six month period. The air monitoring data available from the pulpmill's industrial hygienist were not useful in linking specific events reported by the workers to environmental conditions in the bleach plant.

RESULTS

Over 60% of the workers described a characteristic flu like syndrome that lasted for an average of 11 days and was exacerbated by new bouts of exposure. Irritation of the throat (78%) and eyes (77%), cough (67%), and headache (63%) were the most often reported symptoms. Shortness of breath was reported by 54% of the participants and was not associated with age, smoking state, or history of asthma or chronic bronchitis. First aid self referral was associated with significantly greater reporting of most symptoms, including dyspnoea and cough. A significantly greater proportion of workers in the dyspnoea group had gone at least once for first aid care after a gassing incident (64% as opposed to 48%, p = 0.008). Throat irritation and cough persisted for mean intervals of eight and 11 days respectively. A flu like syndrome lasted for an average of 20 days. Seventy one subjects were considered to be a moderate to high risk of having persisting respiratory symptoms.

CONCLUSION

Throat and eye irritation as well as cough and flu like symptoms are frequent occurrences after repeated accidental inhalation of chlorine. Subjects who consulted first aid care stations after a gassing incident are more likely to have persisting dyspnoea.

Survey of construction workers repeatedly exposed to chlorine over a three to six month period in a pulpmill: II. Follow up of affected workers by questionnaire, spirometry, and assessment of bronchial responsiveness 18 to 24 months after exposure ended

OBJECTIVE

The aim was to determine the prevalence of persistent respiratory symptoms and bronchial hyper-responsiveness due to reactive airways dysfunction syndrome in a population of construction workers at moderate to high risk of developing the syndrome, at an interval of 18 to 24 months after multiple exposures to chlorine gas during renovations to a pulp and paper mill.

DESIGN AND PARTICIPANTS

71 of 289 exposed workers (25%) were identified on the basis of an exposure and the onset of respiratory symptoms shortly after this event (moderate to high risk). A standardised respiratory questionnaire was first presented, followed by spirometry and a methacholine inhalation test on those whose questionnaire suggested the persistence of respiratory symptoms.

RESULTS

64 of 71 (90%) subjects completed the respiratory questionnaire at the time of the follow up. The questionnaire suggested a persistence of respiratory symptoms in 58 of the 64 workers (91%). Of the 58 subjects, 51 underwent spirometry and assessment of bronchial responsiveness. All of them used bronchodilators as required (not regularly) and four required inhaled anti-inflammatory preparations. Sixteen had bronchial obstruction (forced expiratory volume in one second) (FEV1 < 80% predicted) and 29 showed significant bronchial hyper-responsiveness.

CONCLUSION

Of the subjects (n = 71) who were at moderate to high risk of developing reactive airways dysfunction syndrome after being exposed to chlorine and were seen 18 to 24 months after exposure ended, 58 (82%) still had respiratory symptoms, 16 (23%) had evidence of bronchial obstruction, and 29 (41%) had bronchial hyper-responsiveness.

Trends in bicycle helmet use in Ottawa from 1988 to 1991

OBJECTIVE

To determine the prevalence rates of helmet use by cyclists in Ottawa in September 1991 and to compare them with the rates in a baseline survey conducted in September 1988.

DESIGN

Observational survey.

SUBJECTS

A total of 3252 cyclists (commuters, recreational cyclists and students in primary, secondary and postsecondary schools) were observed. In the baseline study 1963 such cyclists had been surveyed.

RESULTS

In 1991, 1056 (32.5%) of the cyclists were observed wearing helmets. After the samples were standardized for varying size across the cyclist groups the total helmet use was found to have increased from 10.7% in 1988 to 32.2% in 1991. The highest increase in the rate of helmet use was found among the commuters (from 17.9% in 1988 to 44.6% in 1991); the rate had increased from 14.3% to 31.1% among the recreational cyclists and from 1.9% to 21.0% among the students. All of the trends were statistically significant (p less than 0.0001). When the student population was subdivided the rate of helmet use was found to be 25% among the elementary school children, 17% among the secondary school students and 20.2% among the postsecondary school students.

CONCLUSIONS

The use of bicycle helmets in Ottawa has increased dramatically. Our experience, as well as evidence from other centres, indicates that specific interventions such as media coverage, bulk-buying projects in schools and discount coupons can accelerate the rate of helmet adoption. Although less than half of cyclists are wearing helmets the trend has acquired considerable momentum, and major gains are expected in the next few years. Nevertheless, resistance among young adults and the cost of helmets for low-income groups may be problems. These challenges call for the refinement of future promotional strategies.

Physicians promoting bicycle helmets for children: a randomized trial

Head injury is the leading cause of death and serious morbidity in bicycle accidents. There is good evidence to recommend helmets, yet few children wear them. We evaluated helmet promotion in a randomized trial targeting children presenting to primary care settings for routine ambulatory care. The intervention consisted of physician counseling and take-home pamphlets. The study involved 339 families, 167 in the intervention group and 172 in the control group. In a follow-up telephone call, 2 to 3 weeks later, only 7.2% of the intervention group had purchased helmets, compared with 7.0% of the control group (chi 2 = 0.0056, P = .94). During the latter half of the study, bicycle safety received considerable media attention in Ottawa, and the provincial medical society sponsored a $5 discount campaign. Therefore both groups were subject to community "co-intervention." Nonetheless, we were surprised that physician counseling made no additional impact. Our results and the success of certain community programs suggest that physicians interested in helmet promotion would do better to participate in the design and implementation of multidisciplinary campaigns.

Helmet promotion in the emergency room following a bicycle injury: a randomized trial

Head injury is the leading cause of serious morbidity and mortality in bicycle accidents. There is good evidence to recommend helmets, yet few children wear them. Following a survey of children presenting to the emergency room with a bicycle injury, helmet promotion was evaluated in a randomized trial. The intervention consisted of physician counseling and take-home pamphlets. The study involved 334 children: 161 in the intervention group and 173 in the control group. In a follow-up telephone call, 2 to 3 weeks later, only 9.3% of the intervention group had purchased helmets, compared with 8.0% of the control group. Families in the intervention group received further counseling during the telephone contact, resulting in one additional purchase at 6-week follow-up. Evidence that a bike injury motivates cyclists to purchase helmets, and the influence of the self-administered questionnaire most likely account for the high purchase rate in the control group. Surprisingly, the helmet promotion intervention, including follow-up phone counseling, made no further impact. The results probably are best explained by a "double threshold" effect. Certain families were easily encouraged to buy a helmet, whereas others were far from ready to adapt this fairly recent innovation as routine cycling equipment. The findings suggest that physicians interested in helmet promotion would do better to participate in the design and implementation of multidisciplinary community campaigns.

Bicycle-related injuries: a survey in a pediatric emergency department

The number of bicycle-related injuries has risen significantly with the increased popularity of bicycle riding in Canada. The risk of injury is highest among children. To assess the magnitude of the problem and to identify the contributing factors we used a questionnaire, injury reports and patient charts to survey bicycle-related injuries among children brought to the emergency department of the Children's Hospital of Eastern Ontario, Ottawa, between May 1 and Sept. 30, 1988. The questionnaire was completed for 517 (91%) of the 568 children; 70% were boys, and the mean age was 9.4 years. Only 2% of the patients had been wearing a helmet at the time of injury, although 13% claimed to own one for cycling. Over 60% of the accidents were attributable to carelessness or poor bicycle control; mechanical failure and environmental hazards were minor factors. Over 80% of the injuries occurred within a kilometre of the child's home. Of the 97 children admitted to hospital 49% had head and skull injuries and 40% had limb fractures. Bicycle-related injuries represented 14.8% of all nonwinter (Apr. 1 to Oct. 31) trauma admissions among children 5 years or older. Our results further document bicycle-related injuries as an important childhood problem and underscore the need for improved safety measures.

Orientation of cobra alpha-toxin on the nicotinic acetylcholine receptor. Fluorescence studies

Four flourescein isothiocyanate (FITC) derivatives of Naja naja siamemsis 3 neurotoxin (alpha-toxin), labeled at the epsilon-amino groups of Lys-23, Lys-35, Lys-49, or Lys-69, and a tetramethylrhodamine isothiocyanate (TRITC) derivative, labeled at epsilon-amino group of Lys-23, were prepared and used to analyze the orientation of cobra alpha-toxin on the nicotinic acetylcholine receptor (AcChR) relative to both the plane of the membrane and the central ion channel. Fluorescence-quenching studies of the AcChR-bound FITC derivatives indicated significant solute accessibility to each site of labeling and suggested that none of the sites of FITC labeling is included in the binding surface of the alpha-toxin. Labeling of Lys-23 with TRITC did not affect the affinity of the alpha-toxin toward the AcChR and confirmed, contrary to some previous reports, a minimal role of Lys-23 in the binding surface of the alpha-toxin. Measurements of energy transfer between the lipid-membrane surface and the sites of labeling on receptor-bound alpha-toxin derivatives show that the relative distances of closest approach between the surface of the lipid membrane domain and the sites of labeling are in the order Lys-23 less than or equal to Lys-49 less than Lys-35 less than or equal to Lys-69. Energy transfer between AcChR tryptophans and the sites of labeling of bound derivatives was about 50% greater to Lys-49 than to Lys-23, Lys-35, or Lys-69, suggesting that Lys-49 is closer to receptor tryptophans and to the center of the extracellular domain of the receptor than Lys-23, Lys-35, or Lys-69. Combined with previous observations that the tip of the central loop of the alpha-toxin directly interacts with the AcChR, the above results suggest a model of the approximate orientation of the snake neurotoxins on the receptor. This model shows the tip of the central loop of the toxin directly interacting with the receptor surface and the major axis of the neurotoxin tilting from a perpendicular projection from the membrane. The surface of the alpha-toxin that includes Lys-23 projects away from the central ion channel and the surface that includes Lys-35 and Lys-69 faces the ion channel.

Bicycle helmet use in Ottawa

A survey of cyclists was conducted in Ottawa in September 1988 to determine the use of protective helmets. The survey observed 1963 cyclists, of whom 211 (10.7%) wore helmets. The highest level of helmet use was found among older, commuting cyclists (17.9%), followed by recreational cyclists (14.3%). Overall helmet use among students was found to be very low (1.9%), and differed significantly (p < 0.0001) from the other two groups, which consisted almost entirely of adults. When the student population was subdivided, helmet use was found to be 3% among university and college students, 1.9% among high school students, and 0.8% among elementary school students. The authors conclude that children and young adults are the least likely groups to wear helmets while cycling. The five to 19 age group, however, suffer the most cycling injuries, particularly head injuries.

Purification and characterization of four monofluorescein cobra alpha-toxin derivatives

We labeled cobra-alpha-toxin (Naja naja siamensis 3) with near stoichiometric quantities of fluorescein isothiocyanate. To reduce labeling of the hyperreactive N epsilon-lysine 23, the alpha-toxin was modified reversibly with citraconic anhydride before fluorescein labeling. The citraconic anhydride was later removed with strong acid, and four of the six possible monofluorescein alpha-toxin derivatives were isolated by isoelectric focusing on an immobilized pH gradient. Thermolysin digestion and subsequent high pressure liquid chromatography of the peptides yielded one dominant fluorescent peak from three of the isolated monofluorescein derivatives. Sequence analyses of these three fluorescent peaks indicated monofluorescein labeling at Lys-69, Lys-35, and Lys-49. Since one derivative (not identified by sequence analysis) displayed essentially identical chromatographic, spectroscopic, and binding properties as our previously identified monofluorescein-Lys-23 toxin (Johnson, D. A., and Taylor, P. (1982) J. Biol. Chem. 257, 5632-5636), we identified the site of labeling of this fourth derivative to be Lys-23. While only small differences were observed in the extinction maxima and molar extinction coefficients, the quantum yields of the isolated derivatives varied markedly and ranged between 0.18 and 0.41. Binding of monofluorescein-Lys-69, -Lys-35, -Lys-49, and -Lys-23 derivatives to the membrane-associated acetylcholine receptor from Torpedo californica was associated with -39, -26, -9, and +96% changes in fluorescence emission intensity, respectively. Based on analyses of the kinetics of fluorescence changes associated with receptor binding, the association and dissociation rate constants were measured. Relative to native cobra alpha-toxin, monofluorescein conjugation reduced the bimolecular association rate constants for binding to the receptor 13-33-fold. The dissociation rate binding rate constants were less affected and were reduced 0-5-fold.

Health economics: an introduction for clinicians

Economic issues have had a growing importance in the health care field as the sector's share of the gross national product has risen. Clinicians are under increasing pressure to adopt more cost-effective treatment practices as a result of initiatives being taken by the major third-party payers, government, and business. However, recent publications suggest that there are some misconceptions about economics in health care and the extent to which it is in conflict with good clinical practice. To provide a foundation for the understanding of this field by clinicians, we have outlined several basic notions of health economics.