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Objective: This study evaluated a Web-based tool to help patients with schizophrenia communicate with clinicians about evidence-based treatments.Methods: Fifty patients used an interactive Web-based intervention featuring actors simulating a patient discussing treatment concerns (intervention group; N=24) or were shown an educational video about schizophrenia treatment before an appointment for routine follow-up care (control group; N=26). The visits were recorded and analyzed by using the Roter Interaction Analysis System.Results: Visits by patients in the intervention group were longer (24 versus 19 minutes, p<.05) and had a proportionately greater patient contribution to the dialogue (288 versus 229 statements, p<.05) and a smaller ratio of clinician to patient talk (1.1 versus 1.4, p<.05) compared with visits by the control group. Patients in the intervention group asked more questions about treatment (2 versus .9, p<.05), disclosed more lifestyle information (76 versus 53 statements, p<.005), and more often checked that they understood information (3.6 versus 2.1 checks, p<.05). Clinicians asked more questions about treatment (7.5 versus 5.1, p<.05) and the medical condition (7.8 versus 4.7, p<.05) to control group patients but made more statements of empathy (1.3 versus .4, p<.03) and cues of interest (48 versus 22, p<.05) with the intervention group. The patient-centeredness ratio was greater for visits by patients in the intervention group than by the control group (8.5 versus 3.2, p<.05). Patients' tone was more dominant and respectful (p<.05) and clinicians' tone was more sympathetic (p<.05) during visits by patients in the intervention.Conclusions: The Web-based tool empowered persons with schizophrenia to engage more fully in a patient-centered dialogue about their treatment. [ABSTRACT FROM AUTHOR] more...

Research on coping during childhood and adolescence is distinguished by its focus on how children deal with actual stressors in real-life contexts. Despite burgeoning literatures within age groups, studies on developmental differences and changes have proven difficult to integrate. Two recent advances promise progress toward a developmental framework. First, dual-process models that conceptualize coping as 'regulation under stress' establish links to the development of emotional, attentional, and behavioral self-regulation and suggest constitutional underpinnings and social factors that shape coping development. Second, analyses of the functions of higher-order coping families allow identification of corresponding lower-order ways of coping that, despite their differences, are developmentally graded members of the same family. This emerging framework was used to integrate 44 studies reporting age differences or changes in coping from infancy through adolescence. Together, these advances outline a systems perspective in which, as regulatory subsystems are integrated, general mechanisms of coping accumulate developmentally, suggesting multiple directions for future research. [ABSTRACT FROM AUTHOR] more...

Background: To ascertain disease and functional capacity in community-resident disabled older women in the Women's Health and Aging Study (WHAS), a prospective investigation of the causes and course of disability, a home-based standardized physical examination and performance test battery were developed. Thirty-nine tests were administered, 9 by a lay interviewer and 30 by a nurse. This scope and intensity of testing had not been performed previously in a home environment or on such a functionally limited population. Thus, substantial developmental work was required. This report describes the administrative procedures and field experience for each exam component, highlighting innovations pertinent to home administration.Methods: Exclusion criteria, safety issues, administration time, completion rates, and reasons for incomplete data are reported. Administration time is based on 30 exams conducted over a 3-week period 90% of the way through baseline data collection. Completion status was determined using all 1,002 participants and is categorized as follows: complete; partial; not done, health; not done, other; and refused.Results: Seventy-two percent of the screened, eligible respondents completed the 30-min interviewer-administered physical assessment and the 2-hr, 10-min nurse examination. Classifiable data were obtained for 90% of participants on 36 examination items. Lower completion rates were obtained on the other three tests primarily due to exclusions for health-related conditions; environmental constraints and participant refusal were minimal.Conclusion: Extensive, research-oriented physical evaluation can be successfully and safely performed in a home setting. In future studies, home-based examination may be preferable, as participation in the WHAS examination substantially exceeded rates for clinic-based exams in similar populations. [ABSTRACT FROM AUTHOR] more...

Developmentalists have increasingly concluded that systems approaches to resilience provide a useful higher-order home for the study of the development of coping. Building on previous work on the complementarity of resilience and coping, this paper had two goals: (1) to propose a set of strategies for examining the role of coping in processes of resilience, and (2) to test their utility in the academic domain, using poor relationships with the teacher as a risk factor, and classroom engagement as an outcome. This study examined whether coping serves as a: (1) promotive factor, supporting positive development at any level of risk; (2) pathway through which risk contributes to development; (3) protective factor that mitigates the effects of risk; (4) reciprocal process generating risk; (5) mechanism through which other promotive factors operate; (6) mechanism through which other protective factors operate; and (7) participant with other supports that shows cumulative or compensatory effects. Analyses showed that academic coping at this age was primarily a mediator of risk and support, and a promotive factor that added to engagement for students with multiple combinations of risk and support. Implications are discussed, along with next steps in exploring the role of coping in processes of resilience. more...

Adolescents face many academic pressures that require good coping skills, but coping skills can also depend on social resources, such as parental support and fewer negative interactions. The aim of this study was to determine if parental support and parental negative interactions concurrently and longitudinally relate to adolescents' ways of academic coping, above and beyond the impact of three types of academic stress, students' achievement at school (i.e., grades in school), and age. Survey data were collected from 839 Australian students in grades 5 to 10 (M age  = 12.2, SD = 1.72; 50% girls). Students completed measures of support and negative interactions with parents; academic stress from workload, external pressure (teachers/parents) to achieve, and intrapsychic pressure for high achievement; and ways of academic coping that were grouped into two positive and two negative types. Hypothesized associations were tested concurrently and from one year to the next using path modeling. Beyond the numerous significant influences of academic stress and achievement on coping, and control for age and COVID-19 timing, adolescents with more parental support reported more use of engagement coping (e.g., strategizing) and comfort-seeking, whereas those who reported more negative interactions with parents reported more use of disengagement coping (e.g., concealment) and escape. In the longitudinal model, parental support predicted an increase in engagement and comfort-seeking and a decrease in disengagement coping, whereas negative interaction with parents predicted an increase in disengagement coping. Overall, the findings support the view that coping with academic stressors will continue to depend on parent-adolescent relationships even into the teen years., (© 2023. The Author(s).) more...

Introduction: Many adolescents are concerned about global and future crises, such as the health of the planet or terrorism/safety. Yet, adolescents can also express hope about the future. Thus, asking adolescents about their concern and hope could yield subgroups with different ways of coping and personal adjustment., Method: Australian adolescents (N = 863; age 10-16) completed surveys to report their concern (worry and anger) and hope about the planet, safety, jobs, income, housing, and technology, as well as their active and avoidant coping, depression, and life satisfaction., Results: Four distinct subgroups were identified using cluster analysis: Hopeful (low on concern and high on hope across all issues, 32%), Uninvolved (low in concern and hope; 26%), Concerned about the Planet (CP, 27%), and Concerned about Future Life (CFL, 15%). When compared (adjusting for age, sex, and COVID timing), the CP subgroup was highest in active coping (e.g., taking action) but moderate in personal adjustment. Hopeful had the most positive adjustment, whereas CFL had the poorest adjustment. Uninvolved were lowest in coping but moderate in adjustment., Conclusions: Findings suggest ways of coping and adjustment may not always align, in that CP is connected with more active coping but also some cost to personal adjustment, whereas Hopeful is associated with optimal adjustment but perhaps at the cost of active coping. In addition, although CFL adolescents emerged as the at-risk group, the low levels of hope and coping in Uninvolved adolescents raise the possibility that they are at risk of future problems., (© 2023 The Authors. Journal of Adolescence published by Wiley Periodicals LLC on behalf of Foundation for Professionals in Services to Adolescents.) more...

Importance: US hospitals report data on many health care quality metrics to government and independent health care rating organizations, but the annual cost to acute care hospitals of measuring and reporting quality metric data, independent of resources spent on quality interventions, is not well known., Objective: To evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts., Design, Setting, and Participants: Retrospective time-driven activity-based costing study at the Johns Hopkins Hospital (Baltimore, Maryland) with hospital personnel involved in quality metric reporting processes interviewed between January 1, 2019, and June 30, 2019, about quality reporting activities in the 2018 calendar year., Main Outcomes and Measures: Outcomes included the number of metrics, annual person-hours per metric type, and annual personnel cost per metric type., Results: A total of 162 unique metrics were identified, of which 96 (59.3%) were claims-based, 107 (66.0%) were outcome metrics, and 101 (62.3%) were related to patient safety. Preparing and reporting data for these metrics required an estimated 108 478 person-hours, with an estimated personnel cost of $5 038 218.28 (2022 USD) plus an additional $602 730.66 in vendor fees. Claims-based (96 metrics; $37 553.58 per metric per year) and chart-abstracted (26 metrics; $33 871.30 per metric per year) metrics used the most resources per metric, while electronic metrics consumed far less (4 metrics; $1901.58 per metric per year)., Conclusions and Relevance: Significant resources are expended exclusively for quality reporting, and some methods of quality assessment are far more expensive than others. Claims-based metrics were unexpectedly found to be the most resource intensive of all metric types. Policy makers should consider reducing the number of metrics and shifting to electronic metrics, when possible, to optimize resources spent in the overall pursuit of higher quality. more...

Background: Parents, teachers, and researchers all share the goal of optimizing students' academic engagement (Handbook of social influences in school contexts: Social-emotional, motivation, and cognitive outcomes, 2016, Routledge, New York, NY). While separate lines of research have demonstrated the importance of high-quality relationships and support from parents and teachers, few studies have examined the collective contributions of adults' warm involvement or the processes by which support from both parents and teachers shapes students' engagement. According to the self-system process model of motivational development, warm involvement from key social partners fosters students' sense of relatedness, competence, and autonomy, (Minnesota Symposium on Child Psychology, Vol. 23: Self processes in development, 1991, University of Chicago Press, Chicago, IL; Theory and Research in Education, 2009, 7, 133), which subsequently fuels their engagement with academic tasks and challenges (Journal of Educational Psychology, 2003, 95, 148)., Aims: The current study sought to examine whether a sense of relatedness, competence, or autonomy could explain the relation between parents' and teachers' warm involvement and changes in students' academic engagement across a school year., Sample: Data was drawn from 1011 third, fourth, fifth, and sixth graders., Method: Students reported on adult warm involvement, self-system processes, and engagement in the fall and spring of a single school year., Results: Structural equation models demonstrated that parent and teacher warm involvement each uniquely, positively, and indirectly predicted changes in students' academic engagement through a combination of students' sense of relatedness, competence, and autonomy, though these patterns differed slightly across adults., Conclusions: Implications for optimizing students' academic engagement are discussed, including the need for intervention efforts focused on both parents and teachers and students' self-system processes., (© 2021 British Psychological Society.) more...

Introduction: This study sought to examine how warm involvement from parents and teachers contributes to the development of students' academic engagement, and whether the relative contributions of adults differ as students begin the transition to middle school., Methods: Trivariate latent growth curve modeling was used to examine 1011 third-sixth graders' (95% White, 52.7% female) reports of parent and teacher involvement and engagement across fall and spring of 2 consecutive school years in the United States., Results: Even though engagement showed different patterns of normative change across grades, parents' and teachers' initial levels and changes in involvement uniquely and positively predicted initial levels and changes in student engagement, respectively. However, initial levels of adult involvement made unique negative contributions to engagement trajectories for students in some grade segments, especially those whose engagement was changing most rapidly. Students with higher initial levels of adult involvement were more likely to experience losses in involvement the following school year, making them susceptible to declines in engagement, even though they remained higher in engagement than students with lower levels of adult involvement., Conclusions: These findings suggest that to maintain or promote engagement over late elementary and early middle school, students need "continuity of caregiving," in which involvement from both adults is sustained or augmented over the time that engagement trajectories are unfolding., (© 2022 The Foundation for Professionals in Services for Adolescents.) more...

Background: Science in the Learning Gardens (henceforth, SciLG) program was designed to address two well-documented, inter-related educational problems: under-representation in science of students from racial and ethnic minority groups and inadequacies of curriculum and pedagogy to address their cultural and motivational needs. Funded by the National Science Foundation, SciLG is a partnership between Portland Public Schools and Portland State University. The sixth- through eighth-grade SciLG curriculum aligns with Next Generation Science Standards and uses school gardens as the milieu for learning. This provides the context to investigate factors that support success of a diverse student population using the motivational framework of self-determination theory., Results: This study reports results from 113 students and three science teachers from two low-income urban middle schools participating in SciLG. Longitudinal data collected in spring of sixth grade in 2015 and fall of seventh grade in 2015 for the same set of students included a measure of students' overall motivational experiences in the garden (that combined their reports of relatedness, competence, autonomy, and engagement and teacher-reports of re-engagement in garden-based learning activities) to predict four science outcomes: engagement, learning, science grades, and science identity. Findings suggest that garden-based activities show promise for supporting students' engagement and learning in science classes and in fostering students' interest in pursuing science long-term., Conclusions: As concern for social justice is growing based on the underachievement of students from minority groups, resurgence of the school garden movement over the last several decades provides an opportunity to tip the scales by engaging students in authentic, real-world learning of science and cultivating their interests in science with holistic garden-based learning. This study highlights the role of students' views of themselves as competent, related, and autonomous in the garden, as well as their engagement and re-engagement in the garden, as potential pathways by which garden-based science activities can shape science motivation, learning, and academic identity in science. Findings also suggest that the motivational model based on self-determination theory can be useful in identifying some of the "active ingredients"-in pedagogy, curriculum, and social relationships-that engage students in these garden-integrated science learning activities., Competing Interests: We received approval from the Institutional Review Board (Human Subjects Research Review Committee) and the Research Integrity office at Portland State University and Portland Public Schools to conduct this research.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. more...

How children and youth deal with academic challenges and setbacks can make a material difference to their learning and school success. Hence, it is important to investigate the factors that allow students to cope constructively. A process model focused on students' motivational resources was used to frame a study examining whether engagement in the classroom shapes students' academic coping, and whether coping in turn contributes to subsequent persistence on challenging tasks and learning, which then feed back into ongoing engagement. In fall and spring of the same school year, 880 children in 4th through 6th grades and their teachers completed measures of students' engagement and disaffection in the classroom, and of their re-engagement in the face of obstacles and difficulties; students also reported on 5 adaptive and 6 maladaptive ways of academic coping; and information on a subset of students' classroom grades was collected. Structural analyses, incorporating student-reports, teacher-reports, and their combination, indicated that the model of motivational processes was a good fit for time-ordered data from fall to spring. Multiple regressions examining each step in the process model also indicated that it was the profile of coping responses, rather than any specific individual way of coping, that was most centrally connected to changes in engagement and persistence. Taken together, findings suggest that these internal dynamics may form self-perpetuating cycles that could cement or augment the development of children's motivational resilience and vulnerability across time. (PsycINFO Database Record, ((c) 2016 APA, all rights reserved).) more...

We examined adjustment problems as risks for patterns of emotions, appraisals, and coping with rejection, and explored whether these processes could account for sex (boy/girl) differences in coping. Young adolescents (N = 669, grades 6-8) completed questionnaires, which assessed responses to peer rejection threat with two short scenarios. Using structural equation modeling to test a multivariate process model, adolescents with heightened social anxiety had the most maladaptive responses to rejection threat, including elevated emotional reactions, more self-blame, and coping using more social isolation, rumination and opposition. Adolescents reporting more depressive symptoms felt less control and anticipated using less adaptive coping (less support seeking, distraction, and negotiation), whereas aggressive adolescents responded with more anger and coped via opposition. Moreover, as anticipated, sex differences in coping, symptoms, emotions, and appraisals were found. However, coping differences between boys and girls were mostly nonsignificant after accounting for symptoms, aggression, emotional reactions, and appraisals., (Copyright © 2015 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.) more...

In a cohort of Maryland Medicaid recipients with severe mental illness followed from 1993-2001, we compared mortality with rates in the Maryland general population including race and gender subgroups. Persons with severe mental illness died at a mean age of 51.8 years, with a standardized mortality ratio of 3.7 (95%CI, 3.6-3.7)., (Copyright (c) 2008 Elsevier Ltd. All rights reserved.) more...

Background: : The usefulness of questionnaires to assess asthma control in clinical practice is recognized in recent international guidelines. While several questionnaires have been developed to measure asthma control in adults, there has been little study of the performance of such instruments in children., Objective: : To determine whether there is an association between asthma-related healthcare use and poor asthma control, as determined by categorical score on the control domain of the Asthma Therapy Assessment Questionnaire for children and adolescents (the pediatric ATAQ)., Methods: : An analysis of a 1998 mailed survey of parents or caregivers of children aged 5-17 years with asthma enrolled in three large managed-care organizations in the Northeast and Midwest US was conducted. Pediatric ATAQ control domain score (reported for the past 4 weeks) was the main outcome measure. The pediatric ATAQ control domain was scored from 0 to 7, with 0 indicating no asthma control problems as measured by the questionnaire, and higher scores indicating increasing asthma problems. The hypothesis of an association between pediatric ATAQ control domain score and asthma-related healthcare use (hospitalizations, ER or urgent care facility visits, and doctor visits for worsening asthma in the past 12 months) was examined., Results: : 406 completed surveys were received. Asthma-related hospitalizations, ER/urgent care visits, and doctor visits were reported for 38, 173, and 319 children, respectively. Of the three control score categories (0, 1-3, and 4-7), children with a control score of 4-7 were more likely to have been hospitalized (p = 0.01), to have visited the ER or urgent care facility (p < 0.0001), or to have visited a doctor (p = 0.0001) because of asthma managed care.In multivariate models including demographic variables and a measure of general health status, higher odds of ER/urgent care visits (odds ratio [OR] 3.47, 95% CI 1.92, 6.26) and doctor visits (OR 7.14; 95% CI 2.40, 21.2) was observed for children with an asthma control score of 4-7 than for children with no identified asthma control problems (score of 0). An asthma control score of 4-7 was significantly associated with hospitalization in a multivariate model including only demographic variables (OR 3.06; 95% CI 1.28, 7.33) but not in a model that included general health status (OR 2.44; 95% CI 0.96, 6.16). Relative to an excellent health status, a fair or poor health status was significantly associated with asthma-related hospitalization (OR 7.03; 95% CI 1.71, 28.87). Compared with White race, Black race was significantly associated with hospitalization (OR 2.30; 95% CI 1.05, 5.04) and ER/urgent care visits (OR 2.89; 95% CI 1.67, 5.01)., Conclusions: : Children identified as having poor asthma control using the pediatric ATAQ instrument had significantly higher rates of asthma-related hospitalizations, ER or urgent care visits, and doctor visits than those with good control. This asthma control measure may be useful in identifying children in need of more intensive asthma management. more...

We summarize progress in the developmental study of coping, including specification of a multilevel framework, construction of definitions of coping that rely on regulation as a core concept, and identification of developmentally graded members of families of coping. We argue that these accomplishments are a prelude to the real tasks of a developmental agenda: (1) identifying age-graded shifts in how children and adolescents recognize, react to, and deal with the stressors they encounter in their daily lives; (2) determining the developmental processes that underlie these shifts; and (3) describing and explaining differential pathways for negotiating these normative transitions. more...

Objective: To assess the effects of Hurricane Katrina on mortality, morbidity, disease prevalence, and service utilization during 1 year in a cohort of 20,612 older adults who were living in New Orleans, Louisiana, before the disaster and who were enrolled in a managed care organization (MCO)., Study Design: Observational study comparing mortality, morbidity, and service use for 1 year before and after Hurricane Katrina, augmented by a stratified random sample of 303 enrollees who participated in a telephone survey after Hurricane Katrina., Methods: Sources of data for health and service use were MCO claims. Mortality was based on reports to the MCO from the Centers for Medicare & Medicaid Services; morbidity was measured using adjusted clinical groups case-mix methods derived from diagnoses in ambulatory and hospital claims data., Results: Mortality in the year following Hurricane Katrina was not significantly elevated (4.3% before vs 4.9% after the hurricane). However, overall morbidity increased by 12.6% (P <.001) compared with a 3.4% increase among a national sample of Medicare managed care enrollees. Nonwhite subjects from Orleans Parish experienced a morbidity increase of 15.9% (P <.001). The prevalence of numerous treated medical conditions increased, and emergency department visits and hospitalizations remained significantly elevated during the year., Conclusions: The enormous health burden experienced by older individuals and the disruptions in service utilization reveal the long-term effects of Hurricane Katrina on this vulnerable population. Although quick rebuilding of the provider network may have attenuated more severe health outcomes for this managed care population, new policies must be introduced to deal with the health consequences of a major disaster. more...

Objective(s): To characterize the longitudinal patterns of antipsychotic treatment and to investigate the relationship between antipsychotic treatment patterns and acute hospitalizations among adults with schizophrenia. We hypothesized that continuous antipsychotic treatment would be associated with fewer hospitalizations and shorter lengths of stay., Method: Seven years of retrospective Maryland Medicaid administrative data were used to examine inpatient medical encounters and outpatient psychotropic treatment in community-based settings from 1993 through 2000. The sample consisted of 1727 adults continuously enrolled in the Maryland Medicaid program from July 1992 through June 1994, and diagnosed with schizophrenia. The main outcome measures were a) any schizophrenia hospitalization; b) number of schizophrenia hospitalizations; and c) inpatient days associated with a primary diagnosis of schizophrenia., Results: The average duration of antipsychotic use was six months in any single year and four and one-half years across the entire study period. Compared to individuals with a more continuous pattern of antipsychotic treatment, individuals with moderate or light use had odds of hospitalization for schizophrenia that were 52 or 72% greater (95%CI: 30-75% greater, 49-100% greater respectively). Light users of antipsychotics have an average length of stay per hospitalization that is approximately 20% longer than the average for continuous users (95%CI: 2-39% longer)., Conclusions: Findings emphasize the benefit of continuous antipsychotic treatment for individuals with schizophrenia. more...

In an insightful review on secondary control, B. Morling and S. Evered argued that the seminal article spawning the construct (F. Rothbaum, J. R. Weisz, & S. S. Snyder) contained the roots of two distinct conceptualizations focusing on "fit" and "control" and that distinguishing between them clarifies inconsistent research findings. They concluded that the best definition of secondary control focuses on fit. The author of the current commentary agrees with Morling and Evered's premises but draws the opposite conclusion. Herein, it is argued that (a) current control-focused definitions have more valid claims to the term secondary control, and (b) current incarnations that focus on "fit" are important, but they are not secondary and they are not control. Hence, fit-focused constructs should be liberated from the domain of control and studied in their own right, under their own more appropriate label, such as accommodative processes. Moreover, theoretical clarity and depth regarding the functions of fit-focused processes can be gained by examining these processes in relation to other underlying motives, such as belongingness or autonomy, to which they are more closely allied. more...

The Asthma Therapy Assessment Questionnaire (ATAQ) for children and adolescents was developed to assist clinicians and health plans to identify children at risk for adverse outcomes of asthma. ATAQ is a brief, 20-item parent-completed questionnaire that generates indicators of potential care problems in several categories, including symptom control, behavior and attitude barriers, self-efficacy barriers, and communication gaps. This paper describes testing of the internal consistency and construct validity of the instrument. A cross-sectional mail survey with telephone follow-up was conducted with parents of 434 children aged 5-17 years being treated for asthma and enrolled in three managed care organizations in the Midwestern and Northeastern United States. ATAQ scales were evaluated using correlations with measures of health status, asthma impact, and healthcare utilization. ATAQ demonstrated good internal consistency and the hypothesized relationships to corresponding measures from existing instruments. Asthma control was significantly associated with measures of physical health, psychosocial health, resource use, and family impact. "Shared decision making," an indicator of patient-provider communication and involvement of the parent and child in developing asthma management plans, was significantly and positively associated with symptoms and parental satisfaction. Other ATAQ components showed similar associations. ATAQ appears to have satisfactory measurement properties and is ready for use to identify patients who might benefit from further disease management efforts or medical attention. more...

Background: Implementation of national guidelines for the treatment of asthma requires physician estimates of patients' underlying asthma severity. Asthma severity is commonly assigned based on respiratory symptoms., Objective: To evaluate the relationship of guideline-based physician assessments to asthma control., Methods: Data were collected by survey as part of a cohort study of adults with asthma. Physicians estimated the underlying severity of their patients' asthma as mild, moderate, or severe. We evaluated the relationship of these estimates to (1) general health status, asthma symptoms, and patient-reported emergency department (ED) visits and hospitalizations in the previous year and (2) outcomes in the following year., Results: A total of 3,468 adults with asthma had physicians who completed assessments of their severity. Physician evaluation of severity was significantly associated with the patient's recent general health status, asthma symptom control, ED visits, and hospitalizations (P < .001 for all). Future outcomes, including hospitalizations and ED visits for asthma, increased with increasing severity rating (hospitalizations: 5% [mild] vs 11% [moderate] vs 19% [severe]; ED visits: 15% [mild] vs 22% [moderate] vs 32% [severe]; P < .001 for all)., Conclusion: This study provides evidence of the validity of physician assessments of patients' underlying asthma severity using the strategy recommended by national guidelines. more...

Objective: Examine the association between emotional quality-of-life (QOL) and asthma morbidity in adolescents with asthma., Study Design: Cross-sectional survey of 185 adolescents with asthma 11 to 17 years of age cared for in three managed care organizations (MCOs) in the United States. The asthma-specific Pediatric Asthma Quality of Life Questionnaire (PAQLQ) and a short version of the generic Child Health and Illness Profile-Adolescent Edition (CHIP-AE) were used to assess emotional QOL. Asthma morbidity measures were: asthma control, emergency department (ED) visits, hospitalizations, doctor visits for worsening asthma, and missed school because of asthma., Results: Of the adolescents surveyed, 45% reported feeling depressed, 41% had ED visits, and 30% missed >or=1 day of school because of asthma. Poorer asthma-specific emotional QOL was associated with poorer control of asthma symptoms ( P < .0001), missed school (OR 7.1, P < .05), and doctor visits for worsened asthma (OR = 7.0, P < .05)., Conclusions: Emotional symptoms related to asthma are common in adolescents with persistent asthma and asthma-specific QOL is related to increased asthma morbidity, healthcare use, and school absenteeism. Adolescents with high morbidity from asthma exhibit poorer QOL. Therefore, the evaluation of asthma-specific emotional QOL should be included in the assessment of adolescents with asthma. more...

Objective: To develop and evaluate a set of questionnaire-based screening tools to identify risk for 1-year adverse outcomes in adults with moderate to severe asthma., Study Design: Prospective cohort study in 16 managed care organizations in the United States., Patients and Methods: Patients (n = 4888) with moderate-to-severe asthma completed baseline and 1-year questionnaires (response rate, 79%). Adverse outcomes included hospitalization in the past year; emergency department (ED) visit in the past year; days of lost activity in the past month; a composite measure combining hospitalization, ED use, and lost days; and severe symptoms. Risk models were constructed for each of these 5 outcomes. Candidate predictors included baseline demographic characteristics, prior asthma healthcare use, access to care, symptoms, and treatment. Outcome variables were dichotomized, and logistic regression analysis was used to estimate the probability of 1-year outcomes., Results: The patients' mean age was 45 years; 69% were female, and 83% were white. At 1-year follow-up, 9% had been hospitalized in the past year, 35% had used the ED, and 36% had reduced activity in the past month; 54% reported at least 1 of these, and 53% reported severe symptoms. Twenty-one items were retained for the 5 final risk models. Overall, the strongest predictors were comorbid illnesses and prior ED use. Model discrimination using receiver operating characteristic area ranged from 0.67 to 0.78 for predicting hospitalization, ED use, lost days, any one of these outcomes, and symptoms., Conclusions: The questionnaire-based risk models identified with good discrimination asthmatics at increased risk for a range of adverse outcomes. Risk models based on patient-reported data could be used to target individuals for intervention. more...

From analyzing 100 assessments of coping, the authors critiqued strategies and identified best practices for constructing category systems. From current systems, a list of 400 ways of coping was compiled. For constructing lower order categories, the authors concluded that confirmatory factor analysis should replace the 2 most common strategies (exploratory factor analysis and rational sorting). For higher order categories, they recommend that the 3 most common distinctions (problem- vs. emotion-focused, approach vs. avoidance, and cognitive vs. behavioral) no longer be used. Instead, the authors recommend hierarchical systems of action types (e.g., proximity seeking, accommodation). From analysis of 6 such systems, 13 potential core families of coping were identified. Future steps involve deciding how to organize these families, using their functional homogeneity and distinctiveness, and especially their links to adaptive processes. more...

Background: Asthma undertreatment has been linked to poor outcomes. National guidelines recommend that physicians classify asthma severity based on pretreatment symptoms and titrate care as the disease changes in the individual patient. This study evaluated the extent to which the physician estimate of underlying severity affects a patient's asthma care., Methods: Data used were collected from a cohort of adults with asthma enrolled in managed care. Eligible patients were adults enrolled in managed care with medical encounters coded for asthma. Physicians were eligible if they were main asthma providers. The patient survey covered demographics, symptoms, asthma treatment, and self-management knowledge. Physicians were asked to assess the underlying severity of their patients' asthma., Results: There were 4005 patients with asthma with physician estimates of underlying severity. Of the patients, 70.1% were female (mean age, 44.8 years) and 83.5% were white. Most patients' current asthma symptoms were moderate (39.4%) and severe (50.1%). Most physician estimates of underlying severity were mild (44.6%) and moderate (44.5%). Among those patients reporting moderate symptoms, daily inhaled corticosteroid use was reported in 35.2% when physician estimates were mild, 53.0% when moderate, and 68.1% when severe (P =.001). Rates of peak flowmeter ownership, allergy testing, and self-management knowledge tracked similarly with physician estimates of underlying severity., Conclusions: Physician estimates of underlying asthma severity appear to determine asthma care. For patients with inadequate symptom control, lower physician estimates of underlying severity were associated with care that is less consistent with national guidelines. To improve the quality of asthma care, physicians need to update treatment based on their patients' current symptoms and adapt care accordingly. more...

Background: Although older adults (> or =65 years) with asthma have higher rates of hospitalization and death from asthma than younger adults, the reasons for this are not known., Objectives: To determine whether patterns of care were less favorable for older than younger adults with asthma and to assess whether patient characteristics such as symptom severity and comorbid illnesses explain the higher rate of hospitalization., Methods: Prospective cohort study of 6590 adults with asthma in 15 managed care organizations in the United States. Participants completed a survey of demographics, symptoms, health status, comorbid illnesses, treatment, access to care, self-care knowledge, physician specialty, and health care use., Results: Among 6590 adults with asthma, 554 (8%) were 65 years or older and 1942 (29%) were aged 18 to 34 years. Older patients were more likely than younger patients to be men, white, non-Hispanic, and less educated. At baseline, older patients reported a greater frequency of asthma-related symptoms, such as daily cough (36% vs 22%, P<.001) and wheezing (27% vs 22%, P<.002). They were also more likely to report comorbid conditions, such as sinusitis (50% vs 38%), heartburn (35% vs 23%), chronic bronchitis (43% vs 16%), emphysema (19% vs 1%), congestive heart failure (8% vs 1%), and history of smoking (54% vs 34%) (all P<.001). Care appeared to be better for the older patients compared with the younger, including more frequent use of inhaled corticosteroids, greater self-management knowledge, and fewer reported barriers to care. In the follow-up year, older patients were approximately twice as likely to be hospitalized (14%) than were younger patients (7%) (P<.001). In multivariate analysis, however, older age was not predictive of future hospitalization (odds ratio, 1.05; 95% confidence interval, 0.68-1.61), after adjustment for sex, ethnicity, education, baseline asthma symptoms, health status, comorbid illnesses, and tobacco use. Factors independently associated with hospitalization included being female, nonwhite, less educated, and less physically healthy, and more frequent asthma symptoms., Conclusions: Although the older adults with asthma had greater respiratory symptoms and more comorbidity than their younger counterparts, chronologic age was not an independent risk for hospitalization. Appropriate care for older adults with asthma should address asthma symptoms and other chronic conditions. more...

Objectives: To assess the adequacy of asthma care reported by a group of older adults who were subsequently hospitalized for their asthma., Design: Prospective cohort study., Setting: Fifteen managed care organizations in the United States., Participants: Adults with asthma, enrolled in managed care., Measurements: Patient survey of demographics, asthma symptoms, health status, comorbid conditions, asthma treatment, asthma knowledge, and asthma self-management at baseline and 1 year later., Results: Of 254 older adults, 38 (15.0%) reported being hospitalized for asthma at 1-year follow-up. Of these, 22.9% owned a peak flow meter (PFM). Of those with allergies, only about half (56.0%) had been told how to avoid allergens and had been referred for formal allergy testing. Adrenergic drug use was high in some patients. Nearly all (94.6%) used beta-agonist metered-dose inhalers (MDIs); 60.0% reported theophylline; 17.1% reported beta-agonist MDI overuse (>8 puffs per day); 10.5% reported beta-agonist MDI over-use and theophylline; and 13.2% reported both beta-agonist MDI over-use and oral beta-agonist use. Only 18.4% of respondents rated their overall asthma attack knowledge as excellent. Compared with nonhospitalized older adults, the hospitalized group reported care that was more consistent with guidelines, but also higher rates of potentially toxic combinations of adrenergic drugs. Compared with younger hospitalized adults, older hospitalized adults had clear deficiencies, including lower use of PFMs (55.3% vs 22.9%) and worse asthma self-management knowledge., Conclusions: There are many opportunities to improve both the pharmacologic and non-pharmacologic care of older adults with asthma. Overuse of and potentially toxic combinations of inhaled and oral sympathomimetics should probably be avoided. Older asthmatics may also benefit from increased specialty referral, PFM use, allergy testing, and asthma teaching. more...

Objective: To determine whether care for children was more consistent with national asthma guidelines when a specialist rather than a generalist was the usual source of asthma care., Design: Cross-sectional survey., Setting: Two large managed care organizations in the United States., Participants: A total of 260 parents of children with asthma., Interventions: None., Main Outcome Measures: Parent reports of the physician primarily responsible for asthma care (specialist, generalist, or both equally) and whom they would call (specialist or generalist) for questions about asthma care were used to define usual source of care. We assessed consistency of care with 1997 National Asthma Education and Prevention Program guidelines using 11 indicators in 4 domains of asthma care: patient education, control of factors contributing to asthma symptoms, periodic physiologic assessment and monitoring, and proper use of medications., Results: In all 4 domains, care was more likely to be consistent with guidelines when specialists were the usual source of care. These differences remained after adjustment for symptom severity, recent care encounters, and parent demographics. Greatest differences for specialist versus generalist management were for use of controller medications (odds ratio [OR] 6.7; 95% confidence interval [CI]: 1.5-30.4), ever having a pulmonary function test (OR 6.5; 95% CI: 2.4-18.1), and having been told about asthma triggers and how to avoid them (OR 5.9; 95% CI: 1.3-26.2)., Conclusions: In these managed care organizations, asthma care in children was more likely to be consistent with national guidelines when a specialist was the primary provider. Greater use of specialists or altering generalist physicians' care may improve the degree to which the care of children with asthma is consistent with national guidelines. more...

Objective: To evaluate the consistency of pediatric asthma care with the National Asthma Education and Prevention Program Guidelines., Design: Cross-sectional survey at 2 managed care organizations in the United States (winter 1997-1998). The participants were parents of children (n = 318) age 5 to 17 years with asthma. There were no interventions. The outcome measures were indicators of care in 4 domains: (1) periodic physiologic assessment, (2) proper use of medications, (3) patient education, and (4) control of factors contributing to asthma severity., Results: Of 533 eligible patients with asthma, 318 (60%) parents responded; 59% of children were male, 76% were white, and 60% were aged 5 to 10 years. Deficiencies in care were identified in all care domains including, for patients with moderate and severe persistent symptoms, only 55% used long-term control medication daily, 49% had written instructions for handling asthma attacks, 44% had instructions for adjustment of medication before exposures, 56% had undergone allergy testing, and 54% had undergone pulmonary function testing., Conclusions: There are significant opportunities to improve the quality of care for children with asthma enrolled in managed care. A comprehensive approach to improving care may be necessary to address multiple aspects of care where opportunities exist. more...

To estimate the prevalence and impact of self-reported hip fracture in elderly women an age-stratified random sample of 3841 community-dwelling women aged 65 years and above were interviewed to determine the occurrence of 13 chronic conditions and difficulty performing 15 tasks. Associations were examined using multiple logistic regression analysis. The weighted prevalence of hip fracture was 4.7 per 100. Prevalence increased with increasing age from 2.9 per 100 in women aged 65-74 years to 12.6 per 100 in women aged 85 years and above, and was higher in white women than black women. Women with hip fracture were significantly more likely to report concomitant Parkinson's disease (age-adjusted odds ratio [aOR] = 2.8) and stroke (aOR = 1.8). After adjustment for potential confounding variables, women with hip fracture were significantly more likely to report difficulty performing 11 activities that map into domains of mobility/exercise tolerance, self-care tasks and higher functioning domains. Hip fracture is common among elderly community-dwelling women and is associated with difficulty in performing activities of daily living. more...

Research on individual differences demonstrates that children's perceived control exerts a strong effect on their academic achievement and that, in turn, children's actual school performance influences their sense of control. At the same time, developmental research shows systematic age-graded changes in the processes that children use to regulate and interpret control experiences. Drawing on both these perspectives, the current study examines (1) age differences in the operation of beliefs-performance cycles and (2) the effects of these cycles on the development of children's perceived control and classroom engagement from the third to the seventh grade. Longitudinal data on about 1,600 children were collected six times (every fall and spring) over 3 consecutive school years, including children's reports of their perceived control and individual interactions with teachers; teachers' reports of each student's engagement in class; and, for a subset of students, grades and achievement tests. Analyses of individual differences and individual growth curves (estimated using hierarchical linear modeling procedures) were consistent, not only with a cyclic model of context, self, action, and outcomes, but also with predictors of individual development over 5 years from grade 3 to grade 7. Children who experienced teachers as warm and contingent were more likely to develop optimal profiles of control; these beliefs supported more active engagement in the classroom, resulting in better academic performance; success in turn predicted the maintenance of optimistic beliefs about the effectiveness of effort. In contrast, children who experienced teachers as unsupportive were more likely to develop beliefs that emphasized external causes; these profiles of control predicted escalating classroom disaffection and lower scholastic achievement; in turn, these poor performances led children to increasingly doubt their own capacities and to believe even more strongly in the power of luck and unknown causes. Systematic age differences in analyses suggested that the aspects of control around which these cycles are organized change with development. The beliefs that regulated engagement shifted from effort to ability and from beliefs about the causes of school performance (strategy beliefs) to beliefs about the self's capacities. The feedback loop from individual performance to subsequent perceived control also became more pronounced and more focused on ability. These relatively linear developmental changes may have contributed to an abrupt decline in children's classroom engagement as they negotiated the transition to middle school and experienced losses in teacher support. Implications are discussed for future study of individual differences and development, especially the role of changing school contexts, mechanisms of influence, and developmentally appropriate interventions to optimize children's perceived control and engagement. more...

Objectives: Some inner-city infants grow to be successful, self-sufficient adults. This study is designed to identify characteristics from early childhood that foster or impede favorable outcomes and are useful for formulation of public policy., Population: 2694 children (G-2s), born 1960 through 1965, to 2307 inner-city women (G-1s) enrolled in the Johns Hopkins Collaborative Perinatal Study., Data: 1) prospective observations (birth through 8 years) of neurologic and cognitive development, health, behavior, and family and neighborhood socioeconomic characteristics and 2) completed interviews with 1758 G-2s (age 27 to 33) and 1552 G-1s, bridging the period from age 9 to present status. An intergenerational, life course model of development identified significant characteristics and events associated with G-2 outcome (education, physical and mental health, healthy lifestyle, and financial independence of public support, emphasizing educational attainment of a high school diploma or a graduate equivalency degree). Multiple logistic regression equations identified independent, predictive variables during infancy, preschool and early school years, and adolescence. The probability of a good outcome was estimated in the presence of combinations of the six variables most strongly associated with that outcome., Results: Among G-2s, 79% had a successful outcome for education, 60% health, 70% lifestyle, and 76% for financial independence. Black G-2s had more favorable outcomes than white G-2s in education and lifestyle, whites for financial outcome; health did not differ by race. The six variables most predictive of adult education were: G-1 education at G-2 birth and G-2 attainment of honor roll, average or better reading skills at 8 years, avoidance of regular smoking, and pregnancy before age 18, and not repeating a grade in school., Conclusions: Substantial proportions of inner-city children become successful adults. Attention to improving public education, particularly language and reading skills, and the prevention of smoking and adolescent pregnancy are clearly indicated. more...

An integrative framework, designed to organize the heterogeneous constructs related to "control", is based on 2 fundamental distinctions: (a) objective, subjective, and experiences of control; and (b) agents, means, and ends of control. The framework is used to analyze more than 100 terms, such as sense of control, proxy control, and primary control. It is argued that although many terms reflect aspects of perceived control (both distinct and overlapping), some are more usefully considered aspects of objective control conditions (e.g., contingency), potential antecedents of perceived control (e.g., choice), potential consequences (e.g., secondary control), sources of motivation for control (e.g., mastery), or other sources of motivation (e.g., autonomy). Implications for theory, measurement, research, and intervention are explored. more...

A consortium of employers and managed health care organizations has come together to test the feasibility and usefulness of an outcomes management system, a new strategy for providing information on what types of medical care are effective, for whom, and under what circumstances. Systematic measurement of health outcomes can provide the information that patients, providers, and insurers/employers need to make informed choices among alternative treatments and services. A pilot project in thirteen sites found that outcomes management is feasible for evaluating ongoing care for chronic conditions but is difficult to apply for short-term diagnostic or treatment episodes. Further, successful implementation requires a commitment of substantial organizational resources. more...

This study examined the contribution of perceived control and autonomy to children's self-reported behavior and emotion in the classroom (N = 246 children ages 8-10 years). Multiple regression analyses revealed unique effects of autonomy over and above the strong effects of perceived control. In addition, both sets of perceptions (and their interaction) were found to distinguish children who were active but emotionally disaffected from those who were active and emotionally positive. Specific predictions were also tested regarding the effects of (a) control attributions to 5 causes and (b) 4 reasons for task involvement that differed in degree of autonomy on children's active (vs. passive) behavior and 4 kinds of emotions: boredom, distress, anger, and positive emotions. Implications of the findings for theories of children's motivation are discussed, as well as for diagnostic strategies to identify children at risk for motivational problems more...

To explore some determinants of physicians' decisions to change practice habits, we posed three questions: To what extent are some particular innovations diffused among office-based primary care physicians? What characterizes the physicians who have adopted these innovations? And, what caused them to change their behavior and adopt the innovations? Three "markers," recent innovation in medical practice, were chosen using an expert consensus technique. A telephone survey of 200 office-based pediatricians was conducted, and the physicians were asked whether or not they used the following three innovations in medical practice: continuous rather than intermittent phenobarbital for the prevention of febrile seizures, glycosylated hemoglobin measurement in the management of diabetes, and slow release theophylline in the management of asthma. The questionnaire was completed by 156 pediatricians. Of the 110 pediatricians who cared for diabetics, 73% used glycosylated hemoglobin measurement; of the 145 who saw patients with febrile seizures, 77% prescribed the continuous use of phenobarbital (if they used it at all); and, of the 152 pediatricians who cared for asthmatics, 86% reported using slow-release theophylline. The characteristics significantly associated with using the innovations were board certification, group rather than solo practice, teaching, medically related publications, academic appointment, younger age, and caring for a greater number of patients per week. For two of the innovations, discussion with a colleague was the most important source of information leading to a change of practice. The subjects cited local specialists as the colleagues who most often sparked the adoption of an innovation. more...

Three studies examined differences between children's (ages 8-15) beliefs about the effectiveness of multiple internal and external causes for producing outcomes in their own lives versus in those of their peers. Differences specific to the school domain were found: Starting at age 11 or 12, children perceived internal causes as more important for others than for themselves; and only beliefs about the self related to perceived control. More strikingly, a sample of gifted children, who presumably receive social feedback that they are different from their peers, reported that (a) they exerted more control and possessed more ability than their peers and (b) other children knew less about the causes of school performance and had to rely more on effort and powerful others; only beliefs about the self correlated to cognitive performance. These results suggest that self-other differences are produced by both developmental change and environmental opportunities. more...

Evidence is accruing that older individuals receive little attention for mental health problems and that any attention that is given is most often within the primary care setting. A randomized clinical trial was carried out at a primary care clinic of The Johns Hopkins University, Baltimore, testing the ability of feedback of the results of a screening instrument (the General Health Questionnaire) to increase awareness in clinicians of the emotional and psychological problems of their patients. This report contrasts those aged 65 years and older with younger patients. Detection and management of mental morbidity were lower for older individuals, but the feedback intervention increased the likelihood of attention to these problems. This was not true for younger patients. Detection was significantly higher for older patients when screening data were made available, as was management, although the latter difference was not statistically significant. There was evidence as well that the intervention moved clinicians to greater congruence with their older patients in the perception that current mental health problems existed. These findings have important implications for primary care. more...

Utilization of health and mental health services by non-institutionalized persons aged 18 years and older is examined based on interviews with probability samples of 3,000 to 3,500 persons in each of three sites of the National Institute of Mental Health Epidemiologic Catchment Area (ECA) program: New Haven, Conn, Baltimore, and St Louis. In all three ECAs, 6% to 7% of the adults made a visit during the prior six months for mental health reasons; proportions were considerably higher among persons with recent DSM-III disorders covered by the Diagnostic Interview Schedule (DIS) or severe cognitive impairment. Between 24% and 38% of all ambulatory visits by persons with DIS disorders were to mental health specialists. In seeking mental health services, men were more likely to turn to the specialty sector than to the generalist; women used both sectors about equally. The aged infrequently received care from mental health specialists. Visits for mental health reasons varied considerably depending on specific types of DIS disorder. more...

Individuals in the gray area between Medicaid eligibility and sufficient income to meet the costs of health care, the near poor, utilize health services less than other groups. As part of a study of health care behavior in an inner-city area based on a household survey of three distinct populations (HMO) members, public housing project residents, and a defined geographical area), we examined this question more thoroughly. Survey results show that the near poor had lower levels of use than Medicaid recipients when other factors were controlled. Particularly among those classified as in poor health, the near poor were more likely to be non-users and less likely to make multiple visits. However, differences in use between the near poor and the Medicaid recipients are substantially and consistently smaller for the HMO users (whose costs were covered by a special contract) than for users of a hospital outpatient department. The patterns persist for regular care received for a chronic condition but not for care sought for episodes of illness. These findings point to the special disadvantage faced by low income individuals who are not receiving Medicaid. more...

Using data from a 1974 household survey, accessibility to ambulatory care is compared for residents of an inner-city area (East Baltimore) whose usual source of care is an HMO (the East Baltimore Medical Plan) and residents of the same area with other usual sources of care. Accessibility is measured by the probability of receiving care for an episode of illness. Results from multivariate linear and probit regressions indicate that children using the HMO are more likely to receive care than are children with other usual care sources, but no significant differences in the probability of receiving care are found among adults. Evidence of a substitution of telephone care for in-person care is also found among persons using the HMO. Data from a 1971 household survey of the same area suggest that selectivity is not an important confounding factor in the analysis. more...