Craig D Blinderman, MD, MA and Nathan I Cherny, MBBS, FRACP
Department of Family Medicine, Beth Israel Medical Center, New York,
Director of Cancer Pain and Palliative Care Unit, Department of Oncology, Shaare Zedek Medical Center, Jerusalem, Israel

Introduction: The author has participated in a project to improve healthcare services for people with asthma.  This paper analyzes the process measures of an innovative educational project designed to improve patient outcomes by improving skills of healthcare providers in caring for patients.
Methods involved small group training in two one hour [or less] sessions delivered to healthcare providers in several sites in the NYC area. A total of more than 240 learners were recruited. Learners completed a questionnaire examining barriers and self-efficacy, and then viewed a short doctor-patient dialogue. They then completed a series of scaled questions as to the likelihood that they would undertake certain actions at that time with the simulated patient.
A similar simulation was then shown, and the group discussed their thoughts on diagnosis and treatment for about 45 minutes. They then viewed a ‘post sim’ and responded to the same questions as posed for the ‘pre sim.’ The three sims had comparable levels of severity, and the responses pre and post were compared.
Results: The sample of learners are predominantly physicians (MD/DO) (53.4%), the next largest contingent are residents (19%). The respondents surveyed were predominantly from Primary Care fields. Participants specializing in Family Medicine constitute 64.5% of the sample, and almost 25% are from the field of Pediatrics.
The t-test analyses indicate that the educational modules impact the targeted clinical skills and domains of asthma assessment, treatment and prevention.
Following completion of the case-based scenarios, providers are significantly more likely to make use of prescriptions, asthma equipment and training (peak flow meter, nebulizer, observations) as well as indicated medications (albuterol, steroids, anti-inflammatories). Significant increases are also seen in terms of action plan development, and contact availability (in the form of office visits). Significant reductions were found for ED referrals and Hospital admissions in the second module.
Perhaps most important is the impact on judgments of asthma severity. Module 1 data show that of those who assessed the patient's asthma as "intermittent" at pre-test, 100% (18 of 18) rated the same patient as “chronic” following the training. Similar improvement was found for module 2, where 21 of the 22 providers who initially assessed the case as "intermittent" rated the patient's condition as "chronic" at post-test.
Modules 1 & 4 contain items that tap learners’ perceptions of efficacy in, and barriers to successful asthma treatment. Upon completing administration of the four module series, analysis of these items can define the critical target domains impacted by the learning modules, and also inform subsequent interventions.
Responses to efficacy items (for module 1) were recorded on a 5-point scale representing a range of confidence, ranging from “Not at all” to “Very” (confident). Of the seven items tapping asthma treatment efficacy, the three areas rated lowest by the sample of learners were: 1) Patients’ ability to use tools correctly (74% were “Not sure” to “Not at all confident”), 2) Patients’ ability to use steroids correctly (65% were “Not sure” to “Not at all confident”), and 3) Clinicians’ ability to accurately assess a patient’s severity (51% were “Not sure” to “Not at all confident”).
It is worth noting that 2 of these (lowest rated) items focus on patients’ abilities, suggesting the appropriateness of training patients to use treatment tools and medications. The third (lowest rated) item pertains to clinicians’ ability to evaluate a patient’s severity, providing validation for a primary directive of this educational effort.
Clinicians were most confident in their ability to 1) Detect the appropriate components of asthma history (84% were somewhat to very confident), and 2) Providing acute in-office interventions (81% were somewhat to very confident).
Barriers to asthma treatment were assessed in a similar manner, with items scored on a 3-point scale (Not a barrier at all- Somewhat a barrier-Definitely a barrier). Issues that were rated as the greatest impediments to treatment were 1) Patients’ denial of their chronic disease (90% of clinicians rated this Somewhat to Definitely a barrier), and 2) Patients’ personal stressors (95% of clinicians rated this Somewhat to Definitely a barrier).
The items that were least problematic to asthma treatment were: 1) Comfort level talking with patients over the phone (63% rated this “Not at all a barrier”), 2) Reimbursement for time required to adequately treat patients (63% rated this “Not at all a barrier”), and 3) Lack of training (in asthma treatment) (60% rated this “Not at all a barrier”).
 Conclusions: Healthcare providers in primary care show a measurable improvement in their intent to follow guidelines in an appropriate way using this method of training. Patient outcome data will be available in the near future to see if such training improves asthma outcomes in daily practice.

Evelina Tsarik, DO, Lilia Gehkman, DO, and Abraham Hamaoui, MD

Objective: To investigate the proportion of low income adults with physician contacts aware of cholesterol as a risk factor in heart disease.
Research Design: Observational cross-sectional survey study and chart review.
Measurements And Results:  Low income patients who mostly spoke Spanish as their native tongue and who were admitted to a community hospital for acute events, mainly infection, uncontrolled diabetes, and heart disease, and with an average age of 61.7 (males) and 65.3 (females) — and who consented (all who were asked did) — were surveyed. Two thirds of patients associated cholesterol (68.6%) and smoking (66.7%) to heart disease. Most (64.4%) declared to have been tested for cholesterol in the past. Slightly a lesser number remember having received patient education by their physician contacts on smoking cessation (44.2%), cholesterol levels (61.5%), and about half remembered recommendations as to exercise (63.5%) and diet (53.8%).
When we looked, at a similar population in an outpatient center, we found that 25.4% in one survey and  32.87% in another recalled having received patient education on cholesterol. However, when we checked the charts only 6.0% had been tested for cholesterol as part of the in-hospital workup, while 42.0% (32.97% in another review) documented testing in the center.
As to other risk factors, patient education is less likely to be missed in inpatients (54% vs. 11%,  p< 0.0001). However few remembered being checked for homocysteine (5.8%), and only 9.6% were actually tested for homocysteine during the hospital stay. None in outpatients.
Conclusions: The survey indicates relatively good understanding of cardiovascular risk factors by participants.
Patient education is fair though screening for cholesterol by physicians may need to be incremented. 
Primary and secondary prevention are still a challenge, but may contribute definitely to ending the Atherosclerosis epidemic.